Created by CK-12 Foundation/Adapted by Christine Miller

Lub dub, lub dub, lub dub… That’s how the sound of a beating heart is typically described. Those are also the only two sounds that should be audible when listening to a normal, healthy heart through a stethoscope, as in Figure 14.3.1.  If a doctor hears something different from the normal lub dub sounds, it’s a sign of a possible heart abnormality. What causes the heart to produce the characteristic lub dub sounds? Read on to find out.

The heart is a muscular organ behind the sternum (breastbone), slightly to the left of the center of the chest. A normal adult heart is about the size of a fist. The function of the heart is to pump blood through blood vessels of the cardiovascular system. The continuous flow of blood through the system is necessary to provide all the cells of the body with oxygen and nutrients, and to remove their metabolic wastes.

The heart has a thick muscular wall that consists of several layers of tissue. Internally, the heart is divided into four chambers through which blood flows. Because of heart valves, blood flows in just one direction through the chambers.

Heart Wall

As shown in Figure 14.3.2, the wall of the heart is made up of three layers, called the endocardium, myocardium, and pericardium.

• The endocardium is the innermost layer of the heart wall. It is made up primarily of simple epithelial cells. It covers the heart chambers and valves. A thin layer of connective tissue joins the endocardium to the myocardium.
• The myocardium is the middle and thickest layer of the heart wall. It consists of cardiac muscle surrounded by a framework of collagen. There are two types of cardiac muscle cells in the myocardium: cardiomyocytes — which have the ability to contract easily — and pacemaker cells, which conduct electrical impulses that cause the cardiomyocytes to contract. About 99 per cent of cardiac muscle cells are cardiomyocytes, and the remaining one per cent is pacemaker cells. The myocardium is supplied with blood vessels and nerve fibres via the pericardium.
• The pericardium is a protective sac that encloses and protects the heart. The pericardium consists of two membranes (visceral pericardium and parietal pericardium), between which there is a fluid-filled cavity. The fluid helps to cushion the heart, and also lubricates its outer surface.

Heart Chambers

As shown in Figure 14.3.3 the four chambers of the heart include two upper chambers called atria (singular, atrium), and two lower chambers called ventricles. The atria are also referred to as receiving chambers, because blood coming into the heart first enters these two chambers. The right atrium receives deoxygenated blood from the upper and lower body through the superior vena cava and inferior vena cava, respectively. The left atrium receives oxygenated blood from the lungs through the pulmonary veins. The ventricles are also referred to as discharging chambers, because blood leaving the heart passes out through these two chambers. The right ventricle discharges blood to the lungs through the pulmonary artery, and the left ventricle discharges blood to the rest of the body through the aorta. The four chambers are separated from each other by dense connective tissue consisting mainly of collagen.

Heart Valves

Figure 14.3.4 shows the location of the heart’s four valves in a top-down view, looking down at the heart as if the arteries and veins feeding into and out of the heart were removed. The heart valves allow blood to flow from the atria to the ventricles, and from the ventricles to the pulmonary artery and aorta. The valves are constructed in such a way that blood can flow through them in only one direction, thus preventing the backflow of blood. Figure 14.3.5 shows how valves open to let blood into the appropriate chamber, and then close to prevent blood from moving in the wrong direction and the next chamber contracts.  The four valves are the:

1. Tricuspid atrioventricular valve, (can be shortened to tricuspid AV valve) which allows blood to flow from the right atrium to the right ventricle.
2. Bicuspid atrioventricular valve (also know as the mitral valve), which allows blood to flow from the left atrium to the left ventricle.
3. Pulmonary semilunar valve, which allows blood to flow from the right ventricle to the pulmonary artery.
4. Aortic semilunar valve, which allows blood to flow from the left ventricle to the aorta.

The two atrioventricular (AV) valves prevent backflow when the ventricles are contracting, while the semilunar valves prevent backflow from vessels.  This means that the AV valves must withstand much more pressure than do the semilunar valves.  In order to withstand the force of the ventricles contracting (to prevent blood from backflowing into the atria), the AV valves are reinforced with structures called chordae tendineae — tendon-like cords of connective tissue which anchor the valve and prevent it from prolapse.  Figure 14.3.6 shows the structure and location of the chordae tendoneae.

The chordae tendoneae are under such force that they need special attachments to the interior of the ventricles where they anchor.  Papillary muscles are specialized muscles in the interior of the ventricle that provide a strong anchor point for the chordae tendineae.

