2.02 Gross Anatomy Trans - Heart

2.
02
17, August, 2015 Dr. AGUSTIN | Heart and Related Structures in the Middle Mediastinum
OUTLINE
I. The Mediastinum
II. The Middle Mediastinum
III. Fibrous Pericardium
IV. Serous Pericardium
V. Pericardial Space/Cavity
VI. Pericardial Sinuses
VII. Innervation of the Pericardium
VIII. Pericardial Sac
IX. Functions of the Heart
X. Weight of the Heart
XI. External Features of the Heart
XII. Interatrial Septum
XIII. Interventricular Septum
XIV. Comparison between Right and Left Atrium
THE MIDDLE MEDIASTINUM
XV. Comparison between Right and Left Ventricles
XVI. Atrioventricular Orifices  Boundaries: (based on past trans)
XVII. Valves  Anterior: Fibrous and parietal layers of the pericardium
XVIII. Blood Vessels Terminating in the Heart  Posterior: Fibrous and parietal layers of the pericardium
XIX. Blood Vessels Arising from the Heart  Superior: Horizontal plane through the sternal angle of
Louis and the intervertebral disc T4/T5
XX. Blood Supply of the Heart
 Inferior: Diaphragm
XXI. Nerve Supply of the Heart
XXII. Sensory Innervation of the Heart
 Contents:
XXIII. Cardiac Plexus  Pericardium
XXIV. Conducting System  Heart
XXV. Skeletal Support of the Heart  Roots of the great vessels
XXVI. Borders of the Heart  Aorta
XXVII. Clinical Valvular Areas on Anterior Surface of Thorax  Pulmonary Trunk
 Superior Vena Cava
XXVIII. Physical Examination
 Inferior Vena Cava
 Pulmonary Veins
THE MEDIASTINUM
 thick, is a movable partition that extends superiorly to the
Pericardium
thoracic outlet and the root of the neck and inferiorly to the
diaphragm  Fibroserous sac that encloses the heart and the roots of
great vessels
 extends anteriorly to the sternum and posteriorly to the nd th
vertebral column  Posterior to the body of the sternum and the 2 to 6
costal cartilages
th th
 Anterior to the 5 to the 8 thoracic vertebrae
DIVISIONS OF THE MEDIASTINUM
 Function:
1. Superior Mediastinum
 Restricts excessive movement of the heart
2. Inferior Mediastinum  Serves as a lubricated container where the parts
a. Anterior - space between the pericardium and the of the heart can contract
sternum  Layers of the Pericardium:
b. Middle - consists of the pericardium and heart ▪ Fibrous
c. Posterior - lies between the pericardium and the vertebral ▪ Serous
column.  Parietal
 Visceral/Epicardium
Transcribers: Balucating, C., Espiridion, E.F., Fabian, H., Gamilla, E., Pasion, S., Reyes, R., Sierra, M.A., Tagra, M., Valdueza, A., Villoria, A.J. Page1 of 15
GROSS ANATOMY
2.02 Dr. AGUSTIN | Heart and Related Structures in the Middle Mediastinum
 Form as a consequence of the way the heart bends during

