Anatomy of Heart
A- Location &Size of Heart
• The heart is a muscular organ.
• Located in the mediastinum of thoracic cavity.
• The size of heart ,slightly larger than a clenched or
(closed) fist, its weighing 300 gm.
• The heart has four chambers. Base – wide &
formed superior border.
• Apex – inferior point located at the 5th intercostal
space.
Position of the heart
Pericardium
• A tough fibroserous sac which is shaped like a cone with an
apex directed superiorly and a wide base inferiorly .
• encloses the heart and the roots of the great vessels
• lies within the middle mediastinum
• The fibrous pericardium is the strong fibrous part of the sac
• The base firmly attached below to the central tendon of the
diaphragm.
• The apex fuses with the outer coats of the great blood vessels
passing through it, at the level of sternal angle.
• Anteriorly :the fibrous pericardium is attached in front to the
sternum by the sternopericardial ligament
• Posteriorly: the fibrous pericardium is related to the principal
bronchi, the descending thoracic aorta and esophagus. This
aspect is pierced by four pulmonary veins.
Layers of Pericardium
1-Fibrous pericardium, Its a dense irregular CT.
2- Serous pericardium: lines the fibrous pericardium and coats
the heart,
divided into:
A-Parietal layer, lines the internal surface of the fibrous pericardium.
B- Visceral layer, lines the surface of the heart.
❑ Pericardial cavity: is the slit like space between the parietal
and visceral layers normally, the cavity contains a small
amount of tissue fluid (about 50ml) Called pericardial fluid,
which acts as a lubricant to facilitate movements of the heart.
This facilitates the sliding of the two serous layers over each
other during cardiac movements
❑ Functions of the pericardium:
▪ Protect and fixes the heart in the mediastinum.
▪ Prevent excessive dilatation (over distension)of the heart .
▪ Keep the mouths of large vessels open.
▪ Serve as a lubricated container in which the different parts of the heart
can contract.
Layers of Pericardium
Pericardial Layers of the Heart
12
Serous membrane
• Oblique sinus: It’s a blind recess of pericardial cavity which
extends upwards between left atrium(in front) and fibrous
pericardium (behind). or The oblique sinus intervenes
between the left atrium anteriorly and the esophagus
posteriorly.
- Significance : 1-It is believed to act as a bursa for the left
atrium to expand during filling by blood.
- 2-It allows pulsation of ascending aorta and expantion of
esophagus on swallowing.
• Transverse sinus: which is a short passage that lies between the
reflection of serous pericardium around the aorta and pulmonary
trunk anteriorly and pulmonary arteries & S.V.C. posteriorly.
- Significance: 1- The transverse sinus provides space during cardiac
surgery to clamp the ascending aorta and pulmonary trunk in order
to insert tubes of heart lung machine in these vessels.
Pericardium
• Blood Supply:
-The pericardiophrenic &musculophrenic artery are
branches of the internal thoracic artery.
-Branches from descending thoracic aorta.
• Nerve supply:
-The fibrous pericardium and the parietal layer of serous
pericardium are supplied by the sensory branches of phrenic
nerve.
-The visceral layer of serous pericardium supplied by: automatic
fibbers(Sympathetic trunks and the vagus nerves)
Heart
▪ Hallow muscular organ
▪ Pyramidal shaped
▪ Apex: blunt round part
▪ Base: flat part opposite
to the apex
▪ In the mediastinum, with
in the pericardium
behind the sternum
▪ Connected to great
vessels in its base
otherwise it is free with
in the mediastinum
▪ The size: size of closed
fist
Surface Projection of the Heart
• Superior right point at the superior border of the 3rd right
costal cartilage
• Superior left point at the inferior border of the 2nd left
costal cartilage 3cm to the left of midline
• Inferior left point at the 5th intercostal space, 9 cm from
the midline
• Inferior right point at superior border of the 6th right
costal cartilage, 3 cm from the midline
Surfaces of the heart
▪ The heart is based on its inferior surface
▪ Three surfaces:
1. Anterior ( sternocostal) surface:
➢Formed by right atrium & right ventricle
➢They are separated by vertical atrioventricular
groove
➢Right ventricle & left venricle are separated by
ant. interventricular groove
Anterior surface
2. Inferior(diaphragmatic) surface:
-Formed by right and left ventricles & inf. Surface of right atrium
-The right &left ventricles separated by post. interventricular
groove
3. Posterior surface (the base) :
▪ Formed by tow atria, mainly by left atrium
▪ Lies opposite to the apex
The apex of the heart
▪ Formed by left ventricle
▪ directed downward, forward & to the left
▪ Level of 5th intercostal space about 9 cm from
midline
Borders of the heart
▪ Right border:
▪ Formed by right atrium
▪ Its continuous above with S.V.C
&below with I.V.C.
▪ Extends from 3rd to 6th right
costal cartilage, 0.5 inch right to
the edge of the sternum
– Left border:
▪ The left ventricle & small part of
left auricle
▪ Extends from a point on the
2nd left costal cartilage 0.5
inch from the edge of the
sternum to the apex beat of
the heart
Borders of the heart
▪ Superior border:
▪ Formed by tow atria(mainly the left atrium)& its hidden
anteriorly by the roots of the great blood vessels( ascending
aorta, pulmonary trunk &S.V.C)
▪ Extends from 2nd left costal cartilage 0.5 inch from sternal
edge to third right costal cartilage 0.5 inch from the edge of
the sternum
▪ Inferior border:
▪ Formed by the right atrium , right ventricle, and the apical
part of the left ventricle.
▪ Extends from the 6th right costal cartilage 0.5 inch from the
sternum to the apex beat
❑ These borders are important to recognize when examining a radiograph of
the heart
Borders of the heart
Borders of the heart
Structure of the heart
▪ The heart is divided by vertical septa into 4 chambers:
– The atrial (interatrial) septum into the right and left
atria
– The ventricular (interventricular) septum into the
right and left ventricles
– Its position is indicated on the surface of the heart
by the anterior and posterior interventricular
grooves
– The lower part of the septum is thick and formed of
muscle.
– The smaller upper part of the septum is thin and
membranous and attached to the fibrous skeleton.
Heart chambers & valves
The heart wall
▪ The heart wall has 3 layers:
1. Epicardium : the outer layer, thin serous layer,visceral
pericardium
2. Myocardium: the middle layer, thickest layer consist
of cardiac muscle
3. Endocardium: the inner layer, thin layer covers the
chambers, endothelium
▪ The atrial portion of the heart has relatively thin walls
▪ The ventricular portion of the heart has thick walls
▪ Right atrium is ant. to left atrium & the right ventricle ant. to left
ventricle
Heart wall
Skeleton of the heart
▪ Consist of fibrous rings that surround the AV,
pulmonary & aortic orifices
▪ Contiues with the membranous upper part of the
ventircular septum
▪ Support the bases of the valve cusps & prevent
the stretching & incompetence of the valve
▪ Provide the cardiac muscle attachment
▪ It separates the muscular walls of the atria from
those of the ventricles & for this reason it forms
the basis of electrical discontinuity between the
atria & the ventricles(electerical isolation)
Skeleton of the heart
Skeleton of the heart
Chambers of the heart
▪ Right Atrium:
▪ Consist of main cavity & small outpouching (the auricle) On the
outside
▪ Sulcus terminalis: is a vertical groove, between the right atrium
and the right auricle of the heart(outside)
▪ Crista terminalis: a vertical ridge lies on the inside of the sulcus
terminalis (embryologically, represent the site of the junction
between the sinus venosus & the right atrium)
▪ The main part of the atrium lie posterior to the ridge & it is
smooth walled
▪ The inner surface of the auricle is roughened by bundles of
muscle fibers called musculi pectinati
Right atrium
Right atrium
Openings into the right atrium
▪ Superior vena cava:
❖Opens into the upper part of the right atrium
❖There is no valve
❖Returns blood from upper half of the body
▪ Inferior vena cava:
❖Opens into the lower part of the right atrium
❖Guarded by rudimentary nonfunctioning valve
❖Returns blood from the lower half of the body
▪ Coronary sinus:
❖Drain most of the blood from the heart wall
❖Between the inf. Vena cava & AV orifice
❖İt has nonfunctioning rudimentary valve
Right atrium
▪ Right AV orifice:
❖Ant. To the inf. Vena cava
❖Guarded by tricuspid valve
▪ Fetal remnants:
▪ Fossa ovalis: a shallow depression on the atrial
septum, it is the site of foramen ovale in the fetal
life
▪ Anulus ovalis: is the upper margin of the fossa
ovale
Openings into the right atrium
Right ventricle
▪ Forms the greater part of the ant. Surface of the heart
▪ Lies anterior to the left ventricle
▪ Communicates with the right artium by AV orifice & with the
pulmonary trunk by pulmonary orifice
▪ The funnel shaped approach to the pulmonary orifice called
infundibulum
▪ The walls are much thicker than the walls of thr atrium
Right ventricle
❑ Trabeculae carneae: are projecting ridges in the internal surface
▪ There are 3 types of trabeculae carneae:
1. Papillary muscles: bases attached to the wall & apices connected to
the cusps of the tricuspid valve by chrdae tendineae
2. Attached at thier ends to the wall & free in the middle. One them
called moderator band crosses the cavity from the septal to the ant.
Wall, conveys the AV bundle
3. Composed of prominent ridges
❑Tricuspid valve:
▪ Gurads the AV orifice
▪ Consist of 3 cusps: anterior, septal, inferior(posterior)
▪ Formed by endothelial folds
▪ Bases attached to the fibrous ring of the skeleton
▪ Free edges attached to chordae tendineae which
connect the valve to papillary muscles
Right ventricle
Right ventricle
• The pulmonary valve:
– guards the pulmonary orifice
– Consists of three semilunar cusps formed by folds of
endocardium with some connective tissue enclosed
– One posterior (left cusp) and two anterior (anterior
and right cusps).
– Curved lower margins attached to the arterial wall
– The open mouths of the cusps are directed upward
into the pulmonary trunk
– The cusps are attached from its sides to the arterial
wall that prevent the cusps from prolapsing into the
ventricle
– Sinuses are dilatations at the root of the pulmonary
trunk three situated external to each cusp
Right ventricle
Thickness of Cardiac Walls
Myocardium of left ventricle is much thicker than the right.
Left atrium
▪ Similar to right atrium
▪ Consist of main cavity & auricle
▪ Situated behind the right atrium
▪ Forms the greater part of the base of the heart
▪ Behind it is the esophagus separated by pericardium
(oblique sinus)
▪ The interior is smooth
▪ The auricle posses muscular ridges
▪ Four pulmonary veins open through the posterior
wall
▪ They have no valves
▪ Left AV orifice guarded by the mitral valve
Left atrium
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Left ventricle
▪ Communicates with the left atrium through the AV orifice &
with the aorta through the aortic orifice
▪ The walls are three times thicker than those of the right
ventricle
▪ The left intraventricular blood pressure is six times higher
than that inside the right ventricle
▪ In cross section, the left ventricle is circular; the right is
crescentic
▪ because of the bulging of the ventricular septum into the cavity of
the right ventricle
▪ Well developed trabeculae carneae
▪ Two large papillary muscles
▪ No oderator band
▪ Aortic vestibule: is the part of the ventricle below the aortic
orifice
Left ventricle
Left ventricle
• The mitral valve:
– Guards the AV orifice
– Consists of two cusps, one anterior and one
posterior
– Have a structure similar to that of the tricuspid
valve
– The anterior cusp is the larger & intervenes
between the AV & aortic orifices.
– The attachment of the chordae tendineae to the
cusps & the papillary muscles is similar to that of
the tricuspid valve.
Left ventricle
• The aortic valve:
– Guards the aortic orifice
– Precisely similar in structure to the pulmonary valve
– One cusp is situated on the anterior wall (right cusp)
and two are located on the posterior wall (left and
posterior cusps).
– Behind each cusp, the aortic wall bulges to form an
aortic sinus
– The anterior aortic sinus gives origin to the right
coronary artery, and the left posterior sinus gives origin
to the left coronary artery.
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Conducting system of the heart
• Consists of specialized cardiac muscle present in the:
1. Sinuatrial (SA)node
2. Atrioventricular (AV)node
3. Atrioventricular bundle (bundle of His)
4. Bundle branches: Right and left terminal branches (RBB & LBB)
5. Purkinje fibers: subendocardial plexus of (specialized cardiac muscle
fibers that form the conducting system of the heart).
