CHAPTER 4

1.1 Cardiology Bundle of His

Cardiology is an exciting and highly competitive branch of medicine which is concerned with the The bundle of His is a structure that connects with the distal part of the compact AV node, perforates the central
identification,assessment and management of diseases affecting the heart and blood vessels. Therefore, an in-depth fibrous body, and continues through the annulusfibrosus, where it is called the nonbranching portion as it penetrates
knowledge of the pathological processes and cardiovascular physiology and pharmacology are required for those the membranous septum. Connective tissue of the central fibrous body and membranous septum encloses the
wishing to proceed in this rapidly evolving speciality. Cardiology is at the very forefront of cutting-edge research. This penetrating portion of the AV bundle, which may send out extensions into the central fibrous body. Proximal cells of
is especially true for interventional cardiologists where increasing numbers of new techniques are becoming available the penetrating portion are heterogeneous and resemble those of the compact AV node; distal cells are similar to
for the treatment of cardiac diseases, such as coronary artery stenting and percutaneous valve replacement. cells in the proximal bundle branches.

The simplest way to describe the heart is as a "pump". The role the heart plays in the cardiovascular system is similar
to the role played by the pump in your central heating system. The heart pumps blood through the arteries and veins
to organs, muscles and tissue, just as the central heating pump forces hot water through the pipes to the radiators.
Branches from the anterior and posterior descending coronary arteries supply the upper muscular interventricular
septum with blood, which makes the conduction system at this site more impervious to the ischemic damage, unless
1:2 Anatomy and Physiology of the Heart the ischemia is extensive.

The Cardiovascular System is made up of : heart; lungs; arteries and veins, and it is under the control of the BUNDLE BRANCHES
autonomic nervous system (sympathetic and parasympathetic). In a healthy individual with a healthy heart, heart rate
is dictated by the body's needs. If an individual is resting then organs, muscles and tissues require a reduced amount
The bundle branches originate at the superior margin of the muscular interventricular septum, immediately below the
of blood and oxygen. The result of this is a reduction in blood pressure and a slowing down of heart rate and
membranous septum, with the cells of the left bundle branch cascading downward as a continuous sheet onto the
respirations.
septum beneath the noncoronary aortic cusp.

When the individual becomes active then the organs, muscles and tissues require an increasing amount of blood and
The right bundle branch
oxygen, resulting in raised blood pressure and an increase in heart rate and respirations. These responses are all
involuntary, under the direct control of the autonomic nervous system.
continucs intramyocardially as an unbranched extension of the AV bundle down the right side of the interventricular
septum to the apex of the right ventricle and base of the anterior papillary muscle. The anatomy of the left bundle
The heart itself is made up of 4 chamber, 2 atria and 2 ventricles, De-ocygenated blood returns to the rightside of
branch system may be variable and may not conform to a constant bifascicular division. However, for clinical
the heart via the venous circulation. It is pumped into the right ventricle and then to the lungs where carbon dioxide
purposes and electrocardiography (ECG), the concept of a trifascicular system remains useful.
is released and oxygen is absorbed. The oxygenated blood then travels back to the left side of the heart into the left
atria, then into the left ventricle from where it is pumped into the aorta and arterial circulation.
TERMINAL PURKINJE
The pressure created in the arteries by the contraction of the left ventricle is the systolic blood pressure. Once the
left ventricle has fully contracted it begins to relax and refill with blood from the left atria. The pressure in the arteries The terminal Purkinje fibers connect with the ends of the bundle branches to form interweaving networks on the
falls whilst the ventricle refills. This is the diastolic blood pressure. endocardial surface of both ventricles, which transmit the cardiac impulse almost simultaneously to the entire right
and left ventricular endocardium. Purkinje fibers tend to be less concentrated at the base of the ventricle and the
papillary muscle tips. They penetrate only the inner third of the endocardium. Purkinje fibers appear to be more
The atrio-ventricular septum completely separates the 2 sides of the heart. Unless there is septal defect ; the 2 sides
resistant to ischemia than ordinary myocardial fibers.
of the heart never directly communicate. Blood thavels from right side to left side via the lungs only. However the
chambers themselves work together . The 2 atria contract Simultaneously and the 2 ventricles contract
simultaneously.

CHAPTER 5

1.1 Cardiac Conduction System

The cardiac conduction system is a group of specialized cardiac muscle cells in the walls of the heart that send signals
to the heart muscle causing it to contract. The main components of the cardiac conduction system are the SA node,
AV node, bundle of His, bundle branches, and Purkinje fibers. The SA node (anatomical pacemaker) starts the
sequence by causing the atrial muscles to contract. From there, the signal travels to the AV node, through the bundle
of His, down the bundle branches, and through the Purkinjc fibers, causing the ventricles to contract. This signal
creates an electrical current that can be seen on a graph called an Electrocardiogram (EKG or ECG). Doctors use an
EKG to monitor the cardiac conduction system's electrical activity in the heart.

Atrioventricular node

The compact portion of the atrioventricular (AV) node is a superficial structure located just beneath the RA
endocardium, anterior to the ostium of the coronary sinus, and directly above the insertion of the septal leaflet of the
tricuspid valve. It is at the apex of a triangle formed by the tricuspid annulus and the tendon of Todaro, which
originates in the central fibrous body and passes posteriorly through the atrial septum to continue with the
Eustachian valve.

Sinoatrial Node

The sinoatrial (SA) node is a spindle- shaped structure composed of a fibrous tissue matrix with closely packed cells. It
is 10-20 mm long, 2-3 mm wide, and thick, tending to narrow caudally toward the inferior vena cava (1vc). The SA
node is located less than 1 mm from the epicardial surface, laterally in the right atrial sulcus terminalis at the junction
of the anteromedial aspect of the superior vena cava (SvC) and the right atrium (RA).

The artery supplying the sinus node branches from the right coronary artery in 55-60% of hearts or the left circumflex
artery in 40-45% of hearts. The artery approaches the node from a clockwise or counterclockwise direction around
the svc-RA junction.

The SA node is densely innervated with postganglionic adrenergic and cholinergic nerve terminals. Neurotransmitters
modulate the SA node discharge rate by stimulation of beta-adrenergic and muscarinic receptors. Both beta; and
beta,adrenoceptors subtypes are present in the SA node. The human SA node contains a more than 3-fold greater
density of beta-adrenergic and muscarinic cholinergic receptors than the adjacent atrial tissue.