J. Anat.

(2004) 205, pp159177

REVIEW
Blackwell Publishing, Ltd.

Cardiac anatomy revisited

Robert H. Anderson,1 Reza Razavi1,2 and Andrew M. Taylor1
1
Institute of Child Health, University College, London, UK
2
Guys and St Thomass Hospitals, London, UK

Abstract
In tomorrows world of clinical medicine, students will increasingly be confronted by anatomic displays reconstructed
from tomographically derived images. These images all display the structure of the various organs in anatomical
orientation, this being determined in time-honoured fashion by describing the individual in the anatomical position,
standing upright and facing the observer. It follows from this approach that all adjectives used to describe the
organs should be related to the three orthogonal planes of the body. Unfortunately, at present this convention is
not followed for the heart, even though most students are taught that the so-called right chambers are, in reality,
in front of their left counterparts. Rigorous analysis of the tomographic images already available, along with
comparison with dissected hearts displayed in attitudinally correct orientation, calls into question this continuing
tendency to describe the heart in terms of its own orthogonal axes, but with the organ positioned on its apex, so
that the chambers can artefactually be visualized with the right atrium and right ventricle in right-sided position.
Although adequate for describing functional aspects, such as right-to-left shunting across intracardiac communi-
cations, this convention falls short when used to describe the position of the artery that supplies the diaphragmatic
surface of the heart. Currently known as the posterior descending artery, in reality it is positioned inferiorly, and
its blockage produces inferior myocardial infarction. In this review, we extend the concept of describing cardiac
structure in attitudinally correct orientation, showing also how access to tomographic images clarifies many aspects
of cardiac structure previously considered mysterious and arcane. We use images prepared using new techniques
such as magnetic resonance imaging and computerized tomography, and compare them with dissection of the
heart made in time-honoured fashion, along with cartoons to illustrate contentious topics. We argue that there is
much to gain by describing the components of the heart as seen in the anatomical position, along with all other
organs and structures in the body. We recognize, nonetheless, that such changes will take many years to be put
into practice, if at all.
Key words anatomical position; attitudinally correct orientation; cardiac septal structures; computerized tomo-
graphy; magnetic resonance imaging.

subject standing upright, and facing the observer. This

Introduction
One of the major conventions of human anatomy is that
all structures within the body should be described in
the setting of the anatomical position. Thus, the loca-
tions of structures within organs, or the relations of
organs to each other, are described on the basis of the
Correspondence
Professor Robert H. Anderson, Cardiac Unit, Institute of Child Health,
30 Guilford Street, London WC1H 1EJ, UK. E: r.anderson@ich.ucl.ac.uk
Accepted for publication 2 August 2004
principle has withstood well the passage of time, and
has permitted surgeons and physicians accurately to
describe the various symptoms of disease, and to establish
the best options for treatment. Perhaps surprisingly,
anatomists over the years have uniformly failed to
observe this convention when describing the human
heart. Internal cardiac structure has consistently, and
inappropriately, been considered in the setting of the
heart positioned on its apex, with the atriums above the
ventricles the so-called Valentine approach, reflecting
the convention of illustrating the organ in characteristic

