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AHMAD, MISTLEY JANE A.

HEART TWO HEART SOUNDS


HEART: are heard with a stethoscope
i slightly larger than ones loosely clenched fist, i
s is a double, self-adjusting suction and pressure pump, s S1
a the parts of which work in unison to propel blood to a as the blood is transferred from the atria
h all parts of the body. h into the ventricles
i results from the closing of the mitral and
i
g Receives poorly oxygenated (venous) blood tricuspid valves
from the body through the SVC and IVC and
g
h h
pumps it through the pulmonary trunk S2
l l as the ventricles expel blood from the heart.
y Receives well-oxygenated (arterial) blood y results from the closing of the aortic and
m from the lungs through the pulmonary veins m pulmonary valves.
o and pumps it into the aorta for distribution o The heart sounds are produced by:
b to the body the snapping shut of the one way valves that
b
normally keep blood from flowing backward
i i
FOUR CHAMBERS OF THE HEART: during contractions of the heart.
il Right Atria l
se Left Atria e THE WALL OF THE HEART CONSISTS OF THREE
ar Right Ventricle r LAYERS; FROM SUPERFICIAL TO DEEP
e Left Ventricle
h i
e
ig s a thin external layer (mesothelium) formed
g
giiATRIUM: a
i
by the visceral layer of serous pericardium
are receiving chambers that pump blood into the h
h
o
s o
ventricles (the discharging chambers). i a thick middle layer composed of cardiac
alnVENTRICLES: n muscle
iy collect and expel blood received from atrium an g
h
sm atrium towards the peripheral beds within the body h a thin internal layer (endothelium and
i
ao and lungs. l subendothelial connective tissue) or lining
g
h
b CARDIAC CYCLE: y membrane of the heart that also covers its
h
ii The synchronous pumping actions of the hearts two m valves.
li atrioventricular (AV) pumps (right and left chambers)
gl o The walls of the heart consist mostly of myocardium,
sy BEGINS: especially in the ventricles.
h
eam b
with a period of ventricular elongation and When the ventricles contract:
lr filling (diastole)
i they produce a wringing motion because of
o
h
ye ENDS: l the double helical orientation of the cardiac
ib
m
ggi with a period of ventricular shortening and e muscle fibers.
o emptying (systole) r This motion initially ejects the blood from
ih
l
b e the ventricles as the outer (basal) spiral
o
le contracts, first narrowing and then
in g
ry shortening the heart, reducing the volume of
l i
e
m the ventricular chambers.
e o Continued sequential contraction of the inner
g
o
r n (apical) spiral elongates the heart, followed by
ib
e widening as the myocardium briefly relaxes,
io increasing the volume of the chambers to draw blood
g
ln from the atria.
i
e
o
r FIBROUS SKELETON OF THE HEART
n Where the cardiac muscles are anchored
e
i is a complex framework
g
s of dense collagen forming four fibrous rings (L. annuli
i
a fibrosi) that surround the orifices of the valves, a
o right and left fibrous trigone (formed by connections
h
n between rings), and the membranous parts of the
i
interatrial and interventricular septa
g
h
l
y
CLINICAL ANATOMY | HEART
m
o
AHMAD, MISTLEY JANE A. 2

BASE OF THE HEART


Keeps the orifices of the AV and semilunar valves Is the hearts posterior aspect (opposite the apex).
patent and prevents them from being overly i Is formed mainly by the left atrium, with a lesser
distended by an increased volume of blood pumping s contribution by the right atrium.
through them. a Faces posteriorly toward the bodies of vertebrae T6
Provides attachments for the leaflets and cusps of h T9 and is separated from them by
the valves. i the pericardium, oblique pericardial sinus, esophagus,
Provides attachment for the myocardium, which, when and aorta.
g
uncoiled, forms a continuous ventricular myocardial Extends superiorly to the bifurcation of the
band that originates primarily from the fibrous ring h pulmonary trunk and inferiorly to the coronary sulcus.
of the pulmonary valve and inserts primarily into the l Receives the pulmonary veins on the right and left
fibrous ring of the aortic valve. y sides of its left atrial portion, and the superior and
Forms an electrical insulator, by separating the m inferior venae cavae at the superior and inferior ends
myenterically conducted impulses of the atria and o of its right atrial portion.
ventricles so that they contract independently and by
b
surrounding and providing passage for the initial part
of the AV bundle of the conducting system of the
i
heart. l
e
r
e
g
i
o
n

The heart appears trapezoidal from an anterior or posterior


view (Fig. 1.52A), but in three dimensions it is shaped like a
ii
tipped-over pyramid with its apex (directed anteriorly and to
thess left), a base (opposite the apex, facing mostly posteriorly),
andaa four sides.
hh
iiAPEX OF THE HEART
Is formed by the inferolateral part of the left
gig
ventricle.
h
sh Lies posterior to the left 5th intercostal space in
lal adults, usually approximately 9 cm (a hands breadth)
yhy from the median plane.
m
i m Remains motionless throughout the cardiac cycle.
o Is where the sounds of mitral valve closure are
go
maximal (apex beat); the apex underlies the site
b
hb where the heartbeat may be auscultated on the
ili thoracic wall.
lyl
em e
ror
ebe
gig
ili
o
eo
CLINICAL ANATOMY | HEART
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rn
AHMAD, MISTLEY JANE A. 3

