10/13/2013 7:17:00 PM Describe the physical layout of the heart within the middle mediastinum (heart borders and

surface anatomy)

Heart Borders & Surface Anatomy

Arch of aorta Left pulmonary a.

Left border - Formed by left ventricle

Arch of aorta

Right border -Right atrium, SVC and IVC

Apex of Heart
- Formed by the left ventricle - Lies deep to 5th intercostal space - Handbreadth from midline

Radiographic appearance of heart

- The Base of the Heart is posterior and opposite to the apex - Formed from mainly the left atrium and part of the right atrium - T5-T8 Vertebrae - Receives (R/L) pulmonary veins on its left atrial portion - Receives SVC and IVC on its right atrial portion

e left atrium and partly

heart

apex. 8 vertebrae. and partly rt veins (R & L) on its left

of its right atrial part.

partly L) on its left trial part.

tral valve insufficiency

(CR) Mitral valve insufficiency

disorder. Mitral valves leaflet disorder ts left Esophagus Blood regurgitates back into the left atrium nto atrium. art . the left The left atrium dilates which causes compression of the esophagus = dysphagia ufficiency Thoracic kely to compress aorta hagia.
Esophagus Thoracic aorta Esophagus Thoracic Anatomical orientation of Heart aorta
Heart Borders Right= right atrium Left= left ventricle Anterior/sternocostal= right ventricle Posterior/base= left atrium Superior= atria and auricles, great vessels

atrium. ency press

Pericardium

ng the heart ssels.

don of

Describe the pericardium: composition, sinuses, blood and nervous supply and clinical implications regarding this structure. The pericardium is a fibrous membrane that covers the heart and the origins of the great vessels. Contains 3 layers: i) Fibrous Pericardium: Attached to the central tendon of diaphragm and sternum pericardium. ii) Serous Pericardium (Parietal Layer) iii) Serous Pericardium ( Visceral Layer) epicardium

pericardium

d visceral m.

dial cavity. elium.

There is a Pericardial Cavity: Space between parietal and visceral layer Pericardial Fluid that is contained within the Pericardial Cavity. Secreted by Serous Mesothelium

Pericardium

he heart s.

nuses

of

and

cardium.
Pericardial Sinuses:

cardium

he verlying

Pericardial sinuses Transverse sinus: Transverse sinus: -A passage behind the ascending o Passage behind ascending aortaaorta and and pulmonary trunk
Oblique sinus: Oblique sinus: o Posterior to the heart -Located posterior to the heart.
-Reflection of of pericardium surrounding the the pulmonary veins, IVC and pericardium o Reflection pericardium surrounding pulmonary veins, IVC and pericardium overlying overlaying the esophagus the esophagus. pulmonary trunk.

ceral

T O

T
Looping of primordial heart Embryology

T O

Clinical Relevance:

cavity. m.

(CR) Transverse

A ligature is passed through the Transverse sinus to clamps Ascending aorta and Pulmonary trunk Sinus clamp Ascending Aorta and Pulmonary during to cardiac surgery.

Trunk during Cardiac surgery

rse sinus ry trunk

Blood Supply and Innervation of the Pericardium:

Arterial Supply o Branch of the Internal Thoracic Artery. Pericardiacophrenic Artery Musculophrenic Artery o Branch of Thoracic Aorta Bronchial Esophogeal Superior Phrenic o Coronary Artery (to visceral layer) Venous Drainage o Pericardiacophrenic Vein o Azygous venous system tributaries Nervous supply o Phrenic Nerves (C3, C4, C5) o Vagus via cardiac plexus o Symphathetic trunks

Supply and Innervation of Pericardium

Internal thoracic artery

upply

es of Internal Thoracic A.

cardiacophrenic a. culophrenic a.
Pericardiacophrenic artery & vein And Phrenic nerve

es from thoracic aorta

nchial phogeal erior phrenic

Vagus nerve

ary arteries (to visceral layer)

drainage

diacophrenic v. s venous system tributaries

supply
o

c nerves (C3, C4, C5) nerves (via cardiac

(CR) Pericarditis: Inflammation Pericardial Friction Rub, sounds like rustle of silk (CR) Pericardial Effusion: Fluid from pericardial caps into pericardial cavity (pus accumulation) (CR) Cardiac Tamponade (heart compressions): Result from extensive pericardial effusion (poor pericardiocentesis) o Compressed volume doesnt allow the heart to fully expand -> limit amount of blood the heart receives -> decrease CO o Hemopericardium blood in the pericardial cavity

