The heart
Anne Le Roy
Overview of the heart circulation
Developement
18th day: cardiogenic area
2 endocardial heart tubes
Single heart tube
Developement – the primitive heart
tube
Sinus venosus
Sinus venarum cavarum
Primitive atrium
Atrium (separated by crista
terminalis)
Primitive ventricle
Vemtricle (inflow part)
Bulbus cordis
Ventricle (outflow part –
separated by crista
supraventricularis)
Truncus arteriosus
Aorta + truncus pulmonalis
Developement – the primitive heart
tube
Further development of the primitive
heart tube
• Bulboventricular loop (inflow part lying dorsal
to the outflow part)
• disapearance of the dorsal mesocardium (
transverse sinus)
Partitioning of the heart
• Endocardial cushions
• ATRIUM:
▫ septum primum: foramen primum + secundum
▫ septum secundum
▫ foramen ovale
• VENTRICLE:
▫ muscular part of the interventricular septum
▫ membranous part of the interventricular septum
• BULBUS CORDIS + TRUNCUS ARTERIOSUS:
▫ mesenchymal cells of walls
▫ cells of neural crest
▫ spiral growth
Foramen ovale and fetal blood
circulation
Heart description
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basis x apex
auricula dextra et sinistra
sulcus coronarius
sulcus interventricularis ant. + post.
▫ incisura apicis cordis
The walls and borders of the heart
Anatomically
Clinically
Facies sternocostalis s. anterior
Anterior wall
Right ventricle
Facies diaphragmatica s. inferior
Posterior wall
Left ventricle + part
of right ventricle
Facies pulmonais sin.
Lateral wall
Left ventricle
Facies pulmonalis dx.
Right atrium
Margo dexter s. acutus
Right atrium
Margo sinister s. obtusus
Left ventricle, left
auricle
Chest X-ray
Heart structure
• endocardium = tunica intima
▫ heart valves
• myocardium = tunica media
• pericardium
Endocardium:
Heart valves
• duplication of endocardium
• attached to fibrous anuli of the skeleton of the heart
• NO blood or lymph vessels
Atrioventricular = cuspidal valves
• valva atrioventricularis dextra = tricuspidalis
• valva atrioventricularis sinistra = bicuspidalis =
mitralis
MECHANISM:
• chordae tendineae
• mm. papillares
chordae tendinae falsae s. spuriae
Semilunar valves
• valva aortae (aortic valve)
• valva trunci pulmonalis (pulmonary valve)
• backflow in aorta/t. pulmonalis during diastole -> closure
• lunulae
• noduli Aranzii
• aortic/pulmonary sinuses
Auscultation points (Testut‘s points)
Valvular replacement
Myocardium
• Left ventricle: 12-14 mm
• Right ventricle: 3-4 mm
• insertion in the fibrous skeleton of the heart
• Ventricles - 3 layers:
▫ external: spiral (=vortex cordis)
▫ middle: circular
▫ internal: longitudinal
 mm. papilares, trabeculae carnae
Pericardium
• Pericardium fibrosum
▫ continuous with the centrum tendineum of the diaphragm
▫ ligg. phrenicopericardiaca
ligg. sternopericardiaca
membrana bronchopericardiaca
• Pericardium serosum
a) parietal layer
fused with the fibrous pericardium
b) pericardial cavity
pericardial fluid = 20 ml
c) viscera layer = epicardium
Pericardium II
• Porta arteriarum
▫ aorta + truncus pulmonalis
• Porta venarum
▫ Vena cava sup. + inf. + vv. pulmonales
• Transverse sinus
• Oblique sinus
N. phrenicus,
a.+ vv. periacardiacophrenicae
Cardiac tamponade
and pericardiocentesis
Heart cavities
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right + left atrium
interatrial septum
atrioventricular septum
right + left ventricle
interventricular septum (membranous +
muscular part)
Atrium dextrum I.
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auricula dextra
sinus venarum cavarum
mm. pectinati
crista terminalis
Atrium dextrum - openings
1. foramen v. cavae inf.
▫
valvula v.c.i. Eustachii
2. foramen v.cavae sup.
▫
tuberculum intervenosum Loweri
3. ostium sinus coronarii
▫
valvula s. coronarii Thebesii
4. ostia vv. ventriculi dx. anteriorum
5. foramina venarum minimarum
Thebesii
6. fossa ovalis
▫
limbus fossae ovalis
7. ostium atrioventriculare dextrum
Ventriculus dexer
• ostium atrioventriculare dextrum
▫ valva tricuspidalis
 cuspis anterior, posterior, septalis
 mm. papillares, chordae tendinae
• trabeculae carneae
▫ trabecula septomarginalis
/moderator band/
• pars glabra = infundibulum =
conus arteriosus = outflow part
• crista supraventricularis
• ostium trunci pulmonalis
▫ valva trunci pulmonalis
 valvulae semilunares dx., sin., ant.
