Cardiovascular Structure and Function

Cardiovascular physiology, while conceptually complex, is based upon clear and concise foundational principles. A practical understanding of these principles is facilitated by their logical and intuitive arrangement. Like many natural processes, the relationships and interactions that exist between a myriad of individual anatomic and physiologic elements displays both an awesome complexity and an elegant simplicity. Individuals with a previous knowledge of the physics underlying electrical circuitry and / or fluid dynamics will appreciate the similarities between cardiovascular function and these physical processes. As eluded to previously, as one gains insight into the mechanisms governing cardiovascular physiology, it is difficult to avoid sensing the inherent aesthetic beauty that natural systems consistently display. In a similar manner to the way the individual systems interconnect, there is a symmetry between the anatomy and physiology of each individual system. The more a student perceives disease as an alteration in normal structure and/or function, the easier it will be to understand specific treatment modalities as targeted attempts at restoring physiologic homeostasis. As alluded to above, the cardiovascular system serves as an excellent example of both types of interdependence; between separate body systems and the individual structures forming a given system. As one appreciates the anatomical design of the individual components of this system, it becomes apparent that the anatomy is perfectly tailored to the physiology. Disruption of this anatomy, whether occurring secondary to genetic abnormalities, disease processes or trauma, lead to relatively predictable compensatory alterations in function. Likewise, physiological abnormalities, over time, will lead to anatomic changes, and this cyclical process will eventually result in permanent system damage, manifested as symptomatic disease, and if not arrested by therapeutic intervention the eventual death of the patient.
Cellular and Tissue Elements of the Cardiovascular System

As with all body structures, the cells that make up the cardiovascular system are perfectly suited to their function. The most numerous cardiac cell, the Cardiac Myocyte, is a unique type of muscle cell. These cells form muscular sheets that are striated and under involuntary control (fig. 1):

Figure 1 - cardiac muscle cells showing: Figure 2 - the striations are the result of horizontal1-cell size, 2- nuclei, 3 -intercalated discs arranged actin and myosin fibers. The interca discs are gap junctions

Cardiovascular Structure and Function

The striations are the result of linearly arranged actin and myosin filaments (fig. 2). The structures termed Intercalated Discs are cellular interconnections that allow for rapid transfer of the action potential between cells. This is an arrangement unique to cardiac muscle and results in the coordinated action of many contiguous cells. When many cells work together for a common function, acting as a single unit, they form a Syncitia. This all for - one action is required to facilitate the organization of myocardial contraction required to push blood up through the semilunar valves (in the case of ventricular contraction) and out to the body and the lungs. When observed using ultrasound, clinically termed an echocardiogram, the incredible organization underlying myocardial contraction can be visualized in real - time. This non-invasive exam is used extensively in both hospitalized and ambulatory patients to view, measure and record their individual cardiac anatomy and physiology.

Gross Anatomy of the Major Cardiovascular Structures

As can be observed in all body systems, there is a strong correlation between structure and function. Over time, from both an individual and species perspective, structure dictates function and occurring simultaneously, function sculpts structure. The major cardiovascular structures, the heart and the great vessels (the aorta, the pulmonary trunk and arteries and the pulmonary veins and sinuses) are located in the center of the thoracic cavity. They reside between the lungs, in a region termed the mediastinum and are enclosed in a bilayered membrane called the pericardium (see figures 3 and 4).

