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The cardiovascular system is composed of 3 parts:

1)‘ : as a pumping organ.

2)‘ a   : there are the  taking the blood from the heart to the tissues and
the  bringing the blood from the tissues to the heart.
3)‘  : where the exchange between the blood and the tissue will take place.

If you take the system again it is composed of two units: one unit is the  


(or pulmonary circulation) which is connecting the heart to the lungs and the other one is the



, which is connecting the heart to the peripheral tissue.

I͛m going to explain the systemic circulation, the pulmonary circulation is going to be
explained by Dr Naif, now let͛s take one by one, heart , blood vessles and then the capillaries.




G
  You have two atria, and two ventricles, the two atria act
simultaneously as one unit , the two ventricles also contract simultaneously as one unit.

They are separated by the 

  G  , and there are two valves, one is
the   that separates the left atrium from the left ventricle and the right one, the

  , seperates the right atrium from the right ventricle

Concerning the Mitral valve, you have two cusps, two chordate tendinae and papillary muscles
and the same thing here for the tricuspid valve , the flow of the blood is always normally in
 
, from the inferior and superior vena cava to the right atrium, from the right
atrium to the right ventricle and the same thing from the pulmonary veins to the left atrium
then to the left ventricle to the aorta

You have two great arteries, one is the  (red) and the other one is the  
(blue). The blood going from the right ventricle to the pulmonary circulation through the
pulmonary artery and the aorta from the left ventricle to the aorta to the peripheral tissues
and these two great vessels are separated from the ventricles by valves and these valves are
called   .

º‘ G  separate the atria from the ventricles

º‘   separate the great vessels from the ventricles
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  anatomically you have 4 chambers which are two atria and two
ventricles, but physiologically the heart is divided into   , the right and the left sides,
the right side is the right atrium + the right ventricle, and the left side is the left atrium + the
left ventricle, anything happening in the right is the same thing happening in the left , but
there is one exception which is in the left side it is the side of     and the right side
is the side of low pressure because the left ventricle is pumping the blood to the peripheral
circulation, the distance on the left side is much more than the distance on the right side that͛s
why it has higher pressure.

you keep in mind from now on, when we talk about the heart, like when we say for example
the function, cardiac output, systolic or diastolic, always we relate that to the ! 
,
like when we say the blood pressure, we relate that to the left ventricle.

If you look at the anatomy of the heart you will see the thickness is much more in the left side
that͛s why the force generated by the left ventricle is much more than the force generated by
the right ventricle

so simply when you look to the heart in here, the right atrium, the blood comes from the
inferior and superior vena cava then passes through the tricuspid valve then to the right
ventricle, from the right ventricle to the pulmonary artery across the semilunar valve which
then goes to the lungs, while in the left side, the blood comes through the pulmonary veins to
the left atrium and then to the left ventricle, to the aorta, finally going to the peripheral
circulation.

  
  the histology of the cardiac muscle, as you can see in here, each
muscle fiber in the heart is divided and then they are united again, so the difference between
the


 fibers and the  
 fibers is that the skeletal muscle fibers are
adjacent to each other, so when you want to increase the power of contraction, it depends on
the weight , so the more you have weight the more you will have fibers , in the cardiac muscle
it is a different story, each fiber is divided and united as we said so what͛s happening here is
all the fibers are as a  , they are as a single skeletal fiber, either there is stimulus and
contraction or there is not , so there is no way to increase the contraction by increasing the
number of fibers because actually there is no numbers, it is only one unit, it is ALL or NONE
law, either there is contraction or there is no contraction, that͛s why there are called sensitial,

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 sensitial means unit, so both atria they are atrial sensitial, both ventricles they are ventricular
sensitial, one unit.

So how the contraction is going to be increased? In the skeletal muscles we said it͛s the
 of fibers, in the cardiac muscle it depends on the   of the fibers, that is the
!"  , exactly if you imagine the elastic thread , if you hold it from one side and
then you stretch it, the more you stretch it the more it will hit your finger, so the more you
stretch it the more force, if you stretch it too much, you will destroy the elasticity, this is what
happens in  !. Normally, within physiological limits, the more you stretch the
myocardium (the cardiac muscle) the more you have contraction; if you stretch it too much
you͛ll have heart failure.

