The heart is a muscular organ located in the middle mediastinum that pumps blood through the circulatory system. The heart is surrounded by the pericardium and is divided into four chambers: two atria and two ventricles. The right atrium and ventricle are often referred to as the right heart while the left atrium and ventricle are often referred to as the left heart. The atria and ventricles are separated by the atrioventricular valves, while the ventricles and the arterial outflow tracts of the heart (namely the pulmonary trunk and the aorta) are separated by the semilunar valves. The heart wall consists of the endocardium (innermost), the myocardium, and the epicardium. The conduction system of the heart is composed of specialized nodes and pacemaker cells that initiate and coordinate the contraction of the heart.
The right heart receives deoxygenated blood from the systemic circulation and pumps it through the pulmonary circulation, where it becomes oxygenated. The left heart then receives the oxygenated blood from the pulmonary circulation and pumps it through the blood vessels of the systemic circulation. The coronary arteries, namely the right coronary artery and the left coronary artery, arise in the root of the aorta and supply the myocardium and endocardium. The heart develops embryologically from the heart tube, which undergoes looping and septation to separate it into the four chambers.
- Two ventricles and two atria, which connect the with the
- Four valves, which ensure that blood flow occurs in only one direction
- Roughly the size of a fist
- Weighs approx. 300–500 g
- Surrounded by fluid-filled sac) (a fibroserous,
Location: in the between the lungs
- Anterior to the heart: sternum and rib cartilage
- Posterior to the heart
- The upper part of the heart is at the level of the third costal cartilage.
- The site of attachment for the venae cavae, aorta, and pulmonary trunk
- The lower part of the heart (cardiac apex) lies left of the sternum at the level between the fourth and fifth ribs.
- Pumps blood through the body via the
The left atrium is the posteriormost part of the heart, located directly in front of the esophagus. It can be visualized using TEE. The right ventricle is the anteriormost part of the heart and is at greatest risk of injury following chest trauma.
The cardiac apex beat can typically be palpated to the left of the sternum, medial to the midclavicular line at the 4th–5th intercostal space. In patients with dextrocardia, the orientation of the heart is inverse so the apex is located to the right of the mediastinum rather than the left.
Separated by the interatrial septum (The fossa ovalis is visible on the septum as a small oval-shaped depression in the interatrial septum.)
- Receives deoxygenated blood via the superior vena cava (SVC), inferior vena cava (IVC), and the coronary veins
- Pumps deoxygenated blood into the right ventricle
Right auricle (right atrial appendage)
- Muscular pouch that acts to increase the capacity of the atrium
- Located close to the ascending aorta
- Separated from the atrium by the terminal sulcus (sulcus terminalis) and terminal crest (crista terminalis).
- Cavotricuspid isthmus, a region of fibrous tissue between the opening of the inferior vena cava and the tricuspid valve, is a common location of the re-entry circuit in atrial flutter.
- Common site for the development of thrombi in patients with atrial fibrillation
- Receives oxygenated blood from the four pulmonary veins
- Pumps oxygenated blood into the left ventricle to enter the systemic circulation
- Left auricle (left atrial appendage)
Two ventricles of the heart
- Receives deoxygenated blood from the right atrium
- Pumps deoxygenated blood into the pulmonary trunk as part of the pulmonary circulation
- Moderator band: a muscular structure located in the right ventricle that extends from the base of the anterior papillary muscle to the ventricular septum; acts as part of the electrical conduction pathway
- Left ventricle
- Frontal view
- Lateral view
The cardiac borders form the cardiac silhouette on chest x-ray.
- Two types of cardiac valves that differ in location and morphology
- Cardiac skeleton
- Closure of heart valves produces (See in for details.)
“Try PULling My AORTA“: Tricuspidal, Pulmonary, Mitral, Aortic is the order in which blood flows through the heart valves.
- Structure: leaflets supported by subvalvular apparatus
- Chordae tendineae: fibrous cords that support the AV valves and connect them to the papillary muscles
Papillary muscles (two in the left ventricle; three in the right ventricle)
- Derive from the myocardium
- Extend from the anterior and posterior ventricular walls and the septum
- Have apices that are attached to the chordae tendineae
- Contract during systole and thereby tighten the chordae tendineae: prevent prolapse of valve leaflets and regurgitation into the atria when pressure rises during ventricular contraction
The tricuspid valve has three leaflets and is located on the right side, as is the three-lobed right lung. The bicuspid (mitral) valve has two leaflets and is located on the left side, as is the two-lobed left lung.
- Structure: three crescent-shaped cusps without subvalvular apparatus
- Pulmonary valve: located between right ventricle and pulmonary trunk
- Located between left ventricle and aorta
Consists of three leaflets and the aortic sinuses (a space immediately above the aortic valve, between an aortic valve leaflet and the wall of the ascending aorta)
- There are three aortic sinuses (one above each aortic leaflet): the left, right, and posterior aortic sinuses.
- The left and right aortic sinus give rise to the left and right coronary artery.
- The three aortic sinuses together with the aortic valve leaflets form a dilation of the root of the aorta called the aortic bulb.
- The left and right coronary arteries arise from the root of the aorta and supply the heart muscle with arterial blood.
- Coronary arterial dominance
- Coronary blood flow peaks during early diastole at a point when the pressure differential between the aorta and the ventricle is the greatest (see left ventricular pressure-volume diagram.)
|Left coronary artery (LCA)|
|Right coronary artery (RCA)|| || |
- Largest vein of the heart, into which all other coronary veins drain
- Lies in the left posterior atrioventricular groove
- Drains into the right atrium between the IVC orifice and the right atrioventricular orifice
- Veins draining into coronary sinus (coronary veins):
|Innervation of the heart|
|Somatic nervous system|| |
|Sympathetic nervous system|| |
|Parasympathetic nervous system|
Structures of cardiac conduction system
- Definition: collection of nodes and specialized conduction cells that initiate and coordinate contraction of the heart muscle.