• The activities of the conducting system can be influenced by the
autonomic nerve supply to the heart
– The parasympathetic nerves slow the rhythm and diminish the rate of
conduction of the impulse
– The sympathetic nerves have the opposite effect
• The conducting system of the heart is responsible for:
– Generating rhythmic cardiac impulses
– Conducting these impulses rapidly throughout the myocardium of
the heart so that the different chambers contract in a coordinated
and efficient manner
Conducting system of the heart
• SA node:
– Initiate the heart beat
– In the wall of the right atrium close to opening sup.
Vena cava
• AV node:
– At the lower part of the atrial septum just above
the attachment of septal cusp
– From it the impulse is conducted to the AV bundle
– It is stimulated by the excitation wave as it passes
through the atrial myocardium
Conducting system of the heart
• AV bundle (bundleof His):
– The only pathway that connect the atrial &ventricular
myocardium
– The impulse travel through it from the atria to the ventricles
– Descend through the fibrous skeleton behind the tricuspid
valve
– At the upper part of muscular septum divided into two bundle
branches one for each ventricle (RBB & LBB)
– The RBB passes down on the right side of the septum & when
reach the moderator band cross to the ant. Wall of the Rt
ventricle & become cotinuous with the fibers of Purkinje
plexus
– LBB pierces the septum and passes down on its left side
beneath the endocardium. It usually divides into two branches
(anterior and posterior),which eventually become continuous
with the fibers of thePurkinje plexus of the left ventricle
Conducting system of the heart
• The heart normally contracts rhythmically at about 70 to 90
beats per minute in the resting adult
• This process originates spontaneously in the conducting
system(SA node)
• The impulse travels to different regions of the heart, so the
atria contract first and together
• Followed later by the contractions of both ventricles together
• The slight delay in the passage of the impulse from the atria to
the ventricles allows time for the atria to empty their blood into
the ventricles before the ventricles contract
Conducting system of the heart
Conducting system of the heart
Blood supply of the heart
• Provided by the right & left coronary arteries
• Arise from the ascending aorta immediately above the aortic
valve
• lying within subepicardial connective tissue
• The coronary arteries are functionally end arteries but
anatomically they are not. The branches of the two coronary
arteries anastomose at arteriolar level, but the caliber of the
anastomosing arteries is not sufficient to maintain normal
circulation, if one of the arteries is suddenly blocked.
• Unlike other arteries of the body the coronary arteries fill during
diastole of the ventricles
• The coronary arteries are more prone to atherosclerosis
(subendothelial deposition of lipids) compared to other arteries
hence ischemic heart diseases are very common.
Right coronary artery
▪ Arises from the anterior aortic sinus of the ascending
aorta
▪ Runs forward between the pulmonary trunk and the right
auricle
▪ It descends almost vertically in the right atrioventricular
groove
▪ At the inferior border of the heart it continues posteriorly
along the atrioventricular groove to anastomose with the
left coronary artery in the posterior interventricular
groove
Right coronary artery
• Supplies :
❖ Right atrium & part of the left atrium
❖ Right ventricle (except for the small area to the right of the anterior
interventricular groove)
❖ AV septum(posteroinferior third of ventricular septum)
❖ Parts of the left atrium & ventricle(diaphragmatic surface of the
ventricle)
❖ SA node 60% & AV node 80% & AV bundle & branches to LBB.
• Branches right coronary artery:
A- The first segment of the artery gives origin off :
1. Right conus artery:
• which supplies the base of the pulmonary trunk and ascending aorta
(infundibulum of the right ventricle) and the upper part of the anterior
wall of the right ventricle.
• If the conus artery arises independently from the anterior aortic sinus, it is
called the third coronary artery.
B-The second segment of the artery gives off:
2- Right Anterior atrial branches: supplying the anterior part of the
right atrium and the SA node through a nodal branch.
3. Right Anterior ventricular branches: 2or 3 branches Supply
the anterior surface of the right ventricle.
4-Right marginal artery: which travels along the inferior
margin of the heart accompanied by small cardiac vein,
supplying both the ventricles on its way.
B-The third segment of the artery gives off:
5. Posterior ventricular branches: 2 branches
▪Supply the diaphragmatic surface of the right ventricle
6. Right posterior atrial branches and AV nodal branches: at the
post.crux in coronary sulcus.
Right coronary artery
7. Posterior interventricular (posterior descending artery
PDA) artery:
▪ Runs toward the apex in the posterior interventricular groove
accompanied by middle cardiac vein.
▪ Branches to the right & left ventricles,including its inferior wall
▪ Branches to the posterior part of the ventricular septum but not
to except the apical part
▪ A large septal branch supplies the AN node
▪ In 10% of individuals it is replaced by a branch from the left
coronary artery.
---. Atrial branches
▪ Supply the anterior & lateral surfaces of the right atrium
▪ One branch supplies the posterior surface of both the right &
left atria
▪ Artery of the sinuatrial node supplies the node & the right & left
atria; in 35% of individuals it arises from the left coronary artery
Coronary arteries
Left coronary artery
▪ Usually larger than the right coronary artery
▪ It arises from the left posterior aortic sinus of the ascending
aorta & passes forward between the pulmonary trunk & the
left auricle
❑Supplies the major part of the heart, including
:
❖The greater part of the left atrium, left ventricle
❖ Anterior 2/3 of Ventricular septum
❖A small area of the right ventricle to the right of
the interventricular groove
❖RBB & LBB
Left coronary artery
• Branches:
1- Anterior interventricular artery (also termed as left
anterior descending or LAD artery)
▪ Runs downward in the anterior interventricular groove
accompanied by great cardiac vein.
▪ In most individuals, it then passes around the apex of the heart
to enter the posterior interventricular groove and anastomoses
with the terminal branches of the right coronary artery
▪ In 1/3of individuals, it ends at the apex of the heart
▪ Supplies large area of left ventricles and small portion of right
ventricle with numerous branches that also supply the anterior
2/3 of the ventricular septum.
--Moreover, it is very much prone to atherosclerosis and narrowing
in men. Hence, its block may cause massive and fatal infarction. On
account of this LAD has been popularly called the “widow maker”
Branches of Anterior interventricular (LAD)artery.
1-A small left conus artery :
supplies the pulmonary conus anastomoses (around the
infundibulum) with the right conus artery (a branch of right coronary
artery).
2-Right and left ventricular :
3- left diagonal artery( left ventricular).
Left coronary artery
▪ Circumflex artery:
▪ The same size as the anterior interventricular artery
▪ Winds around the left margin of the heart in the atrioventricular
groove
• Usually, it terminates to the left of the crux by anastomosing
with the right coronary artery but at times it continues as
the posterior interventricular artery.
Branches of Circumflex artery:
1- Left marginal artery : is a large branch that supplies the left
margin of the left ventricle down to the apex.
2-Anterior ventricular and posterior ventricular
branches supply the left ventricle
3-Atrial branches supply the left atrium
Coronary Dominance:
1-In the right dominance the posterior interventricular
artery(PDA) arises from the right coronary artery, this
called right dominance heart 67% while in the left
dominance the posterior interventricular artery is a branch
of the left coronary artery called left dominance heart 15%.
2-In balanced pattern both the coronary arteries give rise
posterior interventricular artery , which run parallel in the
posterior interventricular sulcus this called Co-dominance
heart 18%.
Venous drainage of the heart
• There are three major veins, which drain blood from the
myocardium. Most of blood from the heart wall drains into the
right atrium through the chief vein called coronary sinus 2.5 cm
which lies in the post. AV groove, It opens into the right atrium to
the left of the inferior vena cava
1-Is a continuation of the great cardiac vein
2-The small and middle cardiac veins are tributaries of the coronary sinus
4-The posterior vein of left ventricle lies parallel to the middle cardiac vein.
5- The oblique vein of left atrium or oblique vein of Marshall opens
near the left end of the coronary sinus.
--The remainder of the blood is returned to the right atrium by the:
1- Anterior cardiac vein : 3 or 4 branches
2- Venae cordis minimae: are scattered all over the myocardium and
open directly into all the cardiac chambers.
91
Figure 18.7b
A coronary angiogram. A contrast medium
(similar in function to a dye) is injected into the coronary arteries,
causing them to become visible on an X-ray photograph. Note the
area of narrowing in the coronary artery indicated by the arrow
Nerve supply of the
heart
Nerve supply of the heart
• Innervated by sympathetic and parasympathetic fibers of the
autonomic nervous system via the cardiac plexuses situated
below the arch of the aorta ,bifurcation of trachea and
around the coronary arteries(coronary plexus).