Symptom BECKs TRIAD i. Hypotension ( due to decrease in CO, caused by decrease stroke vol) ii. Jugular Venous Distension iii. Muffled Heart Sounds (CR) Pericardiocentesis: Withdraw of fluid from the pericardial sac at 5/6th intercostal space near sternum, close to the infrasternal angle

Describe the 4 chambers of the heart: what structures are found within each chamber (egsimilarities and differences between right and left ventricles) and any associated embryological origins/remnants.

Heart Chambers
Left atrium

Right atrium

Right Ventricle

Left ventricle

Right Atrium: Receives Venous blood from four vessels i. Superior Vena Cava ii. Inferior Vena Cava iii. Coronary Sinus iv. Anterior Cardiac Veins

ight atrium
SVC Sinus venarum IVC

Auricle Crista terminalis

enous blood (poorly d) from 4 sources ior vena cava or vena cava nary sinus ior cardiac veins

Pectinate muscle Crista terminalis narum (smooth pt) Opening of es venous blood pt) (poorly e muscle (rough coronary sinus o ated) from 4 sources SVC rminalis (separates Adult structure Embryologic origin perior vena cava from smooth pt) Internal structures Sinus o Sinus Sinus Venarum the smooth Sinus portion venosus of the chamber y= sulcus terminalis venarum erior vena cava venarum Embryological Origin: Sinus Venosus Trabeculated pts. Primitive atrium valis ronary sinus o Pectinate muscle the rough portion of the chamber ovalis Foramen ovale IVC terior cardiac veins Fossa Embryological Origin: Primitive Atrium

pect Right

atrium

Auricle

Fossa ovalis

o Crista Terminalis Separates the rough portion from the smooth portion. (external portion of the Crista Terminalis = the Sulcus Terminalis) Fossa ovalis Pectinate muscle s venarum (smooth pt) o Fossa Ovalis Opening of Embryological Origin: Foramen Ovale nate muscle (rough pt) coronary sinus o Auricle

aspect

a terminalis (separates h pt from smooth pt)nally= sulcus terminalis a ovalis le

Right Ventricle:

Adult structure Sinus venarum Trabeculated pts. Fossa ovalis

Embryologic origin Sinus venosus Primitive atrium Foramen ovale

carneae (rough pt)

Right ventricle

iosus/ infundibulum

pulmonary trunk e pulmonary valve

Pulmonary valve Conus

alve endineae muscles (3) or, Posterior, Septal

Trabeculae carneae (rough pt) arteriosus

Right v

nal trabeculae and) right branch of the AV

Papillary Conus arteriosus / infundibulum S muscle (smooth pt) P A Leads to pulmonary trunk Tricuspid valve Chordae through the pulmonary valve Embryologic origin tendineae Bulbus cordis Primitive ventricle Septomarginal Trabeculae carneae Tricuspid valve trabecula Trabeculae Carneae tendineae rough portion Chordae o Embryological Origin: Primitive Ventricle Papillary muscles (3)Portion Conus Arteriosus/Infundibulum Smooth o Leads to pulmonary trunk through the pulmonary valve Anterior, Posterior, Septal

o Embryological Origin: Bulbus Cordis

Tricuspid Valve Septomarginal trabeculae o Chordae Tendineae (Moderator band) o Papillary Muscles 1. Anterior Contains right branch of the AV 2. Posterior bundle 3. Septal Septomarginal Trabeculae (Moderator Band) o Contains right branch of the AV bundle o

Adult structure

Tricuspid valve Chordae Embryologic origin tendineae Bulbus cordis Primitive ventricle

Conus arteriosus Trabeculated pts.

Pulmonary Trunk:

Trabeculae carne

Take poorly oxygenated blood from the right ventricle to lungs o Divide to right and left pulmonary arteries

Divides into right and left pulmonary arteries.

