血液循環(huán)【-】課件

CHAPTER4CIRCULATION

血液循環(huán)

Prof.WangTinghuaiDepartmentofPhysiology

Section2

CardiacPumpFunction

心臟的泵血功能ⅠCardiaccycle

心動(dòng)周期

Thecardiaccycleincludestwophases:systoleanddiastole,whichformsintoonemechanicalactivitycycle.心動(dòng)周期:心臟一次收縮和舒張構(gòu)成一個(gè)機(jī)械活動(dòng)周期，稱為心動(dòng)周期。

Theheartrateofaverageadultmanisabout75/min,everycardiaccyclecontinuesabout0.8s.正常成年人心率平均每分鐘75次，心動(dòng)周期持續(xù)0.8s。A.Featuresofcardiacmechanicalactivation

心臟機(jī)械活動(dòng)特征⒈Atriumandventriclecontractandrelaxinorder心房和心室依一定的次序收縮和舒張⒉DiastolePeriod＞SystolePeriod

舒張期時(shí)程>收縮期時(shí)程⒊HR↑→diastole↓↓,systole↓HR↓→diastole↑↑,systole↑心率↑→舒張期↓↓,收縮期↓心率↓→舒張期↑↑,收縮期↑

Contractionorrelaxation→changesinpressure→openingorclosingofvalves→directionofbloodflow→thechangeofthevolumeofatriaandventricle

心肌收縮或舒張→壓力改變→瓣膜開或關(guān)

→一定方向的血流，房室容積改變1.心房收縮期2.等容收縮期3.快速射血期4.減慢射血期5.等容舒張期6.快速充盈期7.減慢充盈期AO與AC：主動(dòng)脈瓣開啟和關(guān)閉MO和MC：半月瓣開啟和關(guān)閉B.Mechanicaleventsduringthecardiaccycle

心動(dòng)周期中的機(jī)械變化1、Leftventricularejectionandfillingevent

左室的射血和充盈過(guò)程

心房收縮期等容收縮期快速射血期減慢射血期等容舒張期快速充盈期減慢充盈期心肌狀態(tài)房收縮有張力無(wú)縮短室收縮室收縮室舒張室舒張

室舒張房收縮壓力改變房>室主>室房<室

主>室房<室主<室

房<室主>室房<室主>室房>室主>室房>室主>室瓣膜情況二尖瓣開半月瓣關(guān)關(guān)關(guān)關(guān)開關(guān)開關(guān)關(guān)開關(guān)開關(guān)血流方向房室無(wú)室主

室主

無(wú)房室房

室房室容積房↓室↑房－室－室↓↓室↓室－室↑↑房↓室↑持續(xù)時(shí)間0.1s0.05s0.10s0.15s0.06~0.08s0.11s0.22sa.Atrialsystole：心房收縮期

bicuspidvalveopen二尖瓣開放semilunarvalveclosed半月瓣關(guān)閉Ap>Vp，AOp>Vp，心房收縮，血液從心房心室。

Characteristic:Atriumcontracts,theintra-atrialpressureincreasesandthefillingofleftventriclekeepclimbing.Thisphaselastsabout0.1s.特點(diǎn)：心房收縮，房?jī)?nèi)壓增高，左心室充盈量進(jìn)一步增加。這一時(shí)期持續(xù)0.1s。b.Ventricularsystole:心室收縮期(1)Isovolumesystole

等容收縮期(2)Rapidejectionperiod

快速射血期(3)Reducedejectionperiod

減慢射血期periodofisovolumiccontraction

等容收縮期

bicuspidvalveclosed

二尖瓣關(guān)閉

semilunarvalveclosed

半月瓣關(guān)閉Ap<Vp，AOp>Vp，心室肌強(qiáng)烈收縮，有張力無(wú)縮短。ClosureofAVvalves:firstheartsound房室瓣關(guān)閉：第一心音Characteristc:Theamplitudeofintraventricularpressurepressureincreasesgreatlyandsharply.Thisphaselastsabout0.05s.

