The Cardiovascular System

Anatomy and Physiology: Surface Projections of the Heart and Great Vessels
Written Report by: Faith Marfil (BSN 1-2)

The right ventricle (RV) occupies most of the anterior cardiac surface. This chamber and the
pulmonary artery form a wedge-like structure behind and to the left of the sternum.
The inferior border of the RV lies below the junction of the sternum and the xiphoid process. The
RV narrows superiorly and joins the pulmonary artery at the level of the sternal angle, or “base
of the heart,” a clinical term that refers to the superior aspect of the heart at the right and left
2nd interspaces adjacent to the sternum.

The left ventricle, behind the RV and to the left, forms the left lateral margin of the heart. Its
tapered inferior tip is often termed the cardiac apex. It is clinically important because it
produces the apical impulse, identified during palpation of the precordium as the point of
maximal impulse (PMI).
This impulse locates the left border of the heart and is normally found in the 5th intercostal
space at or just medial to the left midclavicular line (or 7 to 9 cm lateral to the midsternal line).
The PMI is not always palpable, even in a healthy patient with a normal heart.
Detection is affected by both the patient’s body habitus and position during the examination.

 In supine patients the diameter of the PMI may be as large as a quarter, approximately
1 to 2.5 cm.
 In some patients, the most prominent precordial impulse may not be at the apex of the
left ventricle. For example, in patients with chronic obstructive pulmonary disease
(COPD), the most prominent palpable impulse or PMI may be in the xiphoid or
epigastric area due to right ventricular hypertrophy.
Above the heart lie the great vessels. The pulmonary artery bifurcates quickly into its left and
right branches. The aorta curves upward from the left ventricle to the level of the sternal angle,
where it arches posteriorly to the left and then downward.
On the medial border, the superior and inferior venae cavae channel venous blood from the
upper and lower portions of the body into the right atrium.

Cardiac Chambers, Valves, and Circulation

The mitral and tricuspid valves are often called atrioventricular (AV) valves. The aortic and
pulmonic valves are called semilunar valves because the valve leaflets are shaped like half-
moons.
Aorta:

 The aorta is the largest single blood vessel in the body. It is approximately the diameter
of your thumb. This vessel carries oxygen-rich blood from the left ventricle to the
various parts of the body. Pulmonary Valve
Pulmonary Valve:

 The pulmonary valve separates the right ventricle from the pulmonary artery. As the
ventricles contract, it opens to allow the de-oxygenated blood collected in the right
ventricle to flow to the lungs. It closes as the ventricles relax, preventing blood from
returning to the heart.
Tricuspid Valve:

 The tricuspid valve separates the right atrium from the right ventricle. It opens to allow
the de-oxygenated blood collected in the right atrium to flow into the right ventricle. It
closes as the right ventricle contracts, preventing blood from returning to the right
atrium; thereby, forcing it to exit through the pulmonary valve into the pulmonary
artery.
Right Atrium:

 The right atrium receives de-oxygenated blood from the body through the superior vena
cava (head and upper body) and inferior vena cava (legs and lower torso). The sinoatrial
node sends an impulse that causes the cardiac muscle tissue of the atrium to contract in
a coordinated, wave-like manner. The tricuspid valve, which separates the right atrium
from the right ventricle, opens to allow the de-oxygenated blood collected in the right
atrium to flow into the right ventricle.
Right Ventricle:

 The right ventricle receives de-oxygenated blood as the right atrium contracts. The
pulmonary valve leading into the pulmonary artery is closed, allowing the ventricle to fill
with blood. Once the ventricles are full, they contract.
 As the right ventricle contracts, the tricuspid valve closes and the pulmonary valve
opens. The closure of the tricuspid valve prevents blood from backing into the right
atrium and the opening of the pulmonary valve allows the blood to flow into the
pulmonary artery toward the lungs.
Left Ventricle:

 The left ventricle receives oxygenated blood as the left atrium contracts. The blood
passes through the mitral valve into the right ventricle. The aortic valve leading into the
aorta is closed, allowing the ventricle to fill with blood. Once the ventricles are full, they
contract. As the left ventricle contracts, the mitral valve closes and the aortic valve
 opens. The closure of the mitral valve prevents blood from backing into the left atrium
and the opening of the aortic valve allows the blood to flow into the aorta and flow
throughout the body.
Aortic Valve:

 The aortic valve separates the left ventricle from the aorta. As the ventricles contract, it
opens to allow the oxygenated blood collected in the left ventricle to flow throughout
the body. It closes as the ventricles relax, preventing blood from returning to the heart.
Mitral Valve:

 The mitral valve separates the left atrium from the left ventricle. It opens to allow the
oxygenated blood collected in the left atrium to flow into the left ventricle. It closes as
the left ventricle contracts, preventing blood from returning to the left atrium; thereby,
forcing it to exit through the aortic valve into the aorta.
Left Atrium:

 The left atrium receives oxygenated blood from the lungs through the pulmonary vein.
As the contraction triggered by the sinoatrial node progresses through the atria, the
blood passes through the mitral valve into the left ventricle.
Pulmonary Trunk:

 A vessel that arises from the right ventricle of the heart, extends upward, and divides
into the right and left pulmonary arteries that convey unaerated blood to the lungs.
When the right ventricle contacts, the blood inside it is put under pressure and the
tricuspid valve between the right atrium and ventricle closes. The only exit for blood
from the right ventricle is then through the pulmonary trunk. The pulmonary trunk is to
the right ventricle what the aorta is to the left ventricle – the outlet vessel.

