J. Anat.

(2004) 205, pp159–177

REVIEW
Blackwell Publishing, Ltd.

Cardiac anatomy revisited
Robert H. Anderson,1 Reza Razavi1,2 and Andrew M. Taylor1
1
Institute of Child Health, University College, London, UK
2
Guy’s and St Thomas’s Hospitals, London, UK

Abstract
In tomorrow’s world of clinical medicine, students will increasingly be confronted by anatomic displays reconstructed
from tomographically derived images. These images all display the structure of the various organs in anatomical
orientation, this being determined in time-honoured fashion by describing the individual in the ‘anatomical position’,
standing upright and facing the observer. It follows from this approach that all adjectives used to describe the
organs should be related to the three orthogonal planes of the body. Unfortunately, at present this convention is
not followed for the heart, even though most students are taught that the so-called ‘right chambers’ are, in reality,
in front of their ‘left’ counterparts. Rigorous analysis of the tomographic images already available, along with
comparison with dissected hearts displayed in attitudinally correct orientation, calls into question this continuing
tendency to describe the heart in terms of its own orthogonal axes, but with the organ positioned on its apex, so
that the chambers can artefactually be visualized with the right atrium and right ventricle in right-sided position.
Although adequate for describing functional aspects, such as ‘right-to-left’ shunting across intracardiac communi-
cations, this convention falls short when used to describe the position of the artery that supplies the diaphragmatic
surface of the heart. Currently known as the ‘posterior descending artery’, in reality it is positioned inferiorly, and
its blockage produces inferior myocardial infarction. In this review, we extend the concept of describing cardiac
structure in attitudinally correct orientation, showing also how access to tomographic images clarifies many aspects
of cardiac structure previously considered mysterious and arcane. We use images prepared using new techniques
such as magnetic resonance imaging and computerized tomography, and compare them with dissection of the
heart made in time-honoured fashion, along with cartoons to illustrate contentious topics. We argue that there is
much to gain by describing the components of the heart as seen in the anatomical position, along with all other
organs and structures in the body. We recognize, nonetheless, that such changes will take many years to be put
into practice, if at all.
Key words anatomical position; attitudinally correct orientation; cardiac septal structures; computerized tomo-
graphy; magnetic resonance imaging.

subject standing upright, and facing the observer. This
Introduction
principle has withstood well the passage of time, and
One of the major conventions of human anatomy is that has permitted surgeons and physicians accurately to
all structures within the body should be described in describe the various symptoms of disease, and to establish
the setting of the anatomical position. Thus, the loca- the best options for treatment. Perhaps surprisingly,
tions of structures within organs, or the relations of anatomists over the years have uniformly failed to
organs to each other, are described on the basis of the observe this convention when describing the human
heart. Internal cardiac structure has consistently, and
inappropriately, been considered in the setting of the
Correspondence
Professor Robert H. Anderson, Cardiac Unit, Institute of Child Health, heart positioned on its apex, with the atriums above the
30 Guilford Street, London WC1H 1EJ, UK. E: r.anderson@ich.ucl.ac.uk ventricles – the so-called ‘Valentine’ approach, reflecting
Accepted for publication 2 August 2004 the convention of illustrating the organ in characteristic