特點(diǎn)：室內(nèi)壓大幅度升高，且升高速率很快。這一時(shí)相持續(xù)0.05s左右。（2）periodofrapidejection

快速射血相

semilunarvalveopen半月瓣開啟bicuspidvalveclosed二尖瓣關(guān)閉

Ap<Vp，Aop<Vp

心室向主動(dòng)脈快速射血，室內(nèi)壓迅速上升到峰值。Characteristic:Thetimecoursetakesabout1/3ofthewholeejectionperiod,andtheejectionvolumetakesabout2/3ofthewholeejectionvolume.Thisphaselastsabout0.10s.特點(diǎn)：時(shí)間占射血相1/3左右，射血量占總射血量的2/3左右。持續(xù)0.10s左右。（3）periodofslowejection

減慢射血相semilunarvalveopen半月瓣開啟bicuspidvalveclosed二尖瓣關(guān)閉

Ap<Vp，Aop>Vp心室射血速度減慢，Ap和Aop都由峰值下降。Characteristic:Thetimecoursetakesabout2/3ofthewholeejectionperiod,about0.15s.Theintraventricularpressureandaorticpressurebeginstodecreasefrompeakamplitudegradually.特點(diǎn)：時(shí)間占射血相2/3左右，約0.15s。心室內(nèi)壓和主動(dòng)脈壓都相應(yīng)由峰值逐步下降。

c.Ventriculardiastole:

心室舒張期

(1)Isovolumediastole

等容舒張期

(2)Rapidfillingperiod

快速充盈期

(3)Reducedfillingperiod

減慢充盈期(1)periodofisovolumicrelaxation

等容舒張相

semilunarvalveclosed

半月瓣關(guān)閉

bicuspidvalveclosed

二尖瓣關(guān)閉Ap<Vp，AOp>Vp心室繼續(xù)舒張，Vp快速下降，心室容積不變。Closureofaorticvalvesandpulmonaryvalves:secondheartsound主動(dòng)脈瓣和肺動(dòng)脈瓣關(guān)閉：第二心音Characteristc:Theintraventricularpressurepressuredecreasessharply.Thisphaselastsabout0.06s-0.08s.特點(diǎn)：心室內(nèi)壓急劇下降，心室容積保持不變。持續(xù)時(shí)間約0.06s-0.08s。(2)periodofrapidfilling

快速充盈相bicuspidvalveopen二尖瓣開啟

semilunarvalveclosed半月瓣關(guān)閉Ap>Vp，AOp>Vp

血液快速進(jìn)入心室，心室容積迅速增大。

Characteristic:Thephasetakes1/3ofdiastoleperiod,lastsabout0.11s.Thefillingvolumetakesabout2/3ofthewholefillingvolume.特點(diǎn)：占舒張期的前1/3，占總充盈量的2/3，持續(xù)時(shí)間約0.11s。(3)periodofreducedfilling

減慢充盈相bicuspidvalveopen二尖瓣開啟

semilunarvalveclosed半月瓣關(guān)閉Ap>Vp，AOp>Vp

血液緩慢流入心室，心室容積進(jìn)一步擴(kuò)大。Characteristic:Thefillingvolumetakesabout2/3ofthewholefillingvolume.Whichlastsabout0.22s.Followingthisphasethecardiacentersintonextcardiaccycle.

特點(diǎn)：占總充盈量的1/3，持續(xù)時(shí)間約0.22s。此后心臟進(jìn)入下一個(gè)心動(dòng)周期。B,Leftatrialpressurechanges

duringthecardiaccycle

心動(dòng)周期中左心房壓力變化

ascensuswave:awave,cwave,vwav上升波：a波、c波、v波

a波:心房收縮，房?jī)?nèi)壓升高

c波：心室開始收縮，房室瓣凸向心房腔，房?jī)?nèi)壓輕度升高。

v波：靜脈血回流，房?jī)?nèi)壓升高。

descensuswave:xwave,ywave

下降波：x波、y波

x波：左心室繼續(xù)射血，體積縮小，心房容積趨于擴(kuò)大，房?jī)?nèi)壓下降。y波：房室瓣開放，血液流入心室，房?jī)?nèi)壓下降。II.Evaluationofcardiacpumpfunction:

心臟泵功能的評(píng)估

1.Strokevolume

每搏輸出量，約為70ml2.Cardiacoutput=strokevolume×heartrate每分輸出量或心輸出量=每搏輸出量×心率，約為5L/min(4.5-6.0L/min)。3.Cardiacindex心指數(shù)

Cardiacindexisthecardiacoutputpersquaremeterofbodysurfacearea，bywhichthecardiacoutputsofdifferent–sizedpeoplecanbecomparedwithoneanother，about3.0～3.5L/(min·m2).心指數(shù)是單位體表面積的心輸出量,可用以比較不同體表面積者的心輸出量，約為3.0~3.5L/(min·m2)。Cardiacindex=cardiacoutput/areaofbodysurface

心指數(shù)＝心輸出量/體表面積

4.Ejectionfraction(EF)射血分?jǐn)?shù)Ejectionfraction(EF):SVEDV-ESVEF=———=——————EDVEDV