development
 No clinical significance.
a. Transverse Sinus
 Short passage that lies between the reflection of serous
pericardium around the aorta and pulmonary trunk and
the reflection around the large veins
 Lies anterior to the superior vena cava and posterior to
the ascending aorta and pulmonary trunk
b. Oblique Sinus
 Runs along the posterior surface of the left atrium betw
een the orifices of the right and the left pulmonary veins
FIBROUS PERICARDIUM
 Strong fibrous part of the sac
 Fuses with outer coat (Adventitia) of the greatvessels
 Firmly attached below at the central tendon of the diaphragm
 Attached in front to the sternum by STERNOPERICARDIAL
LIGAMENTS
SEROUS PERICARDIUM
 Lines the fibrous pericardium and coats the heart.
 It is divided into:
a. Parietal Layer
 Lines the fibrous pericardium
 Reflected around the roots of the great vesselsto
become continuous with the visceral layer of serous
pericardium that closely covers the heart
b. Visceral layer/Epicardium INNERVATION OF THE PERICARDIUM
 Closely applied to the heart  Vagus nerve - Visceral Layer of the Serous Pericardium
 Covering of the heart  Sympathetic trunks’ branches- Visceral Layer of the Serous
Pericardium
 Phrenic nerve - Fibrous Pericardium + Parietal Layer of Serous
PERICARDIAL SPACE/CAVITY
Pericardium
 Slit-like space between the parietal and visceral layers
 Contains small amount of tissue fluid (~50 mL) called
PERICARDIAL FLUID which acts as a lubricant to facilitate heart PERICARDIAL SAC
motion  Shape: Conical in shape
 Contents: heart and the roots of the great vessels
PERICARDIAL SINUSES  Relations:
 Located on the posterior surface of the heart  Anteriorly:
 Reflections of serous pericardium around the great vessels  separated from the anterior wall of the thorax, in the
greater part of its extent, by the lungs and pleurae
Transcribers: Balucating, C., Espiridion, E.F., Fabian, H., Gamilla, E., Pasion, S., Reyes, R., Sierra, M.A., Tagra, M., Valdueza, A., Villoria, A.J. Page 2 of 15
GROSS ANATOMY
 a small area, usually corresponding with the left half of the * The cusps float into apposition and completely close the aortic and
lower portion of the body of the sternum and the medial pulmonary orifices.
ends of the cartilages of the 4th and 5th ribs of the left
side, comes into direct relationship with the chest wall WEIGHT OF THE HEART
 Lower portion Thymus gland (anterior to the upper part)  Adult male: 280 to 340 grams
 Posteriorly:  Adult female: 230 to 280 grams
 the bronchi
 the esophagus EXTERNAL FEATURES OF THE HEART
 the descending thoracic aorta  The heart has three surfaces: sternocostal surface (anterior),
 the posterior part of the mediastinal surface of each lung diaphragmatic surface (inferior), and a base (posterior)
 Laterally:  Sternocostal surface: formed mainly by the right atrium
 covered by the pleura
and right ventricle; the right border is formed by the right
 in relation with the:
▪ mediastinal surfaces of the lungs atrium, and the left border is formed by the left ventricle
▪ phrenic nerve, with its accompanying vessels, and part of the left auricle
descends between the pericardium and pleura on
either side
 Importance:
 restricts excessive movements of the heart as a whole
 serve as a lubricated container
FUNCTIONS OF THE HEART
 The heart is a muscular pump for the propulsion of blood to all

parts of the body.
 Right side of the heart: receives poorly oxygenated blood
from the superior and inferior vena cava and pumps
it to the lungs for oxygenation
 Left side of the heart: receives oxygenated blood from the  Diaphragmatic surface: formed mainly by the right and
lungs via the pulmonary veins and pumps it to the body via left ventricles; also forming a part of this surface is the
the aorta and its branches inferior surface of the right atrium, into which the
inferior vena cava opens
 Cardiac cycle: series of changes that take place within the heart
as it fills and empties with blood
 Normal beat of the heart: resting adult (70-90 times per
minute) ; newborn child (130-150 times per minute)
 Ventricular systole (contraction): atrioventricular (AV)
valves are closed, and blood is temporarily
accommodated in the large veins and atria
 Ventricular diastole (relaxation): atrioventricular (AV)
valves open, and blood passively flows from the atria
to the ventricles
 Sinuatrial (SA) node: initiates the wave of contraction in
the atria, pushing the blood towards the ventricles
 Atrioventricular bundle and branches: conducts cardiac  B
impulse which reached the atrioventricular node to the  Base (Posterior surface): formed mainly by the left atrium,
papillary muscles; spread of cardiac impulse ensures that into which open the four pulmonary veins; lies opposite
myocardial contraction occurs at almost the same time the apex of the heart
throughout the ventricles
 Apex: formed by the left ventricle, and is directed
* Once the intraventricular blood pressure exceeds that present in downward, forward, and to the left; it lies at the 5th left
the large arteries (aorta and pulmonary trunk), the semilunar valve
intercostal space 3.5 inches (9 cm) from the midline.
cusps are pushed aside, and the blood is ejected from the heart.
* At the conclusion of ventricular systole, blood begins to move back

toward the ventricles and immediately fills the pockets of the
semilunar valves.
GROSS ANATOMY
 Interatrial sulcus: depression which separates the right

and left atria
 Sulcus terminalis: depression on the anterior surface of
the right atrium, which demarcates it from the right
auricle; extends from the termination of the superior vena
cava to the termination of the inferior vena cava
INTERATRIAL SEPTUM
 Divides the atrial portion of the heart (with thin walls) into the
right and left atria; the septum runs from the anterior wall of
the heart backward and to the right.
INTERVENTRICULAR SEPTUM
 Divides the ventricular portion of the heart into right and left
 Certain structures of the heart are separated by depressions ventricles; the septum is placed obliquely, with one surface
termed as sulcus/grooves present on its surface, which include facing forward and to the right and the other facing backward
the following: and to the left. Its position is indicated on the surface of the
 Coronary/Atrioventricular sulcus: depression which heart by the anterior and posterior interventricular grooves;
separates the right and left atria from the right and left the lower part of the septum is thick and formed of muscle,
ventricles; transmits the coronary arteries and coronary whereas the smaller upper part is thin and membranous,
sinus attached to the fibrous skeleton.
 Interventricular sulcus: depression which separates the

