Surface Anatomy of the Heart
‫لجنة الطب البشري‬
Anatomy
14
5
Surface Anatomy of the
Heart
Dr.Nabeel Khouri
‫بالل الياسين ومعتز عبابنة‬
29 March 2009
By the Name of the God
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Surface Anatomy of the Heart
Surface Anatomy of the Heart
Last lecture we have talked about heart, heart chambers and about
the structure within the heart chambers and how we can divide the wall of
the atrium and how to divide the wall of the ventricle. And we have talked
what is the papillary muscles, what are the cordea tendanea and so on… And
we have talked about the coronary circulation and how the coronary
circulation comes and can be seen in living heart and how many branches each
coronary artery will give and what these coronary arteries irrigate as well….
Of course, this is found in the books and any other things.
Now, you will go into more like a clinical aspect of the heart within in
situ, meaning that inside the chest and we will see, first, what are the
margins of the heart and the borders of the heart, what are the surfaces of
the heart… what you can see if you look through the chest “X-ray”, how you
can read the chest X-ray, and so on. So therefore we will have somehow
enjoyable lecture, but first, let us see the chest of a human body and what
are the points, “the remarkable views”, to our precaution, auscultation and
palpation of the chest. Those are three important things that you will do for
the patient.
Now, my advice to you, whenever you come to examine a patient his
chest will be open, you, especially in the winter, make sure that your hands
are warm not cold, because that will increase so many metabolic aspects of
the body as well as the heart beats so therefore you will NOT be listening to
the heart in the normal condition, this is very important…
In addition to that, whenever you look at the chest there are points
that you should see, there are points that you should remark in order for you
to do and to do the auscultation better and palpitation in better way. Now we
have said that we had a remarketed in the first lecture how the chest is
made and what bones surround the thoracic cavity, we have said that we have
very important landmarks within the bones that indicate or lead us to find
out what where we can put our stethoscope in order for us to auscultate or
palpate the heart in situ. The first important thing in the midline – midsagital
line is the suprasternal notch that everybody can palpate it in the superior
border of the sternal notch between the two sternoclavicular joint. There’s a
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Surface Anatomy of the Heart
notch which you can see it over there and this notch is very important that
you can go down from that notch and elevation of the sternum which is
between the manuibrum sternae as well as the body of the sternum. We will
find the sterna angle by moving our finger we can find the sterna angle on
the suprasternal notch or “the jugular notch” into the angle at the level of
the angle we will go to the lateral aspect of the angle and we will hit the
second rib. Now if you want to count the ribs, you should go down from
suprasternal notch to the sterna angle, then you count obliquely inferiorly
and then laterally. When you find the third rib palpated. Then the
subintercostal space then the fourth rib etc… to the tenth rib.
We have four borders of the heart “Superior, inferior, left and
right”. The most important point for you to locate it is the apex f the heart.
Which is located on the parasagital line, on the midclavicular line down to the
fifth intercostals space “Were you can hear the mitral valve’s sound”. You can
find the apex of the heart posterior to the left fifth intercostals space
oriented inferiorly!
The line which passes from left second costal cartilage about one
centimeter away from the margin of the sternum and inferiorly towards the
right, and also one centimeter but on the right to the third costal cartilage
we call this “The superior border of the heart”. “The left border” extends
from second costal cartilage also one centimeter from the sternum down to
the apex and it is convex. Now the line which comes from the superior margin
of the third costal cartilage and it is almost vertical till the inferior border
of the sixth costal cartilage about one to one centimeter and half from the
sternum this is “The right border of the heart”. And finally “The inferior
border” that extends from the apex of the heart to the superior border of
the sixth costal cartilage. And you will find many variations between people
according to the person’s age, built… etc.
Now we will come to the heart surface, if you had opened the
sternum and removed the pericardium and the heart is in situ you will find
the A. anterior surface also costal surface B. posterior surface and it is the
surface that contacts with the posterior mediastinum, and C. the
diaphragmatic surface.
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Surface Anatomy of the Heart
Now, the anterior surface… almost you can see the right ventricle
and a part of the left ventricle. You can see the right atrium and its auricle
and the auricle of the left atrium, okay? If you had removed the
intervenricular sulcus you will find the left anterior descending artery and it
is the main branch of the left coronary artery. And you can see the right
coronary artery as well and somehow the marginal artery as well. The inferior
vena cava is not seen here because of it is posterior position. You can see the
inferior vena cava in the chest X-ray but it is not considered as a part of the
heart. In situ the heart consists of two parts : I- The superior part and it is
formed by an oblique line II- The inferior part: toward the left and contains
the chambers of the heart.