搏出量射血分?jǐn)?shù)=——————舒張末容積舒張末容積–收縮末容積=————————————舒張末容積約為55%~65%

5.Cardiacwork

心臟做功量Strokework=Pressure-volumework+kineticenergy每搏功=壓力-容積功+動(dòng)力功a.pressure-volumework/beat

=Force×DistanceF×D=(P×A)×D=P(A×D)=P×ΔV

壓力容積功＝壓力×距離=(壓強(qiáng)×面積)×距離=壓強(qiáng)(面積×距離)=壓強(qiáng)×體積b.Kineticenergy:1/2mV2,2-4%ofcardiacwork

動(dòng)力功：1/2mV2，占心臟做功的2-4%

每搏功＝搏出量×射血壓力射血壓力＝平均動(dòng)脈壓＝舒張壓＋1/3脈壓c.Mechanicalefficiencyofheart=P×ΔV/E

心臟的機(jī)械效率=壓力×體積改變/

化學(xué)能消耗（E:chemicalenergyexpenditure，化學(xué)能消耗）

III.Regulationofcardiacoutput

心輸出量的調(diào)節(jié)

Cardiacoutput=SV×HR心輸出量=搏出量×心率significance:

意義Tomeettheneedoftissuesunderdifferentconditions

滿足不同條件下的組織需要Tokeepcardiacoutputbalancewithcardiacfilling保持心輸出量與心臟充盈平衡Tomatchtheoutputoftherightandleftventricle

匹配右室左室的輸出量Determinantsofstrokevolume：搏出量的決定因素：initiallength(pre-load)－h(huán)eterometricautoregulation

初長(zhǎng)度（前負(fù)荷）－異長(zhǎng)自身調(diào)節(jié)Contractility－h(huán)omometricautoregulation收縮能力－等長(zhǎng)自身調(diào)節(jié)after-load

后負(fù)荷A.Effectofpre-loadoncardiacoutput

前負(fù)荷對(duì)心輸出量的影響－異長(zhǎng)自身調(diào)節(jié)

Frank-StarlingMechanism-Frank-Starling機(jī)制

Duringonespecificscope，thebiggertheLVEDV,thelongertheinitiallength,andthestrongerthestrengthofthecardiaccontraction，thelargerthestokevolumeandstokework.在一定范圍內(nèi)，心室舒張末期容積（壓力）越大，初長(zhǎng)度越長(zhǎng)，收縮力量越強(qiáng)，搏出量和搏功越大。1.TheprincipleofFrank-Starlingmechanism

Frank-Starling機(jī)制產(chǎn)生原理Beforetheinitiallengthofventricularincreasesintotheoptimumlevel,thelongertheinitiallength,thelargertheamountofoverlapbetweenthickandthinfilaments,andthemorecrossbridgelinkswhenactivated,thebiggerthecontractionintensityofsarcomere.Asaresult,thecontractionintensityofthewholeventricularandthestrokevolumeincrease.

在心室初長(zhǎng)度達(dá)到最適水平之前，隨著心肌細(xì)胞肌小節(jié)的初長(zhǎng)度的增加，使粗、細(xì)肌絲有效重疊的程度增加，因而激活時(shí)可能形成的橫橋連接的數(shù)目相應(yīng)增加，肌小節(jié)的收縮強(qiáng)度增加，其結(jié)果是整個(gè)心室收縮強(qiáng)度增加，搏出量增加。

Thelength–tensioncurveofskeletalmuscle

骨骼肌長(zhǎng)度-張力曲線

Thelefttooptimallength,Tmaxincreasesasinitiallengthincreases.達(dá)到最適初長(zhǎng)度以前，最大張力隨初長(zhǎng)度的增加而增加。Therighttooptimallength,Tmaxdecreasesasinitiallengthincreases.

達(dá)到最適初長(zhǎng)度以后，最大張力隨初長(zhǎng)度的增加而減小。Ventricularfunctioncurve

心室功能曲線12–15mmHg：最適前負(fù)荷5–6mmHg：正常情況15-20mmHg:趨于平坦>20mmHg:曲線并不下降

Featureofventricularfunctioncurve：

心室功能曲線的特征

a.Optimalpre-load(LVEDP)is12–15mmHg，Undernormalcondition,LVEDPis5–6mmHg.

最適前負(fù)荷（左室舒張末壓）為12–15mmHg，正常情況下為5–6mmHg。b.Atthelefttooptimalpre-load,SV↑asLVEDP↑.

在左室達(dá)到最適前負(fù)荷前，搏出量隨左室舒張末壓的增加而增加。c.AtLVEDP15–20mmHg,thecurvestillflat.

