CASE 1

A 61 year old man was seen in the

emergency department complaining of a feeling of
pressure within his chest. On questioning, he said
that he had several attacks before and that they
had always occurred when he was climbing stairs
or digging in the garden. He found that the
discomfort disappeared with the rest after about 5
min. The reason he came to the emergency
department was that the chest discomfort has
occurred with much less exertion.
 Anatomy
• THE HEART
- pumping organ of the cardiovascular system

LAYERS:
1. endocardium
- lining the inner surface of the heart
2. myocardium
- the middle and muscular layer of the heart
3. epicardium
- makes up the external layer of the heart,
synonymous with visceral portion of the serous
pericardium
Layers of the heart
• SURFACE ANATOMY OF THE HEART
- To map out the heart of the anterior chest wall, 4
points are needed.
- Three of these are located in the costal cartilages ½
inch from the lateral sternal line.
The 1st one - 2nd left costal cartilage
½ inch from the left lateral sternal line
2nd one - 3rd right costal cartilage
½ inch from right lateral sternal line
3rd one - 6th right costal cartilage
½ inch from right lateral sternal line

The 4th point is found in an intercostal space - 5th left

intercostal space
- 3 ½ inches from midsternmal
line or midclavicular line.
SURFACE ANATOMY OF THE HEART
 SHAPE OF THE HEART
- the heart resembles a short cone, having
a base and apex
- the base of the heart faces posteriorly
and to the right and made up chiefly of left
atrium
- the apex, points downward and to the
left, and forward. It is formed by the left
ventricle.
SHAPE OF THE HEART
 INTERNAL FEATURES OF THE HEART

Chambers of the heart

1. right atrium
2. left atrium
3. right ventricle
4. left ventricle
 SEPTA OF THE HEART
- the 2 atria are separated by a division –
ATRIAL SEPTUM where there is an
opening the fetal life – FORAMEN OVALE
which closes at birth.,
- the 2 ventricles on the other hand are
separated by INTERVENTRICULAR SEPTUM
which has 2 parts. 1. upper, smaller
membranous portion
2. lower, muscular portion
SEPTA OF THE HEART
SEPTA OF THE HEART
 OPENING OF THE HEART
a. right atrioventricular opening (tricuspid )
b. left atrioventricular opening ( mitral )
c. aortic opening
d. pulmonary opening
 Tricuspid opening
- between right atrium and right ventricle
- guarded by mitral valve – with 3 cusps
- lies behind the right half of the sternum
opposite the 4th CS
 Mitral opening
- between left atrium and left ventricle
- guarded by aortic valve which stronger
than pulmonary valve
-lies behind the left half of the sternum
opposite the 4th ICS
-best heard over the apex beat
MITRAL OPENING
- between left ventricle and ascending aorta
- guarded by aortic valve which consists of 3
semilunar cusps, larger, thicker and stronger
than pulmonary valve
- lies behind left half of sternum opposite the
3rd ICS
Aortic opening
 Pulmonary opening
- between right ventricle and pulmonary trunk
- guarded by pulmonary valve with 3 semilunar
cups like aortic valve
AORTIC SINUSES OF VALSALVA
- dilated pockets between cusps of aortic
valve and aortic wall
 RIGHT ATRIUM
- quadrangular chamber where 3 big vessels open into:
1. superior vena cava – carrying unoxygenated blood from upper
part of the body
2. inferior vena cava – carrying unoxygenated blood from lower part
of the body
3. coronary sinus – the mian venous drainage of the heart.
PARTS OF RIGHT ATRIUM
1. principal cavity or sinus venarum
2. right auricle

These two parts are separated by a smooth vertical ridge extending up from
the front of superior vena cava and down to anterior lip of inferior vena
cava. This is the CRISTA TERMINALIS.
1. PRINCIPAL CAVITY OR SINUS VENARUM
2. RIGHT AURICLE
RIGHT ATRIUM
 RIGHT VENTRICLE
PART OF THE RIGHT VENTRICLE
1. infundibulum or conus arteriosis
2. principal lower part has the following features
 LEFT ATRIUM
- smaller but thicker walled

2 parts:
1. principal cavity – posterior part
2. left auricle – anterior part
LEFT ATRIUM
 LEFT VENTRICLE
- longer and more conical in shape than the right and
walls are about 3x thicker.

Gross features of left ventricle

1. trabeculae carnae more numerous and more densely
packed, especially at the
apex and dorsal wall
2. papillary muscles which are of large size
3. chordae tendinae from each papillary muscles go to
both cusps of the left atrioventricular valve (MITRAL
VALVE)
LEFT VENTRICLE
 AUSCULTATION AREAS OF HEART
VALVES
1. pulmonary valve – medial end of 2nd left
intercostal space
• 2. aortic valve – medial end of 2nd
right intercostal space
• 3. mitral valve - 5th left intercostal
space midclavicular line
• 4. tricuspid valve – right sternal
margin opposite 4th interspace
 CONDUCTING SYSTEMS OF THE
HEART
- these are modified cardiac muscles responsible for the
inherent rhythmicity in the contraction of the
heart

- with the power of spontaneous conduction more highly

developed than the rest of the heart

Parts:
1. sinoatrial node
2. atrioventricular node
3. atrioventricular bundle(bundle of his)
4. purkinje fibers
 SA node
Sinoatrial node (sinus node, node of Keith and
Flack)
- knob small of modified heart muscle situated
in the upper end of crista terminalis where
superior vena cava opens into right atrium.
- called the pacemaker of the heart
 AV node
Atrioventricular node (node of Tawara)
- lies near the orifice of coronary sinus in the
septal wall of the right atrium
 Bundle of His
• Bundle branches:
a. right and left bundle branches
- continues under the endocardium in the
moderator band towards
the apex spreading to all parts of right ventricle,
then breaks up into small bundles, the
terminal conducting fiber called Purkinje.
Purkinje fibers (PK fibers) terminal
conducting fibers:
- penetrate and ramify on individual
fibers throughout the ventricular musculature