right and left ventricles, and may either be anteriorly or
posteriorly located; transmits the branches of the right
and left coronary arteries; corresponds to the
interventricular septum within the heart.
Right Atrium vs Left Atrium
Right Atrium Left Atrium

Auricle Present Present
Opening for SVC, IVC, Present None
& Coronary sinus
Sulcus terminalis Present Absent
Crista terminalis Present Absent
Openings for None Present
pulmonary veins
Musculi pectineti Fewer and smaller
Walls Thicker
GROSS ANATOMY
 A 1.5 inch diameter (larger than the left AV orifice),

oval aperture of communication between the right
atrium and the right ventricle, which lies anterior to
the inferior vena cava opening
2. Left atrioventricular orifice

 It is a large, oval aperture of communication between
the left atrium and the left ventricle, located below
and to the left of the aortic orifice and guarded by the
mitral (bicuspid) valve
Left Ventricle vs Right Ventricle
Right Ventricle Left Ventricle

Adjacent Tricuspid and Mitral and aortic valves
valves pulmonary valves
Ventricular Reference point 3x thicker than those of
wall thickness for left ventricle right ventricle VALVES
thickness  Atrioventricular Valves
Ventricular 6x higher than RV  Formed by the reduplication of the endocardium, the bases
blood of the valves are connected to fibrous rings that surround the
Chamber shape Crescentic Circular atrioventricular orifices, while their free ends are attached to
in cross-section the chordae tendineae (which arise from the tips of the
Character of Deoxygenated Oxygenated papillary muscles)
blood flowing
into it 1. Tricuspid valve
Trabeculae Present Present; Fine and delicate  So named because it consists of three cusps or leaflets.
carneae  Guards the right atrioventricular orifice and lies behind
Musculi Present Present the right half of the sternum opposite the 4th
papillares intercostal space.
Chordae Present Present  It prevents backflow from the right ventricle to the right
tendineae atrium
Moderator Present Absent  Three cusps:
band
Outflow tract Infundibulum Aortic vestibule
ATRIOVENTRICULAR ORIFICES
 Situated at bases of ventricles, surrounded by fibrous rings
(which help to maintain the shape of the opening) and covered
by endocardium
 They are broader in transverse diameter than in antero-
posterior diameter
1. Right atrioventricular orifice

 It is closed during ventricular contraction by the
tricuspid valve
GROSS ANATOMY
 Anterior tricuspid valve leaflet – largest

 Posterior tricuspid valve leaflet
 Septal tricuspid valve leaflet – smallest
2. Mitral (bicuspid) valve

 Guards the left atrioventricular orifice and lies behind
the left half of the sternum opposite the 4th costal
cartilage.
 It is larger, thicker, and relatively stronger than the
tricuspid valve and has two major cusps of unequal size
with two smaller segments found at the angles of the
junction of the larger cusp
 It prevents backflow from the left ventricle to the left
atrium
 Two cusps:
 Anterior mitral valve leaflet – larger
 Posterior mitral valve leaflet – smaller
 Semilunar valves
1. Pulmonary valve
 guards the pulmonary orifice
 consists of three semilunar cusps formedby folds of 2. Aortic valve
endocardium with some connective tissueenclosed  guards the aortic orifice
 curved lower margins and sides of each cusp are  similar in structure to the pulmonary valve
attached to the arterial wall  One cusp is situated on the anterior wall (right
 open mouths of thecusps are directed upward into cusp) and twoare located on the posterior wall (left
the pulmonary trunk and posterior cusps)
 Nochordae or papillary muscles  Behind each cusp, the aortic wall bulges to form an
 attachments of the sides of the cusps to the aortic sinus
arterialwall prevent the cusps from prolapsing into  anterior aortic sinus gives origin to the right
the ventricle coronary artery
 At the root of the pulmonary trunk are three  left posterior sinus gives origin tothe left coronary
dilatationscalled the sinuses, and one is situated artery
external to each cusp
 three semilunar cusps are arranged with one
posterior(left cusp) and two anterior (anterior and
right cusps)
 During ventricular systole, thecusps of the valve are
pressed against the wall of the pulmonarytrunk by
the outrushing blood
 During diastole, bloodflows back toward the heart
and enters the sinuses; the valvecusps fill, come into
apposition in the center of the lumen, and close the
pulmonary orifice
GROSS ANATOMY
 Hepatic vein
3. Pulmonary veins
 Carry oxygenated blood from the lungs to the left atrium
 Within the lungs, it is located behind the bronchi.
 At the root, it is located in front of pulmonary arteries and
bronchi.
 Tributaries:
 Right upper pulmonary vein
 Right lower pulmonary vein
 Left upper pulmonary vein
 Left lower pulmonary vein
4. Coronary veins
 Drains deoxygenated blood from the walls of the heart
during the latter part of coronary circulation
 Terminates to the coronary sinus at the right atrium
BLOOD VESSELS ARISING FROM THE HEART

