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Because the cords are attached to adjacent sides of INFERIOR TO THE CUSP:
two cusps: - the membrane is an interventricular
they prevent separation of the cusps and septum.
their inversion when tension is applied to the SUPERIOR TO THE CUSP:
tendinous cords and maintained throughout - it is an atrioventricular septum, separating the
ventricular contraction (systole)that is, right atrium from the left ventricle.
the cusps of the tricuspid valve are SEPTOMARGINAL TRABECULA (MODERATOR
prevented from prolapsing (being driven into BAND)
the right atrium) as ventricular pressure is a curved muscular bundle that traverses the
rises. right ventricular chamber from the inferior part
Thus, regurgitation of blood (backward flow of the IVS to the base of the
of blood) from the right ventricle back into anterior papillary muscle.
the right atrium is blocked during ventricular This trabecula is important because it carries
systole by the valve cusps. part of the right branch of the AV bundle, a part
THREE PAPILLARY MUSCLES IN THE RIGHT of the conducting system of the heart to the
VENTRICLE CORRESPOND TO THE CUSPS OF THE anterior papillary muscle.
TRICUSPID VALVE: This shortcut across the chamber seems to
facilitate conduction time, allowing coordinated
- the largest and most prominent of the three contraction of the anterior papillary muscle.
- arises from the anterior wall of the right PULMONARY VALVE:
ventricle is located at the apex of the conus arteriosus at
- its tendinous cords attach to the anterior and the level of the left 3rd costal cartilage
posterior cusps of the tricuspid valve. guards the pulmonary orifice
consists of three semilunar cusps formed by
- smaller than the anterior muscle, folds of endocardium with some connective
- may consist of several parts tissue enclosed.
- it arises from the inferior wall of the right The three semilunar cusps are arranged with:
ventricle one posterior (left cusp) and
- its tendinous cords attach to the posterior and two anterior (anterior and right cusps).
septal cusps of the tricuspid valve.
the cusps of the valve are pressed against
- arises from the interventricular septum the wall of the pulmonary trunk by the
- its tendinous cords attach to the anterior and outrushing blood.
septal cusps of the tricuspid valve.
Blood flows back toward the heart and
INTERVENTRICULAR SEPTUM (IVS): enters the sinuses
composed of muscular and membranous parts the valve cusps fill, come into apposition in
is a strong, obliquely placed partition between the the center of the lumen, and close the
right and left ventricles forming part of the walls pulmonary orifice.
of each The curved lower margins and sides of each cusp
are attached to the arterial wall.
which forms the majority of the septum, has The open mouths of the cusps are directed
the thickness of the remainder of the wall of upward into the pulmonary trunk.
the left ventricle. No chordae or papillary muscles are associated
- Because of the much higher blood pressure in with these valve cusps;
the left ventricle the attachments of the sides of the cusps to the
(two to three times as thick as the wall of arterial wall prevent the cusps from prolapsing
the right ventricle) and into the ventricle.
bulges into the cavity of the right ventricle.
PULMONARY SINUSES:
Superiorly and posteriorly are the spaces at the origin of the pulmonary
a thin membrane, formed from part of the trunk between the dilated wall of the vessel
fibrous skeleton of the heart and each cusp of the pulmonary valve.
ON THE RIGHT SIDE: the septal cusp of the The blood in the pulmonary sinuses prevents
tricuspid valve is attached to the middle of the cusps from sticking to the wall of the
this membranous part of the fibrous pulmonary trunk and failing to close
skeleton.
The right atrium contracts when the right ventricle is superior part of the left border of the heart and
empty and relaxed: overlaps the root of the pulmonary trunk.
i thus blood is forced through this orifice into the It represents the remains of the left part of the
s right ventricle, pushing the cusps of the tricuspid primordial atrium.
a valve aside like curtains. A semilunar depression in the interatrial septum
h indicates the floor of the oval fossa; the
The inflow of blood into the right ventricle (inflow tract) surrounding ridge is the valve of the oval fossa
i
enters posteriorly; and when the ventricle contracts, the (L. valvulae foramen ovale).