So the contraction here depends on the  , a good example of that is during p p
p more
blood is coming, so more blood is pumped, so more blood · more stretching · more
contraction. On the other hand during pp, the metabolism decreases · less blood will
come · less contraction · less force.

The lines you see in the picture are called the 
 
, for excitation they have 
  
 for transporting the electricity (the excitation in the heart is electricity) so they
allow the electricity to pass easily, that͛s why at any time we stimulate the heart, all the atria
will stimulate together and then the impulse will go to the ventricles and both ventricles will
stimulate together.

Αow is the heart stimulated? Where is the pacemaker?

The heart is composed of 3 types of fibers:

1) 
 ! : which are contractile fibers.
2) G ! : which are also contractile fibers, the difference between the two is the force of
contraction.
3) 
 ! : they are present in the G  (sinoatrial node), in the G 
(atrioventricular node) and in between those two nodes we have the  ! , after
the AV node we have  G  or  !  , then we have two branches, the !
 
  the    
 and then the last part of this system is the
# ! $

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 So all of
them, the
SA node, AV
node,
internodal
fibers, AV
bundle,
right and
left
branches
and the
purkinje
fibers, we
call them
the


 , they are neither muscle because they are not contractile, nor nerves,
because they don͛t transmit the impulse as fast as in the nerves, in the nerves the
transmission of the impulse is very high, in those fibers there is transmission of impulse but is
not as fast as in the nerves and they are not contractile as the muscles, that͛s why they are

% ! , they have the ability to generate the impulse and to transmit it. Again, you
have only   
, the impulse is started at the SA node going to the AV node, to
the AV bundle to the 2 branches and finally to the purkinje fibers, the impulse cannot go back.

The separation between the two atria and the two ventricles is by a fibrous tissue which is
called 
 !  or  , that tissue is 

   , doesn͛t allow
electricity to pass, it is the opposite of intercalated disc, so there is no way for the current or
for the impulse to pass from the atria to the ventricles except through the AV node.

The excitation starts in the SA node which is the 

 of the heart, but why?

The resting potential is as you know -90 or -80, the resting potential of the SA node is higher
than that, it is "&', it is higher than any other resting potential in the body, and the structure of
the SA node it is leakage to Na (
 ) it allows the Na to get in, so it increases the resting

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potential gradually until it reaches to the threshold which is Ñ' (he showed that on the slide
and explained the  % and during this period the Na is leaking and will get in
until the resting potential will increase and reach to 40 and then the action potential will start)

So the SA node is the pacemaker of the heart for 2 reasons:

1)     

2) (   ).

That͛s why it generates impulses higher than all the other parts of the conductive system, all
parts of the conductive system can generate impulses, but the higher rate is in the SA node.

What will happen now to the impulse? It will start in the SA node and will go to the atria and
the AV bundle, it will stimulate the two atria as one unit, now in the AV node, the impulse will
now cross straight away to the AV bundle, it will be delayed, the velocity will be less to give
time for the atria to contract, because if there no delay the impulse will pass to the ventricles
and all the chambers will contract together, so when the impulse reaches the AV node the
velocity will be decreased and that will give time for the atria to contract,

Now the question is why the velocity is decreased at the AV node? The fibers in the AV node
are very ! in number, and they are very , so they need time to generate voltage, that͛s
why there is a delay

once it reaches the AV bundle, it will go to the two branches and then to the purkinje fibers, as
you can see the numbers of the purkinje fibers are too many that͛s because the two ventricles
are two large masses so we need a system to increase the velocity without that the ventricles
will need very long time to be stimulated, that͛s why we have too many purkinje fibers and the
velocity of transmission in the purkinje fibers is very fast, so it is exactly the opposite of the AV
node, they are * in number, and (  in size

