UERMMMC MEDICINE CLASS 2011A THE HEART Dr. Sta.

Romana, 09/17/07 1 UERMMMC MEDICINE CLASS 2011A THE HEART Dr. Sta. Romana, 09/17/07 1 Contents: I. Review of the Mediastinum II. The Pericardium III. The Heart and the Valves of the Heart IV. The Conducting System V. Cardiac Skeleton VI. Blood Vessels of the Heart VII. Cardiac Plexus VIII. Fetal Circulation I. The Mediastinum Boundaries Superior Thoracic Inlet and the root of the neck Inferiorly The diaphragm Anteriorly Sternum Posteriorly 12 Thoracic Vertebrae of the vertebral column Divisions of the Mediastinum Demarcation Contents Superior Mediastinum Anteriorly - superior border of the manubrium sterni Posteriorly first four thoracic vertebrae 1.thymus 2.large veins and arteries 3.trachea, 4.esophagus 5.thoracic duct 6.sympathetic trunks Inferior Mediastinum *Further subdivided into: Anteriorly body of the sternum Posteriorly lower eight thoracic vertebrae Anterior Mediastinum Space between the pericardium and 1.sternopericardial ligaments sternum 2.lymph nodes 3.remains of the thymus Middle Mediastinum Contains the pericardium and the heart 1.pericardium 2.heart

3.roots of great blood vessels 4.phrenic nerves 5.bifurcation of the trachea 6.lymph nodes Posterior Mediastinum Space between the pericardium and the vertebral column 1.descending thoracic aorta 2.esophagus 3.thoracic duct 4.azygos and hemiazygos vein 5.vagus nerves 6.splanchnic nerves 7.sympathetic trunks 8.lymph nodes II. The Pericardium a. a fibroserous sac lying within the middle The Pericardium mediastinum that encloses the heart and the roots of the great blood vessels b. Layers i. Fibrous Pericardium the fibrous part of the pericardium is strong and limits unnecessary movements of the heart fuses above with the walls of the great blood vessels attached below to the central tendon of the diaphragm attached anteriorly to the sternum by the sternopericardial ligaments trans by: kai

UERMMMC MEDICINE CLASS 2011A THE HEART Dr. Sta. Romana, 09/17/07 2 UERMMMC MEDICINE CLASS 2011A THE HEART Dr. Sta. Romana, 09/17/07 2 ii. Serous Pericardium Two Layers: a.Parietal layer lines the fibrous pericardium and is reflected around the roots of the great vessels to become continuous with the visceral layer b.Visceral layer closely covers the heart and is also known as the epicardium. c. The Pericardial Cavity slit-like space between the parietal and the visceral layer d. Pericardial Reflection of the Great Vessels i.Arterial Mesocardium reflection of visceral pericardium around the ascending aorta and pulmonary artery ii.Venous Mesocardium reflection of visceral pericardium around pulmonary veins, superior and inferior vena cavae e. Pericardial Spaces i.Transverse sinus a passage on the posterior surface of the heart between the reflection of the serous pericardium around the ascending aorta and the pulmonary trunk and the reflection around the great veins ii.Oblique sinus a recess formed by the reflection of the serous pericardium around the venae cavae and the four pulmonary veins. f. Nerve Supply of the Pericardium The phrenic nerve, branches of the vagus nerve and sympathetic trunk Oblique sinus III. The Heart The Heart a hollow muscular organ , somewhat pyramidal in shape, lying within the pericardium in the middle mediastinum, which is connected at its base to the great blood vessels but otherwise free within the pericardium. trans by: kai

UERMMMC MEDICINE CLASS 2011A THE HEART Dr. Sta. Romana, 09/17/07 3 UERMMMC MEDICINE CLASS 2011A THE HEART Dr. Sta. Romana, 09/17/07 3 i. External Features Coronary or atrioventricular sulcus Interatrial groove Anterior and posterior interventricular grooves Auricular appendages Apex formed by the left ventricle directed downward, forward and to the left Lies at the level of the fifth left intercostals space, 3 inches from the midline ii. Surfaces of the Heart : Sternocostal surface (anterior) formed mainly by the right atrium and the right ventricle separated by the vertical antrioventricular groove Diaphragmatic surface (inferior) formed mainly by the right and left ventricles separated by the posterior interventricular groove also formed by the inferior surface of the right atrium (where the inferior vena cava opens) surface where the heart rests Base of the heart (posterior surface) lies opposite the apex formed mainly by the left atrium into which the four pulmonary veins open iii. Borders of the Heart Right Border Left Border Lower Border right atrium left auricle and left ventricle mainly by the right ventricle, but also by the right atrium

Upper Border0 formed by the atria, chiefly the left atria iv. Structure Endocardium Myocardium a layer of endothelium lining the heart internally the wall of the heart, composed of cardiac muscle

Epicardium external covering of serous pericardium Skeleton of the heart consists of fibrous rings that surround the atrioventricular, pulmonary and aortic orifices and are continuous with the membranous upper part of the ventricular septum v. Chambers of the Heart The heart is divided by vertical septa into four chambers. 1. Right Atrium consists of a main cavity and a small outpouching, the auricle.