ig
outflow of blood into the pulmonary trunk (outflow tract)
sh
leaves superiorly and to the left. THE INTERIOR OF THE LEFT ATRIUM HAS:
al A larger smooth-walled part and a smaller
hConsequently,
y the blood takes a U-shaped path through the muscular auricle containing pectinate muscles.
right
iim ventricle, changing direction about 140. Four pulmonary veins (two superior and two
This change in direction is accommodated by the inferior) entering its smooth posterior wall.
gso
supraventricular crest, which deflects the incoming A slightly thicker wall than that of the right
h b
a flow into the main cavity of the ventricle, and the atrium.
lhi outgoing flow into the conus arteriosus toward the An interatrial septum that slopes posteriorly and
ly pulmonary orifice. to the right.
i
m e The inflow (AV) orifice and outflow (pulmonary) orifi A left AV orifice through which the left atrium
g
o r ce are approximately 2 cm apart. discharges the oxygenated blood it receives from
h the pulmonary veins into the left ventricle
b e
l
iyg LEFT VENTRICLE
lm i forms the apex of the heart, nearly all its left
eoo i (pulmonary) surface and border, and most of the
rbn s diaphragmatic surface
ei a the left ventricle performs more work than the right
h ventricle.
gl
i Because arterial pressure is much higher in the
ie
systemic than in the pulmonary circulation.
o g
r The left ventricle communicates with the:
n h left atrium through:
e
l the atrioventricular orifice
g
y the aorta through:
i
m the aortic orifice.
o The walls of the left ventricle are three times thicker
o
n than those of the right ventricle.
LEFT ATRIUM b
The left intraventricular blood pressure is six times
forms most of the base of the heart i
i The valveless pairs of right and left pulmonary veins higher than that inside the right ventricle.
l
s enter the smooth-walled atrium e THE INTERIOR OF THE LEFT VENTRICLE HAS:
a is situated behind the right atrium and forms the r Walls that are two to three times as thick as
h greater part of the base or the posterior surface of
e those of the right ventricle.
the heart
i Walls that are mostly covered with a mesh of
Behind it lies the oblique sinus of the serous g
g trabeculae carneae that are finer and more
pericardium, and the fibrous pericardium separates it i
h numerous than those of the right ventricle.
from the esophagus o A conical cavity that is longer than that of the
l In the embryo: n right ventricle.
y there is only one common pulmonary vein, just as
Anterior and posterior papillary muscles that are
m there is a single pulmonary trunk.
larger than those in the right ventricle.
The wall of this vein and four of its tributaries
o A smooth-walled, non-muscular, supero-anterior
were incorporated into the wall of the left
b outflow part, the aortic vestibule, leading to the
atrium, in the same way that the sinus venosus
i aortic orifice and aortic valve.
was incorporated into the right atrium.
A double-leaflet mitral valve that guards the left
l The part of the wall derived from the embryonic
AV orifice.
e pulmonary vein is smooth walled.
An aortic orifice that lies in its right
r The tubular, muscular left auricle, its wall
posterosuperior part and is surrounded by a
e trabeculated with pectinate muscles, forms the
fibrous ring to which the right posterior,
g
i
CLINICAL ANATOMY | HEART
o
AHMAD, MISTLEY JANE A. 8
and left cusps of the aortic valve are attached; After relaxation of the ventricle (diastole), the
the ascending aorta begins at the aortic orifice. elastic recoil of the wall of the pulmonary trunk
MITRAL VALVE: or aorta forces the blood back toward the heart.
has two cusps, anterior and posterior However, the cusps snap closed like an umbrella
The anterior cusp is the larger and intervenes caught in the wind as they catch the reversed
between the atrioventricular and aortic orifices. blood flow.
guards the atrioventricular orifice They come together to completely close the
The adjective mitral derives from the valves orifice, supporting each other as their edges abut
resemblance to a bishops miter (headdress). (meet), and preventing any significant amount of
is located posterior to the sternum at the level blood from returning to the ventricle.
of the 4th costal cartilage The edge of each cusp is thickened in the region
Each of its cusps receives tendinous cords from of contact, forming the lunule;
more than one papillary muscle. the apex of the angulated free edge is thickened
These muscles and their cords support the further as the nodule.
mitral valve, allowing the cusps to resist the Immediately superior to each semilunar cusp, the
pressure developed during contractions walls of the origins of the pulmonary trunk and
(pumping) of the left ventricle. aorta are slightly dilated, forming a sinus.