© Anatomical Society of Great Britain and Ireland 2004

The methods used for diagnosis now entering at its top and bottom (Fig. the structures of the body that usually because. It is then very confusing for the trainee. clarifying age. showing that the pulmonary ture of the heart as it lies within the body as revealed valve is positioned superiorly and the tricuspid valve with clinical tomographic images. therefore. In the days when diagnosis was largely achieved by As demonstrated by the chest radiograph viewed in inspection or auscultation. with the left border sloping but also the surrounding thoracic structures. 1). ing the cardiac images. with the aorta in 1999). 1999). 2. In this review. we are now able structure in appropriate fashion (Cook & Anderson. correlating the findings inferiorly (Fig. Anderson et al. which recommended that the cardiac compon. The inferior border is made by the right obtained using magnetic resonance or computed tomo. often described as ‘situs solitus’. Indeed. and this preserved the reality position from patient to patient according to bodily of describing ‘left-to-right’ or ‘right-to-left’ shunting make-up or disease. It was respiration. techniques that visualize not only the heart. review. 2. For the purposes of this catheterization. it is possible shown in the anatomical position. the heart is usually medicines or surgical. more infarction. for the beginner structure can be mirror-imaged in the setting of to be told that blockage of the allegedly ‘posterior’ normality. Such frontal sections show that experts. superior border of the silhouette. pulmonary trunk and aorta then emerge from the ment of the cardiac septal structures (Anderson et al. and minor changes occur with in the presence in intracardiac communications. extending horizontally along the diaphragm graphy. In this arrangement during their initial introduction to human way. as images are increasingly with Fig. right). If the fullest With the advances made in manipulation of the data advantage is to be gained from describing cardiac set containing the resonance images. left ventricle (Fig. heart’ being separated one from the other. There are variations in this cardiac to the ‘left’ counterparts. with the caval veins (Cosio et al. this deficiency has now been borders of the frontal cardiac silhouette as revealed in addressed by a group of European and North American the chest radiograph. we describe the struc. we will confine ourselves to the observing the operator advance a catheter from the usual situation. or when there is an associated congenital descending coronary artery produced inferior myocardial cardiac malformation. 2. to With the advent of tomographic imaging. In very rare circumstances. The many previously confusing topics such as the arrange. the right border of the silhouette. and when treatment was by the frontal projections (Fig. 3). which. Nowadays. the entire bodily somewhat confusing. 1b). 1998). increasingly.160 Cardiac anatomy. we can accurately position the cardiac valves anatomy. 2000). to the cardiac apex. tion. H. these two valves of the so-called ‘right where necessary with standard anatomical dissections. more or less vertical. In other circumstances. mass to the right of the midline. 1b). the cardiologist treats structural demonstrate lateralization are arranged in isomeric problems within the heart by means of interventional fashion (Anderson et al. to reconstruct the various chambers and their compon- it is important that students be introduced to the correct ents and superimpose them on the silhouette. this deviation from standard positioned within the mediastinum with one-third of its anatomical practice was of little consequence. nonetheless. be told that the catheter is moving ‘anteriorly’ when. but still norm has much more significant consequences. in subsequent to the acquisition of the data set contain- reality. This is relatively rare. specifically its append- to reveal cardiac anatomy in its smallest details. nonetheless. permits the structure of the scopic screen. because most recognized that axis directed from the right shoulder towards the the so-called ‘right’ chambers were in reality anterior left hypochondrium. and positioned © Anatomical Society of Great Britain and Ireland 2004 . At the top of the left border. left). in which the image of the patient is still heart to be displayed in any desired plane. the departure from the accepted common than the mirror-imaged situation. compare also facilitate this approach. ents be described as seen in the anatomical position is produced by the right atrium. ventricle. of the arterial valves (Anderson. and the nature of attachment of the leaflets rightward position (Fig. within the frontal section. From the stance of accurately to show the structures that produce the the electrophysiologist. 2002). middle. it can be seen moving upwards in the fluoro. In addition upwards from the apex and formed by the wall of the to setting the scene for appropriate anatomical descrip. groin through the inferior caval vein into the heart. contributes to the silhouette (Fig. R. shape balanced on its apex for the greetings cards The location of the heart within the thorax issued to lovers celebrating St Valentine’s Day. and with its own long it had some advantages. these new techniques provide the sophistication a small part of the left atrium.