Together, the pulmonary trunk and the aorta are invested in a
sheath of serous pericardium.
1. Pulmonary trunk (main pulmonary artery)

 Conveys deoxygenated blood from the right side of the
heart, it is a short, wide vessel measuring about 2 inches in
length and 1.2 inches in diameter
 It is located in front of the aorta, extending obliquely to the
left, upwards and backwards.
 It commences at the left side of the base of the right
ventricle and terminates in the concavity of the aortic arch
by dividing into right and left pulmonary arteries at the level
of T5 – T6
 Branches:
a. Right pulmonary artery
BLOOD VESSELS TERMINATING IN THE HEART  Longer and larger than the left pulmonary artery, it
1. Superior vena cava runs horizontally behind the ascending aorta and
 Formed by the union of the brachiocephalic [a.k.a. superior vena cava and enters the root of the right
innominate] veins, it receives blood from the head, the neck, lung
and the upper limbs  It further divides into the upper (supplies the upper
 It is a short trunk measuring 2.5 to 3 inches in length which lobe) and lower (supplies the middle and lower lobes)
commences immediately below the 1st costal cartilage and branches
terminates in the upper portion of the right atrium opposite b. Left pulmonary artery
the upper border of the 3rd right costal cartilage  Shorter and smaller than the right pulmonary artery,
 Tributaries: it runs horizontally in front of the descending aorta
 Right brachiocephalic vein and left bronchus to the root of the left lung. It also
 Left brachiocephalic vein divides into upper and lower branches.
2. Inferior vena cava

 Formed by the union of the common iliac veins on the right
side of L5, it receives blood from parts inferior to the
diaphragm.
 Passes upwards along the front of the spine and perforates
the central tendon of the diaphragm at the level of T8 before
entering the pericardium and terminating in the infero-
posterior portion of the right atrium
 [It is guarded by the Eustachian valve in the fetal heart]
 Tributaries:
 Lumbar vein
 Right spermatic vein
 Renal vein
 Suprarenal vein
 Phrenic vein
GROSS ANATOMY
 Left coronary artery – arises from the left

posterior sinus of Valsalva [a.k.a. left posterior
aortic sinus]
b. Aortic arch (transverse aorta)

