The Heart and the Circulatory System

by
Roger E. Phillips, Jr.
Assistant Director, Preserved Materials
Carolina Biological Supply Company
2700 York Road
Burlington, NC 27215-3398
The Anatomy of the Heart
The Pulmonary and Systemic Circuits and the Blood Supply to the Heart
The Blood Vessels
Circulatory Problems

The Anatomy of the Heart
From this point forward, all discussions about the heart and circulation refer to human
circulation. The human heart is a muscular pump. While most of the hollow organs of the
body do have muscular layers, the heart is almost entirely muscle. Unlike most of the other
hollow organs, whose muscle layers are composed of smooth muscle, the heart is composed
of cardiac muscle. All muscle types function by contraction, which causes the muscle cells to
shorten. Skeletal muscle cells, which make up most of the mass of the body, are voluntary and
contract when the brain sends signals telling them to react. The smooth muscle surrounding
the other hollow organs is involuntary, meaning it does not need to be told to contract.
Cardiac muscle is also involuntary. So functionally, cardiac muscle and smooth muscle are
similar. Anatomically though, cardiac muscle more closely resembles skeletal muscle. Both
skeletal muscle and cardiac muscle are striated. Under medium to high power magnification
through the microscope, you can see small stripes running crosswise in both types. Smooth
muscle is nonstriated. Cardiac muscle could almost be said to be a hybrid between skeletal
and smooth muscle. Cardiac muscle does have several unique features. Present in cardiac
muscle are intercalated discs, which are connections between two adjacent cardiac cells.
Intercalated discs help multiple cardiac muscle cells contract rapidly as a unit. This is
important for the heart to function properly. Cardiac muscle also can contract more
powerfully when it is stretched slightly. When the ventricles are filled, they are stretched
beyond their normal resting capacity. The result is a more powerful contraction, ensuring that
the maximum amount of blood can be forced from the ventricles and into the arteries with
each stroke. This is most noticeable during exercise, when the heart beats rapidly.
There are four chambers in the heart - two atria and two ventricles. The atria (one is called an
atrium) are responsible for receiving blood from the veins leading to the heart. When they
contract, they pump blood into the ventricles. However, the atria do not really have to work
that hard. Most of the blood in the atria will flow into the ventricles even if the atria fail to
contract. It is the ventricles that are the real workhorses, for they must force the blood away
from the heart with sufficient power to push the blood all the way back to the heart (this is
where the property of contracting with more force when stretched comes into play). The
muscle in the walls of the ventricles is much thicker than the atria. The walls of the heart are
really several spirally wrapped muscle layers. This spiral arrangement results in the blood
being wrung from the ventricles during contraction. Between the atria and the ventricles are
valves, overlapping layers of tissue that allow blood to flow only in one direction. Valves are
also present between the ventricles and the vessels leading from it.
Though the brain can cause the heart to speed up or slow drain, it does not control the regular
beating of the heart. As noted earlier, the heart is composed of involuntary muscle. The
muscle fibers of the heart are also self-excitatory. This means they can initiate contraction
themselves without receiving signals from the brain. This has been demonstrated many times
in high school classes of the past by removing the heart of a frog or turtle, and then
stimulating it to contract. The heart continues to beat with no further outside stimulus,
sometimes for hours if bathed in the proper solution. In addition, cardiac muscle fibers also
contract for a longer period of time than do skeletal muscles. This longer period of contraction
gives the blood time to flow out of the heart chambers.
The heart has two areas that initiate impulses, the SA or sinoatrial
node, and the AV or atrioventricular node. The heart also has special
muscle fibers called Purkinje fibers that conduct impulses five times
more rapidly than surrounding cells. The Purkinje fibers form a
pathway for conduction of the impulse that ensures that the heart
muscle cells contract in the most efficient pattern. The SA node is
located in the wall of the right atrium, near the junction of the atrium
and the superior vena cava. This special region of cardiac muscle
contracts on its own about 72 times per minute. In contrast, the
muscle in the rest of the atrium contracts on its own only 40 or so times per minute. The
muscle in the ventricles contracts on its own only 20 or so times per minute. Since the cells in
the SA node contract the most times per minute, and because cardiac muscle cells are
connected to each other by intercalated discs, the SA node is the pacemaker of the heart.
When the SA node initiates a contraction, Purkinje fibers rapidly conduct the impulse to
another site near the bottom of the right atrium and near the center of the heart. This region is
the AV node, and slows the impulse briefly. The impulse then travels to a large bundle of
Purkinje fibers called the Bundle of His, where they move quickly to the septum that divides
the two ventricles. Here, the Purkinje fibers run in two pathways toward the posterior apex of
the heart. At the apex, the paths turn in opposite directions, one running to the right ventricle,
and one running to the left. The result is that while the atria are contracting, the impulse is
carried quickly to the ventricles. With the AV node holding up the impulse just enough to let
the atria finish their contraction before the ventricles begin to contract, blood can fill the
ventricles. And, since the Purkinje fibers have carried the impulse to the apex of the ventricles
first, the contraction proceeds from the bottom of the ventricles to the top where the blood
leaves the ventricles through the pulmonary arteries and the aorta.
The contraction of the heart and its anatomy cause the
distinctive sounds heard when listening to the heart with a
stethoscope. The "lub-dub" sound is the sound of the valves
in the heart closing. When the atria end their contraction and
the ventricles begin to contract, the blood is forced back
against the valves between the atria and the ventricles,
causing the valves to close. This is the "lub" sound, and
signals the beginning of ventricular contraction , known as systole. The "dub" is the sound of