The cords become taut just before and The aortic sinuses and sinuses of the
during systole, preventing the cusps from pulmonary trunk (pulmonary sinuses):
being forced into the left atrium. - are the spaces at the origin of the pulmonary
As it traverses the left ventricle, the trunk and ascending aorta between the dilated
bloodstream undergoes two right angle turns, wall of the vessel and each cusp of the semilunar
which together result in a 180 change in valves.
direction. The blood in the sinuses and the dilation
This reversal of flow takes place around the of the wall prevent the cusps from sticking
anterior cusp of the mitral valve. to the wall of the vessel, which might prevent
SEMILUNAR AORTIC VALVE: closure.
guards the aortic orifice and The mouth of the right coronary artery is:
is precisely similar in structure to the pulmonary in the right aortic sinus
valve the mouth of the left coronary artery is:
between the left ventricle and the ascending in the left aortic sinus
aorta, is obliquely placed. and no artery arises from the posterior aortic
It is located posterior to the left side of the (non-coronary) sinus
sternum at the level of the 3rd intercostal space.
One cusp is situated on the anterior wall (right
cusp) and two are located on the posterior wall
(left and posterior cusps).
Behind each cusp, the aortic wall bulges to form
an aortic sinus.
The anterior aortic sinus gives origin to:
- the right coronary artery, and
the left posterior sinus gives origin to:
- the left coronary artery.
SEMILUNAR VALVES:
Each of three semilunar cusps of the pulmonary valve
i (anterior, right, and left), like the semilunar cusps of
s the aortic valve (posterior, right, and left), is concave
a when viewed superiorly.
h SEMILUNAR CUSPS:
i do not have tendinous cords to support them
Are smaller in area than the cusps of the AV
g
valves, and the force exerted on them is less than
h half that exerted on the cusps of the tricuspid
l and mitral valves.
y The cusps project into the artery but are
m pressed toward (and not against) its walls as
o blood leaves the ventricle.
b
i CLINICAL ANATOMY | HEART
l
AHMAD, MISTLEY JANE A. 9
- ORIGIN: LCA
- COURSE: Passes along anterior IV groove to apex of heart;
Here it turns around the inferior border of the heart and
commonly anastomoses with the posterior IV branch of the right
coronary artery
- DISTRIBUTION: Right and left ventricles via septal branches
and anterior two thirds of IVS
- ANASTOMOSES: Posterior IV branch of RCA (at apex)
- GIVES RISE TO:
- ORIGIN: LCA
- COURSE: Passes to left in AV sulcus and runs to posterior
surface of heart
- DISTRIBUTION: Left atrium and left ventricle
- ANASTOMOSES: RCA
VARIATIONS OF CORONARY ARTERIES
- GIVES RISE TO:
Variations in the branching patterns and
- ORIGIN: Circumflex branch of LCA distribution of the coronary arteries are common.
- COURSE: Follows left border of heart 67% of people:
- DISTRIBUTION: Left ventricle most
- ANASTOMOSES: IV branches the RCA and LCA share about equally in the
blood supply of the heart
the circumflex branch of the LCA terminates in the 15% of hearts:
coronary sulcus on the posterior aspect of the heart the LCA is dominant in that the posterior IV
before reaching the crux of the heart branch is a branch of the circumflex artery
but in approximately one third of hearts it continues 18% of people:
to supply a branch that runs in or adjacent to the codominance, in which branches of both the
posterior IV groove right and left coronary arteries reach the
crux of the heart and give rise to branches
- ORIGIN: LCA (in 33%) that course in or near the posterior IV
- COURSE: Runs in posterior IV groove to apex of heart
groove.
- DISTRIBUTION: Right and left ventricles and posterior third
A few people have only one coronary artery.
of IVS
- ANASTOMOSES: Anterior IV branch of LCA (at apex)
In other people:
the circumflex branch arises from the right Accompanies the posterior interventricular
aortic sinus branch (usually arising from the RCA).