 [Lying behind the manubrium sterni, it arches
upward, backward, and to the left in front of the
trachea then passes downward to the left of the
trachea and becomes continuous with the descending
aorta at the level of the sternal angle]
 Brachiocephalic (innominate) artery
 [The largest branch of the aortic arch, it arises
from the convex surface of the aortic arch, and
passes upward and to the right of the trachea
and bifurcates at the sternoclavicular joint]
 Branches: Right subclavian artery & Right
common carotid artery
 Left common carotid artery
 [It arises from the convex surface of the aortic
arch on the left side of the brachiocephalic
 Ligamentum arteriosum artery, and runs upward and to the left of the
 A fibrous band connecting the root of the left trachea and enters the neck behind the left
pulmonary artery and the concave surface of the sternoclavicular joint]
aortic arch  Left subclavian artery
 It is the remains of the ductus arteriosus from fetal  [It arises from the aortic arch behind the left
circulation common carotid artery and runs upward along
the left side of the trachea and esophagus to
2. Aorta (arteria magna) enter the root of the neck; arches over the apex
 Main trunk of a series of vessels conveying oxygenated blood of the left lung]
to bodily tissues
 It commences at the upper part of the base of left ventricle, c. Descending thoracic aorta
measuring 1.125 inches in diameter, it then arches backward  [It lies in the posterior mediastinum, beginning as a
and to the left, over the root of the left lung, then descends continuation of the aortic arch on the left side of the
in the thorax on the left side of the vertebral column. lower border of the body of T4, it then runs
 It enters the abdominal cavity by passing through the aortic downward in the posterior mediastinum, inclining
hiatus of the diaphragm forward and medially to reach the anterior surface of
 It terminates opposite the lower border of L4 where it the vertebral column, and passes through the aortic
bifurcates into right and left common iliac arteries, hiatus at the level of T12 to become the abdominal
measuring 0.7 inches in diameter aorta].
 Divisions of the Aorta
a. Ascending aorta
 [2 inches long, it commences at the upper part of the
base of the left ventricle at the level of the lower
border of the 3rd costal cartilage, behind the left half
of the sternum]
 [Passes obliquely upwards, forwards, and to the right,
in the direction of the heart's axis, as high as the
upper border of the 2nd right costal cartilage
 [vessel calibre increases at the junction of the
ascending and transverse sections of the aorta]
 Sinuses of Valsalva – dilatations at the aortic root
behind each cusp of the aortic semilunar valve
 Anterior sinus of Valsalva
 Left posterior sinus of Valsalva
 Right posterior sinus of Valsalva
 Coronary arteries – branches of the ascending aorta
that supply blood to the heart itself; commences at
the aorta immediately above the free margin of the
semilunar valves
 Right coronary artery – arises from the anterior
sinus of Valsalva [a.k.a. anterior aortic sinus]
GROSS ANATOMY
BLOOD SUPPLY OF THE HEART v. Atrial Branches

 supply the anterior and lateral surfaces of the RA.
 one branch supplies the posterior surface of both
the RA and LA.
 Artery of the SA node: supplies the node and the
RA and LA.
 in 35% of individuals it arises from the left coronary
artery.
b. Left Coronary Artery (LCA)

 larger than RCA
Arterial Supply  supplies the greater part of LA, LV and ventricular
 Arise from ascending aorta immediately above the aortic valve. septum.
 The coronary arteries and their major branches are distributed
 arises from the left posterior aortic sinus of the
over the surface of the heart, lying within the subepicardial
ascending aorta and passes forward between the
connective tissue.
pulmonary trunk and left auricle.
a. Right Coronary Artery (RCA)
 enters the AV groove and divides into an anterior
 Arises from anterior aortic sinus of the ascending aorta
interventricular branch and a circumflex branch.
and runs forward between the pulmonary trunk and the
right auricle.  Branches:
 Descends almost vertically in the right atrioventricular i. Anterior Interventricular (descending) branch
groove, and at the inferior border of the heart it  Runs downward in the anterior interventricular
continues posteriorly along the atrioventricular groove groove to the apex of the heart.
to anastomose with the left coronary artery in the  Most individuals: it passes around the apex of the
posterior interventricular groove. heart to enter the posterior interventricular groove
 The branches supply the ff: and anastomoses with the terminal branches of the
 Right atrium RCA.
 Right ventricle  1/3 of individuals: ends at the apex of the heart.
 Parts of left atrium and left ventricle  Supplies the RV and LV with numerous branches
 Atrioventricular septum that also supply the anterior part of the ventricular
 Branches: septum.
i. Right Conus Artery  Left diagonal artery: may arise directly from the
 supplies the anterior surface of the pulmonary trunk of LCA.
conus (infundibulum of the RV) and the upper part  Left conus artery (small): supplies the pulmonary
of the anterior wall of the RV conus
ii. Anterior Ventricular Branches
 2 or 3 in number ii. Circumflex Artery
 supply the anterior surface of the RV  Same size as the anterior interventricular artery.
 Winds around the left margin of the heart in the AV
 Marginal Branch: largest and runs along the lower
groove.
margin of the costal surface to reach the apex
 Left Marginal Artery: large branch that supplies
iii. Posterior Ventricular Branches
the left margin of the LV down to the apex.
 usually 2 in number.
 Anterior ventricular and posterior ventricular
 supply the diaphragmatic surface of the RV branches: supply the LV.
iv. Posterior Interventricular (Descending) Artery  Atrial branches: supply the LA.
 runs toward the apex in the posterior
interventricular groove.
 gives off branches to the RV and LV, including its
inferior wall.
 supplies branches to the posterior part of the
ventricular septum.
 a large septal branch supplies the atrioventricular
node.
 in 10% of individuals, the posterior interventricular
artery is replaced by a branch from the left
coronary artery.
GROSS ANATOMY
the great cardiac vein to form the coronary sinus (defining

the beginning of the sinus).
 Remnant of the embryonic left superior vena cava (SVC),
which usually atrophies during the fetal period, but
occasionally persists in adults, replacing or augmenting the
right SVC.
 Anterior Cardiac Veins