Opened heart

The cardiac cycle
the valves closing between the ventricles and their arteries, and signals the beginning of
ventricular relaxation, known as diastole.
A physician listening carefully to the heart can detect if the
valves are closing completely or not. Instead of a distinctive
valve sound, the physician may hear a swishing sound if they
are letting blood flow backward. When the swishing is heard
tells the physician where the leaky valve is located.

The Pulmonary and Systemic Circuits and the
Blood Supply to the Heart.
The heart is responsible for pumping the blood to every cell in the body. It is also responsible
for pumping blood to the lungs, where the blood gives up carbon dioxide and takes on
oxygen. The heart is able to pump blood to both regions efficiently because there are really
two separate circulatory circuits with the heart as the common link. Some authors even refer
to the heart as two separate hearts--a right heart in the pulmonary circuit and left heart in the
systemic circuit. In the pulmonary circuit, blood leaves the heart through the pulmonary
arteries, goes to the lungs, and returns to the heart through the pulmonary veins.
In the systemic circuit, blood leaves the heart through the aorta, goes
to all the organs of the body through the systemic arteries, and then
returns to the heart through the systemic veins. Thus there are two
circuits. Arteries always carry blood away from the heart and veins
always carry blood toward the heart. Most of the time, arteries carry
oxygenated blood and veins carry deoxygenated blood. There are
exceptions. The pulmonary arteries leaving the right ventricle for the
lungs carry deoxygenated blood and the pulmonary veins carry
oxygenated blood. If you are confused as to which way the blood
flows through the heart, try this saying "When it leaves the right, it comes right back, but
when it leaves the left, it's left." The blood does not have to travel as far when going from the
heart to the lungs as it does from the heart to the toes. It makes sense that the heart would be
larger on one side than on the other. When you look at a heart, you see that the right side of
the heart is distinctly smaller than the left side, and the left ventricle is the largest of the four
chambers.
While you might think the heart would have no problem getting enough oxygen-rich blood,
the heart is no different from any other organ. It must have its own source of oxygenated
blood. The heart is supplied by its own set of blood vessels. These are the coronary arteries.
There are two main ones with two major branches each. They arise from the aorta right after it
leaves the heart. The coronary arteries eventually branch into capillary beds that course
throughout the heart walls and supply the heart muscle with oxygenated blood. The coronary
veins return blood from the heart muscle, but instead of emptying into another larger vein,
they empty directly into the right atrium.
The Blood Vessels