4% of people: drain most of the areas commonly supplied by the
have an accessory coronary artery RCA.
However, the AV bundle traverses the center of the postsynaptic sympathetic fibers, with cell bodies
IVS, the anterior two thirds of which is supplied by in the cervical
the septal branches of the anterior IV branch of the and superior thoracic paravertebral ganglia of
LCA the sympathetic trunks
The postsynaptic fibers traverse
Impulse generation and conduction can be summarized cardiopulmonary splanchnic nerves and the
as follows: cardiac plexus to end in the SA and AV nodes and
The SA node initiates an impulse that is rapidly in relation to the terminations of
conducted to cardiac muscle fibers in the atria, parasympathetic fibers on the coronary arteries.
causing them to contract
The impulse spreads by myogenic conduction, INCREASE:
which rapidly transmits the impulse from the SA Heart rate
node to the AV node. Impulse conduction
The signal is distributed from the AV node Force of contraction
through the AV bundle and its branches (the Increased blood flow through the
right and left bundles), which pass on each side coronary vessels to support the
of the IVS to supply subendocardial branches to increased activity.
the papillary muscles and the walls of the ADRENERGIC STIMULATION OF THE SA
ventricles. NODE AND CONDUCTING TISSUE:
Increases the rate of depolarization of
the pacemaker cells while increasing
atrioventricular conduction.
DIRECT ADRENERGIC STIMULATION
FROM THE SYMPATHETIC NERVE FIBERS,
AS WELL AS INDIRECT SUPRARENAL
(ADRENAL) HORMONE STIMULATION:
Increases atrial and ventricular
conduction
ADRENERGIC RECEPTOR ON CORONARY
BLOOD VESSELS:
b2- receptors
when activated, causes relaxation (or
INNERVATION OF THE HEART
perhaps inhibition) of vascular smooth
The heart is supplied by autonomic nerve fibers from
i muscle and, therefore, dilation of the
the cardiac plexus, which is often quite artificially
arteries.
s divided into superficial and deep portions
This supplies more oxygen and nutrients
a This nerve network is most commonly described as to the myocardium during periods of
h lying on the anterior surface of the bifurcation of the
increased activity.
i trachea (a respiratory structure), since it is most
commonly observed in dissection after removal of the
g PARASYMPATHETIC SUPPLY
ascending aorta and the bifurcation of the pulmonary
h is from presynaptic fibers of the vagus nerves.
trunk.
Postsynaptic parasympathetic cell bodies
l However, its primary relationship is to the posterior
(intrinsic ganglia) are located in the atrial wall and
y aspect of the latter two structures, especially the
interatrial septum near the SA and AV nodes and
m ascending aorta.
along the coronary arteries
o The cardiac plexus is formed of both sympathetic and
parasympathetic fibers en route to the heart, as well
b DECREASE:
as visceral afferent fibers conveying reflexive and
i Heart rate
nociceptive fibers from the heart.
l Fibers extend from the plexus along and to the Force of the contraction
Constricts the coronary arteries, saving
e coronary vessels and to components of the conducting
energy between periods of increased
r system, particularly the SA node.
demand.
e Postsynaptic parasympathetic fibers release
SYMPATHETIC SUPPLY:
g acetylcholine, which binds with muscarinic
is from presynaptic fibers, with cell bodies in the
i receptors to slow the rates of depolarization
intermediolateral cell columns (IMLs) of the five
o of the pacemaker cells and atrioventricular
or six thoracic segments of the spinal cord, and
conduction and decrease atrial contractility.
n
CARDIAC CATHETERIZATION The floor of the fossa is formed by the valve of the
a radiopaque catheter is inserted into a peripheral oval foramen.
i vein (e.g., the femoral vein) and passed under The rudimentary IVC valve, a semi lunar crescent of
s fluoroscopic control into the right atrium, right tissue, has no function after birth; it varies
a ventricle, pulmonary trunk, and pulmonary arteries, considerably in size and is occasionally absent.
h respectively.
i Using this technique, intracardiac pressures can be SEPTAL DEFECTS
recorded and blood samples may be removed. ATRIAL SEPTAL DEFECTS
g i A congenital anomaly of the interatrial septum,
If a radiopaque contrast medium is injected, it can
h be followed through the heart and great vessels using is usually incomplete closure of the oval foramen.