 Begin over the anterior surface of the RV, cross over the
coronary sulcus, and usually end directly in the RA;
sometimes they enter the small cardiac vein.
 Smallest Cardiac Veins (venae cordisminimae)

 Are minute vessels that begin in the capillary beds of the
myocardium and open directly into the chambers of the
Arterial Supply to the Conducting System: heart, chiefly, the atria.
 SA Node: RCA, sometimes LCA  Valveless communications with the capillary beds of the
myocardium and may carry blood from the heart chambers
 AV Node and AV Bundle: RCA
into the myocardium.
 Right Bundle Branch (AV Bundle): LCA
 Left Bundle Branch: RCA and LCA
Venous Drainage of the Heart

 The heart is drained mainly by veins that empty into the
coronary sinus and partly by small veins that empty into the RA.
 Coronary Sinus
 main vein of the heart, is a wide venous channel that runs
from left to right in the posterior part of coronary sulcus.
 receives the great cardiac vein at its left and the middle and
small cardiac veins in the right end.
 the left posterior ventricular vein and left marginal vein also Summary of Venous Drainage of the Heart (Snell)
open into the coronary sinus.  Main: Small and middle cardiac veins (right) and great cardiac
 Tributaries: vein (left) → coronary sinus (posterior part of AV groove) → RA
1. Great Cardiac Vein to the left of the inferior vena cava.
 main tributary of the coronary sinus.  Others: anterior cardiac veins and small veins directly to heart
st
 1 part: anterior interventricular vein, begins near the chambers
apex of the heart and ascends with the anterior IV
branch of the LCA. NERVE SUPPLY OF THE HEART
nd
 At the coronary sulcus it turns left, and its 2 part runs  Innervated by sympathetic and parasympathetic fibers of the
around the left side of the heart with the circumflex autonomic nervous system via the cardiac plexuses situated
branch of the LCA to reach the coronary sinus. below the arch of the aorta.
 UNUSUAL SITUATION: Blood is flowing in the same  Sympathetic
direction within a paired artery and vein  arises from the cervical and upper thoracic portions of the
sympathetic trunks.
 Drains the areas of the heart supplied by LCA.
 postganglionicfibers terminate on the SA and AV nodes, on
2. Middle Cardiac Vein (posterior IV vein)
cardiac muscle fibers, and on the coronary arteries.
 Accompanies the posterior interventricular branch
 Afferent fibers: serves as pathway of pain impulses to reach
(usually arising from RCA) consciousness when the blood supply to the myocardium
3. Small Cardiac Vein becomes impaired.
 Accompanies the right marginal branch of RCA.  Activation:
 Together with Middle Cardiac vein, they drain most of a. Cardiac acceleration
the areas supplied by RCA. b. Increased force of contraction
c. Dilatation of the coronary arteries.
 Oblique vein of LA (of Marshall)
 Small vessel, relatively unimportant postnatally, that
descends over the posterior wall of the LA and merges with
GROSS ANATOMY
 Parasympathetic CONDUCTING SYSTEM

 Comes from the vagus nerves.  The nodes and networks of so-called specialized myocardial
 Postganglionic fibers terminate on the SA node and AV nodes cells constitute the cardiac conduction system
and on the coronary arteries.  [Normal heart contracts at 70 to 90 beats/min in a resting
 Afferent fibers: cardiovascular reflexes adult]
 Activation:  The components of this system are:
a. Reduction in the rate and force of contraction 3. Sinoatrial node (SA node)
b. Constriction of coronary arteries  [Located in the wall of the right atrium at the upper part of
the sulcus terminalis, to the right of the SVC, it gives origin
SENSORY INNERVATION OF THE HEART to rhythmical electrical impulses]
 The heart possesses a double sensory innervation made up of
4. Atrioventricular node (AV node)
afferent nerve fibers coursing into the vagal and sympathetic
 [Located at the lower part of atrial septum, above
nerves to the medulla and spinal cord respectively.
attachment of septal cup of tricuspid valve] o [The speed
 Afferent fibers running with the sympathetic nerves carry
of conduction of the impulse through the AV node is about
nervous impulses that normally do not reach consciousness; if
0.11 seconds (allows sufficient time for ventricular filling)]
blood supply to the myocardium become impaired, pain
5. Atrioventricular Bundle (Bundle of His) with its left & right
impulses reach consciousness via this pathway
bundle branches
 Continuous with AV node above and Purkinje plexus below
o Descends through skeleton of the heart, then behind
septal cup of tricuspid valve on membranous part of
ventricular septum; it divides into two branches (RBB and
LBB), one for each ventricle.
6. Subendocardial plexus of ventricular conduction cells
(Purkinje fibers)
CARDIAC PLEXUS
1. Superficial (Ventral) Cardiac Plexus