Stethoscope placements (shade areas)
for hearing heart sounds

Arterial and Venous Systems
We need to briefly discuss the anatomy of the vessels. There are
three types of vessels - arteries, veins, and capillaries. Arteries, veins,
and capillaries are not anatomically the same. They are not just tubes
through which the blood flows. Both arteries and veins have layers of
smooth muscle surrounding them. Arteries have a much thicker
layer, and many more elastic fibers as well. The largest artery, the
aorta leaving the heart, also has cardiac muscle fibers in its walls for
the first few inches of its length immediately leaving the heart.
Arteries have to expand to accept the blood being forced into them
from the heart, and then squeeze this blood on to the veins when the heart relaxes. Arteries
have the property of elasticity, meaning that they can expand to accept a volume of blood,
then contract and squeeze back to their original size after the pressure is released. A good way
to think of them is like a balloon. When you blow into the balloon, it inflates to hold the air.
When you release the opening, the balloon squeezes the air back out. It is the elasticity of the
arteries that maintains the pressure on the blood when the heart relaxes, and keeps it flowing
forward. if the arteries did not have this property, your blood pressure would be more like
120/0, instead of the 120/80 that is more normal. Arteries branch into arterioles as they get
smaller. Arterioles eventually become capillaries, which are
very thin and branching.
Capillaries are really more like a web than a branched tube. It
is in the capillaries that the exchange between the blood and
the cells of the body takes place. Here the blood releases its
oxygen and takes on carbon dioxide, except in the lungs,
where the blood picks up oxygen and releases carbon
dioxide. In the special capillaries of the kidneys, the blood
gives up many waste products in the formation of urine.
Capillary beds are also the sites where white blood cells are able to leave the blood and
defend the body against harmful invaders. Capillaries are so small that when you look at
blood flowing through them under a microscope, the cells have to pass through in single file.
As the capillaries begin to thicken and merge, they become venules. Venules eventually
become veins and head back to the heart. Veins do not have as many elastic fibers as arteries.
Veins do have valves, which keep the blood from pooling and flowing back to the legs under
the influence of gravity. When these valves break down, as often happens in older or inactive
people, the blood does flow back and pool in the legs. The result is varicose veins, which
often appear as large purplish tubes in the lower legs.
Circulatory Problems
No discussion of the circulatory system would be complete without mentioning some of the
problems that can occur. As mentioned earlier, several problems can occur with the valves of
the heart. Valvular stenosis is the result of diseases such as rheumatic fever, which causes the
opening through the valve to become so narrow that blood can flow through only with
difficulty. The result can be blood damming up behind the valve. Valvular regurgitation
occurs when the valves become so worn that they cannot close completely, and blood flows
back into the atria or the ventricles. If the blood can flow backward, the efficiency of the
cardiac stroke is drastically reduced.

Blood vessel anatomy

Capillary Bed
The coronary arteries are also subject to
problems. Atherosclerosis is a degenerative
disease that results in narrowing of the
coronary arteries. This is caused by fatty
deposits, most notably cholesterol, on the
interior walls of the coronary arteries. When
the walls become narrowed or occluded, they
reduce the blood flow to the heart muscle. If the artery remains open to some degree, the
reduced blood flow is noticed when the heart is under stress during periods of rapid heartbeat.
The resulting pain is called angina. When the artery is completely closed or occluded, a
section of the heart muscle can no longer get oxygenated blood, and begins to die. This is
called a heart attack. Only quickly restoring the blood flow can reduce the amount of heart
muscle that will die. At times, the walls of the systemic arteries become weakened. When this
occurs, the wall may balloon outward, much like a weak spot in the radiator hose. This called
an aneurysm, and is an extremely dangerous condition. Like a radiator hose under pressure,
the wall can rupture. Blood can then spill out of the circulatory system into the body cavity. If
an aneurysm ruptures in the aorta, death is almost certain.
The systemic veins also can have problems. When the valves in the veins break down, blood
can pool in the lower legs, causing varicose veins. Clots can also form in veins of the legs.
These clots can break loose and flow to the lungs, causing a pulmonary embolism and
possible death.
The capillary beds are not without their problems. True capillaries do not have any smooth
muscle in their walls. They have no way to control excess pressure other than a small muscle,
the precapillary sphincter. A precapillary sphincter encircles each capillary branch at the point
where it branches from the arteriole. Contraction of the precapillary sphincter can close the
branches off to blood flow. If the sphincter is damaged or can not contract, blood can flow
into the capillary bed at high pressures. When capillary pressures are high (and this can be the
result of gravity), fluid passes out of the capillaries into the interstitial space, and edema or
fluid swelling is the result. This can be seen in people who have to stand all day. Their feet
and ankles often swell from the excess fluid accumulating there. Capillaries are fragile and
can be damaged easily. It is often ruptured capillaries in the skin that cause bruises when one
falls or sustains a blow.
Since the advent of modern medical research, physicians have made quantum leaps in their
understanding of the heart and in ways to treat cardiovascular disorders. When we hear of
breakthroughs in cardiac medicine, we often think of radical treatments such as heart
transplants or artificial hearts. The first heart transplant took place in 1967. It was performed
by the South African surgeon Dr. Christiaan Barnard. The patient lived just 18 days. The first
U.S. transplant took place in 1968. The rate of transplants increased in the 1970's, but most
patients died within a year. The drugs given to fight rejection of the heart also lowered the
body's resistance to infections. It was these infections that often killed the patients. Then, in
the 1980's physicians began using the drug cyclosporine to fight rejection. Patients taking
cyclosporine had a much greater rate of survival. In 1982, the first artificial heart was
implanted into Barney Clark by the American surgeon Dr. William DeVries. Due to
complications, Clark lived only 112 days. As of this writing, the use of the artificial heart is
not approved in the United States. While these two methods both sound less than successful,
you must remember that they are last resort treatments. They are not typical of the success
rates that other, more common, treatments have enjoyed.