SURFACES OF THE HEART

i Formed mainly by the right ventricle


s The right border is formed by the right
a atrium;
h The left border, by the left ventricle and
i part of the left auricle.
The right ventricle is separated from the
g
left ventricle by the anterior
h interventricular groove.
l
y formed mainly by the left ventricle and
m partly by the right ventricle; it is related
o mainly to the central tendon of the
diaphragm.
b
separated by the posterior interventricular
i groove
l
e formed mainly by the right atrium.
r
e formed mainly by the left ventricle; it forms
the cardiac impression in the left lung. The heart appears trapezoidal in both anterior and
g
posterior views
i i
Formed by left atrium
o into which open the four pulmonary veins sFOUR BORDERS OF THE HEART
n lies opposite the apex. a (slightly convex):
i formed by the right atrium and extending
h
the sharp right ventricular margin of the s
i between the SVC and the IVC.
heart a (nearly horizontal):
g
h formed mainly by the right ventricle and
h slightly by the left ventricle.
the more rounded left margin of the heart i
l (oblique, nearly vertical):
g
the inferolateral part of the left ventricle at y formed mainly by the left ventricle and
h slightly by the left auricle.
the 4th to 5th intercostal space 3.5 in. (9 cm) m
from the midline l
o
formed by left ventricle y formed by the right and left atria and
b
is directed downward, forward, and to the m auricles in an anterior view;
i the ascending aorta and pulmonary trunk
left. o
l emerge from this border and the SVC enters
b
ATRIOVENTRICULAR GROOVE (Coronary Sulcus) e its right side.
i Posterior to the aorta and pulmonary trunk
separates the two atria from the ventricles and r
i marks the locations of the right coronary artery and
l and anterior to the SVC, this border forms
e
s the circumflex branch of the left coronary e the inferior boundary of the transverse
g
a artery. r pericardial sinus.
i
h e
oPULMONARY TRUNK
iANTERIOR AND POSTERIOR INTERVENTRICULAR g
n approximately 5 cm long and 3 cm wide
GROOVES
gi
mark the locations of the left anterior descending
ii is the arterial continuation of the right ventricle
sh o
s divides into right and left pulmonary arteries.
(anterior interventricular) branch of the left
la coronary artery and the posterior descending n
a The pulmonary trunk and arteries conduct low-oxygen
yh (posterior interventricular) artery. h blood to the lungs for oxygenation.
m
i i
o
g g
b
h h
il l
ly y
em m
ro o
eb b CLINICAL ANATOMY | HEART
gi i
AHMAD, MISTLEY JANE A. 4

into the inferior part of the right atrium almost


in line with the SVC at approximately the level of
the 5th costal cartilage.

a short venous trunk receiving most of the


cardiac veins
is between the right AV orifice and the IVC
orifice

Separating the atria has an oval, thumbprint-size


depression, the oval fossa (L. fossa ovalis), which
is a remnant of the oval foramen (L. foramen
ovale) and its valve in the fetus.

OPENINGS INTO THE RIGHT ATRIUM


One each for SVC, IVC, and coronary sinus
(venous return from cardiac veins)

opens into the upper part of the right atrium


it has no valve
It returns the blood to the heart from the
RIGHT ATRIUM upper half of the body.
forms the right border of the heart
i receives venous blood from the SVC, IVC, and larger than the superior vena cava
s coronary sinus. opens into the lower part of the right atrium
a It is guarded by a rudimentary,
h ear-like, is a conical muscular pouch that projects nonfunctioning valve.
i from this chamber like an add-on room It returns the blood to the heart from the
embryonic heart tube derivative lower half of the body.
g
increasing the capacity of the atrium as it
h overlaps the ascending aorta. which drains most of the blood from the
l heart wall
y Smooth, thin-walled, posterior part (the sinus opens into the right atrium between the
m venarum) on which the venae cavae (SVC and IVC) inferior vena cava and the atrioventricular
o and coronary sinus open, bringing poorly orifice.
oxygenated blood into the heart. It is guarded by a rudimentary,
b
Rough, muscular anterior wall composed of nonfunctioning valve.
i pectinate muscles (L. musculi pectinati).
l Ridges of myocardium inside auricle lies anterior to the inferior vena caval
e Right AV orifice through which the right atrium opening
r discharges the poorly oxygenated blood it has guarded by the tricuspid valve
e received into the right ventricle.
g FETAL REMNANTS
Or terminal groove
i i
Shallow vertical groove that separates externally lie on the atrial septum, which separates the
o the smooth and rough parts of the atrial wall. s right atrium from the left atrium.
n a forms the upper margin of the fossa
Or terminal crest h the anulus is formed from the lower edge of the
Shallow vertical groove that separates internally septum secundum
i
the smooth and rough parts of the atrial wall.
Ridge that runs from IVC to SVC openings.
g
is a shallow depression, which is the site of the
Its suoerior extent marks site of SA Node. h foramen ovale in the fetus
l The floor of the fossa represents the persistent
into the superior part of the right atrium at the y septum primum of the heart of the embryo.
level of the right 3rd costal cartilage m
o
b
i
l CLINICAL ANATOMY | HEART
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AHMAD, MISTLEY JANE A. 5