 Lies below the aortic arch and anterior to right pulmonary
artery
 It is formed by the cardiac branch of left superior cervical
sympathetic ganglion and the lower cervical cardiac branch
of the left vagus
 A small cardiac ganglion is usually present in this plexus
immediately below the aortic arch (to the right of the
ligamentumarteriosum)
2. Deep (Dorsal) Cardiac Plexus

 Lies anterior to the tracheal bifurcation above the point of
division of the pulmonary trunk, and posterior to the aortic Role Played by the Conducting System
arch  The heart beats ceaselessly to maintain perfusion of pulmonary
 It is formed by cardiac branches of cervical and upper and systemic tissues.
thoracic sympathetic ganglia of vagus and recurrent laryngeal  The unique distribution pattern establishes an important
nerves unidirectional pathway of excitation/contraction.
 The only cardiac nerves that do not join it are those that join  A unidirectional wave of excitation and contraction is
the superficial part of the plexus established, which moves from the papillary muscles and apex
of the ventricles to the arterial outflow tracts.
GROSS ANATOMY
SKELETAL SUPPORT OF THE HEART
 Cardiac skeleton is composed of dense, fibrous, connective

tissue in form of four rings, which have interconnecting areas in
a plane between the atria and ventricles
 The fibrous rings surrounding the arterial orifices serve for the
attachment of the great vessels and semilunar valve, and it also
has a role on impulse conduction
 The interconnecting areas:
1. Right fibrous trigone- thickened area of connective tissue
between aortic ring and right atrioventricular ring
2. Left fibrous trigone- thickened area of connective tissue
between the aortic ring and the left atrioventricular ring
Importance of the skeletal support of the heart

 The skeletal support of the heart serves as a partition that Mapping of the Borders of the Heart by Percussion
electrically isolates the atria from the ventricles. It also  Three basic medical percussion sounds are described: resonant,
separates the atrial musculature from the upper border of the tympanic, and dull. The resonant sound is heard over normal
rings while the ventricular myocardium originates from the lung tissue. The tympanic sound is heard over most portions of
lower border of the rings. the normal abdominal cavity. The dull sound is elicited over
 It helps to maintain the integrity of the openings that it solid organs (eg, the liver) as well as muscles.
surrounds and also provides attachment for the cusps.  Percussion may provide an estimate of a person’s heart size
 The area of decreased resonance or relative dullness is heard
BORDERS OF THE HEART: ANTERIOR SURFACE OF THORAX at the right sternal border, and this comprises the right border
 The borders of the heart can be determined through of the heart
percussion  At the left sternal border, dullness becomes absolute, and this
 Apex- left ventricle, corresponds to the apex beat and is found area is where the heart is closest to the chest wall
in the 5th left intercostal space 3.5 inches from the midline  The absolute heart dullness extends approximately 3-4 cm to
 Superior border- roots of the great vessels, 2nd left costal the left from the left sternal border
cartilage0.5 inch from the edge of the sternum to the 3rd right  Percussion in the left parasternal line estimates the superior
costal cartilage 0.5 inch from the edge of the sternum heart border
 Right border- right atrium, 3rd right costal cartilage 0.5 inch  The relative dullness starts at the3rd intercostal space, and the
from the edge of the sternum to 6th right costal cartilage 0.5 absolute dullness occurs at the 4th intercostal space
inch from the edge of the sternum  The left heart border is percussed at the 5th intercostal space
 Left border- left ventricle, 2nd left costal cartilage 0.5 inch starting from the axillar line
from the edge of the sternum to the apex beat  The relative dullness begins at the left mid-clavicular line and
 Inferior border- right ventricle and apical part, 6th right costal becomes absolute 2-3 cm medially
cartilage 0.5 inch from the sternum of the apex beat  The inferior heart border is not amenable to precise
percussion
GROSS ANATOMY
CLINICAL VALVULAR AREAS ON ANTERIOR SURFACE OF THORAX Heart: Postero-Anterior Chest Radiograph
nd
 AORTIC: 2 ICS RUSB (Intercostal space; Right upper sternal  A heart with a diameter greater than half thoracic diameter is
border) an enlarged heart.
nd
 PULMONIC: 2 ICS LUSB (Intercostal space; Left upper sternal
border)
TH
 TRICUSPID: 5 ICS LLSB (Intercostal space; Left Lower Sternal
border)
TH
 MITRAL: 5 ICS LMC (Left midclavicular)
 The location of the PMI (point of maximal impulse / apex