Stained Cross sections through coronary artery (left) and
a coronary atery with lipid deposits in its walls (right).
Most cardiovascular emergencies are directly caused by coronary artery disease. As noted
earlier, coronary arteries can become clogged or occluded, leading to damage to the heart
muscle supplied by the artery. There are three methods for treating coronary artery disease.
They may be used individually or in combination with the each other. Medication can be
given to control the blood flow to the heart. This is not always effective. Another method,
coronary bypass surgery, involves replacing a blocked coronary artery with either a vein from
the leg or with a thoracic artery from the chest wall. This method requires that the patient's
chest be opened. The heart must be stopped, then restarted after the new vessels are
connected. Another technique, although not new (it was first performed in 1977 by a Swiss
physician), is a highly successful treatment called percutaneous transluminal coronary
angioplasty, or balloon angioplasty by most laypersons. In this procedure, the patient remains
awake. Under local anesthesia, tubes called catheters are inserted into an artery and vein in the
groin. Next, a tiny, flexible guide wire is maneuvered through the arteries, eventually passing
through the narrowed opening in the occluded coronary artery. Next, another catheter with a
balloon near the end is run along the guide wire. When the balloon is in place, it is inflated
and deflated several times, enlarging the opening of the artery and increasing the blood flow.
When the surgeon is satisfied with the size of the opening, the catheters are removed. The
patient remains in the hospital for a few days, but can resume normal activities in a matter of
weeks. Other current cardiovascular research involves drugs that control the blood pressure or
heart rate, artificial blood substitutes, and devices implanted in the wall of the heart that can
detect changes in the rate or patterns of contraction of the ventricles and correct them before a
heart attack occurs.
Modem cardiovascular medicine and our understanding of the heart and
circulation have certainly come a long way since the days of Pliny, Galen,
and Harvey. While we jest about broken hearts in romances, or having the
heart needed to work hard to win an event, we all know that the heart and the
circulatory system are not related to emotions, the soul, or intellect. Without
the four-chambered heart and double circuit circulatory system, mammals
would not have been able to successfully evolve, for this type of circulation
gave rise to the warm-bloodedness needed to out compete the slower responding reptiles. Our
own circulatory system has evolved to feed large amounts of blood to our brains, letting the
brain develop and evolve into the organ it is today. Modern medical research on the heart has
changed the face of the future. Advances in cardiovascular surgery and cardiac care have
given thousands of people the opportunity to live on after the attack of disease, often for
decades. What once would have killed can now be not only survived, but even prevented. All
because an English physician in the 1600's decided that maybe everything was not as he had
been taught, and had the "heart" to try something different.


Stephen Hales