RIGHT VENTRICLE TRICUSPID VALVE:


forms the largest part of the anterior surface of the guards the right AV orifice.
i heart, a small part of the diaphragmatic surface, and The bases of the valve cusps are attached to
s almost the entire inferior border of the heart the fibrous ring around the orifice
a Because the fibrous ring maintains the caliber of
h right atrium: the orifice, the attached valve cusps contact
i through the atrioventricular orifice and each other in the same way with each heartbeat.
pulmonary trunk: consists of three cusps formed by a fold of
g
through the pulmonary orifice endocardium with some connective tissue
h
enclosed:
l it tapers into an arterial cone, the conus anterior cusps: lies anteriorly
y arteriosus (infundibulum), which leads into the septal cusps: lies against the ventricular
m pulmonary trunk septum
o INTERIOR OF THE RIGHT VENTRICLE HAS: inferior (posterior) cusps: lies inferiorly
b The bases of the cusps:
Irregular muscular elevations are attached to the fibrous ring of the
i Composed of three types: skeleton of the heart
l - papillary muscles: their free edges and ventricular surfaces:
e - moderator band are attached to the chordae tendineae.
r - composed of prominent ridges Chordaae tendinae: connect the cusps to the
e papillary muscles.
A thick muscular ridge, which separates the When the ventricle contracts, the papillary
g
ridged muscular wall of the inflow part of the muscles contract and prevent the cusps from
i
chamber from the smooth wall of the conus being forced into the atrium and turning inside
o arteriosus, or outflow part. out as the intraventricular pressure rises.
n To assist in this process, the chordae
- receives blood from the right atrium through tendineae of one papillary muscle are
the right AV (tricuspid) orifice, located posterior connected to the adjacent parts of two
to the body of the sternum at the level of the cusps.
4th and 5th intercostal spaces. TENDINOUS CORD (L. chordae tendineae):
The right AV orifice is surrounded by one of the Attach to the free edges and ventricular
fibrous rings of the fibrous skeleton of the surfaces of the anterior, posterior, and septal
heart. cusps, much like the cords attaching to a
The fibrous ring keeps the caliber of the parachute.
orifice constant (large enough to admit the arise from the apices of papillary muscles
tips of three fingers), resisting the dilation PAPILLARY MUSCLES:
that might otherwise result from blood being Are conical muscular projections with bases
forced through it at varying pressures. attached to the ventricular wall.
begin to contract before contraction of the right
ventricle, tightening the tendinous cords and
drawing the cusps together.

CLINICAL ANATOMY | HEART


AHMAD, MISTLEY JANE A. 6

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.

CLINICAL ANATOMY | HEART


AHMAD, MISTLEY JANE A. 7

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

SURFACE ANATOMY OF HEART VALVES RCA GIVES OFF:


TRICUSPID VALVE
i lies behind the right half of the sternum opposite - ORIGIN: RCA, near its origin (60%)
s the 4th intercostal space. - COURSE: ascends to SA Node
- DISTRIBUTION: Pulmonary trunk and SA Node
a MITRAL VALVE
h lies behind the left half of the sternum opposite
i the 4th costal cartilage.
- ORIGIN: RCA, when the RCA descends in the
PULMONARY VALVE coronary sulcus.
g
lies behind the medial end of the third left costal - COURSE: Passes to inferior margin of heart and apex
h cartilage and the adjoining part of the sternum. - DISTRIBUTION: Right Ventricle and apex of the heart
l AORTIC VALVE - ANASTOMOSES: IV Branches
y lies behind the left half of the sternum opposite
m the 3rd intercostal space After giving off this branch, the RCA turns to the
left and continues in the coronary sulcus to the
o
posterior aspect of the heart.
bVASCULATURE OF HEART
The blood vessels of the heart comprises:
ii the coronary arteries and cardiac veins, which
ls carry blood to and from most of the myocardium - ORIGIN: RCA near origin of posterior IV artery--- At the
ea The blood vessels of the heart: posterior aspect of the: crux (L. cross) of the heartthe
junction of the inter atrial and interventricular (IV) septa
rh normally embedded in fat, course across the
between the four heart chambers.
ei surface of the heart just deep to the epicardium - COURSE: Passes to AV node
Occasionally, parts of the vessels become - DISTRIBUTION: AV node
gg
embedded within the myocardium. - supplies AV Node
ih
are affected by both sympathetic and
ol parasympathetic innervation.
ny The endocardium and some subendocardial tissue - ORIGIN: RCA (67%)
located immediately external to the endocardium - COURSE: Runs in posterior IV groove to apex of heart
m
receive oxygen and nutrients by diffusion or - DISTRIBUTION: Right and left ventricles and posterior third
o of IVS
microvasculature directly from the chambers of the
b - ANASTOMOSES: Anterior IV branch of LCA (at apex)
heart.
i
l Dominance of the coronary arterial system is defined
ARTERIAL SUPPLY OF THE HEART
by which artery gives rise to the posterior
e CORONARY ARTERIES:
i interventricular (IV) branch (posterior descending
r the first branches of the aorta
artery).
s
e supply the myocardium and epicardium
Dominance of the right coronary artery is typical
a supply both the atria and the ventricles;
g (approximately 67%).
h However, the atrial branches are usually
i small and not readily apparent in the
i
o cadaveric heart.
g
n The ventricular distribution of each coronary
h - which descends in the posterior IV groove toward the
artery is not sharply demarcated.
l The right and left coronary arteries arise from the apex of the heart
- supplies adjacent areas of both ventricles and sends
y corresponding aortic sinuses at the proximal part of
perforating interventricular septal branches into the IV
m the ascending aorta, just superior to the aortic valve,
septum
o and pass around opposite sides of the pulmonary
trunk.
b The terminal (left ventricular) branch of the RCA
i RIGHT CORONARY ARTERY: then continues for a short distance in the coronary
l ORIGIN: Right aortic sinus of ascending aorta
sulcus.
e COURSE: passes to the right side of the pulmonary Thus, in the most common pattern of distribution, the
trunk, running in the coronary sulcus; Follows coronary RCA supplies the diaphragmatic surface of the heart.
r
(AV) sulcus between atria and ventricles
e DISTRIBUTION: Right Atrium, SA and AV nodes, and RCA SUPPLIES:
g posterior part of IVS The right atrium.
i ANASTOMOSES: Circumflex and anterior IV branches Most of right ventricle.
of LCA
o Part of the left ventricle (the diaphragmatic
n surface).

CLINICAL ANATOMY | HEART


AHMAD, MISTLEY JANE A. 10

Part of the IV septum, usually the posterior LCA SUPPLIES:


third. The left atrium.
The SA node (in approximately 60% of people). Most of the left ventricle.
The AV node (in approximately 80% of people). Part of the right ventricle.
Most of the IVS (usually its anterior two thirds),
LEFT CORONARY ARTERY including the AV bundle of the conducting system
ORIGIN: left aortic sinus of ascending aorta of the heart, through its perforating IV septal
COURSE: passes between the left auricle and the left branches.
side of the pulmonary trunk, and runs in the coronary The SA node (in approximately 40% of people).
sulcus; Runs in AV groove and gives off anterior IV and
circumflex branches
DISTRIBUTION: Most of left atrium and ventricle,
IVS, and AV bundles; may supply AV node
ANASTOMOSES: RCA
SA NODAL BRANCH :
ORIGIN: Circumflex branch of LCA (in 40%)
COURSE: Ascends on posterior surface of left atrium
to SA node
DISTRIBUTION: Left atrium and SA node

LCA DIVIDES INTO:


As it enters the coronary sulcus, at the superior end
of the anterior IV groove

- 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:

- which descends on the anterior surface of the heart

- 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)

CLINICAL ANATOMY | HEART


AHMAD, MISTLEY JANE A. 11

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.

CORONARY COLLATERAL CIRCULATION accompanies the right marginal branch of the


RCA
branches of the coronary arteries drain most of the areas commonly supplied by the
arteries that supply regions of the RCA
myocardium lacking sufficient anastomoses
from other large branches to maintain
viability of the tissue should occlusion occur is a small vessel, relatively unimportant
postnatally, that descends over the posterior wall
Between branches of the coronary arteries, of the left atrium and merges with the great
subepicardial or myocardial, and between cardiac vein to form the coronary sinus (defining
these arteries and extracardiac vessels such the beginning of the sinus)
as thoracic vessels. is the remnant of the embryonic left SVC, which
Between the terminations of the right and usually atrophies during the fetal period, but
the left coronary arteries in the coronary occasionally persists in adults, replacing or
sulcus and between the IV branches around augmenting the right SVC
the apex in approximately 10% of apparently Some cardiac veins do not drain via the coronary
normal hearts. sinus.
The potential for development of collateral SMALL ANTERIOR CARDIAC VEINS:
circulation probably exists in most if not all begin over the anterior surface of the right
hearts. ventricle, cross over the coronary sulcus, and
usually end directly in the right atrium
VENOUS DRAINAGE OF THE HEART sometimes they enter the small cardiac vein
The heart is drained: SMALLEST CARDIAC VEINS (L. venae cordis
i mainly by veins that empty into the coronary sinus minimae):
s and are minute vessels that begin in the capillary beds
a partly by small veins that empty into the right of the myocardium and open directly into the
h atrium chambers of the heart, chiefly the atria.
i CORONARY SINUS: Although called veins, they are valveless
the main vein of the heart communications with the capillary beds of the
g
is a wide venous channel that runs from left to myocardium
h right in the posterior part of the coronary sulcus may carry blood from the heart chambers to the
l receives the great cardiac vein at its left end and myocardium.
y the middle cardiac vein and small cardiac veins at
m its right end.
o The left posterior ventricular vein and left
marginal vein also open into the coronary sinus.
b
i is the main tributary of the coronary sinus
l drains the areas of the heart supplied by the
e LCA.
r Its first part, the anterior interventricular vein,
e begins near the apex of the heart and ascends
g with the anterior IV branch of the LCA. The great, middle, and small cardiac veins, thye
At the coronary sulcus it turns left, and its oblique vein of left atrium, and the left posterior
i
second part runs around the left side of the ventricular vein are the main vessels draining into the
o heart with the circumflex branch of the LCA to coronary sinus.
n reach the coronary sinus. The coronary sinus, in turn, empties into right atrium
An unusual situation is occurring here: Blood The anterior cardiac veins drains directly into the
is flowing in the same direction within a auricle of the right atrium.
paired artery and vein!