Anatomical Society of Great Britain and Ireland 2004

160 Cardiac anatomy, R. H. Anderson et al.
shape balanced on its apex for the greetings cards
issued to lovers celebrating St Valentines Day.
In the days when diagnosis was largely achieved by
inspection or auscultation, and when treatment was by
medicines or surgical, this deviation from standard
anatomical practice was of little consequence. Indeed,
it had some advantages, because most recognized that
the so-called right chambers were in reality anterior
to the left counterparts, and this preserved the reality
of describing left-to-right or right-to-left shunting
in the presence in intracardiac communications. It was
somewhat confusing, nonetheless, for the beginner
to be told that blockage of the allegedly posterior
descending coronary artery produced inferior myocardial
infarction. Nowadays, the departure from the accepted
norm has much more significant consequences. This is
because, increasingly, the cardiologist treats structural
problems within the heart by means of interventional
catheterization. It is then very confusing for the trainee,
observing the operator advance a catheter from the
groin through the inferior caval vein into the heart, to
be told that the catheter is moving anteriorly when, in
reality, it can be seen moving upwards in the fluoro-
scopic screen, in which the image of the patient is still
shown in the anatomical position. From the stance of
the electrophysiologist, this deficiency has now been
addressed by a group of European and North American
experts, which recommended that the cardiac compon-
ents be described as seen in the anatomical position
(Cosio et al. 1999). The methods used for diagnosis now
also facilitate this approach, as images are increasingly
obtained using magnetic resonance or computed tomo-
graphy, techniques that visualize not only the heart,
but also the surrounding thoracic structures. In addition
to setting the scene for appropriate anatomical descrip-
tion, these new techniques provide the sophistication
to reveal cardiac anatomy in its smallest details, clarifying
many previously confusing topics such as the arrange-
ment of the cardiac septal structures (Anderson et al.
1999), and the nature of attachment of the leaflets
of the arterial valves (Anderson, 2000). If the fullest
advantage is to be gained from describing cardiac
structure in appropriate fashion (Cook & Anderson, 2002),
it is important that students be introduced to the correct
arrangement during their initial introduction to human
anatomy. In this review, therefore, we describe the struc-
ture of the heart as it lies within the body as revealed
with clinical tomographic images, correlating the findings
where necessary with standard anatomical dissections.
The location of the heart within the thorax
As demonstrated by the chest radiograph viewed in
the frontal projections (Fig. 1), the heart is usually
positioned within the mediastinum with one-third of its
mass to the right of the midline, and with its own long
axis directed from the right shoulder towards the
left hypochondrium. There are variations in this cardiac
position from patient to patient according to bodily
make-up or disease, and minor changes occur with
respiration. In very rare circumstances, the entire bodily
structure can be mirror-imaged in the setting of
normality, or when there is an associated congenital
cardiac malformation. In other circumstances, more
common than the mirror-imaged situation, but still
relatively rare, the structures of the body that usually
demonstrate lateralization are arranged in isomeric
fashion (Anderson et al. 1998). For the purposes of this
review, nonetheless, we will confine ourselves to the
usual situation, often described as situs solitus.
With the advent of tomographic imaging, which,
subsequent to the acquisition of the data set contain-
ing the cardiac images, permits the structure of the
heart to be displayed in any desired plane, it is possible
accurately to show the structures that produce the
borders of the frontal cardiac silhouette as revealed in
the chest radiograph. Such frontal sections show that
the right border of the silhouette, more or less vertical,
is produced by the right atrium, with the caval veins
entering at its top and bottom (Fig. 2, middle; compare
with Fig. 1b). The inferior border is made by the right
ventricle, extending horizontally along the diaphragm
to the cardiac apex, with the left border sloping
upwards from the apex and formed by the wall of the
left ventricle (Fig. 2, left). At the top of the left border,
a small part of the left atrium, specifically its append-
age, contributes to the silhouette (Fig. 2, right). The
pulmonary trunk and aorta then emerge from the
superior border of the silhouette, with the aorta in
rightward position (Fig. 1b).
With the advances made in manipulation of the data
set containing the resonance images, we are now able
to reconstruct the various chambers and their compon-
ents and superimpose them on the silhouette. In this
way, we can accurately position the cardiac valves
within the frontal section, showing that the pulmonary
valve is positioned superiorly and the tricuspid valve
inferiorly (Fig. 3), these two valves of the so-called right
heart being separated one from the other, and positioned
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 Cardiac anatomy, R. H. Anderson et al. 161

Fig. 1 The frontal chest radiograph

(a) shows the outline of the cardiac
silhouette relative to the thorax. Note
that the axes of the heart itself are well
out of skew relative to the axes of the
body. The right border of the heart is
shown by the red dotted line, the left
border, or obtuse border of the
ventricular mass, by the yellow dotted
line, and the diaphragmatic border, or
acute border of the ventricular mass,
by the green dashed line. A cast of the
normal heart (b), photographed in
attitudinally appropriate position, with
the so-called right heart cast in blue,
and the left heart cast in red, shows
the chambers corresponding to the
silhouette. See also Fig. 2.

in front of their counterparts in the left heart
(Fig. 4). The two valves of the left heart are directly
adjacent one to the other, with the fibrous continuity
between them forming the roof of the left ventricle
(Fig. 4). As already stated, the leaflets of the pulmonary
and tricuspid valves are widely separated in the roof of
the right ventricle, with the leaflets of the pulmonary
valve lifted away from the base of the ventricular mass
on the free-standing sleeve of the subpulmonary
muscular infundibulum (Fig. 5). The reconstructions
also show that, whereas the leaflets of the mitral and
tricuspid valves are hinged from the atrioventricular
junctions in relatively planar fashion, those of the
arterial valves are attached in semilunar form, being
suspended from the circular sinutubular junctions (Fig. 6).
These sinutubular junctions of the aortic and pulmon-
ary valves themselves have a marked obliquity relative
to each (Fig. 4), with the intrapericardial components

Anatomical Society of Great Britain and Ireland 2004

162 Cardiac anatomy, R. H. Anderson et al.
of the arterial trunks then spiralling round one another
as they extend from the base of the ventricular mass
into the mediastinum (Fig. 7).
Location of the chambers within the heart
The software now available permits the contours of the
separate cardiac chambers to be reconstructed and
displayed within the setting of the thorax. Such
reconstructions confirm that the so-called right cham-
bers are anterior to their left-sided counterparts and,
equally importantly, that the atrial chambers are
Fig. 2 The cuts through the heart in the coronal plane,
running from the front (a) to the back (c), show the different
chambers that contribute to the borders of the cardiac
silhouette as seen in the frontal chest radiograph (Fig. 1).
See text for further discussion.
positioned to the right of their respective ventricles. The
heart itself is positioned with its own axes obliquely
orientated relative to the body, so that a sagittal
section through the thorax taken in the midline shows
the right ventricle positioned most anteriorly, with the
left atrium posteriorly located (Fig. 8). Cardiologists
are today also able to obtain three-dimensional recon-
structions of cardiac structure by means of an ultrasonic
scanner introduced through the oesophagus and into
the stomach. The sagittal scans show well the potential
access of the ultrasonic beam from the oesophagus
into the various cardiac components (Fig. 9).
Anatomical Society of Great Britain and Ireland 2004

Fig. 3 The outlines of the cardiac valvar leaflets from the data set shown in Fig. 2 have been reconstructed in the frontal plane
(a) and superimposed on the chest radiograph (b).
Sectioning the heart in its own short axis then shows
the rationale underlying the traditional description
of the margins of the cardiac silhouette as seen in the
chest radiograph (Fig. 1). Sections taken across the
ventricular mass reveal that the cone of ventricular
musculature is squashed, so that the inferior border lies
along the diaphragm (Fig. 10). The ventricular septum
transects this inferior margin. The squashing of the cone
produces a triangular configuration, with the other
two sides of the triangle being adjacent to the sterno-
costal border anteriorly and to the right, and being
located within the cardiac notch of the left lung poste-
riorly and to the left. The particular shape of the triangle
is such that the angle made at the anterior margin
between the sternocostal and diaphragmatic surfaces,
and the angle between the pulmonary and diaphrag-
matic borders posteriorly, are both acute, being less
than 90. The angle at the superior margin, by contrast,
between the sternocostal and pulmonary surfaces, is
obtuse, being greater than 90. Hence, the inferior margin
of the cardiac silhouette, representing the anterior
border, is known as the acute margin, and corresponds
to the site of the acute marginal branch of the right
coronary artery. The leftward border as seen in the
chest radiograph, representing the superior margin of
Anatomical Society of Great Britain and Ireland 2004
Cardiac anatomy, R. H. Anderson et al. 163
the ventricular cone, is described as the obtuse margin,
with the obtuse marginal branches of the circumflex
artery irrigating the pulmonary surface of the ventricu-
lar mass (Fig. 11).
Another important cardiac landmark is found on the
diaphragmatic surface of the heart, at the point at
which the ventricular septum transects the inferior bor-
der. It is found at the site where the plane of the septal
structures crosses the plane of the inferior atrioventricular
groove (Fig. 12). Known as the crux, this landmark is
particularly important for the echocardiographer,
because a section taken parallel but superiorly to the
diaphragmatic surface reveals all four cardiac cham-
bers, hence its description as the four-chamber plane
(Fig. 13). From what has been described thus far, it is
evident that, owing to the obliquity of the cardiac axes
relative to the bodily axes, this four-chamber plane
cannot be obtained by taking standard sagittal or coro-
nal sections through the body. The echocardiographer
therefore has to obtain images of the heart through
the various echocardiographic windows (Anderson et al.
2001), with the transoesophageal portal now becom-
ing increasingly important (Fig. 9).
Examination of the cross-section of the ventricular
mass then reveals the fundamental nature of the
164 Cardiac anatomy, R. H. Anderson et al.
problem currently existing in the accepted description
of cardiac structures. The artery that irrigates the
inferior part of the ventricular septum (Fig. 10), and
the adjacent inferior ventricular walls, is currently
described as the posterior descending artery. As shown
unequivocally by the resonance images, this artery is
Fig. 4 The outlines of the cardiac
valves reconstructed from the magnetic
resonance images are shown in lateral
projection, and compared with the short
axis of the heart as seen in left anterior
oblique projection looking upwards
from the cardiac apex. The green
dotted line shows the fibrous continuity
between the leaflets of the aortic and
mitral valves that forms the roof of the
left ventricle. Note that, in comparison,
the roof of the right ventricle is
muscular, the supraventricular crest
(red arrow) being interposed between
the leaflets of the tricuspid and
pulmonary valves.
located inferiorly rather than posteriorly. As already
emphasized, blockage of the artery is known to produce
inferior ventricular infarction (Cook & Anderson, 2002).
The description of the electrocardiographic recordings
remains appropriate because these are automatically
registered relative to the anatomical position. Problems
Anatomical Society of Great Britain and Ireland 2004

Fig. 5 The short axis of the heart is
photographed from above and behind
having removed the atrial chambers and
the arterial trunks. Note the obliquity of
the relationship between the aortic and
pulmonary valves, and that the
pulmonary trunk is lifted away from the
ventricular base by the subpulmonary
muscular infundibulum. See also Fig. 4.
now exist, however, with the way that nuclear cardiol-
ogists have agreed to describe the various quadrants of
the ventricular mass. Until recently, the quadrant adjacent
to the diaphragm was considered to be posterior, when
self-evidently it is inferior. This solecism was corrected
by the task force assembled by nuclear cardiologists
and radiologists, which recognized the inferior location
of this quadrant (American Heart Association Writing
Group on Myocardial Segmentation and Registration
for Cardiac Imaging, 2002). For reasons that are not
clear, however, the writing group continued to suggest
that the opposite quadrant should be described as
being anterior. The antonym of inferior, of course, is
superior and not anterior. Examination of the reso-
nance images shows unequivocally that it is the septal
quadrant of the left ventricular cone that is anterior,
while the posterior quadrant is the one closest to the
spine. The other two quadrants therefore are located
inferiorly and superiorly (Fig. 10).
The artery that irrigates the superior quadrant of the
ventricular mass, currently described as being anterior
descending, is one of the major branches of the
left coronary artery (Fig. 14). Blockage of the artery is
currently described as producing antero-septal infarc-
tion. As shown by the tomographic images (Fig. 14),
it would be much more accurate to re-name this artery
as the antero-superior interventricular artery, although
it is likely to continue to be known simply as the
ADA.
Anatomical Society of Great Britain and Ireland 2004
Cardiac anatomy, R. H. Anderson et al. 165
Relationships of the components of the cardiac
chambers
The resonance images, when reconstructed, reveal
particularly clearly the arrangement of the different
cardiac chambers, showing various features that are
currently ignored in standard descriptions.
The atrial chambers each possess a body, a venous com-
ponent, a vestibule and an appendage. The two cham-
bers are separated one from the other by the septum.
The body of the right atrium is virtually non-existent,
although clearly evident in fetal sections (Fig. 15). It is
the space that separates the leftward boundary of the
systemic venous sinus from the septum. It is difficult, if
not impossible, to recognize this part in the definitive
postnatal heart, because the left venous valve is usually
fused with the septal surface after birth. It is possible,
nonetheless, to recognize the extensive appendage,
with its pectinated wall, the smooth-walled vestibule
supporting the hingelines of the tricuspid valve, and
the extensive venous sinus into which drain the supe-
rior and inferior caval veins along with the coronary
sinus (Fig. 16). The junction between the appendage
and the systemic venous sinus is marked internally by
the extensive and prominent terminal crest (crista
terminalis), with this corresponding externally with the
terminal groove (sulcus terminalis). The remnants of
the right venous valve, the Eustachian and Thebesian
valves, are attached to this crest, with the pectinate
166 Cardiac anatomy, R. H. Anderson et al.
muscles extending in parallel fashion from the crest
to run all round the vestibule, separating the smooth-
walled venous sinus from the smooth-walled vestibule.
The left atrium has an obvious smooth-walled
body, interposed between the vestibular and pulmonary
venous components, with the pulmonary veins at the
four corners of the venous part enclosing a prominent
atrial dome (Fig. 17). Reconstructions from the tomo-
graphic images now demonstrate the precise relation-
ships of the great veins to each other and to both atrial
chambers (Fig. 18), with detailed analysis now revealing
unexpected variations within the normal arrangement
(Kato et al. 2003; Lickfett et al. 2004). The appendage
Fig. 6 The upper panel shows the
opened pulmonary root having removed
the leaflets of the pulmonary valve. The
semilunar attachments of the leaflets
are marked by the red line, with the blue
line showing the sinutubular junction,
the yellow line the anatomic junction
between the muscular infundibulum
and the arterial wall of the pulmonary
trunk, and the green line the ring made
by joining together the basal attachments
of the three arterial valvar leaflets. The
lower panel shows the three-dimensional
crown-like configuration produced by
interdigitation of the semilunar
attachments with the three rings
existing in the root. There is no annulus
supporting the attachments of the
leaflets see text for further discussion.
of the left atrium is a true diverticulum, with all the
pectinated muscles contained within it, so that the larger
part of the internal surface of this atrium is smooth-
walled. There is no muscular structure comparable
to the terminal crest to be found in the left atrium
(Fig. 19).
The coronary sinus drains to the systemic venous
sinus of the right atrium. Morphologically, it is related
to the left atrium, running within the left atrioven-
tricular groove (Fig. 20). Within this groove, it possesses
it own muscular walls (Chauvin et al. 2002), there being
no evidence to support the notion that a party wall,
allegedly derived from a purported left sinuatrial fold,
Anatomical Society of Great Britain and Ireland 2004
 Cardiac anatomy, R. H. Anderson et al. 167

Fig. 9 A slice parallel to the image shown in Fig. 8 reveals the

location of the oesophagus directly posterior to the so-called
left-sided cardiac structures.

Fig. 7 The ventricles and arterial trunks have been

reconstructed from a data set obtained using magnetic
resonance imaging, and the so-called right-sided structures
coloured in blue, with the left-sided structures coloured in
red. Note the spiralling arrangements of the arterial trunks.
The apparent hole in the cast of the right ventricle is produced
by the prominent right ventricular trabeculations.

Fig. 10 The section across the ventricular mass in short

axis shows that the angle between the sternocostal and
diaphragmatic surfaces is acute, giving the acute margin,
whereas that between the sternocostal and pulmonary
margins is obtuse. It also shows how the short axis of the left
ventricle can be divided into quadrants (red lines). Quadrant
4 is obviously positioned inferiorly. Currently, however,
nuclear cardiologists describe the opposite quadrant (2) as
being anterior. As the images show, this quadrant is really
positioned superiorly. It is the septal quadrant (1) that is
Fig. 8 The magnetic resonance image, taken in lateral projection
anterior.
(sagittal plane), shows that the so-called right-sided structures,
the right ventricle, infundibulum and pulmonary trunk, are in
reality anterior to their left-sided counterparts.

Anatomical Society of Great Britain and Ireland 2004

168 Cardiac anatomy, R. H. Anderson et al.
Fig. 11 The magnetic resonance images have been programmed
to permit the data set to be cut in the plane of the coronary
arteries. The section shows the obtuse marginal branches of
the circumflex artery irrigating the obtuse margin of the
ventricular mass, with the right coronary artery taking its
acute turn at the acute margin (star).
is interposed between the cavities of the coronary sinus
and left atrium (Knauth et al. 2002). When there is
a persistent left superior caval vein, it almost always
drains to the coronary sinus, having coursed between
the left appendage and the left pulmonary veins. This
arrangement is found in about one-twentieth of indi-
Fig. 13 The long axis taken along the heart itself shows the so-
called four-chamber projection.
viduals with congenital cardiac malformations, but more
usually this left-sided embryonic channel regresses, being
represented in the postnatal heart by the oblique vein
of the left atrium (Fig. 20).
Until recently, it was usual to see the ventricles described
as possessing a sinus and a conus. It is difficult to find
evidence of any anatomical boundaries that support
this convention, although examination of congenitally
malformed hearts shows that it is more logical to
Fig. 12 The section across the ventricular
mass in its own short axis shows how the
postero-inferior extent of the ventricular
septum (red star) cuts the atrioventricular
junction between the right (RAVO) and
left (LAVO) atrioventricular orifices. This
corresponds to the so-called crux of the
heart (see also Fig. 22). Note how the atrial
myocardium (green dotted line) overlaps
the ventricular myocardium at this point,
the two muscle masses separated by the
fibro-fatty tissue of the atrioventricular
groove.
Anatomical Society of Great Britain and Ireland 2004
 Cardiac anatomy, R. H. Anderson et al. 169

Fig. 14 The magnetic resonance image in frontal projection

shows that the so-called anterior descending coronary artery
emerges from the aorta in superior position.
analyse the ventricular chambers as possessing three
components (Anderson & Ho, 1998). This is because the
ventricles are the pumps to the circulations, and effi-
cient pumps possess inlet and outlet valves, along with
a driving piston. So do the ventricles. When analysing
in this fashion, we recognize that the ventricular mass
extends from the atrioventricular to the ventriculo-
arterial junctions. The inlet components then surround
Fig. 16 The cast of the right atrium, photographed in lateral
projection from the right side, shows how the pectinated
appendage interposes between the smooth-walled systemic
venous sinus, receiving the superior and inferior caval veins
(SCV, ICV) and the coronary sinus, and the vestibule of the
tricuspid valve.
and support the atrioventricular valves, along with their
tension apparatus. The apical components are the most
characteristic intrinsic components of the ventricles,
with the apex of the right ventricle, situated anteriorly,

Fig. 15 This section of a developing

human heart at Carnegie stage 15,
and taken in four-chamber projection,
shows that, at early stages, the systemic
venous sinus is separated from the
remainder of the developing right
atrium by well-formed right and left
venous valves.

Anatomical Society of Great Britain and Ireland 2004

170 Cardiac anatomy, R. H. Anderson et al.
being coarsely trabeculated in comparison with the
fine criss-crossing trabeculations found in the posterior
left ventricular apex (Fig. 21). The inlets also differ
markedly in the normal ventricles, as do the outlets.
Thus, the tricuspid valve, possessing inferior, septal and
antero-superior leaflets, has extensive cordal attach-
ments to the ventricular septum, and is supported by
markedly eccentric papillary muscles. The mitral valve
possesses only two leaflets, located anteriorly and pos-
teriorly but positioned obliquely within the left ven-
tricle, and closing along a solitary zone of apposition
(Fig. 22). Significantly, this solitary zone of apposition is
orientated in concavo-convex fashion, with the leaflets
guarding markedly dissimilar proportions of the valvar
circumference (Fig. 22). Because of this, it is usual to
find slits in the extensive posterior leaflet, hinged from
the parietal part of the atrioventricular junction, and
guarding two-thirds of the valvar orifice. The anterior
leaflet is much deeper, but guards only one-third of the
orifice. This leaflet is separated from the septum by the
subaortic vestibule, having fibrous continuity with two
of the leaflets of the aortic valve (Fig. 4). Because of the
obliquity of the valve within the left ventricle, it is bet-
ter to describe the two leaflets as being mural and aor-
tic, a concept that dates back to Andreas Vesalius and
the birth of observation-based anatomy in Padova in
the 16th century. The papillary muscles of the valve are
also distinctive, being paired and positioned one at
each end of the solitary zone of apposition between
the valvar leaflets. Tendinous cords attach each muscle
Fig. 17 The cast of the left atrium shows
that the pectinate muscles are confined
within the tubular appendage, but an
extensive smooth-walled body
interposes between the vestibule of the
mitral valve and the pulmonary venous
component.
to both leaflets. Currently, the muscles are described
by clinicians as being postero-septal and antero-
lateral. The difference in antero-posterior disposition,
however, is marginal. As shown by either tomographic
images (Fig. 23) or cross-sectional echocardiograms,
the muscles are positioned infero-septally and
supero-laterally. Only time and consensus will deter-
mine the most appropriate names for these papillary
muscles.
The arrangement of the tendinous cords has also
been a matter of controversy. Although some have
devised complex systems to categorize the cords sup-
porting the leaflets (Silver et al. 1971), in our opinion it
is sufficient to distinguish those attached to the free-
edge from those attached to the ventricular surface of
the leaflets, these latter being either the strut or basal
cords. The most important feature, particularly for the
mitral valve, is that tendinous cords should support the
entirety of the free edges of both leaflets (Fig. 24).
Unequal support to the free edge is believed to be the
mechanism leading to prolapse of the leaflets (Van der
Bel-Kahn et al. 1985).
Important differences are also found in the structure
of the ventricular outlets. In the right ventricle, the
anteriorly located pulmonary valve is lifted in its
entirety away from the ventricular base by the extens-
ive free-standing infundibular sleeve (Fig. 6). When
seen internally, the arrangement produces an extens-
ive muscular shelf between the hinges of the tricuspid
and pulmonary valves, the so-called supraventricular
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 Cardiac anatomy, R. H. Anderson et al. 171

Fig. 19 This cut in the short axis of the heart itself shows the
triangular right atrial appendage (white star), with a broad
junction to the atrium (double-headed arrow), marked by
the prominent terminal crest (red star). In comparison, the
junction of the left atrial appendage with the atrium is
narrow, and is not marked by any terminal crest.

Fig. 18 Reconstruction from magnetic resonance images

showing the interrelations of the systemic and pulmonary
venous components from (a) the front and (b) the back.
Fig. 20 The cast of the cardiac chambers, photographed to show
the diaphragmatic aspect, shows how the coronary sinus occupies
crest (crista supraventricularis Fig. 4). On the septal the left atrioventricular groove, receiving the great cardiac vein
aspect, this crest inserts between the limbs of another at its origin at the site of the oblique vein of the left atrium,
and the middle cardiac vein at the crux.
important right ventricular landmark, namely the
septomarginal trabeculation, or septal band (Fig. 25).
This muscular strap reinforces the septal surface of the

Anatomical Society of Great Britain and Ireland 2004

172 Cardiac anatomy, R. H. Anderson et al.
right ventricle, breaking up at the apex to form the
moderator band and the anterior papillary muscle, and
giving rise to a further series of septoparietal trabecu-
lations that run to the parietal ventricular wall. These
structures are absent from the left ventricle, where the
outlet is much reduced in size because of the fibrous
continuity between two of the leaflets of the aortic
valve and the aortic leaflet of the mitral valve.
Although the two ventricular outlets have important
differences in their structure, they also have one feat-
ure in common, namely the semilunar attachment of
their leaflets. This is the more significant, because sur-
geons continue to describe these valves as possessing
an annulus. There are, in fact, at least three rings to be
Fig. 21 The heart has been sectioned
in its own long axis to reveal the four
cardiac chambers (compare with Fig. 13).
Note the coarse trabeculations at the
apex of the right ventricle in comparison
with the smooth surface of the left
ventricle.
Fig. 22 The mitral valve is photographed
from above to show its atrial aspect in
closed position. The two leaflets close
along a solitary zone of apposition,
with multiple slits in the larger leaflet
ensuring competent coaptation. Original
photograph reproduced by kind
permission of Dr Val S. Galstyan,
Armenia.
found within the ventricular outlets, but none supports
the hingelines of the valvar leaflets. The rings are the
sinutubular junction distally, the anatomic ventriculo-
arterial junction within the valvar complex, and a vir-
tual ring proximally, the last constructed by joining
together the nadir of the semilunar hinges of the three
leaflets (Fig. 5). The discrepancy between the anatomic
and haemodynamic ventriculo-arterial junctions, the
latter represented by the semilunar hingelines of the
leaflets, has important consequences for the relation-
ships of the outflow tracts that can now be revealed by
the tomographic images.
Because the semilunar attachments extend from
within the ventricles to the sinutubular junctions, they
Anatomical Society of Great Britain and Ireland 2004

