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Outline
• Pericardium
• Heart
• Surface anatomy
• Internal anatomy
• Valves
• Chambers
• Skeleton
• Conduction pathway
• Nerve
• Blood supply
• Arterial
• Venous
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PERICARDIUM
• fibroserous sac w/c surrounds heart & root of great
vessels
• Invaginate the serous sac from behind during devt
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Components of the pericardium
1. FIBROUS Pericardium
• outer layer of pericardial sac
~ cone shaped bag
Boarders:
• superior: pretracheal fascia
• anterior: sternum
• IVC [R side]
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Components of the pericardium
2. SEROUS Pericardium
a. PARIETAL
• lines inner surface of
fibrous pericardium
b. VISCERAL
• ‘epicardium’
EXCEPT POSTERIORLY
b/w entrance of 2 vena
cavae & 4 pulmonary
veins 5
Pericardial Cavity
• space b/w parietal & visceral percardium
• (+) small amt of pericardial fluid ~ prevents
friction, “lubrication”
• normal capacity ~ 50 ml
• max capacity ~ 300 ml
• Pericardial effusion ~ accumulation of fluid w/in
sac
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Pericardial tamponade
• “cardiac tamponade”
• Limits diastole (PRELOAD)
~restricted expansion of relaxed heart
~compromise ability to fill w/ blood properly
~inadequate amount propelled to systemic circ
• 60 ~ 100 ml acute accumulation of
blood/clots/fluid can produce tamponade
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Cardiac tamponade
Clinical picture
• Beck’s triad
(hypotension,
distended neck veins,
muffled heart sounds)
• Pulsus paradoxus
(exaggerated fall in
systolic BP during
inspiration
• Drain fluid
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Constrictive Pericarditis
• Inflammation~affects both
parietal & visceral
• Thickening ~ adherence to
underlying myocardium
• May initially present w/
pericardial effusion
• Chronic constriction
• In PI, TB #1 etiology
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Pericardiectomy/pericardial
stripping
• Pericardiectomy ~
allow chamber to
expand
• Thickened
pericardium
• Anterior, posterior
• CP bypass machine
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Constrictive Pericarditis
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Constrictive Pericarditis
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Constrictive Pericardiectomy
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Sinuses
1. Transverse
• Breakdown of embryonic dorsal
mesocardium
• passage fr L --> R
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Transverse Sinus
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Sinuses
2. Oblique
• behind LV & LA
fibrous p as parietal p
• Reflection of serous p forms blind ending
sac
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Oblique Sinus
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Nerve supply
• Fibrous / Parietal - Somatic N [ fr phrenic N]
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Blood supply of Pericardium
• Fibrous & parietal → branches from:
– internal thoracic [mammary] a
– bronchial a
– pericardiacophrenic a
– aorta
– arteries to diaphragm
• Visceral → coronary a [ share w/ myocardium ]
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Pericardial pain
• felt diffusely posterior to the sternum ~
substernal pain
• May radiate to other areas
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Heart
• central organ of circulatory system
• wall :
EPICARDIUM - external surface
MYOCARDIUM - middle, muscular, thickest
ENDOCARDIUM - internal surface
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Heart
• short CONE
• base: faces posteriorly
• formed b y LA &
part of RA
• apex: points downward,
to Left & forward
formed by LV
• Apex beat is Point of
Maximal Impulse
• located at 5th ICS, L
midclavicular line
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Surfaces
1. Diaphragmatic or inferior
• LV & part of RV
• rests on diaphragm
2. Left surface
• LV
3. Right surface
• RA
4. Sternocostal
• faces anteriorly
• RV , partly by RA & LV
• RV = m ost c ommon ly
injur ed in penetrating
trauma
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Penetrating cardiac injury
• Pathophysiology
• Injury pattern
• Right ventricle most common (>40 %)
• Left ventricle 2nd most common (40%)
• Right atrium 24%
• Left atrium 3%
• Complex 8%
• Coronary arteries 5%
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Cardiac Box
- Penetrating cardiac injury
- In stable patients
~ r/o (+/─) pericardial
effusion
~ prove if blood
- In unstable patients
~ open/surgery to locate &
repair external cardiac
injury
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Traumatic cardiac tamponade
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Traumatic Cardiac Injury
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D. Internal Anatomy
1. Chambers : R atrium R ventricle
L atrium L ventricle
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Internal Anatomy
2. Openings/ Valves
Function of valves: prevent backward flow of blood
a. Tricuspid = R atrioventricular, valve w/ 3 cusps
b. Mitral = L atrioventricular, valve w/ 2 cusps
c. Aortic = bet LV & aorta
d. Pulmonic = bet. RV & pulmonary trunk
e. Aortic sinuses - dilated pockets bet cusps &
aortic wall
- origin of coronary arteries
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Rheumatic Heart Disease
• vegetations
• calcifications
• affects mainly mitral valve
• cause stenosis or insufficiency
• severity may affect other valves
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Valvular surgery
• Closed Valve repair
• Open Valve repair
• Open Valve replacement
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PROSTHETIC VALVES
• Types of valves
• Mechanical
• Tissue
• Xenografts
• autografts/human homografts
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MECHANICAL VALVES
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TISSUE VALVES
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VALVE REPLACEMENT
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CHAMBERS of the HEART
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1. R ATRIUM
• quadrangular shaped
• communicates w/ RV
thru R AV opening
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R ATRIUM
• crista terminalis =
smooth muscular ridge
w/c divides into 2 parts:
• 1. sinus venarum =
smooth,thin, posterior
part where vena cava
open, coronary sinus
• 2. musculi pectinati =
rough, thick, anterior
part
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R ATRIUM
• fossa o va lis