Figure 3 - the heart and great vessels in the mediastinum

Figure 4 - the two layers of the pericardium

Cardiovascular Structure and Function

In a similar manner to all membranes lining body cavities, there is an inner layer, in this case called the visceral pericardium, which is adherent to the heart and great vessels, and an outer layer, referred to as the parietal pericardium. Between these two layers exists a virtual cavity referred to as the pericardial sac. In healthy patients, there may be a small amount of viscous fluid present, acting as a lubricant. In patients presenting with certain pathologic disorders and/or after acute trauma, this virtual cavity can fill with air, fluid and/or blood. The presence of these substances will frequently result in diminished cardiac output by physically preventing ventricular expansion, thus inhibiting ventricular filling during the period of myocardial relaxation. Patients who acutely develop this condition frequently require emergent aspiration of this intra-pericardial fluid and/or air to re-establish adequate cardiac output and promote appropriate perfusion of the body and the lungs. The human heart consists of four individual chambers and is in reality two pumping systems that function simultaneously. The parallel arrangement of the dual cardiovascular circuits can be seen in figure 5. The right atrium and ventricle are functionally termed the pulmonary circuit (figure 6) and the left atrium and ventricle are considered the systemic circuit (figure 7). Blood entering the right atrium comes from the lower body via the inferior vena cava. Blood draining from the upper body and the head enters the right atrium by means of the superior vena cava. The blood returned from the upper body mixes with the blood that has returned from the lower body in the right atrium. The mixed blood then passes through the tricuspid atrioventricular valve into the right ventricle. During ventricular contraction, the blood in the right ventricle exits via the pulmonary semilunar valve and enters the lungs via the pulmonary trunk and the paired left and right pulmonary arteries. After undergoing gas exchange in the lungs, the blood returns to the heart via the pulmonary veins. It should be noted that because of this unique arrangement, the pulmonary arteries are the only arteries in the body containing deoxygenated blood. In a similar manner, the pulmonary veins are the sole venous structures in the body carrying oxygenated blood.

Figure 5: pulmonary and systemic circuits

Figure 6: pulmonary circuit

Figure 7: systemic circuit

Cardiovascular Structure and Function

Cardiac Valvular Function
Effective functioning of the cardiac valvular system is required to maintain a sufficient cardiac output. In addition, the syncopation between the pulmonary and systemic cardiovascular circuits, necessary for maximizing the effectiveness of gas and nutrient exchange, depends upon valvular efficiency and timing. Anatomically, there are two pairs of functionally similar valves. The atrio-ventricular valves include the tricuspid valve (between the right atrium and ventricle) and the bicuspid or mitral valve (between the left atrium and ventricle). The semilunar valves, which earn their name because of their half-moon appearance, consist of the pulmonary valve (between the right ventricle and the pulmonary trunk) and the aortic valve (between the left ventricle and the aorta). It is of note that both sets of paired valves occupy a narrow horizontal anatomic plane. This can be visualized in figure 8.

Figure 8 - the two pairs of cardiac valves As a whole, valvular function is primarily a passive event. There are no specific nerve or hormonal signals which directly cause valve opening or closing. The disposition of a valve (whether it is open or closed) depends upon the pressure differential across the valve. Stated directly, if the pressure of the blood behind a valve (in relation to the direction of blood flow) is greater then pressure of the blood in front of the valve, the valve opens. Likewise, if the pressure of the blood behind a valve is lower then the pressure of the blood in front of the valve, then the valve remains closed. This is another example of the interaction that must occur between many simultaneous systems to ensure adequate and effective functioning of each of the individual systems. Effective valve function depends on effective symmetry between the pulmonary and systemic circuits, which in turn depends on adequate ventricular filling and myocardial perfusion and on and on. As with many processes that are required for the optimal health of an organism, the true importance of that process is most evident when the process is NOT functioning adequately. In relation to cardiac valvular function, inefficient action of the valves, commonly due to incomplete valve closure (which then allows blood to flow backward) or narrowing of the valve circumference (increasing the resistance to flow through the valve) is a primary factor in the development of many cardiovascular disorders including congestive heart failure.

The Cardiac Cycle

The cardiac cycle can be defined as the period of time that includes the events associated with a single occurrence of ventricular myocardial contraction (systole) and relaxation (diastole). As seen below (figure 3), multiple phenomena are occurring simultaneously during this sequence of ventricular myocardial events. Concurrent measurements and recordings made during the cardiac cycle and plotted together reveal the intricate timing and synchronization required to fill the ventricles with blood and then pump that blood to the body and the lungs. When one realizes that this complex sequence of orchestrated events occurs approximately 60 - 80 times every minute and over 2.5 billion times in the seventy years that make up an average human life, it is difficult not to appreciate the remarkable fact that in many of us, this constant chain of cardiac cycles continues uninterrupted from birth to death!

Cardiovascular Structure and Function

Figure 3 - the cardiac cycle Descriptively, a complete cardiac cycle consists of the total time period that encompasses the period of ventricular contraction, called systole, and ventricular relaxation, termed diastole. From a superficial viewpoint, it is easy to conclude that the events occurring during systole are more significant then those occurring during diastole. For, it is during this phase that the blood is actually pumped into the metabolically deprived tissues. However, closer examination reveals that the events comprising both systole and diastole are of equal importance in the process of perfusing the body with blood. The plot of the cardiac cycle pictured here reveals that during a complete cycle the heart spends close to double the amount of time in diastole as compared with the time that is spent in systole. This is important as many significant processes need to occur during the diastolic period to ensure that the systolic events will maintain a consistent and effective cardiac output (defined as the volume of blood pumped from the ventricles per unit of time and described in more detail below). Indeed, the maintenance of an effective cardiac output is the ultimate goal of the heart, and is of primary concern when evaluating the degree to which a specific pathologic event or illness has on the overall physical condition of a patient. Additionally, most therapeutic measures, both pharmacologically and mechanically are aimed at restoring an effective cardiac output. As noted above, there are many important processes that occur during the diastolic portion of the cardiac cycle. Perhaps, the two most significant of these events are ventricular filling and perfusion of the myocardium. Dividing the diastolic period into three is helpful in appreciating the timing and sequence of these physiologic processes. During the first two thirds of diastole, the blood recently returned to the atria from the body and lungs drains through the paired atrio - ventricular valves (tricuspid and mitral valves) into the ventricles. This is a passive event as the primary force favoring this chamber to chamber transit of blood is gravity. During the final third of the diastolic period, blood is actively pushed through the AV valves by muscular contraction of the atria. This is commonly referred to as the atrial kick and is somewhat analogous to squeezing the last bit of water out of a balloon with ones hands. It should be noted that although this final and active emptying of atrial blood is an important process, it is not absolutely critical to survival. Many pathologic processes, such as chronic atrial fibrillation (persistent and ineffective twitching of the atrial myocardium), prevent the active expulsion of atrial blood, decreasing the overall efficiency of a patients cardiac function but not directly compromising survival. Occurring simultaneously with ventricular filling, the oxygen deprived cells of the cardiac myocardium are perfused with oxygenated blood via the coronary arteries. In the majority of patients, the right and left main coronary arteries connect with and receive blood from the proximal aorta. If one could stand on the cusps of the aortic valve, facing forward and looking

Cardiovascular Structure and Function

down, they would visualize two small openings that mark the origination of these important vessels. This arrangement can be visualized in figure # 4.

Figure 4 - the coronary arteries originate from the proximal aorta

During diastole, the myocardium is relaxed, and thus presents minimal resistance to flow. In addition, the blood pressure present in the proximal aorta is high due to the recent receipt of blood from the ventricles during the most recent systole. This pressure gradient favors the flow of blood from the aorta into the coronary arterial system. Patients who develop pathology that decreases the compliance (distensibility) of the ventricular myocardium, can not completely relax this muscular tissue. This phenomena raises the resting pressure in the myocardium, increasing the resistance to blood flow and therefore compromising perfusion. This pathologic process is termed Diastolic Dysfunction and can significantly impact a patients ability to perform any activity that requires increased activity of the cardiovascular system.