l serially exposed X-ray films. sa A probe-size patency is present in the superior part
y Alternatively, cineradiography or cardiac ah of the oval fossa in 1525% of adults
m ultrasonography can be performed to observe the h
i These small openings, by themselves, cause no
o fl ow of dye in real time. ig hemodynamic abnormalities and are, therefore,
Both techniques permit study of the circulation of no clinical significance and should not be
b gh
through the functioning heart and are helpful in the considered forms of ASDs.
i study of congenital cardiac defects. h
l Clinically significant ASDs vary widely in size and
l ly location and may occur as part of more complex
eEMBRYOLOGY OF THE RIGHT ATRIUM ym congenital heart disease.
r The primordial atrium is represented in the adult by m
o Large ASDs allow oxygenated blood from the lungs to
i the right auricle. be shunted from the left atrium through the ASD
e o
b
s The definitive atrium is enlarged by incorporation of into the right atrium, causing enlargement of the
g b
i
a most of the embryonic sinus venosus. right atrium and ventricle and dilation of the
i il
h The coronary sinus is also a derivative of this venous pulmonary trunk.
o sinus. le This left to right shunt of blood overloads the
i
n The part of the venous sinus incorporated into the er pulmonary vascular system, resulting in hypertrophy
g
primordial atrium becomes the smooth-walled sinus re of the right atrium and ventricle and pulmonary
h venarum of the adult right atrium into which all the arteries.
g e
l veins drain, including the coronary sinus.
gi
y The line of fusion of the primordial atrium (the adult VENTRICULAR SEPTAL DEFECTS
io
m auricle) and the sinus venarum (the derivative of the The membranous part of the IVS develops separately
venous sinus) is indicated internally by the crista io
n from the muscular part and has a complex
o
terminalis and externally by the sulcus terminalis. sn embryological origin.
b
The sinu-atrial (SA) node is located just in front of a Consequently, this part is the common site of
i the opening of the SVC at the superior end of the ventricular septal defects (VSDs), although
h
l crista terminalisthat is, in the border between the defects also occur in the muscular part.
i
e primordial atrium and the sinus venosus; hence its VSDs rank first on all lists of cardiac defects.
g
r name. Isolated VSDs account for approximately 25% of all
Before birth, the valve of the IVC directs most of h forms of congenital heart disease.
e
the oxygenated blood returning from the placenta in l The size of the defect varies from 1 to 25 mm.
g
the umbilical vein and IVC toward the oval foramen in y A VSD causes a left to right shunt of blood through
i
the interatrial septum, through which it passes into m the defect.
o the left atrium. A large shunt increases pulmonary blood flow, which
o
n The oval foramen has a flap-like valve that permits a causes severe pulmonary disease (hypertension, or
b
right to left shunt of blood but prevents a left to increased blood pressure) and may cause cardiac
right shunt.
i failure.
At birth, when the baby takes its first breath, the l The much less common VSD in the muscular part of
lungs expand with air and pressure in the right atrium e the septum frequently closes spontaneously during
falls below that in the left atrium r childhood.
Consequently, the oval foramen closes for its first e
and last time, and its valve usually fuses with the
gPERCUSSION OF HEART
interatrial septum.
ii
The closed oval foramen is represented in the defines the density and size of the heart.
postnatal interatrial septum by the depressed oval o
s The classical percussion technique is to create
fossa. n
a vibration by tapping the chest with a finger while
The border of the oval fossa (L. limbus fossae ovalis) h listening and feeling for differences in soundwave
surrounds the fossa. i conduction.
g
h
l CLINICAL ANATOMY | HEART
y
AHMAD, MISTLEY JANE A. 15
g
h
l
y CLINICAL ANATOMY | HEART
m
AHMAD, MISTLEY JANE A. 16
CORONARY ANGIOGRAPHY
In pulmonary valve stenosis, the valve cusps are Using coronary angiography, the coronary arteries
fused, forming a dome with a narrow central i can be visualized with coronary arteriograms.