Left pulmonary artery Left pulmonary artery

artery

Righ pulmo

nary 2

s blood (rich in ulmonary d (rich and 2 in

atrium eftLeft atrium

o Left Atrium:

Pulmonary Trunk

Posteroinferior view

Auricle

Auricle

wall portion uscular portion m

ortion portion ression (floor of

oval fossa
Adult structure

ns pectinate

Floor of Fossa ovalis

Pulmonary veins

inate g ridge)

Embryologic origin

Receives venous blood O2 rich, from 4 pulmonary Pulmonary venousveins (2 superior and 2 inferior) Left atrium

n (floor of

ossa )

Adult structure Left atrium

tissue Internal Aspect o Large smooth wall portion Floor of and smaller muscular portion than the right atrium Pulmonary o Auricle has pectinate muscles Fossa ovalis o Semilunar depresson floor of foosa ovalis veins Valve of the oval fossa (surrounding ridge)

Embryologic origin Pulmonary venous tissue

Left Ventricle:

Left ventricle
Papillary muscles

Aortic vestibule

icle

e (rough pt) mooth pt) a through

A P
Bicuspid valve Trabeculae carneae Chordae tendineae

alve eae s (2) Posterior

Internal aspect o Trabeculae Carneae - rough portion o Aortic Vestibule smooth portion Leads to Aorta through aortic valve o Bicuspid Mitral Valve Choradae Tendineae Papillary Muscles 01. Anterior Aortic valve opened 02. Posterior Thicker wall than Right Ventricle

Valves: Tricuspid Valve o RA to RV Pulmonary/pulmonic Valve o RV to Pulmonary Trunk Mitral Valve (bicuspid) o LA to LV Aortic Valve o LV to Aorta

Valves

lmonic valve
trunk

bicuspid one)

In the diagram it shows the coronary arteries feeding into the aortic valve Diagram the flow of blood through the heart.

Heart in Circulation System

Pulmonary Circulation

Right side receives (oxygen poor) blood via SVC and IVC from the body and tissues.

- Pumps blood to the lungs t pick up oxygen and dispel carbon dioxide.

Systemic Circulation

Left side receives oxygenate blood (oxygen rich) returning from the lungs.

- Pumps this blood throughou the body via aorta.

Blood Flow Through the Heart Initially there is inflow from the Superior Vena Cava towards the Atrial Ventricular Orifice. There is also inflow from the Inferior Vena Cava towards the Fossa Ovalis

Blood Flow Through the Heart

Pulmonary valve

Fossa ovalis
AV orifice

From the right atrium to the right ventricle the flow is right to left via the tricuspid valve Tricupsid valve Inflow from due to the orientation of the heart. Mitral valve SVC directed From the The right ventricle the flow takes a U-turn andright is directed superior to the pulmonary valve. towards the AV Inflow into left atrium to the right orifice. atrium from 4 ventricle, the flow is pulmonary veins is right-to-left via the

Blood Flow Through the Heart

Pulmonary valve

Fossa ovalis
AV orifice

Tricupsid valve nflow from Mitral The inflow into the the left atrium from the 4 pulmonary veins ( 2 superior 2 valve inferior) is od Flow Through Heart directed From the right downward and left ards the AV Pulmonary valve Inflow into left atrium to the right Inflow from Lt at ce. atrium from 4 ventricle, the flow is into Lt. ventricle pulmonary veins is right-to-left via the thru the Mitral v flow from IVC downward and to Tricupsid valve. the flow makes a cted towards the left. turn directed Fossa ovalis. In right ventricle, superiorly. the flow takes a U turn and is directed Outflow is from psid valve superiorly towards valve left ventricle the PulmonaryMitral valve. m the right toward its apex from the left atrium into the left ventricle is through the bicuspid Mitral Valve. The into left to the right InflowInflow flow makes a U-turn directed superiorly Inflow from Lt atrium Aortic valve. atrium from 4 le, the flow is Outflow is from left ventricle towards its into the apex/Aortic Valve Lt. ventricle is pulmonary veins is o-left via the thru the Mitral valve; downward and to id valve. the flow makes a U the left. turn directed ght ventricle, superiorly. w takes a U nd is directed Outflow is from the orly towards left ventricle monary valve.

toward its apex or Aortic valve.

hrough the Heart

valve

Mitral valve

Inflow into left Cardiac Cycle and Valves: Inflow from Lt atrium atrium from 4 into Lt. ventricle Cardiac and Valvesis pulmonary veins is Cycles thru the Mitral valve; downward and to the flow makes a U the left. turn directed superiorly.
Early & during diastole Outflow is from the (AV valves Opens) ventricle produce Dubleft sound) Diastole toward its apex or Systole Aortic valve. http://www.youtube.com/
watch?v=NeMJXMSkA7g

Beginning of diastole (Closure of A & P valves

Late diastole (Atrial contraction)

During systole (Opening of A & P valves)

Beginning of systole (High ventricular pressure close AV valves produce Lub sound)

Differentiate between heart valves placement and auscultation.