Cardiac Valvular Function

Effective functioning of the cardiac valvular system is required to maintain a sufficient cardiac output. In addition, the syncopation between the pulmonary and systemic cardiovascular circuits, necessary for maximizing the effectiveness of gas and nutrient exchange, depends upon valvular efficiency and timing. Anatomically, there are two pairs of functionally similar valves. The atrio-ventricular valves include the tricuspid valve (between the right atrium and ventricle) and the bicuspid or mitral valve (between the left atrium and ventricle). The semilunar valves, which earn their name because of their half-moon appearance, consist of the pulmonary valve (between the right ventricle and the pulmonary trunk) and the aortic valve (between the left ventricle and the aorta). It is of note that both sets of paired valves occupy a very narrow horizontal anatomic plane. This can be visualized in figure 5. Figure 5 - the two pairs of cardiac valves

Cardiovascular Structure and Function

As a whole, valvular function is primarily a passive event. There are no specific nerve or hormonal signals which directly cause valve opening or closing. The disposition of a valve (whether it is open or closed) depends upon the pressure differential across the valve. Stated directly, if the pressure of the blood behind a valve (in relation to the direction of blood flow) is greater then pressure of the blood in front of the valve, the valve opens. Likewise, if the pressure of the blood behind a valve is lower then the pressure of the blood in front of the valve, then the valve remains closed. This is another example of the interaction that must occur between many simultaneous systems to ensure adequate and effective functioning of each of the individual systems. Effective valve function depends on effective symmetry between the pulmonary and systemic circuits, which in turn depends on adequate ventricular filling and myocardial perfusion and on and on. As with many processes that are required for the optimal health of an organism, the true importance of that process is most evident when the process is NOT functioning adequately. In relation to cardiac valvular function, inefficient action of the valves, commonly due to incomplete valve closure (which then allows blood to flow backward) or narrowing of the valve circumference (increasing the resistance to flow through the valve) is a primary factor in the development of many cardiovascular disorders including congestive heart failure.

Measuring Cardiac Function

It is of note that despite this awe - inspiring combination of natural anatomic and physiologic engineering, the human heart, functioning at maximal effectiveness will, at best, perform at about 70 % mechanical efficiency. This fact is apparent as one measures the volume of blood that the ventricles are able to pump out compared to the total volume of blood present in the ventricles at the start of systole. Clinically, these volumes are termed:

Left End - Diastolic Volume (LEDV) = volume of blood (measured in ccs) present in the left ventricle after diastole and just prior to systole Stroke Volume (SV) = actual volume of blood (ccs) ejected from the ventricle during systole
* it is of note that these measurements can reflect left, right or total ventricular volumes, however, by convention, left ventricular volumes are most frequently employed when evaluating the efficiency of a patients cardiac function The mechanical efficiency of a patients heart can be expressed as the ratio of stroke volume to the total left enddiastolic volume. This ratio is termed the:

Ejection Fraction (EF) = stroke volume

Left end-diastolic volume

(x 100)

and is expressed as a percentage. Normal values for the ejection fraction are usually between about 60 and 70 %. This mathematical value is extensively used in clinical settings to quantify a patients true cardiac function. In addition, a patients ejection fraction can be used as benchmark measurement to compare a patients cardiac function over time, after disease (or injury) and / or therapeutic intervention. A frequent question that arises after one learns these principles is, how are these measurements obtained? For, it is apparent that these volumes can not be obtained by physical examination. Currently, these volumes are primarily obtained using the non-invasive echocardiogram described above. Additionally, these measurements can also be made during cardiac catheterization. It should be noted, however, that this procedure is invasive and is most frequently performed for diagnosis and / or treatment of coronary artery disease (CAD).