A-The preganglionic sympathetic fibers arises from the cervical
and upper thoracic portions (T1 – T4 or T 5) of the
sympathetic trunks.
▪ The postganglionic sympathetic fibers terminate on the heart
(sinoatrial and atrioventricular nodes, on cardiac muscle
fibers, and on the coronary arteries) , lungs, esophagus&descending
aorta.
▪ Activation of these nerves results in:
❖Cardiac acceleration, increased force of
❖Contraction of the cardiac muscle
❖Dilatation of the coronary arteries
NERVES
• Thoracic Part of Sympathetic Trunks: (Superior & posterior
mediastinum)
• Beginning: the cervical part continues as thoracic part by passing
in front of neck of first ribs
• Termination: the thoracic part continues as lumbar part by
passing behind medial arcuate ligament of diaphragm.
• The right &left sympathetic chain united together on the
anterior surface of sacral bone at the level of S4 segment and
form single chain called ganglion impar.
• Course:
1. In upper part of thorax: descend in front of heads of ribs
2. In lower part of thorax: descend on the sides of bodies of
vertebrae
• Ganglia: usually 11 (1st thoracic ganglion fuses with inferior
cervical ganglion forming stellate ganglion)
NERVES
• BRANCHES:
1. Rami communicantes: each ganglion receives a white ramus
(preganglionic) & gives a grey ramus (postganglionic) to
corresponding thoracic spinal nerve
2. Visceral branches (postganglionic) to thoracic organs (from upper
5 ganglia): to heart, lungs, esophagus, descending aorta.
3. The lower eight ganglia give preganglionic fibers which are
grouped together to form the splanchnic nerves and supply
abdominal organs(Viscera):
• Greater splanchnic nerve (from 5th to 9th ganglia).
• Lesser splanchnic nerve (from 10th 7 11th ganglia).
• Lowest splanchnic nerve (from 12th ganglion).
Formation of superficial and deep cardiac plexuses.
Nerve supply of the heart
B-The parasympathetic nerve ( craniosacral division)
comes from the vagus nerves.
▪ The postganglionic parasympathetic fibers terminate
on the heart (sinoatrial and atrioventricular nodes
and on the coronary arteries), lungs, esophagus &
descending aorta.
▪ Activation of these nerves results in: (cardioinhibitory in
function)
❖Reduction in the rate and force of contraction of the heart
❖Constriction of the coronary arteries (vasoconstriction).
NERVES
• Vagus Nerves: (Superior & posterior mediastinum)
• ORIGIN: 10th cranial nerve
• Course & Relations In Thorax:
1. RIGHT: descends to the right side of: trachea, behind root of
right lung (pulmonary plexus), behind esophagus (esophageal
plexus), passes through esophageal opening of diaphragm to
reach posterior surface of stomach
2. LEFT: descends to the left side of: arch aorta, behind root of left
lung (pulmonary plexus), in front of esophagus (esophageal
plexus), passes through esophageal opening of diaphragm to
reach anterior surface of stomach
NERVES
• Branches In Thorax:
• Both Vagi: to lungs & esophagus
• Right Vagus: to heart
• Left Vagus: left recurrent laryngeal nerve: curves
below arch of aorta, behind ligamentum
arteriosum, ascends in groove between trachea
& esophagus to reach the neck. It supplies:
heart, trachea, esophagus (in thorax) & larynx
(in neck)
Surface Anatomy of the Heart
Valves
▪ The tricuspid valve lies behind the right half of the
sternum opposite the 4th intercostal space.
▪ The mitral valve lies behind the left half of the
sternum opposite the 4th costal cartilage.
▪ The pulmonary valve lies behind the medial end of
the third left costal cartilage and the adjoining part
of the sternum.
▪ The aortic valve lies behind the left half of the
sternum the level of the 3rd intercostal space.
Heart Sounds
Action of the heart
• The heart is a muscular pump
• Cardiac cycle: is changes that take place within it as it fills with
blood and empties.
• The first heart sound (“lub”) is produced by the closure of the
tricuspid and mitral valves, at the beginning of ventricular
systole
• The second heart sound (“dub”) is produced by the closure of
the aortic and pulmonary valves at the beginning of
ventricular diastole .
• The normal heart beats 70 to 90 times per minute in the
resting adult and 130 to 150 times per minute in the newborn
child.
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