Now, the posterior surface is made mainly of the left atrium and
part of the right atrium and a small part of the left ventricle. About the
diaphragmatic surface, it is mainly made by the left ventricle and it sets on
the diaphragm as the name indicates, and it has right, left and posterior
part. Now, the right part is mainly made by the right ventricle about the
third of this surface, the left part is made by the left ventricle and it is
about the other two thirds. And the posterior part is just consists of the
right atrium and the junction of the inferior vena cava, and it is separated
from the two ventricles by the coronary sulcus. And again the diaphragmatic
surface is horizontal but the posterior surface could be more or could be
less toward the right superiorly.
The heart contracts by this way, “somehow squeezing way, so who
had attended the lecture he/she will be able to see how the doctor had
explained that by his hand”, so the borders of the heart almost contacts
with the diaphragmatic surface. Which is a surface that consists of the
posterior and inferior surface of the heart.
Here the doctor was talking about the oblique sinus and the transverse sinus
but the voice was not clear in a very bad way so I could not give you any information
about it and I have searched in Shifa’s lecture and it was not found, so you can find
more informations about this point in details in Clinical Anatomy by Systems for
SNELL. “Fourth chapter, page 155”. And Here is the text from the textbook:-
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Surface Anatomy of the Heart
Pericardial Sinuses
On the posterior surface of the heart, the reflection of the serous
pericardium around the large veins forms a recess called the oblique sinus.
Also on the posterior surface of the heart is the transverse sinus, which is a
short passage that lies between the reflection of serous pericardium
around the aorta and pulmonary trunk and the reflection around the
large veins. The pericardial sinuses form as consequences of the way of the
heart bends during development. They have no clinical significance.
The base of the heart is made by the line which makes the superior
border, it could be more or less posterior and on the contrary of what the
name indicates it is superior but NOT inferior, the apex is located inferiorly,
and it is toward the right and the apex in the opposite position. Posterior to
the heart you will find, particularly posterior to the mediastinum, is the
esophagus, descending aorta, thoracic vertebrae 5th – 8th and the thoracic
duct. And do not forget that just the superior vena cava is considered as a
part of the superior mediastinum but not the inferior.
Anyway, the base of the heart consists of the left atrium mainly and
the posterior aspect of the right atrium from it is upper surface.
Again the superior mediastinum is limited by the vertebral bodies
1st-3rd and 4th-6th vertebral bodies limit the posterior mediastinum and make
the posterior aspect of the heart but the descending aorta, esophagus and
the thoracic duct separate them.
Where are the valves located within the heart then the sound will be
different, so the location of the heart valves are different from where you
can hear them best .why?
The presence of the sternum”1” (which is a thick bone) most of
those valves are located posterior to the sternum, posterior to the sternal
body there is a fat”2” and the pericardium”3” and these will limit the
auscultation.
I did not say that you cannot do the auscultation of the valves
anterior to the sternum, you can do that...But your hearing is not perfect. So
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Surface Anatomy of the Heart
therefore you can hear these valves best in the spaces between the ribs,
Because there is no bone matter that does not allow the voice to penetrate .
Only the tissue are presented over there .so you can hear it best .
So we always refer to the position of the heart, and how the vessels are
arranged, and where are the valves in situ. If you know these things you
will be able to know how can you hear and how can u determine where
the point where you can do your best auscultation. So we know that the
pulmonary trunk passes from the right to the left and it’s located
anterior to the origin or the beginning aspect to the ascending aorta.
So the pulmonary trunk practically over lap small part of the
ascending aorta. So the ascending aorta going superiolaterally (to the
right) and curves and makes the arch and then the descending aorta
going from the lift in to the right and localized anterior to the thoracic
vertebrae.
Now these two big vessels have tow valves which are the semilunar
valves now because the aorta going to the right and because the semilunar
valve of the aorta is practically in the initial aspect of the aorta... you will
have to hear the aortic valve toward the right and we considered the second
intercostal space into the right side of the sternum as the best place to here
that sound. So the location of this valve is inferior and to the right of the
semilunar valve of the pulmonary trunk (notice that the pulmonary trunk is
located more anterior and going into the left, the aorta is going to the right
and more posteriorly).so practically the two of them one is located more
superior and to the right (the pulmonary semilunar valve location) if you
compare it with the aortic semilunar valve. (As I heard it from the dr.!!!!)
Look at slide num. 10
Aortic semilunar valve auscultation:
The aorta is going superiorly and then it will curve posteriorly (in
the arch of the aorta)and then it will going inferiorly (in the descending
aorta ) so the aorta come in touch with the right margin of the sternum so if
you want to hear it best you can hear it in the second inter costal space.
Pulmonary semilunar valve auscultation:
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Surface Anatomy of the Heart
The pulmonary will go toward the left ,toward the second intercostal
space in the left side so you can hear it in the second intercostal space in the
lift side .