Coronary Circulation

The cardiomyocytes of the muscular walls of the heart are very active cells, because they are responsible for the constant beating of the heart. These cells need a continuous supply of oxygen and nutrients. The carbon dioxide and waste products they produce also must be continuously removed. The blood vessels that carry blood to and from the heart muscle cells make up the coronary circulation. Note that the blood vessels of the coronary circulation supply heart tissues with blood, and are different from the blood vessels that carry blood to and from the chambers of the heart as part of the general circulation. Coronary arteries supply oxygen-rich blood to the heart muscle cells. Coronary veins remove deoxygenated blood from the heart muscles cells.

• There are two coronary arteries — a right coronary artery that supplies the right side of the heart, and a left coronary artery that supplies the left side of the heart. These arteries branch repeatedly into smaller and smaller arteries and finally into capillaries, which exchange gases, nutrients, and waste products with cardiomyocytes.
• At the back of the heart, small cardiac veins drain into larger veins, and finally into the great cardiac vein, which empties into the right atrium. At the front of the heart, small cardiac veins drain directly into the right atrium.

Figure 14.3.7 shows how blood circulates through the chambers of the heart. The right atrium collects blood from two large veins, the superior vena cava (from the upper body) and the inferior vena cava (from the lower body). The blood that collects in the right atrium is pumped through the tricuspid valve into the right ventricle. From the right ventricle, the blood is pumped through the pulmonary valve into the pulmonary artery. The pulmonary artery carries the blood to the lungs, where it enters the pulmonary circulation, gives up carbon dioxide, and picks up oxygen. The oxygenated blood travels back from the lungs through the pulmonary veins (of which there are four), and enters the left atrium of the heart. From the left atrium, the blood is pumped through the mitral valve into the left ventricle. From the left ventricle, the blood is pumped through the aortic valve into the aorta, which subsequently branches into smaller arteries that carry the blood throughout the rest of the body. After passing through capillaries and exchanging substances with cells, the blood returns to the right atrium via the superior vena cava and inferior vena cava, and the process begins anew.

The cardiac cycle refers to a single complete heartbeat, which includes one iteration of the lub and dub sounds heard through a stethoscope. During the cardiac cycle, the atria and ventricles work in a coordinated fashion so that blood is pumped efficiently through and out of the heart. The cardiac cycle includes two parts, called diastole and systole, which are illustrated in the diagrams in Figure 14.3.8.

• During diastole, the atria contract and pump blood into the ventricles, while the ventricles relax and fill with blood from the atria.
• During systole, the atria relax and collect blood from the lungs and body, while the ventricles contract and pump blood out of the heart.

Electrical Stimulation of the Heart

The normal, rhythmical beating of the heart is called sinus rhythm. It is established by the heart’s pacemaker cells, which are located in an area of the heart called the sinoatrial node (shown in Figure 14.3.9). The pacemaker cells create electrical signals with the movement of electrolytes (sodium, potassium, and calcium ions) into and out of the cells. For each cardiac cycle, an electrical signal rapidly travels first from the sinoatrial node, to the right and left atria so they contract together. Then, the signal travels to another node, called the atrioventricular node (Figure 14.3.9), and from there to the right and left ventricles (which also contract together), just a split second after the atria contract.

The normal sinus rhythm of the heart is influenced by the autonomic nervous system through sympathetic and parasympathetic nerves. These nerves arise from two paired cardiovascular centers in the medulla of the brainstem. The parasympathetic nerves act to decrease the heart rate, and the sympathetic nerves act to increase the heart rate. Parasympathetic input normally predominates. Without it, the pacemaker cells of the heart would generate a resting heart rate of about 100 beats per minute, instead of a normal resting heart rate of about 72 beats per minute. The cardiovascular centers receive input from receptors throughout the body, and act through the sympathetic nerves to increase the heart rate, as needed. Increased physical activity, for example, is detected by receptors in muscles, joints, and tendons. These receptors send nerve impulses to the cardiovascular centers, causing sympathetic nerves to increase the heart rate, and allowing more blood to flow to the muscles.

Besides the autonomic nervous system, other factors can also affect the heart rate. For example, thyroid hormones and adrenal hormones (such as epinephrine) can stimulate the heart to beat faster. The heart rate also increases when blood pressure drops or the body is dehydrated or overheated. On the other hand, cooling of the body and relaxation — among other factors — can contribute to a decrease in the heart rate.

When a patient’s heart is too diseased or damaged to sustain life, a heart transplant is likely to be the only long-term solution. The first successful heart transplant was undertaken in South Africa in 1967. There are over 2,200 Canadians walking around today because of life-saving heart transplant surgery.  Approximately 180 heart transplant surgeries are performed each year, but there are still so many Canadians on the transplant list that some die while waiting for a heart. The problem is that far too few hearts are available for transplant — there is more demand (people waiting for a heart transplant) than supply (organ donors). Sometimes, recipient hopefuls will receive a device called a Total Artificial Heart (see Figure 14.3.10), which can buy them some time until a donor heart becomes available.