So after reaching the purkinje fibers there is the resting potential, now what will happen to the
next beat? The time between one beat and the next beat is the time where the heart will rest
and this is called the resting potential and in this period where we have the leakage of Na
which will lead to the next beat.

you have numbers on this slide, the numbers start from zero time which is the SA now, once
the impulse starts in the SA node it will spread to both atria reaching to the AV node, by the
time from zero until it reaches to the AV node it is only À' ms (millisecond) and for both atria

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to be excited it takes &' ms (the Dr you said you don͛t have to know the exact numbers but
there is something else he wants you to know) the delay in the AV node is cÀ' ms, so how long
the impulse will take from the SA node until it reaches to the ventricles? 30+130 = c&' ms, so
now the impulse is in the ventricles, from 160 until all the chambers of the ventricles to be
excited it takes 60 ms, so from the zero time until the ventricles get excites it is dd' ms. this is
the normal impulse

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The action potential in skeletal muscles is composed of depolarization (leakage of Na) and
then repolarization (opening of K channels) this is the simple excitation which develops in the
skeletal muscles , that͛s why the skeletal muscle is very fast, but in the heart it is not the same,
the action potential of the heart is different from the action potential of the skeletal muscle, in
the action potential of the cardiac muscle, you have the depolarization and then by the time
all the Na channels are open the repolarization starts, it cannot continue because there is
another channel that opens which is the Ca, and the calcium channels will remain opened and
this is what we call the  (same line), during this plateau we will have the

,
and then the repolarization.

¬‘ Skeletal muscle action potential = depolarization and repolarization

¬‘ Cardiac muscle action potential = depolarization, plateau and repolarization

Α The   is affected by both the Na and the K, if you have too much Na you͛ll have
very fast rate, if you have too much K, you͛ll have less rate.

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 Α The 

 is affected by the Ca, the more Ca the more contraction and vice
versa.

+

  +, it is the recording of the action potential, when you want to record
electricity you will need two electrodes and volt meter, concerning the two electrodes one has
to be positive and the other negative, now it depends on the current, the direction of current,
if the current is going towards the positive electrode it will cause positive deflection, if the
current is going towards the negative electrode, it will give negative deflection, that is the
same for the potential, now imagine that on the heart, when the excitation starts in the SA
node which is located in the right side of the heart, and when we connect two electrodes one
on the right arm and one on the left arm (right
hand ʹve and the left hand +ve) always keep in
mind that the right side is negative
because always excitation starts in the right
side, our body is composed of tissues that
contains fluids and ions all over, and it is good
for conduction of electricity anywhere in the
body, the electricity will reach the surface where
the electrodes are, but keep in mind that the
voltage recorded is less than the actual voltage

+   the man who first recorded the ECG is called Einthoven, he assumed
that the heart is in the chest
cavity and the chest cavity he
assumed it as a collateral
triangle and the heart is at the
center of that triangle, so the
right side is negative and the left
is positive and he connected the
right arm with the left leg, and
this is called lead II, so lead I is

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between right arm and left arm, and lead II between right arm and left leg, lead III connects
the left arm to the left leg

In lead I the direction is from right to left so you have a positive deflection

In lead II the direction is from the right arm to the left leg again you have a positive deflection

In lead III the direction is from the left arm to the left leg and the direction of the current is
again towards the positive.

 
º‘ Always keep in mind, the current which is going towards the positive electrode gives
positive deflection, the current which is going away from the positive electrode towards
the negative electrode gives negative deflection
º‘ always remember the SA node is the source of excitation
º‘ always the right side is negative because excitation starts there
º‘ always the left side is positive
º‘ always keep in mind that the SA node is the pacemaker of the heart because of higher
resting potential and leakage of Na,
º‘ the delay in the AV node is because of the fibers are few in number and small in size,
º‘ the fast velocity in purkinje fibers is because the fibers are many in number and large in
size
º‘ Where is the least resistance? (the less the resistance the more the velocity) ʹ it is in the
purkinje fibers
º‘ Where is the highest resistance ʹ it is in the AV node

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