~ depression above
orifice of IVC
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Congenital Heart Disease
= blood flows fr LA → RA
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ATRIAL SEPTAL DEFECT
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2. R VENTRICLE
• C -shaped cavity
~ capacity of 85 ml
• interventricular septum =
partition b/w RV & LV
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R VENTRICLE
• 2 parts:
1] membranous = thin
2] muscular = thick
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R VENTRICLE
• se ptoma rgin al tra becu la
= elevated band w/c bridges interventricular septum &
anterior wall near apex
= transmits right branch of conducting system
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R VENTRICLE
• chordae tendinae = fibrous cords attached to
apices of papillary muscles fr cusps of valves
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VENTRICULAR SEPTAL
DEFECT
• Congenital or acquired
• Hole/s in interventricular septum (IVS)
• May be part of other major cardiac anomalies
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VENTRICULAR SEPTAL
DEFECT
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VSD PATCH CLOSURE
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3. L ATRIUM
• sm al ler but t hicke r
wall (v s. R A)
• base of heart
• mo st co mm on si te
of b enign ca rdiac
tumo rs ca lled
my xo ma
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L ATRIUM
2 par ts :
1. Princ ip al c avity
= contains openings of 4
pulmonary veins
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L ATRIUM
2. A ur icle
= interior marked by
ridges of musculi
pectinati
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4. L VENTRICLE
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L VENTRICLE
• trabeculae carnae are
more nume rou s &
dense ly packe d
• papillary mu scl es
are l arg er
• Interventricular septum
• > oblique position
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SKELETON OF THE HEART
• formed by merging of fibrous
rings
• attachment for myocardium
• attachment for cusps of
valves
• keep valves patent & from
overdistension
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SKELETON OF THE HEART
• “Wringing” of blood in
• Allows myocardium to contract against a rigid
base
• Provides connective tissue skeleton for
controlled contraction of the heart
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SKELETON OF THE HEART
co mp onents :
1. 4 fib ro us rings =
each encircles a valve
2. 2 f ibrous trigones =
bet aortic ring and AV
ring
3. te ndon of co nus
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CONDUCTING SYSTEM
• modified cardiac muscles w/ power of
spontaneous rhythmicity & conduction
• more highly developed than rest of the heart
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CONDUCTING SYSTEM
Parts:
1. SINO ATRIAL (S A) No de
- in crista terminalis at junction of SVC-RA
- not visible grossly
- initiates contraction of heart
internal PA CEM AKER
2. Atriov entricular (A V) node
- near orifice of coronary sinus in septal wall
of RA
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CONDUCTING SYSTEM
3. Atri ov en tricu lar bundle (B undle of H is)
• begins at AV node & follows along membranous
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Conduction pathway:
• SA node ---> AV node ---> AV bundle ----> bundle
branch ----> Purkinje fibers
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Cardiac Plexus
• Controls impulse conduction for the ♥
• Enables ♥ to respond to Δ-ing physiological
needs
• located at base of ♥
• extends fr trachea to aortic arch, pulmonary
trunk & ligamentum arteriosum
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Cardiac Plexus
1. Parasympathetic – fr Vagus n
- ↓ in heart rate
- ↓ force of heartbeat
- constricts CAs
- dilates CAs
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Sy mpa the tic
Subdivisions:
1. Superficial cardiac plexus
-lies in arch of aorta
2. Deep cardiac plexus
-deep to arch of aorta
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Angina Pectoris & Myocardial
Infarction
• Cardiac referred pain
• Commonly present as:
• Substernal
• L pectoral
• L arm medial
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Cardiac referred pain
• Heart insensitive to touch, cutting, cold &
heat
• Ischemia + accumulated metabolic products
~ stimulate pain endings in myocardium
• Sympathetic trunk
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Blood Supply
Coronary arteries
- fr aortic sinus of
ascending aorta
1) Right
2) Left
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Right coronary artery (RCA)
branches:
1. posterior interventricular
branch = supplies
diaphragmatic surface of
both ventricles, lo ng est
2. marginal
3. br to SA node
4. br to AV node
5. br to conus
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Left coronary artery (LCA)
• bifurcates into:
1. anterior interventricular
= both ventricles,
interventricular septum,
conus
2. circumflex
Branches :
-Posterior L ventricular art
-Marginal
-Intermediate
-branch to SA node & AV
node 78
Coronary Angiogram
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Coronary Angiogram
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Coronary Angiogram
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Venous system
1. coronary sinus
~ main venous drainage (except 2.)
~ opens into RA
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Venous Drainage
Coronary sinus tributaries:
1. Great cardiac
2. Middle cardiac
3. Small cardiac
4. Left posterior
ventricular
5. Left oblique atrial
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Myocardial ischemia
- insufficient blood supply to heart
- necrosis of an area of myocardium
- Myocardial Infarct or MI
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Common sites of coronary occlusion:
“ Triple vessel disease”
1. Anterior interventricular branch of Left coronary
art (LCA)
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Most common cause of
coronary occlusion :
Atherosclerosis
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Heart-Lung Bypass Machine
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Heart-Lung Bypass Machine
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Heart-Lung Bypass Machine
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Internal Mammary Artery Grafts
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CORONARY ARTERY BYPASS
GRAFTING (CABG)
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THANK YOU
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