CLINICAL ANATOMY | HEART


AHMAD, MISTLEY JANE A. 12

LYMPHATIC DRAINAGE OF THE HEART


Lymphatic vessels in the myocardium and parasympathetic division to return to or
i subendocardial connective tissue pass to the approach its basal rate.
s SUBEPICARDIAL LYMPHATIC PLEXUS.
a Vessels from this plexus pass to the ATRIOVENTRICULAR (AV) NODE
h coronary sulcus and follow the coronary a smaller collection of nodal tissue than the SA
i arteries node
A single lymphatic vessel, formed by the union of
g
various lymphatic vessels from the heart, ascends In the posteroinferior region of the
h between the pulmonary trunk and left atrium and ends interatrial septum near the opening of the
l in the inferior tracheobronchial lymph nodes, usually coronary sinus
y on the right side.
m The signal generated by the SA node passes
o STIMULATING, CONDUCTING, AND REGULATING through the walls of the right atrium,
SYSTEMS OF HEART propagated by the cardiac muscle which
b
i transmits the signal rapidly from the SA
isCONDUCTING SYSTEM OF THE HEART: node to the AV node
la generates and transmits the impulses that produce
eih the coordinated contractions of the cardiac cycle Symphatetic, which speeds up conduction
sr CONSISTS OF:
i
ae that initiates the Parasymphatetic, slows conduction
g
heartbeat and coordinates contractions of
gh
h
i the four heart chambers
l the only bridge between the atrial and
go
y for conducting them rapidly to the ventricular myocardium
h
n different areas of the heart passes from the AV node through the fibrous
m
l The impulses are then propagated by the cardiac skeleton of the heart and along the
o
y striated muscle cells so that the chamber walls membranous part of the IVS.
b
m contract simultaneously. Through this bundle, AV node then
i distributes the signal to the ventricles
o
l SINU-ATRIAL (SA) NODE: DIVIDES INTO:
b
e a small collection of nodal tissue, specialized at the junction of
i cardiac muscle fibers, and associated the membranous and muscular parts of
r
l fibroelastic connective tissue the IVS.
e
e is the pacemaker of the heart. These branches proceed on each side of the
g
r The contraction signal from the SA node spreads muscular IVS deep to the endocardium and
i
e myogenically (through the musculature) of both then ramify into
o atria. , which extend into the walls
g
n of the respective ventricles.
i
anterolaterally just deep to the epicardium
o at the junction of the SVC and right atrium, stimulate the muscle of the IVS, the anterior
n near the superior end of the sulcus papillary muscle through the septomarginal
terminalis trabecula (moderator band), and the wall of the
right ventricle
initiates and regulates the impulses for the
contractions of the heart divides near its origin into approximately six
giving off an impulse approximately 70 times smaller tracts
per minute in most people most of the time. which give rise to subendocardial branches
stimulate the IVS, the anterior and posterior
papillary muscles, and the wall of the left
ventricle.
sinu-atrial nodal artery, which usually arises
as an atrial branch of the RCA (in 60% of the AV nodal artery, the largest and usually the
people), but it often arises from the LCA (in first IV septal branch of the posterior IV artery,
40%). a branch of the RCA in 80% of people.
Thus the arterial supply to both the SA and AV nodes
sympathetic division of the autonomic is usually derived from the RCA.
nervous system to accelerate the heart rate