Sulcus Terminalis a vertical groove which is the junction between the right atrium and the right auricle on the outside of the heart Crista Terminalis a ridge continuous to the inside of the heart

Sinus Venarium smooth walled portion of the atria; derived embryologically from the sinus venosus. Musculi Pectinati muscle of the atrium proper; roughened or trabeculated bundles of muscle fibers; derived embryologically from the primitive atrium *Openings into the Right Atrium: i. Superior Vena Cava opens into the upper part of the right atrium, it has no valve ii. Inferior Vena Cava larger than SVC, opens into the lower part of the atrium and guarded by a rudimentary, nonfunctioning valve iii. Coronary Sinus drains most of the blood from the heart wall, opens into the right atrium between the IVC and the atrioventricular orifice iv. Right Atrioventricular Orifice anterior to the IVC opening and is guarded by the tricuspid valve trans by: kai

UERMMMC MEDICINE CLASS 2011A THE HEART Dr. Sta. Romana, 09/17/07 4 UERMMMC MEDICINE CLASS 2011A THE HEART Dr. Sta. Romana, 09/17/07 4 2. Right Ventricle communicates with the right atrium through the atrioventricular orifice and with the pulmonary trunk through the pulmonary orifice Infundibulum/Conus Arteriosus the cavity as it approaches the pulmonary orifice Supraventricular Crest outflowing parts Trabeculae Carnae like appearance 3 Types: 1. projected inward, with their bases attached to the ventricular wall (papillary muscles) *** chordae tendinae fibrous chords connecting the apices of the papillary muscles to the cusps of the tricuspid valve. 2. attached at their ends to the ventricular wall and free in the middle ***the moderator band (septomarginal trabecula) is a large ridge and it is attached at its ends to the septal and the anterior ventricular walls; and conveys within it the right branch of the atrioventricular bundle, which is part of the conducting system of the heart 3. simple, prominent projections *Valves of the Right Ventricle: Tricuspid valve guards the atrioventricular orifice. a muscular ridge, partially separates inflowing and

projecting ridges giving the ventricular wall a sponge-

consists of three cusps whose bases are attached to the fibrous ring of the skeleton of the heart. free edges and ventricular surfaces are attached to the chordae tendinae, which connect the cusps to the papillary muscles division of cusps: i.anterior-lies anteriorly ii.septal-against ventricular septum iii.inferior-lies inferiorly Pulmonary Valve guards the pulmonary orifice

three seminular cusps are attached by their curved, lower margins to the arterial wall. (one posterior and two anterior) pulmonary sinuses three dilatations of the pulmonary trunk, one being situated external to each cusp. Right Atrium and Ventricle 3. Left Atrium lies posterior to the right atrium, consisting of a main cavity and an auricle, with the interior of the auricle possessing muscular ridges as in the right auricle

trans by: kai

UERMMMC MEDICINE CLASS 2011A THE HEART Dr. Sta. Romana, 09/17/07 5UERMMMC MEDICINE CLASS 2011A THE HEART Dr. Sta. Romana, 09/17/07 5 Left Atrium and Ventricle *Openings into the Left Atrium: i. Pulmonary Veins two from each lungs, open through the posterior wall; there are no valves ii. Atrioventricular orifice guarded by the mitral valve 4. Left Ventricle behind the right ventricle; but a small portion projects to the left and forms the left margin of the heart and the heart apex walls are three times thicker than those of the right ventricle there are trabeculae carnae and two papillary muscles (anterior and posterior), but no moderator band. aortic vestibule- part of the ventricle below the aortic orifice *Valves of the Left Ventricle: Mitral Valve guards the left atrioventricular orifice and consists of two cusps (anterior and posterior) attached to the chordae tendineae and papillary muscles similar to those in the tricuspid valve. Aortic Valve guards the aortic orifice and , as with the pulmonary valve, consists of three semilunar cusps (one on the anterior wall and two on the posterior wall) aortic sinus the bulging of the aortic wall which gives rises to: - the right coronary artery from the right anterior sinus - the left posterior sinus gives rise to the left coronary artery. Aortic Sinuses trans by: kai

UERMMMC MEDICINE CLASS 2011A THE HEART Dr. Sta. Romana, 09/17/07 6 UERMMMC MEDICINE CLASS 2011A THE HEART Dr. Sta. Romana, 09/17/07 6 IV. The Conducting System The conducting system of the heart is composed of modified cardiac muscle. 1. Sinoatrial Node (Pacemaker) initiates heartbeat situated at the upper part of the sulcus terminalis close to the opening of the superior vena cava ** Heart Sounds First Sound: LB contraction of the ventricles and the closure of the tricuspid and mitral valves Second Sound: DUP shorter, produced by the sharp closure of the aortic and the pulmonary valves -usually supplied by the right coronary artery 2. Atrioventricular Node -lower part of the atrial septum, just above the attachment of the septal cusp of the tricuspid valve -receives its blood supply from the right coronary artery 3. Atrioventricular Bundle of His -continuous with the atrioventricular node above and with the fibers of the Purkinje plexus below -descends behind the septal cusp of the tricuspid valve on the membranous part of the ventricular septum -divides into two branches on the muscular part (right bundle branch to the right ventricle and left bundle branch to the left ventricle) Valve Area Best Heard Tricuspid Over the right half of the lower end of the body of the sternum Mitral Over the apex beat at the level of the fifth left intercostals space, approximately 3.5 in (9 cm) from the midline Pulmonary Over the medial end of the second left intercostals space Aortic Over the medial end of the second right intercostals space -the atrioventricular bundle is the only muscular connection between the myocardium of the atria and the myocardium of the ventricle. V. Cardiac Skeleton

-the terminal branches become continuous with the fibers of the Purkinje plexus in the ventricular walls. - collection of dense connective tissue -the av bundle is supplied by the right provide attachment of heart musculature -the right bundle branch is supplied by surrounding valvular orfices and coronary artery (origin and insertion); also the left coronary artery

serves as an electric insulator during conduction -the left bundle branch is supplied by the right and left coronary artery. Parts: 4. Purkinje fibers in the ventricular wall a. Annuli fibrosi b. Septum membranaceum upper part of the interventricular septum c. Right and left fibrous trigones trans by: kai

UERMMMC MEDICINE CLASS 2011A THE HEART Dr. Sta. Romana, 09/17/07 7 UERMMMC MEDICINE CLASS 2011A THE HEART Dr. Sta. Romana, 09/17/07 7 VI. Blood Supply of the Heart **Arterial Supply: 1. Right Coronary Artery from the anterior aortic sinus of the ascending aorta -descends in the right atrioventricular groove and sends branches to the right atrium and ventricle ends by anastomosing with the left coronary artery in the posterior interventricular groove Branches: right conus artery supplies the anterior surface of the infundibulum of the right ventricle and the uppoer part of the anterior wall of the right ventricle anterior ventricular branches supply the anterior surface of the right ventricle; the marginal branch is the largest, and it follows the lower margin of the costal surface to reach the apex posterior ventricular branches right ventricle supply the diaphragmatic surface of the

posterior interventricular (descending) artery runs towards the apex in the posterior interventricular groove and sends branches to the right and left ventricles atrial branches supply the anterior and the lateral surfaces of the right atrium. 2. Left Coronary Artery arises from the left posterior aortic sinus of the ascending aorta - larger than the right coronary artery and divides into an anterior interventricular branch and a circumflex branch Branches: 1.anterior interventricular branch runs downward in the anterior interventricular groove to the apex of the heart and supplies the right and the left ventricles 2. circumflex artery winds around the left margin of the heart in the atrioventricular groove and branches into: i. the left marginal, anterior ventricular and posterior ventricular branches supplying the left ventricle ii. atrial branches supply the left atrium. ** Venous Drainage: 1. Coronary Sinus lies in the posterior part of the atrioventricular

groove; it is the largest vein draining the heart wall and is a continuation of the great cardiac vein trans by: kai

UERMMMC MEDICINE CLASS 2011A THE HEART Dr. Sta. Romana, 09/17/07 8 UERMMMC MEDICINE CLASS 2011A THE HEART Dr. Sta. Romana, 09/17/07 8 VIII. Gross Anatomic Changes in the Fetal Circulation at Birth 2. Great Cardiac Vein ascends from the apex of the heart in the anterior interventricular groove, enters the atrioventricular groove, curves to the left side and back of the heart and empties into the coronary sinus 3. Middle Cardiac Vein runs from the apex of the heart in the posterior interventricular groove and empties into the coronary sinus 4. Small Cardiac Vein accompanies the marginal artery along the inferior border of the heart and empties into the coronary sinus 5. Anterior Cardiac Vein drains anterior surface of the right atrium and the right ventricle and empties directly into the right atrium VII. Cardiac Plexus Fetal Post-Natal Foramen ovale (blood circulates from the inferior vena cava to the right atrium and into the left atrium) Fossa ovalis Ductus arteriosus ( connects left pulmonary artery with arch of aorta) Ligamentum arteriosum Ductus venosus Ligamentum venosum of the liver Umbilical Vein Ligamentum teres Umbilical artery Medial umbilical ligament/medial umbilical folds of peritoneum Nerve Supply of the Heart - The heart is innervated by the sympathetic and the parasympathetic fibers of the autonomic nervous system via the cardiac plexuses - Postganglionic sympathetic fibers terminate on SA and AV nodes, cardiac muscle fibers and coronary arteries and activation results in cardiac acceleration, increased force of contraction by cardiac muscle and dilatation of the coronary arteries - Parasympathetic fibers reach the cardiac plexuses in the vagus nerve - Postganglionic parasympathetic fibers terminate on the SA and AV nodes, and on the coronary arteries - Activation of the parasympathetic nerves results in a reduced rate and force of contraction by the heart and a constriction of the coronary arteries. ____________________ **final version unless noted for correction. thank you for your patience.

Good Luck to All!!! trans by: kai