opening. s A long, narrow catheter is passed into the ascending
In infundibular pulmonary stenosis, the conus a aorta via the femoral artery in the inguinal region.
arteriosus is underdeveloped. h Under fluoroscopic control, the tip of the catheter is
Both types of pulmonary stenoses produce a i placed just inside the opening of a coronary artery.
restriction of right ventricular outflow and may A small injection of radiopaque contrast material is
g
occur together. made, and cine radiograph are taken to show the
The degree of hypertrophy of the right ventricle h lumen of the artery and its branches, as well as any
is variable. l stenotic areas that may be present.
y
If the free margins (lunules) of the cusps of a m CORONARY ARTERY DISEASE OR CORONARY HEART
semilunar valve thicken and become inflexible or o DISEASE
are damaged by disease, the valve will not close i Coronary artery disease (CAD) is one of the leading
b
completely. s causes of death.
An incompetent pulmonary valve results in a
i It has many causes, all of which result in a reduced
a
backrush of blood under high pressure into the l blood supply to the vital myocardial tissue.
h
right ventricle during diastole. e
i
Pulmonic regurgitation may be heard through a r
g
stethoscope as a heart murmur, an abnormal e With sudden occlusion of a major artery by an
sound from the heart, produced in this case by h embolus (G. embolos, plug), the region of
gl
damage to the cusps of the pulmonary valve. myocardium supplied by the occluded vessel
i
y becomes infarcted (rendered virtually bloodless)
Aortic valve stenosis is the most frequent valve o and undergoes necrosis (pathological tissue
m
abnormality. n death).
o
For those born in the early and mid-20th century, The three most common sites of coronary artery
b
rheumatic fever was a common cause but now occlusion and the percentage of occlusions
accounts for <10% ofcases of aortic stenosis.
i involving each artery are the:
The great majority of aortic stenosis is a result l 1. Anterior IV (LAD) branch of the LCA (40
of degenerative calcification and comes to clinical e 50%).
attention in the 6th decade of life or later. r 2. RCA (3040%).
Aortic stenosis causes extra work for the heart, e 3. Circumfl ex branch of the LCA (1520%).
resulting in left ventricular hypertrophy. An area of myocardium that has undergone
g
necrosis constitutes a myocardial infarction
i
Insufficiency of the aortic valve results in aortic (MI).
regurgitation (backrush of blood into the left o The most common cause of ischemic heart
ventricle), producing a heart murmur and a n disease is coronary artery insufficiency resulting
collapsing pulse (forcible impulse that rapidly from atherosclerosis.
diminishes).
The atherosclerotic process, characterized by
ECHOCARDIOGRAPHY lipid deposits in the intima (lining layer) of the
Or ultrasonic cardiography is a method of graphically coronary arteries, begins during early adulthood
i recording the position and motion of the heart by the and slowly results in stenosis of the lumina of the
s echo obtained from beams of ultrasonic waves arteries.
a directed through the thoracic wall As coronary atherosclerosis progresses, the
h This technique may detect as little as 20 mL of fluid collateral channels connecting one coronary
i in the pericardial cavity, such as that resulting from artery with the other expand, which may initially
pericardial effusion. permit adequate perfusion of the heart during
g
relative inactivity.
h is a technique that demonstrates and records the Despite this compensatory mechanism, the
l flow of blood through the heart and great vessels myocardium may not receive enough oxygen when
y by Doppler ultrasonography, making it especially the heart needs to perform increased amounts of
m useful in the diagnosis and analysis of problems work.
o with blood flow through the heart, such as septal Strenuous exercise, for example, increases the
defects, and in delineating valvular stenosis and hearts activity and its need for oxygen.
b
regurgitation, especially on the left side of the Insufficiency of blood supply to the heart
i heart. (myocardial ischemia) may result in MI.
l
e
r CLINICAL ANATOMY | HEART
e
AHMAD, MISTLEY JANE A. 17
Here the electrode is fi rmly fi xed to the trabeculae As coordinated contractions and hence pumping of
carneae in the ventricular wall and placed in contact the heart is re-established, some degree of systemic
with the endocardium. (including coronary) circulation results.
g
h
l CLINICAL ANATOMY | HEART
y