CLINICAL ANATOMY | HEART


AHMAD, MISTLEY JANE A. 13

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

CLINICAL ANATOMY | HEART


AHMAD, MISTLEY JANE A. 14

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

is the failure of a valve to open fully, slowing


is performed at the 3rd, 4th, and 5th intercostal blood flow from a chamber.
spaces from the left anterior axillary line to the Valvular stenosis, on the other hand, is almost
right anterior axillary line (Fig. B1.21) always the result of a valve abnormality and is
Normally, the percussion note changes from essentially always a chronic process.
resonance to dullness (because of the presence
of the heart) approximately 6 cm lateral to the
left border of the sternum. is failure of the valve to close completely, usually
owing to nodule formation on (or scarring and
STROKE OR CEREBROVASCULAR ACCIDENT contraction of) the cusps so that the edges do
Thrombi (clots) form on the walls of the left atrium not meet or align.
i in certain types of heart disease. This allows a variable amount of blood (depending
s If these thrombi detach, or pieces break off from on the severity) to flow back into the chamber it
a them, they pass into the systemic circulation and was just ejected from.
h occlude peripheral arteries. Insufficiency may result from pathology of the
i Occlusion of an artery supplying the brain results in a valve itself or its supporting structures (anulus,
stroke or cerebrovascular accident (CVA), which may tendinous cords, dilation of chamber wall, etc.).
g
affect vision, cognition, or the motor function of It may occur acutely (suddenlyfor example,
h parts of the body previously controlled by the now- from a rupture of the cords) or chronically (over
l damaged (ischemic) area of the brain. a relatively long timefor example, scarring and
y retraction).
mBASIS FOR NAMING CUSPS OF THE AORTIC AND Both stenosis and insufficiency result in an increased
o PULMONARY VALVES workload for the heart.
i The truncus arteriosus, the common arterial trunk Restriction of high-pressure blood flow (stenosis) or
b
s from both ventricles of the embryonic heart, has four passage of blood through a narrow opening into a
ia cusps. larger vessel or chamber (stenosis and regurgitation)
l The truncus arteriosus divides into two vessels, each produces turbulence.
h
e
i with its own three-cusp valve (pulmonary and aortic) Turbulence sets up eddies (small whirlpools) that
r The heart undergoes partial rotation so that its apex produce vibrations that are audible as murmurs.
g
e becomes directed to the left, resulting in the Superficial vibratory sensations (thrills) may be
h arrangement of cusps. felt on the skin over an area of turbulence.
gl
Consequently, the cusps are named according to their The clinical significance of a valvular dysfunction
i
y embryological origin, not their postnatal anatomical ranges from slight and physiologically insignificant to
o position. severe and rapidly fatal.
m
n
o Thus the pulmonary valve has right, left, and anterior Factors such as degree, duration, and etiology (cause)
cusps, and the aortic valve has right, left, and affect secondary changes in the heart, blood vessels,
b
posterior cusps. and other organs, both proximal and distal to the
i Similarly, the aortic sinuses are named right, left, and valve lesion.
l posterior. Because valvular diseases are mechanical problems,
e This terminology also agrees with the coronary damaged or defective cardiac valves can be replaced
r arteries. surgically in a procedure called valvuloplasty.
e Note that the right coronary artery arises from the Most commonly, artificial valve prostheses made of
right aortic sinus, superior to the right cusp of the synthetic materials are used in these valve-
g
aortic valve, and that the left coronary has a similar replacement procedures, but xenografted valves
i
relation to the left cusp and sinus. (valves transplanted from other species, such as pigs)
o The posterior cusp and sinus do not give rise to a are also used.
n coronary artery; thus they are also referred to as a
noncoronary cusp and sinus.
A prolapsed mitral valve is an insufficient or
VALVULAR HEART DISEASE incompetent valve with one or both leaflets
Disorders involving the valves of the heart disturb enlarged, redundant or floppy, and extending
i the pumping efficiency of the heart back into the left atrium during systole.
s Valvular disorders may be congenital or acquired. As a result, blood regurgitates into the left
a atrium when the left ventricle contracts,
h Stenosis (narrowing) producing a characteristic heart sound or
i Insufficiency murmur.