Fig. 23 The magnetic resonance images in frontal (a) and
short axis (b) planes across the body show that the paired
papillary muscles supporting the mitral valves are positioned
adjacent to the septum and inferiorly (yellow star with red
line), and posteriorly and superiorly (red star with yellow line).
cross the circular anatomic ventriculo-arterial junctions
where the musculature of the ventricles supports the
fibro-elastic walls of the arterial trunks. This arrangement
is best seen in the right ventricle, where all the valvar
leaflets are supported by the muscular infundibulum
(Fig. 5). The base of each leaflet is supported by muscle
proximal to the anatomic junction, while the triangles
between the distal attachments of the leaflets are made
Anatomical Society of Great Britain and Ireland 2004
Cardiac anatomy, R. H. Anderson et al. 173
of fibrous tissue, and separate the ventricular outflow
tract from the pericardial cavity. The same arrange-
ment is then found in the left ventricular outflow tract,
with the fibrous interleaflet triangles immediately
beneath the sinutubular junction separating the left
ventricular cavity from the pericardial cavity (Fig. 26),
and also from the tissue plane existing between the
back of the subpulmonary infundibulum and the aortic
root (Anderson, 2000).
The triangle formed between the non-coronary and
right coronary leaflets of the aortic valve is of particular
interest because, at its base, this area is continuous
with the membranous septum. The fibrous triangle
interposes between the left ventricular outflow tract
and the right side of the transverse sinus of the pericar-
dium (Fig. 26). How can such a fibrous membrane, part
of the septal components of the heart, also be a parie-
tal structure? The answer is simple. Initially, this part
of the developing heart was encased in a muscular
sleeve that extended to the sinutubular junction (Ya
et al. 1998). Subsequent to formation and maturation
of the arterial valvar sinuses and leaflets, the muscular
sleeve regresses to the level of the anatomic ventriculo-
arterial junction. This process then leaves the fibrous
walls of the outflow tract interposed between the ven-
tricular cavities and extracardiac space (Fig. 26).
Structure of the septal components
The tomographic images also serve to clarify the
arrangement of those parts of the heart that are
directly interposed between adjacent chambers, rather
than being parietal walls. This is the definition we have
suggested to distinguish between partitions that sep-
arate directly adjacent chambers, as opposed to folds
that interpose between chambers but incorporate within
them extracardiac tissues (Anderson & Brown, 1996).
The tomographic images show exquisitely how the
so-called septum secundum, forming the superior,
anterior and posterior rims of the oval fossa, is no more
than an infolding of the atrial walls, at its deepest
between the attachments of the pulmonary veins to
the left atrium and the caval veins to the right (Fig. 27).
The true atrial septum is the flap valve of the oval
foramen, along with the antero-inferior buttress that
anchors the flap to the atrioventricular junctions
(Anderson et al. 1999). Significantly, the tomographic
images then clarify the arrangement of the atrial and
ventricular musculatures in the floor of the triangle of
174 Cardiac anatomy, R. H. Anderson et al.
Koch. Initially, we thought that this important area,
which contains the atrial components of the atrioven-
tricular conduction axis, was a muscular atrioventricular
septum (Becker & Anderson, 1982). We have now come
to appreciate that, in reality, the area is a muscular
sandwich, with an extension from the inferior atrioven-
tricular groove interposed between the myocardial
layers (Fig. 12). The true atrioventricular septum is that
part of the membranous septum positioned on the atrial
aspect of the hinge of the septal leaflet of the tricuspid
valve. The remainder of the membranous septum is
positioned between the cavities of the two ventricles
(Fig. 28), and is continuous superiorly with the fibrous
Fig. 24 The two leaflets of the mitral
valve, both supported all along their
free edge by tendinous cords, guard
markedly dissimilar lengths of the valvar
orifice, the mural leaflet (red) being long
and shallow whereas the aortic leaflet
(blue) is short and deep.
Fig. 25 The photograph of the septal
aspect of the right ventricle shows the
arrangement of the muscle bundles,
with the supraventricular crest inserting
between the limbs of the septomarginal
trabeculation. The septomarginal
trabeculation has a body (blue star) and
superior (red star) and inferior (yellow
star) limbs, the two limbs clasping the
insertion of the supraventricular crest
( yellow dotted line). The medial
papillary muscle arises from the inferior
limb. Note also the septoparietal
trabeculations and the moderator band.
triangle that separates the attachments of the non-
coronary and right coronary leaflets of the aortic valve
at the level of the sinutubular junction (Fig. 26).
As already discussed, the images also confirm that
the subpulmonary infundibulum, inserting between
the limbs of the septomarginal trabeculation, is for its
most part a free-standing sleeve. Only a very small part
of this structure is positioned as a true septum between
the subpulmonary and subaortic outflow tracts. The
larger part of the extensive muscular ventricular sep-
tum separates the apical ventricular components. Also
significant is the fact that, because of the deeply
wedged location of the subaortic outflow tract within
Anatomical Society of Great Britain and Ireland 2004
 Cardiac anatomy, R. H. Anderson et al. 175

Fig. 26 The magnetic resonance image

(upper) and anatomic section (lower)
show the relationships produced
because of attachment of the leaflets
of the aortic valve at the sinutubular
junction. Because of the height of this
attachment (red arrows), a fibrous
extension of the aortic root separates
the outflow tract from the transverse
sinus of the periciardium (yellow
double-headed arrow). The blue arrow
shows the attachment of the wall of the
right atrium.

the left ventricle, most of the septum beneath the sep-

tal leaflet of the tricuspid valve separates the right ven-
tricular inlet from the subaortic outlet (Fig. 29).

Conclusions
There are many important aspects of cardiac anatomy
that we have ignored in our review, such as the

Fig. 27 The long axis (oblique axial) image across the atrial
chambers shows the structure of the atrial septum. Note that
the septum itself is directly related to the aorta. The yellow
double-headed arrow is through the floor of the oval fossa.
The supero-posterior rim of the fossa, however, often
described as the septum secundum, is shown by the image to
be a deep infolding between the connections of the
pulmonary veins to the left atrium and the caval veins to the
right atrium. This area is better described as the interatrial
groove (green and red arrow).

Anatomical Society of Great Britain and Ireland 2004

176 Cardiac anatomy, R. H. Anderson et al.
arrangement and disposition of the coronary arteries.
The sophistication of tomographic imaging is now such
that these features can also be demonstrated with
great precision, making it possible to identify the site
of any atherosclerotic lesions that might cause ischae-
mic myocardial disease (Fig. 30). Such investigations
have great potential for preventive medicine. Interpre-
tation of these, and all other images, will be greatly
enhanced in future if students learn cardiac anatomy,
as with the anatomy of all other organs, in the setting
of the anatomical position. It is easy to understand
why, in the past, morphologists and anatomists
removed the heart from the body, and described its
Fig. 28 The section through the aortic
root shows the relationships of the
membranous part of the septum. The
hingepoint of the tricuspid valve,
emphasized by the blue dotted line,
divided the fibrous part of the septum
into atrioventricular (red arrow) and
interventricular ( yellow arrow)
components.
Fig. 29 This frontal section, through
the part of the muscular septum that
supports the membranous septum
(yellow arrow) and the aortic root,
shows that the muscular septum itself,
by virtue of the deeply wedged
location of the left ventricular outflow
tract, separates the inlet of the right
ventricle from the subaortic outlet of the
left ventricle (green and red arrow).
Previously, we had considered this part
of the septum to be an inlet septum. In
reality, it is an inletoutlet septum.
parts in isolation. There is now no reason to continue
to use a system of anatomical description based on this
approach, even if its usage will remain in such matters
as the description of the direction of shunting of blood
between the cardiac components. If we are to rational-
ize nomenclature, however, this can only be done by
consensus, and by demonstration that the new system
is better than the one it is intended to replace. The
advent of the new techniques for imaging, such as
resonance imaging, computerized tomography and
three-dimensional echocardiography, all display cardiac
structure in its appropriate bodily context. This there-
fore needs to be the context for a logical revision of
Anatomical Society of Great Britain and Ireland 2004

