ELEKTROFISIOLOGI

JANTUNG
Irawan Yusuf

Tujuan Pokok Bahasan

1.
2.

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6.
7.

Discuss the ionic basis of the resting potential in atrial and ventricular cells.
Discuss the ionic basis of each of the four phases of the action potential in
"working" myocardial (atrial and ventricular) cells and Purkinje cells, and of
the two phases of the action potential in (S-A and A-V) nodal cells.
Discuss the ionic basis of diastolic depolarization (phase 4); explain why these
mechanisms differ between nodal and Purkinje cells; list the pacemakers of the
heart and their approximate firing rates in order of fastest to slowest.
Discuss the ionic basis of the absolute and relative refractory periods, and how
faster heart rates shorten these periods.
Discuss the ionic basis of propagation of action potentials throughout the heart;
list the factors that affect conduction velocity; list approximate conduction
velocities, in the different regions of the heart, from slowest to fastest; explain
why such velocities are fast or slow.
Describe the mechanisms that underlie the positive and negative chronotropic
and dromotropic effects of sympathetic and parasympathetic neurotransmitters.
Given clinically relevant situations of electrophysiological disturbances.

Pendahuluan
Mengawali aktifitas mekanik jantung
Potensial aksi yang lebih lama
dibandingkan sel saraf dan otot rangka
Setiap bagian jantung mempunyai
karakteristik potensial aksi yang khas
Menjadi dasar untuk memahami
kelainan irama jantung
3

Heart Valves and Major Blood Vessels

Aorta (to the systemic
circulation)

Superior
Vena cava

Pulmonary Arteries
(to lungs)
Semilunar valves
(aortic & pulmonary)

Pulmonary Veins
(from lungs)

LA
RA

Tricuspid
(AV) Valve
Inferior
Vena cava
interatrial septum
interventricular septum

Bicuspid (AV; mitral)

Valve

LV
RV
apex

ventricular muscle

RA: right atria

LA: left atria
RV: right ventricle
LV: left ventricle

Dasar Ionik Aktifitas Listrik

Jantung
Disebabkan oleh pergerakan arus ion
dari luar sel kedalam sel atau sebaliknya
melalui saluran ion (ion channel)
Pergerakan ion terjadi akibat perbedaan
konsentrasi ion di dalam dan di luar sel

Konsentrasi ion di dalam dan diluar sel

Ion

Ekstrasel (mM)

Na+

145

12

K+

135

Ca2+

10-4

150

Cl-

Intrasel (mM)

Struktur dan Fungsi Saluran Ion

Merupakan protein integral pada membran
sel otot jantung dan pacemaker cells
Bersifat selektif terhadap ion tertentu
Arah pergerakan ion ditentukan oleh
perbedaan konsentrasi ion di luar dan di
dalam sel
Proses gating diatur oleh rangsangan listrik,
kimia dan mekanik
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Potensial Aksi Pada Otot Jantung

Mempunyai lima fase, masing-masing:

Fase 0 (upstroke, fast depolarization)

Fase 1 (early repolarization)
Fase 2 (plateau)
Fase 3 (fast repolarization)
Fase 4 (resting membrane potential)

Terdapat dua jenis potensial aksi:

Potensial aksi cepat (fast responses)
Potensial aksi lambat (slow responses)
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Cardiac Action Potential

(differ from cell to cell: size

and channel numbers)

Length
Plateau
Ca++ (Em and contraction)
K+ channel closure

Cardiac contractile
cells have a stable
resting potential

Time (msec)

Cardiac versus Skeletal Muscle AP

Cardiac Muscle Cells are Electrically Connected via Gap Junctions

desmosome
(protein fibres)

Cardiac Muscle Cells

sar
c

om
er s

intercalated disk
Gap Junction
desmosome resist stretching
important as it occurs every time the heart fills
(cardiac cycle)

Plasma membrane

hypertrophy: reduced contraction

gap junction passage of current

steps in conduction

Dasar Ionik Potensial

Membran Istirahat
Potensial membran istirahat berkisar
antara -80 mV sampai -90 mV pada otot
ventrikel, lebih positif pada otot atrium,
nodus AV dan nodus SA
Ditentukan oleh pergerakan ion K + keluar
sel, dan aktifitas pompa Na+-K+ (Na+-K+
pump)
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Dasar Ionik Potensial Aksi

Fase 0 (depolarisasi cepat)
Disebabkan oleh arus ion Na+ kedalam sel
(INa) melalui activation gate (m gate)
Pada saat potensial membran (Vm)
mencapai 30 mV-40 mV terjadi proses
inaktifasi saluran Na+, inactivation gate (h
gate) mulai tertutup
Proses inaktifasi saluran Na+ mendasari
masa refrakter
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Dasar Ionik Potensial Aksi

Fase 1 (repolarisasi awal)
Merupakan repolarisasi awal yang berlangsung
singkat
Terjadi akibat inaktifasi saluran Na+ dan
aktifasi saluran K+
Terjadi pergerakan K+ keluar sel yang
berlangsung singkat (Ito, transient outward
current)
Fase ini sangat menonjol pada potensial aksi di
serabut Purkinje
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Dasar Ionik Potensial Aksi

Fase 2 (plateau)
Merupakan fase yang paling panjang
Terjadi akibat INa, ICa dan IK, IK1 dan Ito
ICa masuk melalui saluran Ca2+ tipe L dan T
ICa berperan dalam proses kontraksi jantung
dengan memicu pelepasan Ca2+ intrasel di
retikulum sarkoplasma (Ca2+-induced Ca2+
release)
Modifikasi ICa melalui saluran Ca2+ dengan obatobatan dapat mengurangi atau meningkatkan
kontraksi jantung
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Dasar Ionik Potensial Aksi

Fase 3 (repolarisasi cepat)
Fase ini terjadi bila arus K + keluar sel
melebihi masuknya arus Ca2+ (ICa)
Ito menentukan lamanya fase 2 atau awal
fase 3, terutama pada atria
IK1 (inwardly rectified), memegang
peranan paling penting pada proses
repolarisasi
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SISTIM KONDUKSI JANTUNG

Sistem konduksi jantung berfungsi untuk
menyebarkan aktifitas listrik ke seluruh
otot jantung
Sistim konduksi jantung terdiri dari:

nodus SA (pacemaker utama jantung)

traktus internodal
nodus AV
berkas His
serabut Purkinje
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The Conduction System of the Heart

(pacemaker conduction fibres contractile fibres )
conduction fibres: larger diameter
atria ventricles: separated by
fibrous bundles

2. Internodal pathways
1. Sinoatrial (SA) node
3. Atrioventricular (AV) node

4. AV bundle
(Bundle of His)

6. Purkinje fibres
5. Right and left
bundle branches
coordinated contraction

LV
RV

gap junctions

a. AP is initiated in the SA node

f. rest

e. AP
spread
through
the
ventricles
(bottom
to top)

b. AP are
conducted
throughout
the atria
very rapid
large cells
c. Conduction
slows at
the AV node
small cells
d. AP travel rapidly
through the branch
bundles

SISTIM KONDUKSI JANTUNG

Penyebaran Potensial aksi
Kecepatan penghantaran potensial aksi tergantung
dari struktur dan sifat sel masing-masing sistem
konduksi
Terjadi perlambatan penyebaran potensial aksi
dari atria ke ventrikel karena:
memungkinkan pengisian ventrikel yang optimal
optimasi kontraksi ventrikel
memaksimalkan proses ejeksi ventrikel

Depolarisasi berakhir pada bagian posterobasal

ventrikel kiri, konus pulmonal dan bagian atas
septum
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Kecepatan konduksi pada

jaringan sel otot jantung
Jaringan
Nodus SA
Otot atrial
Nodus AV
Berkas His
Purkinje
Otot Ventrikel

Kecepatan
konduksi (m/det)
0.05
1.0-1.2
0.02-0.05
1.2-2.0
2.0-4.0
0.3-1.0

Lama
konduksi (det)
0.15
0.15
0.08
0.08
0.08
0.08

Frekwensi
kali/menit)
60-100
40-45
25-40
25-40

Gangguan Irama Jantung

Gangguan pembentukan impuls
Gangguan penghantaran impuls
Gangguan pembentukan dan
penghantaran impuls

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Dasar-dasar ionik aritmia

Perubahan pada potensial membran istirahat
Menurunnya potensial membran istirahat

Perubahan kecepatan fase 0

Menurunnya membran potensial istirahat
Berubahnya aktifitas saluran Na+ dan Ca2+

Perubahan pada fase 1 sampai 3

Lamanya fase 2
Lamanya proses repolarisasi (fase3)
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Gangguan Pembentukan
Impuls
Otomatisitas normal
Kecepatan abnormal : Takikardi dan Bradikardi
Irama abnormal
: Impuls premature

Otomatisitas abnormal
Trigger activity
Early after depolarization (EAD)
Delayed after depolarization (DAD)

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Gangguan Konduksi Impuls

Perlambatan dan hambatan konduksi

Blok SA
Blok AV
Blok percabangan berkas His

Mekanisme reentry

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ELECTROCARDIOGRAM
As the heart undergoes depolarization and
repolarization, the electrical currents that are
generated spread not only within the heart, but also
throughout the body.
This electrical activity generated by the heart is
generally measured by an array of electrodes placed
on the body surface and the resulting tracing is
called an electrocardiogram (ECG, or EKG).
The different waves that comprise the ECG represent
the sequence of depolarization and repolarization of
the atria and ventricles.

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ELECTROCARDIOGRAM
Uses of the EKG

Heart Rate
Conduction in the heart
Arrythmias
Direction of the cardiac vector
Damage to the heart muscle
Provides NO information about pumping or
mechanical events in the heart
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Normal ECG

ELECTROCARDIOGRAM
The P-wave represents the wave of depolarization that
spreads from the SA node throughout the atria and is
usually 0.08 to 0.1 seconds (80-100 ms) in duration.
The period of time from the onset of the P-wave to the
beginning of the QRS is termed the PR interval and
normally ranges from 0.12 to 0.20 seconds. This interval
represents the time between the onset of atrial
depolarization and the onset of ventricular
depolarization.
The QRS complex represents ventricular depolarization.
The duration of the QRS complex is normally 0.06 to 0.1
seconds indicating that ventricular depolarization
normally occurs very rapidly.
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ELECTROCARDIOGRAM
The isoelectric period (ST segment) following the QRS is
the time at which the entire ventricle is depolarized and
roughly corresponds to the plateau phase of the
ventricular action potential.
The T-wave represents ventricular repolarization and is
longer in duration than depolarization (i.e., conduction
of the repolarization wave is slower than the wave of
depolarization).
The QT interval represents the time for both ventricular
depolarization and repolarization to occur, and therefore
roughly estimates the duration of an average ventricular
action potential. This interval can range from 0.2 to 0.4
seconds depending upon heart rate.
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The Normal EKG recorded on the Bipolar Limb Leads