What are heart valves?

The heart consists of four chambers, two atria (upper chambers) and two ventricles (lower
chambers). There is a valve through which blood passes before leaving each chamber of the
heart. The valves prevent the backward flow of blood. These valves are actual flaps that are
located on each end of the two ventricles (lower chambers of the heart). They act as one-way
inlets of blood on one side of a ventricle and one-way outlets of blood on the other side of a
ventricle. Each valve actually has three flaps, except the mitral valve, which has two flaps. The
four heart valves include the following:

 tricuspid valve: located between the right atrium and the right ventricle
 pulmonary valve: located between the right ventricle and the pulmonary artery
 mitral valve: located between the left atrium and the left ventricle
 aortic valve: located between the left ventricle and the aorta
How do the heart valves function?
As the heart muscle contracts and relaxes, the valves open and shut, letting blood flow into the
ventricles and atria at alternate times. The following is a step-by-step illustration of how the
valves function normally in the left ventricle:

 After the left ventricle contracts, the aortic valve closes and the mitral valve opens, to
allow blood to flow from the left atrium into the left ventricle.
 As the left atrium contracts, more blood flows into the left ventricle.
 When the left ventricle contracts again, the mitral valve closes and the aortic valve
opens, so blood flows into the aorta.

Events in the Cardiac Cycle

The heart serves as a pump that generates varying pressures as its chambers contract and relax.
Systole is the period of ventricular contraction. When pressure in the left ventricle rises, from
less than 5 mm Hg in its resting state, to a normal peak of 120 mm Hg. After the ventricle ejects
much of its blood into the aorta, the pressure levels off and starts to fall.
Diastole is the period of ventricular relaxation. Ventricular pressure falls further to below5 mm
Hg, and blood flows from atrium to ventricle. Late in diastole, pressure rises slightly during inflow
of blood from atrial contraction.
During systole the aortic valve is open, allowing ejection of blood from the left ventricle into the
aorta. The mitral valve is closed, preventing blood from regurgitating back into the left atrium. In
contrast, during diastole the aortic valve is closed, preventing regurgitation of blood from the
aorta back into the left ventricle. The mitral valve is open, allowing blood to flow from the left
atrium into the relaxed left ventricle. At the same time, during systole the pulmonic valve opens
and the tricuspid valve closes as blood is ejected from the RV into the pulmonary artery. During
diastole, the pulmonic valve closes and the tricuspid valve opens as blood flows into the right
atrium.

During diastole, pressure in the bloodfilled left

atrium slightly exceeds that in the relaxed left
ventricle, and blood flows from left atrium to left
ventricle across the open mitral valve. Just before
the onset of ventricular systole, atrial contraction
produces a slight pressure rise in both chambers.

During systole, the left ventricle starts to contract

and ventricular pressure rapidly exceeds left atrial
pressure, closing the mitral valve. Closure of the
mitral valve produces the first heart sound, S1.

As left ventricular pressure continues to rise, it

quickly exceeds the pressure in the aorta and
forces the aortic valve open. In some pathologic
conditions, an early systolic ejection sound (Ej)
accompanies the opening of the aortic valve.
Normally, maximal left ventricular pressure
corresponds to systolic blood pressure.

As the left ventricle ejects most of its blood,

ventricular pressure begins to fall. When left
ventricular pressure drops below aortic pressure,
the aortic valve closes. Aortic valve closure
produces the second heart sound, S2, and another
diastole begins.
In diastole, left ventricular pressure continues to
drop and falls below left atrial pressure. The mitral
valve opens. This event is usually silent, but may
be audible as a pathologic opening snap (OS) if
valve leaflet motion is restricted, as in mitral
stenosis.

After the mitral valve opens, there is a period of

rapid ventricular filling as blood flows early in
diastole from left atrium to left ventricle. In
children and young adults, a third heart sound, S3,
may arise from rapid deceleration of the column of
blood against the ventricular wall. In older adults,
an S3, sometimes termed “an S3 gallop,” usually
indicates a pathologic change in ventricular
compliance.

Finally, although not often heard in normal

adults, a fourth heart sound, S4, marks atrial
contraction. It immediately precedes S1 of the
next beat and can also reflect a pathologic change
in ventricular compliance.

References:
1. Bickley, L. S., Szilagyi, P. G., & Hoffman, R. M. (2017). Bates' guide to physical examination
and history taking (Twelfth edition.). Philadelphia: Wolters Kluwer.
2. GW Heart & Vascular Institute. Anatomy and Function of the Heart Valves. Retrieved
from: http://www.gwheartandvascular.org/education/anatomy-and-function-of-the-
heart-valves/