6). the right ventricle. in front of their counterparts in the ‘left heart’ muscular infundibulum (Fig. by the yellow dotted line. shows the chambers corresponding to the silhouette. The two valves of the left heart are directly also show that. 4). As already stated. 4). the left border. Note that the axes of the heart itself are well out of skew relative to the axes of the body. and the diaphragmatic border. by the green dashed line. 2. with the fibrous continuity tricuspid valves are hinged from the atrioventricular between them forming the roof of the left ventricle junctions in relatively planar fashion. or acute border of the ventricular mass. Cardiac anatomy. 1 The frontal chest radiograph (a) shows the outline of the cardiac silhouette relative to the thorax. with the leaflets of the pulmonary These sinutubular junctions of the aortic and pulmon- valve lifted away from the base of the ventricular mass ary valves themselves have a marked obliquity relative on the free-standing sleeve of the subpulmonary to each (Fig. photographed in attitudinally appropriate position. the leaflets of the pulmonary arterial valves are attached in semilunar form. being and tricuspid valves are widely separated in the roof of suspended from the circular sinutubular junctions (Fig. and the ‘left heart’ cast in red. The right border of the heart is shown by the red dotted line. The reconstructions (Fig. or obtuse border of the ventricular mass. those of the (Fig. whereas the leaflets of the mitral and adjacent one to the other. 4). with the so-called ‘right heart’ cast in blue. See also Fig. A cast of the normal heart (b). H. 5). with the intrapericardial components © Anatomical Society of Great Britain and Ireland 2004 . 161 Fig. R. Anderson et al.

1).162 Cardiac anatomy. 8). H. Such scanner introduced through the oesophagus and into reconstructions confirm that the so-called ‘right’ cham. running from the front (a) to the back (c). 9). access of the ultrasonic beam from the oesophagus equally importantly. of the arterial trunks then spiralling round one another positioned to the right of their respective ventricles. © Anatomical Society of Great Britain and Ireland 2004 . R. show the different chambers that contribute to the borders of the cardiac silhouette as seen in the frontal chest radiograph (Fig. the stomach. that the atrial chambers are into the various cardiac components (Fig. The as they extend from the base of the ventricular mass heart itself is positioned with its own axes obliquely into the mediastinum (Fig. 7). with the Location of the chambers within the heart left atrium posteriorly located (Fig. The sagittal scans show well the potential bers are anterior to their ‘left-sided’ counterparts and. Cardiologists The software now available permits the contours of the are today also able to obtain three-dimensional recon- separate cardiac chambers to be reconstructed and structions of cardiac structure by means of an ultrasonic displayed within the setting of the thorax. 2 The cuts through the heart in the coronal plane. orientated relative to the body. Fig. See text for further discussion. so that a sagittal section through the thorax taken in the midline shows the right ventricle positioned most anteriorly. Anderson et al.

R. Hence. 2 have been reconstructed in the frontal plane (a) and superimposed on the chest radiograph (b). From what has been described thus far. The echocardiographer obtuse. so that the inferior border lies diaphragmatic surface of the heart. Sectioning the heart in its own short axis then shows the ventricular cone. being less relative to the bodily axes. representing the superior margin of mass then reveals the fundamental nature of the © Anatomical Society of Great Britain and Ireland 2004 . is described as the obtuse margin. this landmark is costal border anteriorly and to the right. the inferior margin therefore has to obtain images of the heart through of the cardiac silhouette. hence its description as the ‘four-chamber’ plane between the sternocostal and diaphragmatic surfaces. located within the cardiac notch of the left lung poste. The squashing of the cone der. evident that. being greater than 90°. at the point at along the diaphragm (Fig. The ventricular septum which the ventricular septum transects the inferior bor- transects this inferior margin. this ‘four-chamber’ plane than 90°. H. with the other structures crosses the plane of the inferior atrioventricular two sides of the triangle being adjacent to the sterno. 9). 3 The outlines of the cardiac valvar leaflets from the data set shown in Fig. 10). The leftward border as seen in the Examination of the cross-section of the ventricular chest radiograph. Anderson et al. It is found at the site where the plane of the septal produces a triangular configuration. Sections taken across the lar mass (Fig. groove (Fig. border. with the transoesophageal portal now becom- to the site of the acute marginal branch of the right ing increasingly important (Fig. 163 Fig. The angle at the superior margin. ventricular mass reveal that the cone of ventricular Another important cardiac landmark is found on the musculature is squashed. the rationale underlying the traditional description with the obtuse marginal branches of the circumflex of the margins of the cardiac silhouette as seen in the artery irrigating the pulmonary surface of the ventricu- chest radiograph (Fig. Cardiac anatomy. is known as the acute margin. cannot be obtained by taking standard sagittal or coro- between the sternocostal and pulmonary surfaces. 12). (Fig. 1). owing to the obliquity of the cardiac axes matic borders posteriorly. it is and the angle between the pulmonary and diaphrag. is nal sections through the body. are both acute. Known as the ‘crux’. by contrast. 13). representing the anterior the various echocardiographic ‘windows’ (Anderson et al. The particular shape of the triangle diaphragmatic surface reveals all four cardiac cham- is such that the angle made at the anterior margin bers. and being particularly important for the echocardiographer. and corresponds 2001). coronary artery. because a section taken parallel but superiorly to the riorly and to the left. 11).