- SA node): in the upper wall of the right atrium (at the junction where the SVC enters) (
- AV node): within the AV septum (superior and medial to the opening of the coronary sinus in the right atrium) (
- bundle of His): directly below the cardiac skeleton within the membranous part of the interventricular septum (
- myocytes): terminal conducting fibers in the subendocardium (modified
See ““ in ““ for more details.
Layers of the heart
- The heart wall itself consists of three layers (from inside to outside):
- Pericardium: membrane that directly surrounds the heart
Description: innermost layer of heart tissue, consisting of the following three sublayers:
- Endothelium (innermost): simple squamous epithelium
- A layer of loose connective tissue
- Subendocardium (outermost): loose connective tissue containing
Description: thick myocardial layer composed of the following:
Cardiomyocytes: striated muscle cells containing a single, centrally located nucleus
- Contain many mitochondria, which produce ATP for contraction.
- Myofibrils within cardiomyocytes are organized into (smallest functional contractile unit of cardiac muscle).
Connected by intercalated discs to form long fibers.
- Intercalated discs connect individual cardiomyocytes into a functional syncytium and force transmission during muscle contraction.
- They contain adherent junctions (transmit mechanical stimuli) and gap junctions (transmit electrical stimuli)
- They appear as slightly darker-staining lines between cardiac muscle cells under light microscopy and electron microscopy.
- See also ” ” in the article on .
- Atrial cardiomyocytes release atrial natriuretic peptide (ANP) when stretched (i.e., at higher BPs) → ↑ water and sodium excretion by the kidneys → ↓ BP
- Fibroblasts (these become myofibroblasts after injury)
- Extracellular matrix: collagen, elastin, and glycosaminoglycans
- Cardiomyocytes: striated muscle cells containing a single, centrally located nucleus
- Fibroserous sac enclosing the heart
- Defines the pericardial cavity
Serous pericardium (innermost)
- Visceral layer of serous pericardium (epicardium)
- Parietal layer of serous pericardium
- Fibrous pericardium (outermost)
- Serous pericardium (innermost)
- Pericardial cavity: space between the visceral and parietal layers of the serous pericardium that contains serous, pericardial fluid
- Innervation: innervated by the phrenic nerve
The capacity of the pericardial cavity is limited by the stiff, fibrous pericardium. If fluid abnormally accumulates in the pericardial space (pericardial effusion), intrapericardial pressure increases and may impair cardiac function → pericardial tamponade.
Microscopy of the heart valves
- Composed of connective tissue and endocardium
- Mostly vessel-free, with nutrition derived from the surrounding blood (This makes valvular involvement in endocarditis difficult to treat because both the cells of the immune system and antibiotics typically reach sites of infection via the circulatory system.)
- Mesodermal origin
Steps of heart development
- Two single endocardial tubes merge to form the heart tube.
- The straight heart tube transforms into an S-shaped heart loop.
- Endocardial cushions grow towards each other and fuse to separate the atria and ventricles.
- Two atria and two ventricles form and one common outflow tract divides into an aortic trunk and a pulmonary trunk.
- Valves form from the endocardial cushion.
- Fetal circulation is covered in the corresponding section of prenatal and postnatal physiology.
- Postnatal derivatives of fetal vascular structures are covered in the section on prenatal and postnatal physiology article. in the
|Overview of embryonic structures of the heart|
|Embryonic structures||Details||Give rise to|
Atrial septum, interventricular septum, and heart valves
A single cavity separated from the ventricular cavity by the endocardial cushion
|Trabeculated portions of the atria|
A single cavity separated from the atrial cavity by the endocardial cushion
|Trabeculated portions of ventricles|
Primitive pulmonary vein
|Smooth portion of the left atrium|
|Bulbus cordis||Left and right ventricular outflow tracts|
|Truncus arteriosus|| |
A single arterial trunk that originates from both ventricles of the embryonic heart
|Ascending aorta and pulmonary trunk|
|Inferior vena cava|
|Superior vena cava|
- Ectopia cordis
- See ““ and “ “ for associated heart defects.
Week 4 of gestation: looping of the primary heart tube establishes left-right polarity
- Development of the septum primum and foramen primum
- Narrowing of the foramen primum occurs as the septum primum grows towards the endocardial cushion.
- Development of the foramen secundum
- Development of the septum secundum
- Development of the foramen ovale cordis
Formation of the atrial septum (no further interatrial communication)
- occurs shortly after birth, when the left atrial pressure increases (due to loss of low resistance placental circulation) and the right atrial pressure decreases (due to increased pulmonary circulation upon lung inflation).
- The septum secundum completely fuses with the remnant of the septum primum to form the atrial septum during infancy.
If the septum primum and septum secundum fail to fuse after birth, a patent foramen ovale (PFO) remains. Later in life, a PFO can result in a paradoxical embolus, in which a venous thrombus may travel via the PFO from the venous to the arterial circulation and cause end-organ infarction (e.g., stroke).
- A caudally located muscular interventricular septum forms with an interventricular foramen between the two ventricles.
- The cranially developing aorticopulmonary septum rotates and caudally fuses with the muscular interventricular septum, and this fusion forms the membranous interventricular septum and closes the interventricular foramen (heart).
- Endocardial cushions grow to further separate the ventricles and the atria.
Development of the outflow tract
Sequence of events
- Development of the aorticopulmonary septum (AP septum)
- Division of the ventricular outflow tract
- Associated conotruncal abnormalities
|Overview of valve formation|
|Development of semilunar valves|| |
|Development of atrioventricular valves|| |
- Defective development of the heart valves can result in: