0103 10am B3T1

Anatomy of the Heart & Pericardium [Arslan]

Learning Objectives: 1. Discern the layers of the pericardium, innervation and associated sinuses a. The heart is surrounded by the pericardium. i. The brous pericardium is the outermost layer. It is separated from the mediastinal pleura of the lungs by the phrenic nerve and the pericardiophrenic vessels. 1. Pericarditis or pleuritis may lead to referred pain in dermatomes C3-5 due to inammation of the phrenic nerve ii. The serous pericardium underlies the brous pericardium and consists of two layers, the parietal which directly underlies the brous and the visceral (aka epicardium) which directly overlies the heart. The two serous layers are divided by the pericardial cavity.

b.

Pericardial sinuses are reections of the parietal serous pericardium around major vessels. There are two - the oblique sinus which is bounded by the pulmonary veins and superior and inferior vena cavae, and the transverse which is bounded by the pulmonary trunk/ascending aorta anteriorly and atria posteriorly.

2.

Describe the anatomic basis of cardiac tamponade a. Cardiac tamponade is the compression of the heart due to accumulation of uid (pericardial effusion) in the pericardial cavity. It can be caused by pericarditis. i. The compression of the heart muscle minimizes its ability to contract, and is characterized by weak/rapid pulse, dyspnea, JVD, and reduced cardiac output.

3.

Explain the characteristics and relationships of atria and ventricles a. The heart consists of two atria and two ventricles. b. The interatrial septum separates the two atria c. d. e. f. The interventricular (membranous and muscular parts) separates the two ventricles The atrioventricular separates the left ventricle from the right atrium The coronary sulcus is between the atria and ventricles, and contains the coronary sinus, beginnings of the coronary arteries, and the small cardiac vein. The interventricular sulci are between the ventricles. The anterior i.s. contains the left anterior descending (LAD) artery (aka anterior interventricular artery of the left coronary artery) and the great cardiac vein. The posterior i.s. contains the posterior interventricular artery of the right coronary artery and the middle cardiac vein. Right atrium i. Derived from the sinus venarum and primitive atrium which are separated by the crista terminalis that contains the sinuatrial (SA) node. 1. The sinus venosus receives the superior/inferior vena cavae and coronary sinus. It contains the fossa ovalis. a. The inferior v.c. and coronary sinus openings are guarded by the eustachian and thebesian valves, respectively. h. 2. The primitive atrium contains pectinate muscles and right auricle Right ventricle i. Made up of proper right ventricle (inow) and pulmonary vestibule (infundibulum) (outow) separated by supraventricular crest 1. Proper right ventricle: trabeculae carnea; anterior/posterior/septal papillary muscles connected to the tricuspid valve (separates right atrium from ventricle) cusps via chordae tendinea; trabeculae septomarginalis 2. (transmits right branch of AV bundle) Infundibulum: continues with pulmonary trunk guarded by semilunar pulmonary valve which divides into right/left pulmonary arteries, the left being connected to the aortic arch via the ligamentum arteriosum a. Pulmonary hypertension = pulmonary artery wall and its smaller vessels become damaged, resulting in narrowing of the lumen and hypertrophy of R. ventricle and restricting blood ow to lungs exertional dyspnea

g.

0103 10am B3T1

Anatomy of the Heart & Pericardium [Arslan]

i. Left atrium i. ii. Left auricle; receives pulmonary veins; Lies anterior to esophagus 1. Mitral stenosis dilation of left atrium compression of esophagus (and bronchi) dysphagia (and dysp-

j.

nea) Left ventricle i. Made up of proper left ventricle (inow) and aortic vestibule (outow) 1. Proper left ventricle: trabeculae carnea; anterior/posterior papillary muscles connected to mitral (bicuspid) valve (connection to left atrium) via chordae tendineae a. Mitral stenosis (see above) b. Mitral valve prolapse Aortic vestibule: leads to ascending aorta guarded by semilunar aortic valve which surrounds the 3 aortic sinuses (of Valsalva), 2 of which contain ostia for the right/left coronary arteries a. Aortic stenosis = usually congenital, associated with hypertrophy of L. ventricle and regurgitation of blood into lungs exertional dyspnea, angina, syncope, cardiac murmur, dec. BP, rising carotid pulse

2.

