Table Of ContentHandbook of Cardiac Anatomy, Physiology,
and Devices
Paul A. Iaizzo
Editor
Handbook of Cardiac
Anatomy, Physiology,
and Devices
Second Edition
Foreword by Timothy G. Laske
1 3
Editor
Paul A. Iaizzo
University of Minnesota
Department of Surgery
B172 Mayo, MMC 195
420 Delaware St. SE.,
Minneapolis, MN 55455
USA
Foreword
A revolution began in my professional career and education in 1997. In that year, I visited
the University of Minnesota to discuss collaborative opportunities in cardiac anatomy,
physiology, and medical device testing. The meeting was with a faculty member of the
Department of Anesthesiology, Professor Paul Iaizzo. I didn’t know what to expect but,
as always, I remained open minded and optimistic. Little did I know that my life would
never be the same. . . .
During the mid to late 1990s, Paul Iaizzo and his team were performing anesthesia
research on isolated guinea pig hearts. We found the work appealing, but it was unclear
how this research might apply to our interest in tools to aid in the design of implantable
devices for the cardiovascular system. As discussions progressed, we noted that we would
be far more interested in reanimation of large mammalian hearts, in particular, human
hearts. Paul was confident this could be accomplished on large hearts, but thought that it
would be unlikely that we would ever have access to human hearts for this application.We
shook hands and the collaboration was born in 1997. In the same year, Paul and the
research team at theUniversity ofMinnesota (including Bill Gallagher and Charles Soule)
reanimated several swine hearts. Unlike the previous work on guinea pig hearts which
were reanimated in Langendorff mode, the intention of this research was to produce a
fully functional working heart model for device testing and cardiac research. Such amodel
would allow engineers and scientists easy access to the epicardium and the chambers
through transmural ports. It took numerous attempts to achieve the correct osmotic
balance and an adequately oxygenated perfusate, and to avoid poisoning the preparation
with bacteria (which we found were happy to lurk anywhere and everywhere in the
plumbing of the apparatus). This project required a combination of art, science, and
dogged persistence.
In addition to the breakthrough achieved in the successful animation of numerous
swine hearts, bigger and better things were in store. Serendipitously, when faced with a
need to see inside the heart, the research team found a fiberoptic scope on an upper shelf in
the laboratory. The scope was inserted into the heart and a whole new world was
observed. Due to the clear nature of the perfusate, we immediately saw the flashing of
the tricuspid valve upon insertion of the scope. We were in awe as we viewed the first
images ever recorded inside of a working heart. This is the moment when my personal
revolution began.
The years that have followed have included numerous achievements which I attribute
to the vision and persistence of Paul and the team. The human hearts that Paul initially
considered impossible to access and reanimate were soon functioning in the apparatus due
to a collaboration with LifeSource. Indeed, the team’s ‘‘never say never’’ attitude is at the
heart of their pursuit of excellence in education and research.
v
vi Foreword
The Visible Heart Laboratory has evolved into a dream for engineers, educators, and
cardiac physiologists as scientific equipment has been added (echocardiography, electrical
mapping systems, hemodynamic monitors, etc.) and endoscopic video capabilities have
improved (the lab is currently using video endoscopes with media quality recording
equipment). The lab produces educational images, conducts a wide spectrum of cardiac
research, and evaluates current and future medical device concepts each week. Hundreds
of engineers and students have worked and studied in the lab, countless physicians have
assisted with procedures, and thousands of educational CDs/DVDs have been distributed
(free of charge).
Eleven years after the beginning of our collaborative effort, the Visible Heart Labora-
tory remains the only place in the world where a human heart can be reanimated outside of
the body and made to work for an extended period of time. This is a tribute to the efforts
of Paul and his team in managing the difficulty it takes to make this happen. Interestingly,
the team currently works in the laboratory in which Lillehei and Bakken first tested the
battery-powered pacemaker; the ‘‘good karma’’ lives on.
This book is a result of Paul’s passion for excellence in teaching and for innovation in
the medical device field. I am confident that the reader will find this book an invaluable
resource. It is a testament to Paul’s dedication to both education, collaboration, and the
ongoing development of his current and past students.
By the way. . . . The personal revolution I referred to, fueled by my collaboration with
Paul, has included numerous patents, countless device concepts accepted and/or rejected,
several scientific articles, a PhD in Biomedical Engineering, and a collaboration in black
bear hibernation physiology. None of this would have happened had I not met Paul that
day in 1997, and benefited from his friendship and mentoring over the years. I can only
imagine what the future will bring, but you can be rest assured that success is sure to come
to those that associate themselves with Paul Iaizzo.
Minneapolis, MN Timothy G. Laske, Ph. D.
Preface
Worldwide, the medical device industry continues to grow at an incredibly rapid pace.
