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Applied Cardiac Anatomy

Jui-Sung Hung, MD, FACC, FAHA


Cardiovascular System

Structure and Function


() (Means)
Mechanical
() 1. (history)
2.
Intricate (physical Exam)
interactions
3.
Electrical Perfusion (laboratory tests)
() () Proper ()
Timely ()
Neuro-humoral regulations
Autonomic nervous system
Endocrine-humoral catecholamines,
RAS, natriuretic peptides, endothelin etc.

*
(Imagings)*
Physical Exam in CV System
Cardiac Cycles 1. Hemodynamic
Pressure
2. Volumetric flow
3. Hemodynamic
resistance
4. Compliance
5. Laplace law
6. Poiseuilles Law

Applied Anatomy Applied Physiology and Hemodynamics

Fundamentals in Clinical Cardiology

*ECG, radiographs, echo, CT, MRI etc.


Frontal View ()

Cross Section
View
()

LA
RA LV
bb RV

RA
RV LV

LA = left atrium; LV = left ventricle; RA = right atrium; RV = right ventricle


Thorax () Anomaly
Impacts on Clinical Diagnosis, PE, and Imaging Tests

1) Diagnostic clues
Barrel chest
(emphysema)
Pectus carinatum* Barrel Pectus Pectus Straight
(pigeon chest); Marfan Chest excavatus carinatum spine
Pectus excavatus*
Marfan 2) Impact on impedance*
Straight spine PE - vibration energy
MVP Low frequency, sonic
Ankylosing spondylitis Electric
Imaging *Left
Left parasternal bulge mastectomy
Ultrasound (ECHO)
Obese or thin chest wall*
Radiation ECG
Left mastectomy** X-ray, CT, MRI Expected findings?
Thorax () Anomaly
Impacts on Clinical Diagnosis, PE, and Imaging Tests

1) Diagnostic clues
Barrel chest
(emphysema)
Pectus carinatum* Barrel Pectus Pectus Straight
(pigeon chest); Marfan Chest excavatus carinatum spine
Pectus excavatus*
Marfan 2) Impact on impedance*
Straight spine PE - vibration energy
MVP Low frequency, sonic
Ankylosing spondylitis Electric
Imaging *Left
Left parasternal bulge mastectomy
Ultrasound (ECHO)
Obese or thin chest wall*
Radiation Tall R in V3-4
ECG
Left mastectomy** X-ray, CT, MRI Expected findings?
Thorax () Anomaly
Impacts on Clinical Diagnosis, PE, and Imaging Tests

1) Diagnostic clues
Barrel chest
(emphysema)
Pectus carinatum* Barrel Pectus Pectus Straight
(pigeon chest); Marfan Chest excavatus carinatum spine
Pectus excavatus*
Marfan 2) Impact on impedance*
Straight spine PE - vibration energy
MVP Low frequency, sonic
Ankylosing spondylitis Electric
Imaging *Left
Left parasternal bulge mastectomy
Ultrasound (ECHO)
Obese or thin chest wall*
Radiation Tall R in V3-4
ECG
Left mastectomy** X-ray, CT, MRI Expected findings?
Echo Windows (Air-free Window)

TTE - 4 Widows
3) Suprasternal

Long axis Short-axis views

1) Parasternal

2) Apical 1) Parasternal Approach


4) Subxyphoid

TEE
Esophsgus

LA

2) Apical Approach
(Landmarks)

Louis angle
Latitude ()
Intercostal
spaces
AA PA
Longitude ()
Parasternal
Mid-clavicular TA
Apex
Axillary line
anterior, mid- *LA
posterior
Mid-clavicular
Line
Pulmonic valve

Aortic valve AA = aortic area


PA = pulmonic area
PV = pulmonic valve
TA = tricuspid area
Angle of Louis (sternal angle)
A palpable clinical landmark
A. Approximate level of
1) Trachial bifurcation (carina)
2) Beginning/end of aortic arch
3) Pulmonary trunk bifurcation
4) Upper SVC margin
5) Azygos vein drainage into
SVC
B. Landmark for:
Estimation of internal jugular venous pressure
Louis angle - 5 cm vertical distance from
mid-RA (zero reference point) Venous pressure
10 cm H2O
5 cm
Supine Louis angle
30 recumbent
Neighborhood Anatomic Relations
Left recurrent Esophagus
laryngeal nerve

Aortic Isthmus
LA
Aortic valve
annulus
Nerve Palsy
Ortner syndrome
Enlarged PA, LA

Aorta, relatively fixed at isthmus in front of vertebra 1) TEE


and aortic annulus 2) Dysphagia
1) Isthmus portion, vulnerable to trauma - transection Enlarged LA
2) Arterosclerotic,aorta, elongated to right and anteriorly;
heart, lying more horizontally
Pericardium Clinical implications
Structures
Two layers Pericarditis w/s
Parietal effusion
Visceral Cardiomegaly
Pericardial reflexion* *Cardaiac tamponade
Functions AO
MPA
*Chronic constrictive
SVC
Cardio-protection pericarditis
RA
Restraining
cardiac volume Hemopericardium/
IVC RV LV
Tamponade
Congenital anomaly Hemorrhage sources
Absent pericardium Cardiac
Partial defect chambers
Strangulation or *Pericardial Reflection coronary vessels
about 2 cm from borders of
Herniation Extra-cardiac*
RA, RV, LV; thus,*proximal
ventricle, atrium aorta, PA,
AO, PA, and distal ends of
cavae in pericardial cavity vena cavae
Cardiac Borders

SVC
AO AO
SVC
AO

LAA

...
MPA SVC MPA
LAA

RA ... RA
LV
RV LV
.. RV
-



AO
PA

LAA
RAA

AO
RV LV
PA

MV

RA
TV LV

RV

Apex
-
(Long-axis) (Short-axis)

Long- Long-
axis axis

Short-
axis RV
Short-
LV axis

Apex

-
Right
PV

AV
AO
PA

RA MV TV

RV LV
PA
A
AV
MV
RA RA (right, anterior, caudal)
TV LV
LA (left, posterior, cephalid)
RV
Apex RV (right, anterior);
LV (left, posterior)
PV (left, anterior, cephalid);
AV (right, posterior, caudal)
Echo Windows (Air-free Window)

TTE - 4 Widows
3) Suprasternal

Long axis Short-axis views

1) Parasternal

2) Apical 1) Parasternal Approach


4) Subxyphoid

TEE
Esophsgus

LA

2) Apical Approach
Neighborhood Anatomic Relations
Left recurrent Esophagus
laryngeal nerve

Aortic Isthmus
LA
Aortic valve
annulus
Nerve Palsy
Ortner syndrome
Enlarged PA, LA

Aorta, relatively fixed at isthmus in front of vertebra 1) TEE


and aortic annulus 2) Dysphagia
1) Isthmus portion, vulnerable to trauma - transection Enlarged LA
2) Arterosclerotic,aorta, elongated to right and anteriorly;
heart, lying more horizontally
Applied Cardiac Anatomy

Case Example
Chest radiogram *PE
Cardiac PE Diffuse
ECG/Radiograph precordial
/Echo Correlates heave
RV rocking
motion
Palpable P2
ECG *PE
PA, Loud, P2

Apex
Echocardiography
D-shape
LV
Coronary Arteries
Right Coronary Artery Left Coronary Artery
Front
LAD
Cx
RCA

RCA Cx
LAD

Back LAD
RCA Cx
LAD

RCA

LAD = left anterior descending artery; RCA = right coronary artery


Cx = circumflex artery
Blood Supplies to Conduction System
RAO
SA node

AV node

His bundle
Right bundle
Right bundle
LAO
Right BB
LAO
Blood supplies Complete AV block in AMI
SA node Inferior MI
55% RCA; AV junctional block;
45% LCX Transient and self limiting
AV node Anterior MI - Large infarct Left bundle (cascade like)
90% RCA; with tri-fascicular block (also
Supeior and Inferior divisions
10%, LCX affecting right bundle);
As a rule, poor prognosis Blood supply: LAD
Application of Vector Concept and Anatomy in ECG

Vector Different vectors


Magnitude with direction

z y A
( x, y, z ) Same vectors A
C
A
B
z
x A

B
y A

x D C

Scaler
Simplely, magnitude; no direction A+B+C=D

Normal ECG

I I

II III II III

aVf aVf Determinants of P wave changes


In hypertrophy of either atrium
1) Depolarization sequence of atria
2) Relative atrial anatomic relations
V1 V1 3) Atrial electrical power shifts
Horizontal Plane Normal QRSs
(-)
S S
R

q (+)
r R
r r
(+) r
(+)

V1 V3 V6

S S q S
Horizontal Plane

LV
o

RVH

RV Normal LVH

o
o
Horizontal Plane - RVH

s V6
o o

R R
R
V2 V6

s S
Posterior MI
() Normal ECG

V1-3R (
)
Horizontal Plane - Anteroseptal MI

R
S S

S
r

R (+)
(+) (+) r

V1 V3 V6
S S S

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