4.

Verify the role of autonomic nervous system in the transmission of cardiac pain a. Sympathetic segmental contribution is responsible for referred cardiac pain - visceral afferents accompany the sympathetic bers (from T1-T4), the somatic afferents and visceral afferents both travel together in the dorsal root and converge on a single ascending secondary neuron. when the pain travels up the AL tract it is interpreted as originating from the somatic sensory nerves (because pain felt in the skin is more common) leading to the perception of a diffuse referred pain in the T1-T4 dermatomes.

5.

State the areas of distribution of the coronary arteries a. Ascending aorta right coronary artery right marginal and posterior interventricular arteries b. i. R.C. Artery = dominant; supplies SA and AV nodes, posterior and anterior surface of the heart Ascending aorta left coronary artery LAD and circumex i. LAD supplies anterior surface of ventricles, interventricular septum ii. Circumex supplies left atrium and upper left ventricle 1. Gives rise to posterior interventricular artery in left dominant coronary circulation

6.

Describe the course, sites of drainage and relationships of the cardiac veins a. Coronary sulcus: coronary sinus, small cardiac vein b. Anterior interventricular sulcus: great cardiac vein c. Posterior interventricular sulcus: middle cardiac vein

7.

Outline the location of the elements of the conduction system a. b. c. d. Sinuatrial (SA) node - adjacent to crista terminalis of right atrium Internodal tracts - connect SA and AV node Atrioventricular (AV) node - right interatrial septum, adjacent to ostium of coronary sinus Bundle of His - along posterior border of membranous interventricular septum i. Divides into left and right branches that perfuse the ventricles

0103 10am B3T1

Anatomy of the Heart & Pericardium [Arslan]

Notes: 1. Heart & Pericardium a. Heart is invested by the pericardium, which consists of brous and serous pericardium i. Fibrous pericardium 1. continues with the adventitia of aorta and pulmonary trunk 2. connected to the sternum via the sternopericardial ligaments 3. separated from the mediastinal pleura (medial side of lungs) by the phrenic nerve and pericardiocophrenic vessels a. Pain due to pericarditis and pleuritis may project to dermatomes C3, C4 & C5 (due to inammation of the phrenic nerve) ii. Serous pericardium 1. Consists of parietal & visceral (epicardium) layers separated by the pericardial cavity a. Pericardial effusion due to pericarditis --> lls the pericardial cavity --> cardiac tamponade (compression of heart due to accumulation of uid; characterized by weak and rapid pulse, dyspnea, JVD (jugular venous distention), reduced cardiac output) 2. Pericadiocentesis a. Aspiration of pericardial content is accomplished through subcostal or parasternal route to ensure that damage to the left anterior descending and right marginal arteries as well as the pleural cavity (pneumothorax) is avoided b. In subcostal approach, a needle is introduced through the left xiphisternal angle (45) c. In parasternal route, a needle is introduced through the left 3rd or 4th intercostal space, lateral to the internal thoracic artery 3. Pericardial Sinuses (contain nothing) a. Recesses formed by reections of the parietal layer of the serous pericardium around major vessels of the heart: i. Oblique: bounded by the pulmonary veins and superior and inferior vena cava ii. Transverse: lies between the ascending aorta and pulmonary trunk anteriorly and the atria posteriorly 1. used to place a ligature around the pulmonary trunk and aorta to stop circulation and to insert coronary bypass machine

0103 10am B3T1

Anatomy of the Heart & Pericardium [Arslan]