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

Anginal pain is relieved by a period of rest (12 min


are often adequate).
In slow occlusion of a coronary artery, the Sublingual nitroglycerin (medication placed or
collateral circulation has time to increase so that sprayed under the tongue for absorption through the
adequate perfusion of the myocardium can occur oral mucosa) may be administered because it dilates
when a potentially ischemic event occurs. the coronary (and other) arteries.
Consequently, MI may not result. This increases blood flow to the heart, while
On sudden blockage of a large coronary branch, decreasing the workload and the hearts need for
some infarction is probably inevitable, but the oxygen because the heart is pumping against less
extent of the area damaged depends on the resistance.
degree of development of collateral anastomotic Further more, the dilated vessels accommodate more
channels. of the blood volume, so less blood arrives in the heart,
If large branches of both coronary arteries are relieving heart congestion.
partially obstructed, an extracardiac collateral Thus the angina is usually relieved.
circulation may be used to supply blood to the Such angina provides a warning that the coronary
heart. arteries are compromised and that there is a need for
These collaterals connect the coronary arteries a change of lifestyle, a healthcare intervention, or
with the vasa vasorum (small arteries) in the both.
tunica adventitia of the aorta and pulmonary The pain resulting from MI is usually more severe
arteries and with branches of the internal than with angina pectoris, and the pain resulting from
thoracic, bronchial, and phrenic arteries. the infarction does not disappear after 12 min of
Clinical studies show that anastomoses cannot rest.
provide collateral routes quickly enough to
prevent the effects of sudden coronary artery CORONARY BYPASS GRAFT
occlusion. Patients with obstruction of their coronary
The functional value of these anastomoses thus i circulation and severe angina may undergo a coronary
appears to be more effective in slowly s bypass graft operation.
progressive CAD in individuals that are physically a A segment of an artery or vein is connected to the
active. h ascending aorta or to the proximal part of a coronary
i artery and then to the coronary artery distal to the
ANGINA PECTORIS stenosis.
g
Pain that originates in the heart is called angina or The great saphenous vein is commonly harvested for
i angina pectoris (L. angina, strangling pain + L. pectoris, h coronary bypass surgery because it:
s of the chest). l has a diameter equal to or greater than that of
a Individuals with angina commonly describe the y the coronary arteries,
h transient (15 sec to 15 min) but moderately severe m can be easily dissected from the lower limb
i constricting pain as tightness in the thorax, deep to o offers relatively lengthy portions with a minimum
the sternum. occurrence of valves or branching.
g b
The pain is the result of ischemia of the myocardium Reversal of the implanted segment of vein can negate
h that falls short of inducing the cellular necrosis that
i the effect of a valve if a valved segment must be
l defines infarction. l used.
y Most often, angina results from narrowed coronary e Use of the radial artery in bypass surgery has become
m arteries. r increasingly more common.
o The reduced blood flow results in less oxygen being e A coronary bypass graft shunts blood from the aorta
delivered to the cardiac striated muscle cells. g to a stenotic coronary artery to increase the flow
b
As a result of the limited anaerobic metabolism of the distal to the obstruction.
i i
myocytes, lactic acid accumulates and the pH is Simply stated, it provides a detour around the
l reduced in affected areas of the heart. o stenotic area (arterial stenosis) or blockage (arterial
e Pain receptors in muscle are stimulated by lactic acid. n atresia).
r Strenuous exercise (especially after a heavy meal), Revascularization of the myocardium may also be
e sudden exposure to cold, and stress all require achieved by surgically anastomosing an internal
increased activity on the part of the heart, but the thoracic artery with a coronary artery.
g
occluded vessels cannot provide it.
i
When food enters the stomach, blood flow to it and
o other parts of the digestive tract is increased.
n As a result, some blood is diverted from other
organs, including the heart.

CLINICAL ANATOMY | HEART


AHMAD, MISTLEY JANE A. 18

CORONARY ANGIOPLASTY CORONARY OCCLUSION AND CONDUCTING SYSTEM


In selected patients, surgeons use percutaneous OF HEART
i transluminal coronary angioplasty in which they pass i Damage to the conducting system of the heart, often
s catheter with a small infl atable bal loon attached to s resulting from ischemia caused by coronary artery
a its tip into the obstructed coronary artery. a disease, produces disturbances of cardiac muscle
h When the catheter reaches the obstruction, the h contraction.
i balloon is inflated, flattening the atherosclerotic i Since the anterior IV branch (LAD) gives rise to the
plaque against the vessels wall. septal branches supplying the AV bundle in most
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The vessel is stretched to increase the size of the people, and branches of the RCA supply both the SA
h lumen, thus improving blood flow. h and AV nodes , parts of the conducting system of the
l In other cases, thrombokinase is injected through l heart are likely to be affected by their occlusion, and
y the catheter; this enzyme dissolves the blood clot. y a heart block may occur.
m Intraluminal instruments with rotating blades and m In this case (if the patient survives the initial stages),
o lasers have also been employed. o the ventricles will begin to contract independently at
After dilation of the vessel, an intravascular stent their own rate: 2530 times per minute (much slower
b b
may be introduced to maintain the dilation. than the slowest normal rate (4045 times per
i Intravascular stents are composed of rigid or i minute).
l semirigid tubular meshes, collapsed during l The atria continue to contract at the normal rate if
e introduction. e the SA node has been spared, but the impulse
r Once in place, they expand or are expanded with a r generated by the SA node no longer reaches the
e balloon catheter, to maintain luminal patency. e ventricles.
Damage to one of the bundle branches results in a
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COLLATERAL CIRCULATION VIA THE SMALLEST bundle branch block, in which excitation passes along
i i
CARDIAC VEINS the unaffected branch and causes a normally timed
o
i Reversal of flow in the anterior and smallest cardiac o systole of that ventricle only.
n
s veins may bring luminal blood (blood from the heart n The impulse then spreads to the other ventricle via
a chambers) to the capillary beds of the myocardium in myogenic (muscle propagated) conduction, producing a
h some regions, providing some additional collateral late asynchronous contraction.
i circulation. In these cases, a cardiac pacemaker (artificial heart
However, unless these collaterals have dilated in regulator) may be implanted to increase the
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response to pre-existing ischemic heart disease, ventricular rate of contraction to 7080 per minute.
h especially in conjunction with physical conditioning, With a VSD, the AV bundle usually lies in the margin
l they are unlikely to be able to supply suffi cient blood of the VSD.
y to the heart during an acute event and thus prevent Obviously, this vital part of the conducting system
m MI. must be preserved during surgical repair of the
o defect.
bELECTROCARDIOGRAPHY Destruction of the AV bundle would cut the only
The passage of impulses over the heart from the SA physiological link between the atrial and ventricular
i node can be amplifi ed and recorded as an musculature, also producing a heart block as
sl electrocardiogram (ECG or EKG). described above.
ea Functional testing of the heart includes exercise
r
h tolerance tests (treadmill stress tests), primarily to ARTIFICIAL CARDIAC PACEMAKER
ie check the consequences of possible coronary artery In some people with a heart block, an artificial cardiac
disease. i pacemaker (approximately the size of a pocket watch)
g
Exercise tolerance tests are of considerable s is inserted subcutaneously.
i
h importance in detecting the cause of heartbeat a The pacemaker consists of a pulse generator or
lo irregularities. h battery pack, a wire (lead), and an electrode.
n
y Heart rate, ECG, and blood pressure readings are Pacemakers produce electrical impulses that initiate
i
m monitored as the patient does increasingly demanding ventricular contractions at a predetermined rate.
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o exercise on a treadmill. An electrode with a catheter connected to it is
The results show the maximum effort a patients h inserted into a vein and its progression through the
b l
heart can safely tolerate. venous pathway is followed with a fluoroscope, a
i y device for examining deep structures in real time (as
l m motion occurs) by means of radio graphs.
e o The terminal of the electrode is passed through the
r SVC to the right atrium and through the tricuspid
b
e valve into the right ventricle.
i
g l
i e
o r CLINICAL ANATOMY | HEART
n e
AHMAD, MISTLEY JANE A. 19