在左室舒張末壓為15–20mmHg時(shí)，曲線趨于平坦。d.AtLVEDP＞20mmHg,curvedoesnotdeclineduetosmalldistensibilityofcardiacmuscle.

在左室舒張末壓＞20mmHg時(shí)，由于心肌可擴(kuò)張能力小，曲線并不下降。

LVEDPis7mmHg,sarcomerelengthis2.2m.

左室舒張末壓為7mmHg，肌小節(jié)長(zhǎng)度是2.2m。

LVEDPisashighas30mmHg，sarcomerelengthisstill2.2m.

左室舒張末壓高達(dá)30mmHg時(shí)，肌小節(jié)長(zhǎng)度仍是2.2m。Smalldistensibilityandbigpassivetensionduetocardiacconnectivetissue.較小的可擴(kuò)張性和較大的靜息張力與心臟的結(jié)締組織有關(guān)Abilitytoresiststretchofmyocardiumatfillingpressure.

在充盈時(shí)防止心肌過(guò)度牽張

Asafetyfactoragainstoverloadingofheartindiastole.

在舒張期防止心臟負(fù)荷過(guò)重骨骼肌和心肌長(zhǎng)度－張力曲線比較

骨骼肌心肌

安靜狀態(tài)最適初長(zhǎng)度左側(cè)升支段,偏離最適初長(zhǎng)初長(zhǎng)度儲(chǔ)備很小較大收縮功能調(diào)節(jié)范圍很窄很寬2.ThephysiologicalfunctionsofFrank-Starlingmechanism

Frank-Starling機(jī)制的生理意義a.Balancetheinjectionvolumeofventricularandthevenousreturn

使心室射血量與靜脈回心血量相平衡b.Keepthecardiacoutputoftheleftandrightventricularsequal維持左右心室的心輸出量相等3.ThemainfunctionofFrank-Starlingmechanism

Frank-Starling機(jī)制的主要作用

ThemainfunctionofFrank-Starlingmechanismistocarryoutthesubtleregulationofstrokevolume.whenundertakingcontinuousandintensephysicallabor,thereisagreatdemandofincreaseinstrokevolume.ThemechanismofFrank-Starlinglawnolongerplayaroleinthisprocess,andit’smainlydependontheregulationofcardiacmusclecontractility.

Frank-Starling機(jī)制的主要作用是對(duì)搏出量進(jìn)行精細(xì)的調(diào)節(jié)。在進(jìn)行持續(xù)、劇烈的體力勞動(dòng)時(shí),要求搏出量持久而且大幅度的提高，F(xiàn)rank-Starling機(jī)制就不起作用，主要是依靠心肌收縮能力的變化來(lái)調(diào)節(jié)。B.Themodulationofcardiacmusclecontractility

心肌收縮能力的調(diào)節(jié)—等長(zhǎng)自身調(diào)節(jié)

Contractilityisdependedby：

心肌收縮能力的影響因素：

a.Numberofactivatedcross-bridgelinkage/totalnumberofcross-bridgelinkage:

活化橫橋數(shù)目/最大橫橋數(shù)的比例Intracellularfree[Ca2+]:胞內(nèi)游離鈣離子濃度AffinityoftroponintoCa2+：肌鈣蛋白和Ca2+的親和力b.ActivityofATPaseactivity

ATP酶的激活程度1.Sympatheticnerveandcatecholamine→↑c(diǎn)ontractility→ventricularfunctioncurveshiftsupwardandtotheleft.交感神經(jīng)興奮，釋放兒茶酚銨→激活A(yù)C→cAMP↑→激活cAMP依賴性蛋白激酶

磷酸化鈣通道，↑鈣內(nèi)流，鈣誘導(dǎo)鈣釋放→

↑肌鈣蛋白對(duì)的Ca2＋親和力

→心肌收縮能力↑，心室功能曲線左上移位。

AC→cAMP↑→激活cAMP依賴性蛋白激酶

磷酸化phospholabam,Ca2＋加速泵回SR,胞內(nèi)Ca2＋↓↓→

磷酸化肌鈣蛋白I,抑制肌鈣蛋白與Ca2＋結(jié)合，→舒張過(guò)程加速

2.Inglobal,cardiacvagusnerveonlyhaveaminorinfluenceonthecardiaccontractibility.ThevagusnervemailydominatestheSNtoregulatetheheartrate,andthedistributionofvagusnerveonventricularisstillunkown.整體情況下，心迷走神經(jīng)對(duì)心臟的收縮能力影響不大。迷走神經(jīng)主要支配竇房結(jié)調(diào)節(jié)心率，支配心室的迷走神經(jīng)的分布情況尚不確定。C.Effectofafter-loadoncardiacoutput