So what you have to do is to find the sterna angle then the second
rib and inferior to it (almost 1 to 2 cm laterally from the sternum in the
second inter costal space) :
In the left you can hear the pulmonary semilunar valve
In the right you can hear the aortic semilunar valve
The right tricuspid valve auscultation:
We know that the tricuspid valve located between the right atrium
and the right ventricle. and the most anterior aspect of the heart is
represented by the right ventricle. And some part of the lift ventricle is
oriented in to the right and superiorly. so there for if u looking into the
aorta which should coming toward the right from the left ventricle going
upward toward the left then it will overlap somehow with the tricuspid valve
in situ between the right atrium and the right ventricle.
So the right tricuspid valve of the heart is located inferior
posterior to the sternum inferior to what we call it the aortic valve but
where can we auscultate better???
We know that the right border of the heart is short and concave.
Where the inferior border is longer and practically is mad by the curving of
the right ventricle. so 1-the auscultation can be at the lower sternal border.
Some people will say that the best auscultation place of this 2-is the
sixth intercostal space but because the heart beats by a specific way; in
which it elevates the right ventricle toward the chest wall. so whenever we
have heart beat ,the chest wall will be pumped by the anterior aspect of the
right ventricle bringing up and toward the chest more or less the tricuspidic
valve (but the dr. said mitral valve??) and u can hear it better in the region
below the intercostal space .
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Surface Anatomy of the Heart
Some people like to hear this valve 3-into the epigastrium (below the
subcostal angle).
The mitral valve (bicuspid valve) auscultation:
The mitral valve (bicuspid valve) can be heard best in the fifth
intercostal space because the beating of the ventricle bring the sound of
closure of this valve at the apex of the heart, and that the thickness of the
wall of the ventricle on the anterior aspect (that is presented over there);
prevent hearing it from in another space ,that doesn’t mean that you cannot
hear it in the 4th , doesn’t mean that u cannot hear it in the 3rd or you
cannot hear it lateral to the left border of the sternum, but u can best hear
it in to the intercostal space number 5 in the lift side.
In the movement of the heart you can see that the right ventricle
brings up the inferior aspect of this ventricle anteriorly so therefore if you
have the tricuspid valve which is assorted in the sixth intercostals space or
some time sicoosterni “Not sure”!!! It does not matter, depending on how big
is the patient you can hear.
So these point are not perfectly location of where you can hear
.that mean when I say that you can hear it best on that space! Yes, you can
hear it best, but some time you can hear it somewhere else. So what I mean
that the movement of the heart will bring up the auscultation point toward
the chest, and that is where it varies in the point whereyo u can do your
auscultation.
Again those are surface margins of the valves of the heart. You will
see that the pulmonary valve is located superior to the aortic valve and
toward the left.
Toward the right we have the pulmonary valve, immediately inferior
to the pulmonary valve we have the tricuspid valve and between them and
toward the lift we can find the mitral valve.
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Surface Anatomy of the Heart
As u can see in the figure below; This is the sternal angle being over
here and that is the second rib and that is the third rib so if you count these
ribs u will go second intercostal third, fourth, fifth intercostal and you will
see that the apex is located in the fifth intercostal space and in the midline
that comes as a parasagittal line from the midclavicular line passing though
the nipple and inferior to the nipple .
Within an X-ray you can see so many things you can see: growth,
Obesity “Not Sure”, dark, The image of the ribs.
Now any opaque line passes laterally and inferiorly that considered
to be the posterior surface of the rib and opaque lines that passes medially
and inferiorly considered as the anterior aspect of ribs so if you want to
count the ribs (in the figure below):
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Surface Anatomy of the Heart
In this figure you can see the
anterior aspect of the x-ray
where the heart in situ you can
see aorta, pulmonary trunk and
its valve , u can notice that the
valve of the aorta is inferior to
the lift ,the tricuspidic valve is
inferior to the aorta ,toward
the lift and medially you can
see the mitral valve. This is an
important figure which may
come in the practical exam .
This is the palpation aspect of the
arteries
This the
Superficial
Temporal Artery
Wich u can hear
it anterior to the
auricle of the
ear
These are
the tow
carotid
arteries
This is the Brachial Artery
This is the radial artery
Above the rest
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Surface Anatomy of the Heart
This is the Popliteal Artery
Posterior tebial artery
And you can hear the femoral artery in the
femoral triangle
This is the Dorsalis Pedis
Artery on the anterior aspect.
The End of the Lecture.
Finally as your colleague Bilal, I want to apologize from all of you for being late;
because of the circumstances! This lecture was almost to be replaced by Shifa’s
lecture but it was escaped by the efforts of my friends who deserve more than being
thanked… I am really so thankful for Motaz because he had relieved me a lot by
writing the last part of this lecture, and “WE” are deeply… deeply thankful for
“Hazem Zebdeh” for helping Motaz till the midnight. And I am so thankful to my
dearest brother “Motasem Al-Amari”; because he had helped me a lot in this lecture.
And of course, we are so thankful for Malek for his patience and for everybody as
well for the same reason.
And forgive us if we had perpetrated any mistake!
AlMu’taz Bellah Ababneh & Bilal AlYaseen.
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