4. Heart a. Located in the middle mediastinum, medial to the lungs, posterior to the thymus, sternum and 3rd to 5th costae, and anterior to the esophagus and descending aorta b. Consists of atria & ventricles separated by the coronary sulcus c. has a base, apex, sternocostal and diaphragmatic surfaces i. Base- consists of left atrium & small portion of the right atrium ii. Apex- left ventricle, lies posterior to the 5th intercostal space at the point of intersection with the midclavicular line- Apical pulse (PMIpoint of maximal impulse) below the nipple iii. Sternocostal surface- formed mainly by the right ventricle with small contribution from the left ventricle iv. Diaphragmatic surfaceformed primarily by the left ventricle with small contribution from the right ventricle d. Heart exhibits two sets of sulci i. coronary sulcus- separates atria from ventricles 1. contains the coronary sinus posteriorly, initial part of coronary arteries, and the small cardiac vein ii. Interventricular sulci are divisible into: 1. Anterior Interventricular sulcus: contains the anterior interventricular artery and great cardiac vein 2. Posterior interventricular sulcus: contains the posterior interventricular artery and middle cardiac vein e. Right atrium i. Derived embryologically from the sinus venarum and primitive atrium, which are separated by the crista terminalis - contains the sinuatrial node ii. Primitive atrium- contains pectinate muscles and auricle (potential site of thrombi) iii. Fossa ovalis - remnant of foramen ovale iv. Sinus venosus receives the superior and inferior vena cavae, and coronary sinus v. Inferior vena cava and coronary sinus openings are guarded by a primitive (Eustachian &Thebesian) valves, respectively 4

0103 10am B3T1

Anatomy of the Heart & Pericardium [Arslan]

f. Right ventricle i. Consists of the proper ventricle and the vestibule (infundibulum), which are separated by the supraventricular crest 1. Proper right ventricle (inow) contains: a. Trabeculae carnea b. Ant., post. & septal papillary muscles connected via chordae tendinea to the cusps of tricuspid valve that guards the right atrioventricular orice i. Trabeculae septomarginalis (moderator band) 1. extends from the base of anterior papillary muscle to the septal wall 2. transmits the right branch of AV bundle 2. Infundibulum (pulmonary vestibule) represents the outow part of right ventricle a. continues with the pulmonary trunk guarded by the semilunar pulmonary valves b. Pulmonary trunk divides into R & L pulmonary arteries. Left pulmonary artery is connected to the aortic arch via the ligamentum arteriosum (remnant of ductus arteriosus)

g. Pulmonary Hypertension

i. ii.

An obliterative condition that affects small and medium pulmonary arteries Hyperplasia and scar tissue narrowing of the lumen increased pulmonary arterial pressure increased resistance to blood ow to the lungs alveolar hypoxia iii. Associated with hypertrophy of the R-ventricle and shrinkage of the L-ventricle iv. Exertional dyspnea is common, however syncope and substernal angina may also be seen

0103 10am B3T1

Anatomy of the Heart & Pericardium [Arslan]

h. Left atrium i. extends as the left auricle, which is the potential site of thrombi ii. receives the pulmonary veins iii. lies anterior to the esophagus 1. mitral stenosis results in dilation of the left atrium, compression of the esophagus, and the resultant dysphagia i. Left ventricle i. Consists of the proper left ventricle & aortic vestibule 1. Proper ventricle contains: a. Trabeculae carnea b. Anterior and posterior papillary muscles, which are connected to the bicuspid valve via the chorda tendinea 2. Aortic vestibule a. Located superior to and to the right of the mitral valve- leads to the ascending aorta i. Ascending aorta- located in the middle mediastinum; contains the aortic (of Valsalva) sinuses and valves Aortic Stenosis i. Congenital except when the valve undergoes sclerosis as a result of endocarditis ii. Associated with left ventricular hypertrophy and increase pressure in LV and regurgitation of blood into the lungs iii. Patients exhibit dyspnea on exertion (associated with regurgitated blood in the lung), angina (chest pain- due to insufcient blood in the heart) and syncope (reduced blood to the brain) iv. Physical exam reveals cardiac murmur, decrease in blood pressure, and rising carotid pulse also occur

j.