/semilunar cusps/
Atrium sinistrum
Openings:
1. – 4. ostia venarum
pulmonalium
5. ostium atrioventricularis sin.
6. valvula foraminis ovalis
(= former falx septi Parchappei)
7. foramina venarum minimarum
Others:
auricula sinistra
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mm. pectinati
Ventriculus sinister
• trabeculae carneae
• ostium atrioventriculare sinistrum
▫ valva mitralis s. bicuspidalis
 cuspis anterior, posterior
▫ mm. papillares, chordae tendinaeae
• ostium aortae
▫ valva aortae
 valvulae semilunares dx., sin., post.
 sinus aortae Valsalvae
(right, left, non-coronary)
<- mitre
Fibrous skeleton of the heart
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= fibrous connective tissue
valve support
myocardium insertion
electric isolation of atrial and ventricular
myocardium
• anulus fibrosus dexter + sinister
• trigonum fibrosum dextrum /= central fibrous
body/ + sinistrum
• anulus aorticus + a. trunci pulmonalis
• tendo infundibuli
• tendo valvulae venae c. inf. Todaroi
▫ between the Eustachian and Thebesian valves
• pars membranacea septi interventricularis
Arterial supply
of the heart
Coronary arteries
• Coronary artery disease
= most common cause of death in industrialized
countries
• filled during diastole
• running subepicardially (the subendothelial layer is
more prone to ischemia)
• functional end arteries
Right coronary artery (RCA)
arising from the right aortic sinus (sinus aortae dexter)
Branches:
• right conus artery → Vieussens´ circle
• atrial branches
• SA nodal artery -65 %
• Right marginal artery (RMA)
Final branches – only in right-dominance (75%)
 Posterior interventricular/descending artery (PDA)
• septal branches – for 1/3 of the IV septum
• AV nodal branch - 80 %
(can also arise from RCA)
 Right posterolatral artery (RPLA)
Arteria coronaria dextra (ACD)
Branches:
• r. coni arteriosi -> circulus Vieussensi
• rr. atriales
• r. nodi sinuatrialis -65 %
• r. marginalis dexter - RMD
Final branches – only in right-dominance (75%)
 r. interventricularis posterior - RIP
• rr. interventriculares septales – for 1/3 of the IV septum
• r. nodi atrioventricularis - 80 %
(can also arise from RCA)
 r. posterolateralis dexter – RPLD
You have to know the coronary arteries in LATIN!
Left coronary artery - LCA
Left aortic sinus→ short trunk - 2-3cm (also called left
main – LM)
• Left anterior interventricular/descending artery - LAD
▫ left conus artery → Vieussens´ circle
▫ septal branches
▫ diagonal artery
• Circumflex artery
▫ atrial branches
▫ Left marginal artery (LMA)
▫ Left posteroateral artery (LPLA)
• Intermediate artery – from bifuraction (trifurcation)of
LCA – var.
Arteria coronaria sinistra (ACS)
sinus aortae sinister → short (2-3cm) → ACS
• r. interventricularis ant. (RIA)
▫ r. coni arteriosi → Vieussens´ circle
▫ rr. interventriculares septales
▫ r. diagonalis (RD)
• r. circumflexus (RC)
▫ rr. atriales
▫ r. marginalis sinister (RMS)
▫ r. posterolateralis sinister (RPLS)
• r. intermedius (RIM) – from bifuraction
(trifurcation) of ACS
Coronary arteries
Coronary cathetrisation and
coronarography
PCI (PTCA) – angioplasty + stenting
CABG: Coronary artery bypass
grafting
• v. saphena magna
• a. thoracica interna
(LIMA/RIMA)
• a. radialis
Coronary cathetrisation coronarography
Coronarography – RCA
Coronarography– RCA – stent
implantation
Coronarography - LCA
Coronarograpy - LCA
Dominance of the coronary arteries
Right dominant
pattern (75%)
• PDA from RCA
Left dominant
pattern (15%)
• PDA from
circumflex artery
Codominance
(10%)
• PDA from both
Blood supply of the heart in rightdominant pattern
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Right coronary artery
right ventricle
inferior wall of left ventricle
highest risk of injury of the
conducting system
1/3 of IV septum
right atrium
Conducting system from SA
node to prox. part of the bundle
branches.