Our overall understanding of the molecular basis of disease continues to increase, in
addition to the number of available therapies to treat specific health problems. This
remains particularly true in the field of cardiovascular care. Hence, with this rapid growth
rate, the biomedical engineer has been challenged to both retool and continue to seek out
sources of concise information.
The major impetus for the second edition of this text was to update this resource
textbook for interested students, residents, and/or practicing biomedical engineers. A
secondary motivation was to promote the expertise, past and present, in the area of
cardiovascular sciences at the University of Minnesota. As Director of Education for
The Lillehei Heart Institute and the Associate Director for Education of the Institute for
Engineering in Medicine at the University of Minnesota, I feel that this book also
represents a unique outreach opportunity to carry on the legacies of C. Walton Lillehei
and Earl Bakken through the 21st century. Interestingly, the completion of the textbook
also coincides with two important anniversaries in cardiovascular medicine and engineer-
ing at the University of Minnesota. First, it was 50 years ago, in 1958, that the first
wearable, battery-powered pacemaker, built by Earl Bakken (and Medtronic) at the
request of Dr. Lillehei, was first used on a patient. Second, 30 years ago, in 1978, the
first human heart transplantation was performed at the University of Minnesota.
For the past 10 years, the University of Minnesota has presented the week-long short
course, Advanced Cardiac Physiology and Anatomy, which was designed specifically for
the biomedical engineer working in industry; this is the course textbook. As this course has
evolved, there was a need to update the textbook. For example, six new chapters were
added to this second edition, and all other chapters were either carefully updated and/or
greatly expanded. One last historical note that I feel is interesting to mention is that my
1
current laboratory, where isolated heart studies are performed weekly (the Visible Heart
laboratory), is the same laboratory in which C. Walton Lillehei and his many esteemed
colleagues conducted a majority of their cardiovascular research studies in the late 1950s
and early 1960s.
As with the first edition of this book, I have included electronic files on the companion
DVD thatwill enhance this textbook’s utility. Part of the companionDVD, the ‘‘TheVisible
1
Heart Viewer,’’ was developed as a joint venture between my laboratory at the Uni-
versity of Minnesota and the Cardiac Rhythm Management Division at Medtronic, Inc.
Importantly, this electronic textbook also includes functional images of human hearts.
These images were obtained from hearts made available via LifeSource, more specifically
through the generosity of families and individuals whomade the final gift of organ donation
(these hearts were not deemed viable for transplantation). Furthermore, the companion
vii
viii Preface
DVD contains various additional color images and movies that were provided by the
various authors to supplement their chapters. Since the first printing of this textbook,
my laboratory has also developed the free-access website, ‘‘The Atlas of Human Cardiac
Anatomy,’’ that readers of this text should also find valuable as a complementary resource
(http://www.vhlab.umn.edu/atlas).
I would especially like to acknowledge the exceptional efforts of our lab coordinator,
Monica Mahre, who for a second time: (1) assisted me in coordinating the efforts of the
contributing authors; (2) skillfully incorporated my editorial changes; (3) verified the
readability and formatting of each chapter; (4) pursued requested additions or missing
materials for each chapter; (5) contributed as a co-author; and (6) kept a positive outlook
throughout. I would also like to thank Gary Williams for his computer expertise and
assistance with numerous figures; William Gallagher and Charles Soule who made sure
the laboratory kept running smoothly while many of us were busy writing or editing; Dick
Bianco for his support of our lab and this book project; the chairman of the Department
of Surgery, Dr. Selwyn Vickers, for his support and encouragement; and the Institute for
Engineering in Medicine at the University of Minnesota, headed by Dr. Jeffrey McCul-
lough, who supported this project by funding the Cardiovascular Physiology Interest
Group (many group members contributed chapters).
1
I would like to thankMedtronic, Inc. for their continued support of the Visible Heart
Laboratory for the past 12 years, and I especially acknowledge the commitments, partner-
ships, and friendships of Drs. Tim Laske, Alex Hill, and Nick Skadsberg for making our
collaborative research possible. In addition, I would like to thank Jilean Welch and Mike
Leners for their creative efforts in producing many of the movie and animation clips that
are on the DVD.
It is also my pleasure to thank the past and present graduate students or residents who
have worked inmy laboratory and whowere contributors to this second edition, including
Sara Anderson, James Coles, Anthony Dupre, Michael Eggen, Kevin Fitzgerald, Alex-
ander Hill, Jason Johnson, Ryan Lahm, Timothy Laske, Anna Legreid Dopp, Michael
Loushin, Jason Quill, Maneesh Shrivastav, Daniel Sigg, Eric Richardson, Nicholas
Skadsberg, and Sarah Vieau. I feel extremely fortunate to have the opportunity to work
with such a talented group of scientists and engineers, and I have learned a great deal from
each of them.