Fig. 30 Computed tomography section
through the right coronary artery shows
the potential for the new imaging
techniques. The image, expanded in the
inset, has revealed the presence of a
calcified, atherosclerotic plaque (white
arrows, black arrow shows calcification),
significantly reducing the calibre of the
vessels, and potentially producing
myocardial ischaemia. Reproduced by
kind permission of Dr Ronald Kuzo, MD
(Mayo Clinic, Jacksonville, FL, USA), and
Professor Jan Bogaert, MD, PhD
(Gasthuisberg University Hospital,
Leuven, Belgium).
anatomic terminology for the heart. It might be argued
that, from the stance of the interventional cardiologist,
the heart is a stand-alone organ. The experiences of
electrophysiologists, however, have demonstrated that
this is not the case, because the catheters are manoeu-
vred into the heart using the standard anatomical coor-
dinates (Cosio et al. 1999). The tomographic images
also serve to clarify some of the more difficult areas of
cardiac morphology, such as the arrangement of the
septal structures, and the three-dimensional structure
and relationships of the arterial roots. Our review, we
hope, has demonstrated the advantage of the anato-
mist keeping abreast of these remarkable achieve-
ments in imaging.
Acknowledgements
The research on which this review is based was sup-
ported by grants from the British Heart Foundation
together with the Joseph Levy Foundation. Research at
the Institute of Child Health and Great Ormond Street
Hospital for Children NHS Trust benefits from R & D
funding received from the NHS Executive. We are also
indebted to our colleagues in the United States of
America and Belgium for permission to reproduce Fig. 30.
References
American Heart Association Writing Group on Myocardial
Segmentation and Registration for Cardiac Imaging (2002)
Standardized myocardial segmentation and nomenclature
for tomographic imaging of the heart. Circulation 105, 539
547.
Anderson RH, Brown NA (1996) The anatomy of the heart
revisited. Anat. Rec. 246, 17.
Anderson RH, Ho SY (1998) What is a ventricle? Ann. Thorac.
Surg. 66, 616620.
Anatomical Society of Great Britain and Ireland 2004
Cardiac anatomy, R. H. Anderson et al. 177
Anderson RH, Webb S, Brown NA (1998) Defective lateralisa-
tion in children with congenitally malformed hearts. Car-
diol. Young 8, 512531.
Anderson RH, Webb S, Brown NA (1999) Clinical anatomy of
the atrial septum with reference to its developmental com-
ponents. Clin. Anat. 12, 362374.
Anderson RH (2000) Clinical anatomy of the aortic root. Heart
84, 670673.
Anderson RH, Ho SY, Brecker SJ (2001) Anatomic basis of
cross-sectional echocardiography. Heart 85, 716720.
Becker AE, Anderson RH (1982) Atrioventricular septal defects.
Whats in a name? J. Thorac. Cardiovasc. Surg. 83, 461469.
Chauvin M, Shah DC, Haissaguerre M, Marcellin L, Brechen-
macher C (2002) The anatomic basis of connections between
the coronary sinus musculature and the left atrium in
humans. Circulation 101, 647652.
Cook AC, Anderson RH (2002) Editorial. Attitudinally correct
nomenclature. Heart 87, 503506.
Cosio FC, Anderson RH, Kuck K, et al. (1999) Living Anatomy
of the Atrioventricular Junctions. A Guide to Electrophysio-
logical Mapping. A Consensus. Statement from the Cardiac
Nomenclature Study Group, Working Group of Arrhythmias,
European Society of Cardiology, and the Task Force on Cardiac
Nomenclature from NASPE. Circulation 100, E31-E37.
Kato R, Lickfett L, Meininger G, et al. (2003) Pulmonary vein
anatomy in patients undergoing catheter ablation of atrial
fibrillation. Lessons learned by use of magnetic resonance
imaging. Circulation 107, 20042010.
Knauth A, McCarthy KP, Webb S, et al. (2002) Interatrial com-
munication through the mouth of the coronary sinus. Car-
diol. Young 12, 364372.
Lickfett L, Kato R, Tandri H, et al. (2004) Characterization of
a new pulmonary vein variant using magnetic resonance
angiography: incidence, imaging, and interventional im-
plications of the right top pulmonary vein. J. Cardiovasc.
Electrophysiol. 15, 538543.
Silver MD, Lam JHC, Ranganathan N, Wigle ED (1971) Mor-
phology of the human tricuspid valve. Circulation 43, 3348.
Van der Bel-Kahn J, Duren DR, Becker AE (1985) Isolated mitral
valve prolapse: chordal architecture as an anatomic basis in
older patients. J. Am. Coll. Cardiol. 5, 13351340.
Ya J, van den Hoff MJB, de Boer PA, et al. (1998) Normal devel-
opment of the outflow tract in the rat. Circ. Res. 82, 464472.