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.

RESTARTING HEART CARDIAC REFERRED PAIN


In most cases of cardiac arrest, first-aid workers The heart is insensitive to touch, cutting, cold, and
i perform cardiopulmonary resuscitation (CPR) to i heat; however, ischemia and the accumulation of
s restore cardiac output and pulmonary ventilation. s metabolic products stimulate pain endings in the
a By applying firm pressure to the thorax over the a myocardium.
h inferior part of the sternal body (external or closed h The afferent pain fibers run centrally in the middle
i chest massage), the sternum moves posteriorly 45 i and inferior cervical branches and especially in the
cm. thoracic cardiac branches of the sympathetic trunk.
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The increased intrathoracic pressure forces blood The axons of these primary sensory neurons enter
h out of the heart into the great arteries. h spinal cord segments T1 through T4 or T5, especially
l When the external pressure is released and the intra l on the left side.
y thoracic pressure falls, the heart again fills with y
m blood. m is a phenomenon whereby noxious stimuli
o If the heart stops beating (cardiac arrest) during o originating in the heart are perceived by a person
heart surgery, the surgeon attempts to restart it as pain arising from a superficial part of the
b b
using internal or open chest heart massage. bodythe skin on the left upper limb, for
i i example.
lFIBRILLATION OF HEART l
e e is transmitted by visceral afferent fibers
ir is multiple, rapid, circuitous contractions or r accompanying sympathetic fibers and is typically
se twitchings of muscular fibers, including cardiac e referred to somatic structures or areas such as
ag muscle. a limb having afferent fibers with cell bodies in
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h the same spinal ganglion, and central processes
i i
io the normal regular rhythmical contractions of that enter the spinal cord through the same
the atria are replaced by rapid irregular and o posterior roots.
gn n
uncoordinated twitchings of different parts of
h the atrial walls. is commonly felt as radiating from the substernal
l The ventricles respond at irregular intervals to and left pectoral regions to the left shoulder and
y the dysrhythmic impulses received from the the medial aspect of the left upper limb.
m atria, but usually circulation remains This part of the limb is supplied by the medial
o satisfactory. cutaneous nerve of the arm.
Often the lateral cutaneous branches of the 2nd
b
the normal ventricular contractions are replaced and 3rd intercostal nerves (the
i by rapid, irregular twitching movements that do intercostobrachial nerves) join or overlap in their
l not pump (i.e., they do not maintain the systemic distribution with the medial cutaneous nerve of
e circulation, including the coronary circulation). the arm.
r The damaged conducting system of the heart Consequently, cardiac pain is referred to the upper
e does not function normally. limb because the spinal cord segments of these
As a result, an irregular pattern of uncoordinated cutaneous nerves (T1T3) are also common to the
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contractions occurs in the ventricles, except in visceral afferent terminations for the coronary
i
those areas that are infarcted. arteries.
o Ventricular fi brillation is the most disorganized Synaptic contacts may also be made with commissural
n of all dysrhythmias, and in its presence no (connector) neurons, which conduct impulses to
effective cardiac output occurs. neurons on the right side of comparable areas of the
The condition is fatal if allowed to persist. spinal cord.
This occurrence explains why pain of cardiac origin,
DEFIBRILLATION OF HEART although usually referred to the left side, may be
A defibrillating electric shock may be given to the referred to the right side, both sides, or the back.
i heart through the thoracic wall via large electrodes
s (paddles).
a This shock causes cessation of all cardiac movements
h and a few seconds later the heart may begin to beat
i more normally.

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h
l CLINICAL ANATOMY | HEART
y

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