Heart valves location vs auscultation sites

Location (white circles)
Aortic- medial aspect of left 3rd intercostal space, behind sternum Pulmonic- medial aspect of left 3rd costal cartilage Tricuspid- medial aspect of right 5th costal cartilage, behind sternum
Mitral- medial aspect of left 3rd intercostal space

Auscultation site (red circles)

Aortic- 2nd intercostal space, right parasternal

Pulmonic- 2nd intercostal space, left parasternal Tricuspid- 5th intercostal space, left parasternal Mitral- 5th intercostal space, left midclavicular line

Mnemonic: All Physicians Take Money Auscultation site are the areas where the sound is most clear, not where the valve is located (CR) Valvular Heart Diseases Insufficiencies: failure of valve to close completely Stenosis: failure of the valves to fully open Describe the coronary arteries: their branches and anastomoses between the different arteries, dominance of the heart, disease processes associated with the coronary arteries. Vasculature of the Heart: Coronary Arteries o Right and left First the branches of the aorta o Arise from Rt and Lt aortic sinuses Cardiac Veins o Great o Middle

o Small Cardiac Veins o Coronary Sinus (walls made of cardiac muscle not smooth) Right coronary artery Anterior view o Thebesian Cardiac Veins Contains 4 branches Right Coronary Artery: 4 Branches o SA Node o Right Marginal o AV Node o Posterior Interventricular
SA nodal AV nodal Posterior interventricular Right marginal
SA node

Posterior view

AV node

Supplies blood to o Right atrium o Right ventricle o Posterior 1/3 of interventricular septum o SA and AV nodes Left Coronary Artery:

Right marginal

RCA supplies: right atrium, right ventricle, post. 1/3interventricular septum, SA and AV nodes.

Anterior R RV LV L

RCA supply= Dark pink

2 Branches o Anterior Interventricular (left anterior descending) A branch off the interventricular = the Diagonal Branch o Circumflex A branch off the circumflex = Left Marginal Supplies blood to: o Left atrium o Left ventricle o Portion of the right ventricle o Anterior 2/3 of interventricular septum o AV node o SA node in 40%

Breakdown of specific coronary artery branches and their location of supply to the heart
Artery (source) Distribution Anastomoses

SA nodal (RCA)
Right marginal (RCA)

Pulmonary trunk; SA node

Rt ventricle; apex of heart Interventricular (IV) branches Anterior interventricular br. of LCA (at apex) Posterior interventricular br. of RCA (at apex) RCA IV branches

Posterior Rt. and Lt. ventricles; interventricular (RCA) posterior 1/3 of Interventricular septum

AV nodal (RCA)
Anterior interventricular/ LAD (LCA) Circumflex (LCA) Left marginal (LCA)
Coronary Collateral Circulation:

AV node
Rt. And Lt. ventricles; anterior 2/3 of Interventricular septum Lt. atrium; Lt. ventricle Lt. ventricle

Anastomoses at the apex o Left Interventricular artery (Left Coronary Artery Branch) -> Posterior Interventricular artery (Right Coronary Artery Branch) Anastomoses at the sulcus o Left Circumflex artery ( Left Coronary Artery Branch) -> Right Coronary Artery

Describe the venous drainage of the heart.

Venous Drainage of the Heart

TWO pathways: 1. Coronary Sinus and it tributaries Great cardiac vein, Small cardiac and Middle cardiac veins Two Pathways:
Coronary Sinus ( w/ tributaries) 2. Anterior cardiac veins drain directly into the right atrium o Great Cardiac Vein o Small Cardiac Vein Anterior view Venous TWO pathways: o Middle Cardiac Vein

Posterior view Drainage of the Heart

Anterior Cardiac Vein Great cardiac vein, Small cardiac and Middle cardiac veins o Drain into right atrium 2. Anterior cardiac veins drain directly into the right atrium Great cardiac
Anterior view