Finally, I would like to thank my family and friends for their continued support of my
career and their assistance over the years. Specifically, I would like to thank my wife,
Marge, my three daughters, Maria, Jenna, and Hanna, my mom Irene, and siblings Mike,
Chris, Mark, and Susan for always being there for me. On a personal note, some of my
inspiration for working on this project comes from the memory of my father, Anthony,
who succumbed to a sudden cardiac event, and from the memory of my Uncle Tom
Halicki, who passed away 9 years after a heart transplantation.
Minneapolis, MN Paul A. Iaizzo
Contents
Part I Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1 General Features of the Cardiovascular System . . . . . . . . . . . . . . . . . . . . . . . . . 3
Paul A. Iaizzo
Part II Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
2 Attitudinally Correct Cardiac Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Alexander J. Hill
3 Cardiac Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Brad J. Martinsen and Jamie L. Lohr
4 Anatomy of the Thoracic Wall, Pulmonary Cavities, and Mediastinum . . . . . . . 33
Mark S. Cook, Kenneth P. Roberts, and Anthony J. Weinhaus
5 Anatomy of the Human Heart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Anthony J. Weinhaus and Kenneth P. Roberts
6 Comparative Cardiac Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
Alexander J. Hill and Paul A. Iaizzo
7 The Coronary Vascular System and Associated Medical Devices . . . . . . . . . . . 109
Sara E. Anderson, Ryan Lahm, and Paul A. Iaizzo
8 The Pericardium. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
Eric S. Richardson, Alexander J. Hill, Nicholas D. Skadsberg,
Michael Ujhelyi, Yong-Fu Xiao and Paul A. Iaizzo
9 Congenital Defects of the Human Heart: Nomenclature and Anatomy . . . . . . . 137
James D. St. Louis
Part III Physiology and Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
10 Cellular Myocytes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
Vincent A. Barnett
11 The Cardiac Conduction System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
Timothy G. Laske, Maneesh Shrivastav, and Paul A. Iaizzo
12 Autonomic Nervous System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177
Kevin Fitzgerald, Robert F. Wilson, and Paul A. Iaizzo
ix
x Contents
13 Cardiac and Vascular Receptors and Signal Transduction . . . . . . . . . . . . . . . . . 191
Daniel C. Sigg and Ayala Hezi-Yamit
14 Reversible and Irreversible Damage of the Myocardium: New Ischemic
Syndromes, Ischemia/Reperfusion Injury, and Cardioprotection . . . . . . . . . . . . 219
James A. Coles, Daniel C. Sigg, and Paul A. Iaizzo
15 The Effects of Anesthetic Agents on Cardiac Function. . . . . . . . . . . . . . . . . . . . 231
Jason S. Johnson and Michael K. Loushin
16 Blood Pressure, Heart Tones, and Diagnoses . . . . . . . . . . . . . . . . . . . . . . . . . . . 243
George Bojanov
17 Basic ECG Theory, 12-Lead Recordings and Their Interpretation. . . . . . . . . . . 257
Anthony Dupre, Sarah Vieau, and Paul A. Iaizzo
18 Mechanical Aspects of Cardiac Performance . . . . . . . . . . . . . . . . . . . . . . . . . . . 271
Michael K. Loushin, Jason L. Quill, and Paul A. Iaizzo
19 Energy Metabolism in the Normal and Diseased Heart . . . . . . . . . . . . . . . . . . . 297
Arthur H.L. From and Robert J. Bache
20 Introduction to Echocardiography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 319
Jamie L. Lohr and Shanthi Sivanandam
21 Monitoring and Managing the Critically Ill Patient in the Intensive
Care Unit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331
Greg J. Beilman
22 Cardiovascular Magnetic Resonance Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . 341
Michael D. Eggen and Cory M. Swingen
Part IV Devices and Therapies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 363
23 A Historical Perspective of Cardiovascular Devices and Techniques
Associated with the University of Minnesota . . . . . . . . . . . . . . . . . . . . . . . . . . . 365
Paul A. Iaizzo and Monica A. Mahre
24 Pharmacotherapy for Cardiac Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 383
Anna Legreid Dopp and J. Jason Sims
25 Animal Models for Cardiac Research. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 393
Richard W. Bianco, Robert P. Gallegos, Andrew L. Rivard,
Jessica Voight, and Agustin P. Dalmasso
26 Catheter Ablation of Cardiac Arrhythmias . . . . . . . . . . . . . . . . . . . . . . . . . . . . 411
Xiao-Huan Li and Fei Lu¨
27 Pacing and Defibrillation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 443
Timothy G. Laske, Anna Legreid Dopp, and Paul A. Iaizzo
28 Cardiac Resynchronization Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 475
Fei Lu¨
29 Cardiac Mapping Technology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 499
Nicholas D. Skadsberg, Bin He, Timothy G. Laske, and Paul A. Iaizzo
30 Cardiopulmonary Bypass and Cardioplegia . . . . . . . . . . . . . . . . . . . . . . . . . . . . 511
J. Ernesto Molina
31 Heart Valve Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 527
Ranjit John and Kenneth K. Liao