As already of cardiac structures.164 Cardiac anatomy. is currently The description of the electrocardiographic recordings described as the ‘posterior descending artery’. 10). and compared with the short axis of the heart as seen in left anterior oblique projection looking upwards from the cardiac apex. and inferior ventricular infarction (Cook & Anderson. 2002). As shown remains appropriate because these are automatically unequivocally by the resonance images. the supraventricular crest (red arrow) being interposed between the leaflets of the tricuspid and pulmonary valves. the adjacent inferior ventricular walls. this artery is registered relative to the anatomical position. Note that. H. the roof of the right ventricle is muscular. Problems © Anatomical Society of Great Britain and Ireland 2004 . problem currently existing in the accepted description located inferiorly rather than posteriorly. blockage of the artery is known to produce inferior part of the ventricular septum (Fig. Fig. in comparison. The artery that irrigates the emphasized. R. 4 The outlines of the cardiac valves reconstructed from the magnetic resonance images are shown in lateral projection. Anderson et al. The green dotted line shows the fibrous continuity between the leaflets of the aortic and mitral valves that forms the roof of the left ventricle.

It is being ‘anterior’. because the left venous valve is usually while the posterior quadrant is the one closest to the fused with the septal surface after birth. The junction between the appendage currently described as producing antero-septal infarc. reveal self-evidently it is inferior. with this corresponding externally with the as the antero-superior interventricular artery. For reasons that are not bers are separated one from the other by the septum. clear. a vestibule and an appendage. and ventricular mass. The remnants of it is likely to continue to be known simply as the the right venous valve. is one of the major branches of the rior and inferior caval veins along with the coronary left coronary artery (Fig. now exist. showing various features that are and radiologists. postnatal heart. the smooth-walled vestibule The artery that irrigates the superior quadrant of the supporting the hingelines of the tricuspid valve. and the systemic venous sinus is marked internally by tion. currently described as being ‘anterior the extensive venous sinus into which drain the supe- descending’. and that the pulmonary trunk is lifted away from the ventricular base by the subpulmonary muscular infundibulum. 16). that the opposite quadrant should be described as although clearly evident in fetal sections (Fig. is the space that separates the leftward boundary of the ‘superior’ and not ‘anterior’. Cardiac anatomy. 14). the Eustachian and Thebesian ‘ADA’. of course. the writing group continued to suggest The body of the right atrium is virtually non-existent. although terminal groove (‘sulcus terminalis’). systemic venous sinus from the septum. It is possible. H. 10). 165 Fig. Until recently. to recognize the extensive appendage. spine. See also Fig. 14). R. when The resonance images. The other two quadrants therefore are located nonetheless. 5 The short axis of the heart is photographed from above and behind having removed the atrial chambers and the arterial trunks. if nance images shows unequivocally that it is the septal not impossible. inferiorly and superiorly (Fig. Blockage of the artery is sinus (Fig. with the pectinate © Anatomical Society of Great Britain and Ireland 2004 . when reconstructed. with its pectinated wall. the quadrant adjacent to the diaphragm was considered to be posterior. As shown by the tomographic images (Fig. The two cham- for Cardiac Imaging. with the way that nuclear cardiol- Relationships of the components of the cardiac ogists have agreed to describe the various quadrants of chambers the ventricular mass. This solecism was corrected particularly clearly the arrangement of the different by the task force assembled by nuclear cardiologists cardiac chambers. of this quadrant (American Heart Association Writing The atrial chambers each possess a body. however. the extensive and prominent terminal crest (‘crista it would be much more accurate to re-name this artery terminalis’). which recognized the inferior location currently ignored in standard descriptions. a venous com- Group on Myocardial Segmentation and Registration ponent. are attached to this crest. 4. valves. Anderson et al. 2002). Examination of the reso. The antonym of ‘inferior’. to recognize this part in the definitive quadrant of the left ventricular cone that is anterior. Note the obliquity of the relationship between the aortic and pulmonary valves. It is difficult. 15). however.