后負(fù)荷對(duì)心輸出量的影響

After-load––aorticpressure↑→strokevolume↓→bloodaccumulatesinventricle→LVEDV↑→recoveryofstrokevolume.Contractility↑→recoveryofLVEDV,cardiacwork↑.↑后負(fù)荷（主動(dòng)脈壓）→搏出量↓→血液積聚在心室→左室舒張末壓↑→Starling機(jī)制→搏出量恢復(fù)→心肌Contractility↑→左室舒張末壓恢復(fù)，心臟做功量↑。D.Effectofheartrateoncardiacoutput

心率對(duì)心輸出量的影響

CO=HR×SV

心輸出量＝心率×每搏輸出量HR↑,CO↑；HR＞200bpm,CO↓duetodiastoletooshort,venousreturntoosmall.心率增加，心輸出量增加；心率＞200次/m，由于心舒期縮短，靜脈回流減少，心輸出量減少。Theinfluenceofautonomicnervetowardsspontaneousdepolarizationvelocityin4phaseofSN

自主神經(jīng)對(duì)心率的調(diào)節(jié)1.sympatheticnerveexcited→NA↑→combinedwithβadrenoceptor→↑Ifofautorhythmiccell→automaticdepolarization↑→autorhythmicityofSN↑,HR↑.交感神經(jīng)興奮→去甲腎上腺素↑→和β腎上腺素受體結(jié)合→↑自律細(xì)胞4期的跨膜內(nèi)向電流If

→4期自動(dòng)除極↑→SN自律性↑，心率↑。2.Vagusnerveexcited→Ach↑→combinedwithMcholinoceptor→theopeningvelocityofK＋channel↑→K＋efflux↑→theabsolutevalueofMRP↑andIKattenuation↓→automaticdepolarization↓→autorhythmicityofSN↓,HR↓.迷走神經(jīng)興奮→Ach↑→和M型膽堿受體結(jié)合→↑K＋通道開放速率→K＋外流↑→最大復(fù)極電位絕對(duì)值↑，IK衰減↓→自動(dòng)去極化速度↓→SN自律性↓，心率↓。調(diào)節(jié)因素心室前負(fù)荷(異長(zhǎng)自身調(diào)節(jié))心肌收縮能力（等長(zhǎng)自身調(diào)節(jié)）心室后負(fù)荷（動(dòng)脈血壓）定義心肌初長(zhǎng)度改變對(duì)心室搏出量的影響。心肌收縮能力改變對(duì)心室搏出量的影響。心室收縮射血過(guò)程中所遇到的負(fù)荷對(duì)搏出量的影響。表現(xiàn)形式一定范圍內(nèi),心舒末期容積增大,初長(zhǎng)度增加,收縮加強(qiáng),使搏出量增加。心肌收縮能力增強(qiáng)，搏出量增加心肌收縮能力減弱,搏出量減少。一定范圍內(nèi)血壓升高，心輸出量不下降。血壓過(guò)高心輸出量減少。調(diào)節(jié)機(jī)制初長(zhǎng)度的增加,可使心肌肌小節(jié)中粗細(xì)肌絲有效重疊程度增加?；罨瘷M橋數(shù)多,ATP酶活性高,橫橋與肌纖蛋白結(jié)合體的數(shù)量多,心肌收縮能力強(qiáng)。后負(fù)荷增加,心室收縮速度減慢,射血期縮短,心肌收縮遇到阻力增大。影響因素充盈時(shí)間長(zhǎng)回心血多或剩余血多心舒末期容積大。心肌伸展小靜息張力大,抵抗過(guò)度延伸。兒茶酚胺,強(qiáng)心藥,交感神經(jīng)興奮,收縮能力增強(qiáng)。缺02、ACh、酸中毒、心衰，心肌收縮能力下降。心臟的負(fù)擔(dān)加重，長(zhǎng)時(shí)間作用可致心肌肥厚、心室擴(kuò)大。IV.Cardiacreserve

心力儲(chǔ)備Theabilityofcardiacoutputincreasingwiththestrengtheningofbodymetabolismiscalledcardiacreserve.心力貯備指心輸出量隨機(jī)體代謝而增加的能力。

Heartratereserve心率儲(chǔ)備（約2倍）

Strokereserve:搏出量?jī)?chǔ)備（約2倍）

Diastolicreserve

收縮期儲(chǔ)備（55-60ml）

Systolicreserve

舒張期儲(chǔ)備（15ml）

Adultrestingstatestrongphysicallabor

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