Cardiovascular Structure and Function

As noted previously, the ultimate goal of the heart is to maintain an overall level of cardiac output sufficient to effectively perfuse the bodys tissues and organs. Quantification of a patients cardiac output is achieved by multiplying the amount of blood actually ejected from the left ventricle during systole (stroke volume) and the number of times the heart beats unit of time (heart rate). Expressed mathematically, the cardiac output appears as follows:

Cardiac Output = stroke volume (ccs) x heart rate (BPM)

In the clinical setting, measurement of a patients cardiac output can be made using the same techniques as those used to obtain a patients ejection fraction. In addition, the cardiac output can be approximated at the bedside using the Thermodilution technique, described below:

The thermodilution technique uses a special thermistor-tipped catheter (Swan-Ganz catheter) that is inserted from a peripheral vein into the pulmonary artery. A cold saline solution of known temperature and volume is injected into the right atrium from a proximal catheter port. The injectate mixes with the blood as it passes through the ventricle and into the pulmonary artery, thus cooling the blood. The blood temperature is measured by a thermistor at the catheter tip, which lies within the pulmonary artery, and a computer is used to acquire the thermodilution profile; that is, the computer quantifies the change in blood temperature as it flows over the thermistor surface. The cardiac output computer then calculates flow (cardiac output from the right ventricle) using the blood temperature information, and the temperature and volume of the injectate. The injection is normally repeated a few times and the cardiac output averaged. Because cardiac output changes with respiration, it is important to inject the saline at a consistent time point during the respiratory cycle. In normal practice this is done at the end of expiration.
As can be observed in all body systems, there is a strong correlation between structure and function. Over time, from both an individual and species perspective, structure dictates function and occurring simultaneously, function sculpts structure. The major cardiovascular structures, the heart and the great vessels (the aorta, the pulmonary trunk and arteries and the pulmonary veins and sinuses) are located in the center of the thoracic cavity. They reside between the lungs, in a region termed the mediastinum and are enclosed in a bilayered membrane called the pericardium. In a similar manner to all membranes lining body cavities, there is an inner layer, in this case called the visceral pericardium, which is adherent to the heart and great vessels, and an outer layer, referred to as the parietal pericardium. Between these two layers exists a virtual cavity referred to as the pericardial sac. In healthy patients, there may be a small amount of viscous fluid present, acting as a lubricant. In patients presenting with certain pathologic disorders and/or after acute trauma, this virtual cavity can fill with air, fluid and/or blood. The presence of these substances in this cavity frequently results in diminished cardiac output by physically preventing ventricular expansion, thus inhibiting ventricular filling during the period of myocardial relaxation. Patients who acutely develop this condition frequently require emergent aspiration of this intra-pericardial fluid and/or air to re-establish adequate cardiac output and promote appropriate perfusion of the body and the lungs. The human heart consists of four individual chambers and is in reality two pumping systems that function simultaneously. The right atrium and ventricle are functionally termed the pulmonary circuit and the left atrium and ventricle are considered the systemic circuit. Blood entering the right atrium comes from the lower body via the inferior vena cava. Blood draining from the upper body and the head enters the right atrium by means of the superior vena cava. This pooled and un-oxygenated blood passes through the tricuspid atrio-ventricular valve and then enters the right ventricle. During ventricular contraction, the blood in the right ventricle is pushed out through the pulmonary semilunar valve, and

Cardiovascular Structure and Function

then enters the lungs by way of the pulmonary artery. It should be noted that the blood in this vessel has not yet been oxygenated and therefore this is the sole artery that carries de-oxygenated blood.

Congestive Heart Failure

As discussed above, the human cardiovascular system is a prime example of physiologic engineering. Over eons of time, structure and function have evolved to meet the constantly changing needs of homo sapien existence. When functioning appropriately, our cardiovascular system is capable of maintaining a cardiac output in the range of 5 liters / minute for years without ceasing. However, secondary to genetic abnormalities and / or detrimental environmental factors, many forms of pathology exist at the present time. These morbid states, many that result directly from unhealthy human activities, are responsible for billions of healthcare dollars, job related loses and unquantifiable amounts of suffering. One of the most prevalent types of cardiovascular pathology seen