beat) is the same as the location where mitral valve can be
th
heard best. (LEFT 5 ICS)
Importance of knowledge of cardiac borders

and clinical valvular areas
 Normal placing of heart on the thorax and normal blood flow
through the valves
 Cardiomegaly - If apex is located beyond 5th ICS
 Heart Murmurs - Occurs due to turbulent blood flow caused by
valvular defects (e.g. stenosis, regurgitation/insufficiency).
 Anterior Chest PE
1. Inspection- dynamic (abnormal)/ adynamic (normal)

precordium
2. Palpation- PMI (pulse of macimalimpulase/ apical beat),

thrills (palpable murmur caused by turbulent flow), heaves
(forceful lift associated with dilation of a heart chamber)
3. Percussion
4. Auscultation- Rate, Rhythm, Murmurs
PHYSICAL EXAMINATION
https://www.youtube.com/watch?v=SJ3UwKkLyy0 – PHYSICAL
EXAMINATION VIDEO (start on 3:41 mark) or
https://www.youtube.com/watch?v=eBnzjerIHj0 (start on 3:16
mark).
GROSS ANATOMY
EXAMPLES of PA chest x-rays.
Figure 1 (Top left) - normal chest x-ray. There is good exposure with
both costophrenic angles clearly visible as well as the primary
bronchi.
Figure 2 (Top right) - heart failure (HF). Classic features of HF include

alveolar oedema, interstitial oedema, cardiomegaly, dilated
prominent upper lobe vessels and pleural effusion.
Figure 3 (Bottom left) - dextrocardia. Note the fact that the heart is
on the right hand side instead of the left. This is a congenital
condition.
Figure 4 (Bottom right) - cardiomegaly. This can be demonstrated if

the heart measures more than 50% of the cardiothoracic ratio.
You made it!
CONGRATULATIONS Dr. ________! ;)
GROSS ANATOMY

2.02 Gross Anatomy Trans - Heart

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2.

 Form as a consequence of the way the heart bends during

FUNCTIONS OF THE HEART

 The heart is a muscular pump for the propulsion of blood to all

* At the conclusion of ventricular systole, blood begins to move back

 Interatrial sulcus: depression which separates the right

 Interventricular sulcus: depression which separates the

Right Atrium vs Left Atrium

Right Atrium Left Atrium

 A 1.5 inch diameter (larger than the left AV orifice),

2. Left atrioventricular orifice

Left Ventricle vs Right Ventricle

Right Ventricle Left Ventricle

1. Right atrioventricular orifice

 Anterior tricuspid valve leaflet – largest

2. Mitral (bicuspid) valve

BLOOD VESSELS ARISING FROM THE HEART

1. Pulmonary trunk (main pulmonary artery)

2. Inferior vena cava

 Left coronary artery – arises from the left

b. Aortic arch (transverse aorta)

BLOOD SUPPLY OF THE HEART v. Atrial Branches

b. Left Coronary Artery (LCA)

the great cardiac vein to form the coronary sinus (defining

 Anterior Cardiac Veins

 Smallest Cardiac Veins (venae cordisminimae)

Venous Drainage of the Heart

 Parasympathetic CONDUCTING SYSTEM

1. Superficial (Ventral) Cardiac Plexus

2. Deep (Dorsal) Cardiac Plexus

SKELETAL SUPPORT OF THE HEART

 Cardiac skeleton is composed of dense, fibrous, connective

Importance of the skeletal support of the heart

 The location of the PMI (point of maximal impulse / apex

Importance of knowledge of cardiac borders

1. Inspection- dynamic (abnormal)/ adynamic (normal)

2. Palpation- PMI (pulse of macimalimpulase/ apical beat),

4. Auscultation- Rate, Rhythm, Murmurs

EXAMPLES of PA chest x-rays.

Figure 2 (Top right) - heart failure (HF). Classic features of HF include

Figure 4 (Bottom right) - cardiomegaly. This can be demonstrated if

You made it!

CONGRATULATIONS Dr. ________! ;)

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