0103 10am B3T1

Anatomy of the Heart & Pericardium [Arslan]

k. Mitral Valve i. Left ventricle is connected to the left atrium via the left atrioventricular orice guarded by the bicuspid mitral valve ii. Mitral valve stenosis may occur subsequent to rheumatic fever & syphilis dilation of the left atrium and pulmonary veins compression of esophagus & bronchi dysphagia & dyspnea iii. Mitral Valve Prolapse 1. Protrusion of the mitral valve into the left atrium a. familial condition b. most common cardiac problem (5-25% ) c. Affect all ages; women are predominantly affected d. patients exhibit chest pain, shortness of breath, anxiety and/or panic attacks, low exercise tolerance, chronically cold hands and feet, numbness or tingling of the arms or legs and difculty swallowing Cardiac Septae (3) i. Interatrial septum - separates the atria (contains fossa ovale) ii. Interventricular septum- separates the ventricles 1. Membranous part- common site of VSD 2. Muscular part iii. Atrioventricular septum- separates the right atrium from the left ventricle

l.

m. Cardiac Skeleton i. Maintains patency of the AV and semilunar valves ii. Provides attachment to cardiac muscles and cusps of the cardiac valves iii. Secure independent contraction of the atria and ventricles iv. Consists of: 1. Fibrous trigones 2. Right and left atrioventricular rings 3. Aortic ring 4. Pulmonary ring

0103 10am B3T1

Anatomy of the Heart & Pericardium [Arslan]

n. Cardiac Layers i. Epicardium- composed of mesothelial cells and contains adipose tissue and cardiac vessels and nerves ii. Myocardium- consists of specialized skeletal (cardiac) muscles that attach to the skeleton of the heart iii. Endocardium- lines the heart, consists of endothelial cells 1. thickening of the endocardium contributes to the formation of the cardiac valves 2. contains elements that mediate cardiac conduction o. Conduction System i. Maintains autorhythmicity of the myocardial muscle contraction ii. Consists of the: 1. Sinuatrial (SA) node located adjacent to the crista terminalis 2. Internodal tracts connect the SA and AV nodes 3. Atrioventricular (AV) node lies in the right interatrial septum, adjacent to the ostium of coronary sinus 4. Atrioventricular (HIS) bundle a. descends along the posterior border of the membranous interventricular septum b. divides into left and right branches 5. Cardiac Plexus a. Consists of i. parasympathetic bers that emanate from the vagus nerve ii. sympathetic bers- that arise from T1-T4(T5) b. Sympathetic segmental contribution is responsible for referred cardiac pain 6. Coronary Arterial Ischemia a.Pain associated with ischemia induced coronary artery occlusion refers to the precordium (angina pectoris), epigastrium, shoulder, jaw, and frequently, left arm

0103 10am B3T1

Anatomy of the Heart & Pericardium [Arslan]

7. Ascending Aorta a. Lies on the right side of the pulmonary trunk b. Forms a content of the middle mediastinum c. Constitutes the anterior wall of the transverse pericardial sinus d. Gives rise to the right and left coronary arteries e. Ascending aorta is guarded by the aortic semilunar valve that surround aortic sinuses f. Two of the aortic sinuses contain ostia (openings) for the right and left coronary arteries 8. Right Coronary Artery a. Dominant artery b. Supplies the SA and AV nodes, posterior (and anterior) surface of the heart c. Gives rise to the right marginal and posterior interventricular branches d. Dominance of a coronary artery is determined by the origin of the posterior interventricular artery 9. Coronary Arteries a. Left coronary artery- gives rise to the LAD and circumex branches i. Anterior interventricular artery (LAD) supplies the anterior surfaces of ventricles and interventricular septum ii. Circumex artery- supplies the left atrium & upper left ventricle and gives rise to the posterior interventricular artery in left dominant coronary circulation