so that the larger walled venous sinus from the smooth-walled vestibule. part of the internal surface of this atrium is smooth- The left atrium has an obvious smooth-walled walled. 18). Morphologically. with detailed analysis now revealing it own muscular walls (Chauvin et al. (Kato et al. with the blue line showing the sinutubular junction. 2002). muscles extending in parallel fashion from the crest of the left atrium is a true diverticulum. Within this groove. Lickfett et al. © Anatomical Society of Great Britain and Ireland 2004 . it possesses chambers (Fig. 17).166 Cardiac anatomy. interposed between the vestibular and pulmonary to the terminal crest to be found in the left atrium venous components. sinus of the right atrium. running within the left atrioven- ships of the great veins to each other and to both atrial tricular groove (Fig. 2004). to the left atrium. 19). with all the to run all round the vestibule. four corners of the venous part enclosing a prominent The coronary sinus drains to the systemic venous atrial dome (Fig. There is no muscular structure comparable body. pectinated muscles contained within it. Reconstructions from the tomo. the yellow line the anatomic junction between the muscular infundibulum and the arterial wall of the pulmonary trunk. 20). 2003. H. The appendage allegedly derived from a purported left sinuatrial fold. separating the smooth. The lower panel shows the three-dimensional crown-like configuration produced by interdigitation of the semilunar attachments with the three rings existing in the root. it is related graphic images now demonstrate the precise relation. The semilunar attachments of the leaflets are marked by the red line. Fig. 6 The upper panel shows the opened pulmonary root having removed the leaflets of the pulmonary valve. There is no ‘annulus’ supporting the attachments of the leaflets – see text for further discussion. Anderson et al. there being unexpected variations within the normal arrangement no evidence to support the notion that a ‘party wall’. with the pulmonary veins at the (Fig. R. and the green line the ring made by joining together the basal attachments of the three arterial valvar leaflets.

the right ventricle. however. whereas that between the sternocostal and pulmonary margins is obtuse. 10 The section across the ventricular mass in short axis shows that the angle between the sternocostal and diaphragmatic surfaces is acute. H. Cardiac anatomy. 8 The magnetic resonance image. this quadrant is really positioned superiorly. are in reality anterior to their left-sided counterparts. The apparent hole in the cast of the right ventricle is produced by the prominent right ventricular trabeculations. 9 A slice parallel to the image shown in Fig. nuclear cardiologists describe the opposite quadrant (2) as being ‘anterior’. (sagittal plane). Fig. It is the septal quadrant (1) that is Fig. Fig. shows that the so-called right-sided structures. Quadrant 4 is obviously positioned inferiorly. R. taken in lateral projection anterior. As the images show. Currently. 7 The ventricles and arterial trunks have been reconstructed from a data set obtained using magnetic resonance imaging. It also shows how the short axis of the left ventricle can be divided into quadrants (red lines). with the left-sided structures coloured in red. Anderson et al. and the so-called right-sided structures coloured in blue. infundibulum and pulmonary trunk. 8 reveals the location of the oesophagus directly posterior to the so-called left-sided cardiac structures. Note the spiralling arrangements of the arterial trunks. © Anatomical Society of Great Britain and Ireland 2004 . giving the acute margin. 167 Fig.