▫ SAN – 65%
▫ AVN – 80%
m. papillaris post. dx.
mm. papillares septales dx.
m. papillaris ant. dx. (with LCA)
m. papillaris post. sin. (with
LCA)
Left coronary artery
Left anterior descending a.:
• anterior part of left ventricle
• apex
• 2/3 of the IV septum
• small part of the anterior wall of
right ventricle
• m. papillaris ant. sin.
• m. papillaris ant. dx (with RCA)
Circumflex artery:
• lateral wall of left ventricle
• left atrium
• m. papillaris post. sin. (with
RCA)
Veins of the heart
All empty in the right atrium
• sinus coronarius
▫ v. cordis magna (with LAD)
 v. marginalis sin. (with LMA)
▫ v. ventriculi sin. post. (with
RPLA/LPLA)
▫ v. obliqua atrii sin. Marshalli
(remnant of left SVC)
▫ v. cordis media (with PDA)
▫ v. cordis parva (with RMA)
• vv. ventriculi dx. ant.
• vv. cordis minimae Thebesii
Stimulating and conducting system of
the heart
• subendocardially
• Sinuatrial node /Keith-Flack/
▫ „pacemaker of the heart“
▫ approx. 70/min
▫ Superior part of the right atrium
• Atrioventricular node /Aschoff-Tawara/
▫ AV delay
▫ approx. 40-60/min
▫ Triangle of Koch
borders: - cuspis septalis valvae tricuspidalis
- ostium sinus coronarii
- tendo Todaroi
• Atrioventricular bundle of His
(fasciculus atrioventricularis)
• Bundle branches /Tawara/
(crus fasciculi AV)
▫ right
 -> branch for anterior papillary muscle via the
septomarginal trabecule
▫ left
 anterior
 posterior
• Subendocardial fibers /Purkyně/
Innervation of the heart
• autonomic nerve fibres from the cardiac
plexus
▫ deep part
▫ superficial part
Innervation of the heart
• Sympathetic supply
▫ nn. cardiaci:
- cervicales sup., med., inf.
- thoracici
▫ β1 receptors
▫ positive dromotropic, bathmotropic, inotropic,
chronotropic effect
▫ relaxation of the smooth muscle in the coronary arteries
• Parasympathetic supply
▫ rr. cardiaci n. X
▫ decrease in heart rate (up to 20-40 bpm)
• Viscerosensory fibres
▫ Afferent fibres via the sympathetic trunk and n. X
Cardiac reffered pain
• Head‘s zone: behind sternum and unlar edge of
left upper limb (A)
Fetal circulation
Remnants of structures of the fetal
circulation
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foramen ovale
ductus arteriosus Botali
ductus venosus Arantii
v. umbilicalis
aa. umbilicales
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fossa ovalis
ligamentum arteriosum
ligamentum venosum
lig. teres hepatis
lig. umbilicale mediale
Some important congenital heart
defects
No shunt:
• dextrocardia
• aortic coarctation
With L-R shunt (non-cyanosing)
• atrial septal defects
• ventricular septal defects
• persisting ductus arteriosus
With R-L shunt (cyanosing)
• transposition of the great arteries
• tetralogy of Fallot
Dextrocardia
• with situs inversus
• isolated dextrocardia
Atrial septal defect (ASD)
• foramen ovale patens –
25%
usually of no hemodynamic
significance
• large foramen ovale patens
(>9mm)
left-to-right shunt
Ventricular septal defect (VSD)
• membranous VSD – most common type
• muscular VSD = swiss cheese VSD
Transposition of the great vessels
Tetralogy of Fallot
1. Ventricular septal defect
2. Right ventricular hypertrophy
3. Overriding aorta
(incomplete transposition)
4. Pulmonary stenosis
400/1 000 000 births
Eponyms - overview
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ductus arteriosus Botalli
valvula v. cavae inferioris Eustachii
tuberculum intervenosum Loweri
valvula sinus coronarii Thebesii
trigonum nodi atrioventricularis
Kochi
• noduli Aranzii
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falx septi Parchappei (=valvula foraminis
ovalis)
• sinus aortae Valsalvae
• tendo valvulae v. cavae inferioris
Todaroi
• Vieussens‘ ring
• v. obliqua atrii sinistri Marshalli
• vv. cordis minimae Thebesii
• Head‘s zones
• nodus sinuatrialis Keith-Flack
• fasciculus Bachmanni
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fasciculus Wenckebachi
fasciculus Thoreli
• nodus atrioventricularis
Aschoff-Tawara
• fasciculus atrioventricularis His,
Kent, Gaskell
• crus fasciculi atrioventricularis
Tawara
• rami subendocardiales Purkyně
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fasciculus accessorius Kenti
Holzknecht‘s field
• ductus Cuvieri ( = v. cardinalis
communis)
Systolic/disatolic
pressure in parts
of the heart