The heart Anne Le Roy Overview of the

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The heart Anne Le Roy

The heart Anne Le Roy

Overview of the heart circulation

Overview of the heart circulation

Developement 18 th day: cardiogenic area 2 endocardial heart tubes Single heart tube

Developement 18 th day: cardiogenic area 2 endocardial heart tubes Single heart tube

Developement – the primitive heart tube Sinus venosus Sinus venarum cavarum Primitive atrium Atrium

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

Developement – the primitive heart tube

Further development of the primitive heart tube • Bulboventricular loop (inflow part lying dorsal

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

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

Foramen ovale and fetal blood circulation

Heart description • • basis x apex auricula dextra et sinistra sulcus coronarius sulcus

Heart description • • 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

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

Chest X-ray

Heart structure • endocardium = tunica intima ▫ heart valves • myocardium = tunica

Heart structure • endocardium = tunica intima ▫ heart valves • myocardium = tunica media • pericardium

Endocardium: Heart valves • duplication of endocardium • attached to fibrous anuli of the

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

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) •

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)

Auscultation points (Testut‘s points)

Valvular replacement

Valvular replacement

Myocardium • Left ventricle: 12 -14 mm • Right ventricle: 3 -4 mm •

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 ▫

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 ▫

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

Cardiac tamponade and pericardiocentesis

Heart cavities • • • right + left atrium interatrial septum atrioventricular septum right

Heart cavities • • • right + left atrium interatrial septum atrioventricular septum right + left ventricle interventricular septum (membranous + muscular part)

Atrium dextrum I. • • auricula dextra sinus venarum cavarum mm. pectinati crista terminalis

Atrium dextrum I. • • auricula dextra sinus venarum cavarum mm. pectinati crista terminalis

Atrium dextrum - openings 1. foramen v. cavae inf. ▫ valvula v. c. i.

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.

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.

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 ▫ mm. pectinati

Ventriculus sinister • trabeculae carneae • ostium atrioventriculare sinistrum ▫ valva mitralis s. bicuspidalis

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 • • = fibrous connective tissue valve support myocardium

Fibrous skeleton of the heart • • = 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

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 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%) Ø Posterior interventricular/descending artery (PDA) • septal branches – for 1/3 of the IV septum • AV nodal branch - 80 % (can also arise from RCA) Ø Right posterolatral artery (RPLA)

Arteria coronaria dextra (ACD) Branches: • r. coni arteriosi -> circulus Vieussensi • rr.

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%) Ø r. interventricularis posterior - RIP • rr. interventriculares septales – for 1/3 of the IV septum • r. nodi atrioventricularis - 80 % (can also arise from RCA) Ø r. posterolateralis dexter – RPLD You have to know the coronary arteries in LATIN!

Left coronary artery - LCA Left aortic sinus→ short trunk - 2 -3 cm

Left coronary artery - LCA Left aortic sinus→ short trunk - 2 -3 cm (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 -3 cm) → ACS

Arteria coronaria sinistra (ACS) sinus aortae sinister → short (2 -3 cm) → 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 arteries

Coronary cathetrisation and coronarography

Coronary cathetrisation and coronarography

PCI (PTCA) – angioplasty + stenting

PCI (PTCA) – angioplasty + stenting

CABG: Coronary artery bypass grafting • v. saphena magna • a. thoracica interna (LIMA/RIMA)

CABG: Coronary artery bypass grafting • v. saphena magna • a. thoracica interna (LIMA/RIMA) • a. radialis

Coronary cathetrisation coronarography

Coronary cathetrisation coronarography

Coronarography – RCA

Coronarography – RCA

Coronarography– RCA – stent implantation

Coronarography– RCA – stent implantation

Coronarography - LCA

Coronarography - LCA

Coronarograpy - LCA

Coronarograpy - LCA

Dominance of the coronary arteries Right dominant pattern (75%) • PDA from RCA Left

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 • • • Right coronary artery

Blood supply of the heart in rightdominant pattern • • • 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 ▫

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/ ▫

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

• 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

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. ,

Innervation of the heart • Sympathetic supply ▫ nn. cardiaci: - cervicales sup. , med. , inf. - thoracici ▫ β 1 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

Cardiac reffered pain • Head‘s zone: behind sternum and unlar edge of left upper limb (A)

Fetal circulation

Fetal circulation

Remnants of structures of the fetal circulation • • • foramen ovale ductus arteriosus

Remnants of structures of the fetal circulation • • • foramen ovale ductus arteriosus Botali ductus venosus Arantii v. umbilicalis aa. umbilicales • • • 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

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

Dextrocardia • with situs inversus • isolated dextrocardia

Atrial septal defect (ASD) • foramen ovale patens – 25% usually of no hemodynamic

Atrial septal defect (ASD) • foramen ovale patens – 25% usually of no hemodynamic significance • large foramen ovale patens (>9 mm) left-to-right shunt

Ventricular septal defect (VSD) • membranous VSD – most common type • muscular VSD

Ventricular septal defect (VSD) • membranous VSD – most common type • muscular VSD = swiss cheese VSD

Transposition of the great vessels

Transposition of the great vessels

Tetralogy of Fallot 1. Ventricular septal defect 2. Right ventricular hypertrophy 3. Overriding aorta

Tetralogy of Fallot 1. Ventricular septal defect 2. Right ventricular hypertrophy 3. Overriding aorta (incomplete transposition) 4. Pulmonary stenosis 400/1 000 births

Eponyms - overview • • • ductus arteriosus Botalli valvula v. cavae inferioris Eustachii

Eponyms - overview • • • ductus arteriosus Botalli valvula v. cavae inferioris Eustachii tuberculum intervenosum Loweri valvula sinus coronarii Thebesii trigonum nodi atrioventricularis Kochi • noduli Aranzii • 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 • fasciculus Wenckebachi • fasciculus Thoreli • nodus atrioventricularis Aschoff -Tawara • fasciculus atrioventricularis His, Kent, Gaskell • crus fasciculi atrioventricularis Tawara • rami subendocardiales Purkyně • fasciculus accessorius Kenti • Holzknecht‘s field • ductus Cuvieri ( = v. cardinalis communis)

Systolic/disatolic pressure in parts of the heart

Systolic/disatolic pressure in parts of the heart