Watch the video below “Total artificial heart option…” from Stanford Health Care to see how it works:

Total artificial heart option at Stanford (Includes surgical graphic footage), Stanford Health Care, 2014.

Attributions

Figure 14.3.1

• Female clinician dressed in scrubs using a stethoscope by Amanda Mills, USCDCP, on Pixnio is used under a CC0 public domain certification license (https://creativecommons.org/licenses/publicdomain/).
• Human heart beating loud and strong (audio) by Daniel Simion on Soundbible.com is used under a CC BY 3.0 (https://creativecommons.org/licenses/by/3.0) license.

Figure 14.3.2

Blausen_0470_HeartWall by BruceBlaus on Wikimedia Commons is used under a CC BY 3.0 (https://creativecommons.org/licenses/by/3.0) license.

Figure 14.3.3

Diagram_of_the_human_heart_(cropped).svg by Wapcaplet on Wikimedia Commons is used under a CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0/) license.

Figure 14.3.4

Heart_Valves by OpenStax College on Wikimedia Commons is used under a CC BY 3.0 (https://creativecommons.org/licenses/by/3.0) license.

Figure 14.3.5

CG_Heart Valve Animation by DrJanaOfficial on Wikimedia Commons is used under a CC BY-SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0) license.

Figure 14.3.6

Heart_tee_four_chamber_view by Patrick J. Lynch, medical illustrator from Yale University School of Medicine, on Wikimedia Commons is used under a CC BY 2.5 (https://creativecommons.org/licenses/by/2.5) license.

Figure 14.3.7

Circulation of blood through the heart by Christinelmiller on Wikimedia Commons is used under a CC BY-SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0) license. [Original image in the bottom right is by Wapcaplet / CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0/)]

Figure 14.3.8

Human_healthy_pumping_heart_en.svg by Mariana Ruiz Villarreal [LadyofHats] on Wikimedia Common is released into the public domain (https://en.wikipedia.org/wiki/Public_domain).

Figure 14.3.9

Cardiac_Conduction_System by Cypressvine on Wikimedia Commons is used under a CC BY-SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0) license.

References

Betts, J. G., Young, K.A., Wise, J.A., Johnson, E., Poe, B., Kruse, D.H., Korol, O., Johnson, J.E., Womble, M., DeSaix, P. (2013, June 19). Figure 19.12 Heart valves with the atria and major vessels removed [digital image].  In Anatomy and Physiology (Section 19.1). OpenStax. https://openstax.org/books/anatomy-and-physiology/pages/19-1-heart-anatomy#fig-ch20_01_04

Blausen.com Staff. (2014). Medical gallery of Blausen Medical 2014. WikiJournal of Medicine 1 (2). DOI:10.15347/wjm/2014.010. ISSN 2002-4436.

Heart and Stroke Foundation of Canada. (n.d.). https://www.heartandstroke.ca/

Sliwa, K., Zilla, P. (2017, December 7). 50th anniversary of the first human heart transplant—How is it seen today? European Heart Journal, 38(46):3402–3404. https://doi.org/10.1093/eurheartj/ehx695

Stanford Health Care. (2014, December 3). Total artificial heart option at Stanford (Includes surgical graphic footage). YouTube. https://www.youtube.com/watch?v=1PtxaxcPnGc&feature=youtu.be

TED. (2012, March 21). Noel Bairey Merz: The single biggest health threat women face. YouTube. https://www.youtube.com/watch?v=1bnzVjOJ6NM&feature=youtu.be

TEDx Talks. (2018, April 18). A change of heart: My transplant experience | Thomas Volk | TEDxUWLaCrosse. YouTube. https://www.youtube.com/watch?v=zU6mmix04PI&feature=youtu.be

UMagazine. (2015, Fall). The cutting edge: Patient first to bridge from experimental total artificial heart to transplant. UCLA Health. https://www.uclahealth.org/u-magazine/patient-first-to-bridge-from-experimental-total-artificial-heart-to-transplant

UnityPoint Health – Cedar Rapids. (2018, February 7). Watch a transcatheter aortic valve replacement (TAVR) Procedure at St. Luke’s in Cedar Rapids, Iowa. YouTube.  https://www.youtube.com/watch?v=jJm7zBcN6-M&feature=youtu.be

WMC Health. (2018, September 13). Heart transplant recipient meets donor family for the first time. YouTube. https://www.youtube.com/watch?v=biGuwQhuAsk&feature=youtu.be