1. Coronary Sinus and it tributaries

Coronary sinus Small cardiac vein

Coronary sinus Small cardiac vein

vein
Great cardiac vein

Posterior view

Coronary sinus
Coronary sinus

Middle cardiac vein Middle cardiac

vein

Vein
Small cardiac vein Great cardiac vein Coronary sinus

o o

Small cardiac vein

Small cardiac vein

Vein
Small cardiac vein Great cardiac vein

Runs with Runs with Right marginal artery

Anterior interventricular artery (LAD)

Middle cardiac vein Posterior interventricular artery

Right marginal artery

Middle cardiac veinCoronary Posterior interventricular artery sinus Circumflex artery Circumflex artery

Anterior interventricular artery (LAD)

(CR) Coronary Atherosclerosis Lipid deposits in the tunica intima of coronary arteries (CR) Myocardial infarction sudden occlusion of major artery Artery becomes infarcted and then necrotic Commonly due to atherosclerosis

LAD = 40-50% RCA = 30-40% Circumflex = 15-20% (CR) Coronary Angioplasty Catheter with balloon tip. Flattens Plaques (CR) Thrombolytics Time Sensitive (CR) Intravascular Stent

 Placed after dilation of vessel. Maintain dilation Clinical Relevance: (CR) Coronary Artery Bypass Graft

Coronary Artery Bypass Graft (CABG)

Arteries and veins from else where to reroute blood flow to heart elsewhere n i potients bdy used a Arterial Stenosis or Arterial Atresia to reroute blood flow to the heart o Arterial Provide a detour around the Arterial stenosis OR Arterial atresia Internal Thoracic Radial Arterial Gastroepiploic Internal thoracic, radial, Inferior epigastric gastroepiploic, inferior
epigastric o Venous Great Saphenous Venous Great saphenous, small Small Saphenous saphenous

Arteries and veins from

Explain the location of the structures that are involved with the conduction system of the heart.

Conduction System of Heart

Conduction system structure

Sinuatrial (SA) node Bachmanns Bundle Atrioventricular (AV) node Bundle of His Right bundle branches Left bundle branches Purkinje fibers (subendocardial brs.) Right to Left atrium

Location within the heart

Located in the Rt. atrium between Crista terminalis and opening of SVC

Located in the Rt atrium at interatrial septum close to the opening of coronary sinus. Membranous pt. of interventricular (IV) septum Muscular IV septum, moderator band, wall of R. ventricle Muscular IV septum, wall of L. ventricle Right side- IVS, wall of R. ventricle, Ant. papillary muscle Left side- IVS, wall of L. ventricle, Ant. and Post. papillary muscle

(CR) Damage of Conducting System Cause Ischemia LAD -> AV buddle branch RVC -> SA node and sometimes AV Ventricles contract Independently

Unilateral damage of bundles -> late asynchronous contraction of ventricles (CR) Pacemakers Replaces SA node Pathway of the pacemaker in the heart: Left Subclavian vein -> left brachiocephalic vein >Superior Vena Cava -> Right atrium -> right ventricle (Trabeculae Carneae) Explain the innervation of heart and the concept of Heart referred pain.

Innervation of th

1. Pa - Slow

2. Sy - Incr

Parasympathetic o Vagus Sympathetic o Presynaptic (T1-T4) o Postsynaptic Cervical and Superior Thoracic Ganglia Visceral Afferent o With Sympathetic o Transmit Noxious stimuli Pain from heart to visceral afferent, travel with sympathetic Perceived as peripheral pain Enters spinal cord through same posterior dorsal root with somatic sensory fibers Pain in: o Medial upper limb o Neck o Shoulder o Jaw o Pain through intercostobrachial nerve

- Pres - Pos thora

3. Vis - Trav fibers - Tran from

Specific functions o covered in details i

Visceral Afferent

Visceral Afferent

Clinical Relevance:

n from heart is transmitted visceral afferent (VA) rs which travel with the mpathetic fibers.

Cardiac Referred Pain

ious stimuli originating m the heart is perceived as n arising from superficial .

enter the spinal cord ugh the same posterior sal) root with somatic sory fibers. From Thoracic Lecture Intercostobrachial nerve

nterpreted as coming from c sensory nerves)

where pain is referred: dial upper limb, k, ulder &

10/13/2013 7:17:00 PM

10/13/2013 7:17:00 PM