Anderson et al. This corresponds to the so-called crux of the heart (see also Fig. usually this left-sided embryonic channel regresses. 20). 13 The long axis taken along the heart itself shows the so- to permit the data set to be cut in the plane of the coronary called ‘four-chamber’ projection. When there is Until recently. 11 The magnetic resonance images have been programmed Fig. malformed hearts shows that it is more logical to Fig. 22).168 Cardiac anatomy. it was usual to see the ventricles described a persistent left superior caval vein. 12 The section across the ventricular mass in its own short axis shows how the postero-inferior extent of the ventricular septum (red star) cuts the atrioventricular junction between the right (RAVO) and left (LAVO) atrioventricular orifices. although examination of congenitally arrangement is found in about one-twentieth of indi. Fig. This this convention. H. Note how the atrial myocardium (green dotted line) overlaps the ventricular myocardium at this point. but more acute turn at the acute margin (star). © Anatomical Society of Great Britain and Ireland 2004 . arteries. with the right coronary artery taking its viduals with congenital cardiac malformations. It is difficult to find drains to the coronary sinus. The section shows the obtuse marginal branches of the circumflex artery irrigating the obtuse margin of the ventricular mass. and left atrium (Knauth et al. the two muscle masses separated by the fibro-fatty tissue of the atrioventricular groove. R. 2002). being represented in the postnatal heart by the oblique vein is interposed between the cavities of the coronary sinus of the left atrium (Fig. having coursed between evidence of any anatomical boundaries that support the left appendage and the left pulmonary veins. it almost always as possessing a ‘sinus’ and a ‘conus’.

R. ICV) and the coronary sinus. So do the ventricles. photographed in lateral emerges from the aorta in superior position. shows that. shows how the pectinated appendage interposes between the smooth-walled systemic venous sinus. 15 This section of a developing human heart at Carnegie stage 15. The apical components are the most extends from the atrioventricular to the ventriculo. Anderson et al. situated anteriorly. along with their in this fashion. receiving the superior and inferior caval veins analyse the ventricular chambers as possessing three (SCV. © Anatomical Society of Great Britain and Ireland 2004 . 16 The cast of the right atrium. along with a driving piston. 169 Fig. arterial junctions. Cardiac anatomy. 1998). This is because the tricuspid valve. ventricles are the pumps to the circulations. H. The inlet components then surround with the apex of the right ventricle. we recognize that the ventricular mass tension apparatus. and effi- cient pumps possess inlet and outlet valves. projection from the right side. and taken in ‘four-chamber’ projection. at early stages. the systemic venous sinus is separated from the remainder of the developing right atrium by well-formed right and left venous valves. characteristic intrinsic components of the ventricles. and the vestibule of the components (Anderson & Ho. 14 The magnetic resonance image in frontal projection shows that the so-called ‘anterior descending coronary artery’ Fig. When analysing and support the atrioventricular valves. Fig.

the muscles are positioned infero-septally and ments to the ventricular septum. is that tendinous cords should support the leaflet is much deeper. muscles. The most important feature. The anterior mitral valve. Fig. teriorly but positioned obliquely within the left ven. the muscles are described fine criss-crossing trabeculations found in the posterior by clinicians as being ‘postero-septal’ and ‘antero- left ventricular apex (Fig. In the right ventricle. obliquity of the valve within the left ventricle. located anteriorly and pos. possessing inferior. and cords. hinged from the leaflets. The arrangement of the tendinous cords has also tricle. The papillary muscles of the valve are ive free-standing infundibular sleeve (Fig. Only time and consensus will deter- markedly eccentric papillary muscles. septal and images (Fig. is marginal. The mitral valve mine the most appropriate names for these papillary possesses only two leaflets. but guards only one-third of the entirety of the free edges of both leaflets (Fig. but an extensive smooth-walled body interposes between the vestibule of the mitral valve and the pulmonary venous component. the tic. Although some have (Fig. it is usual to edge from those attached to the ventricular surface of find slits in the extensive posterior leaflet. has extensive cordal attach. 6). markedly in the normal ventricles. the tricuspid valve. this solitary zone of apposition is devised complex systems to categorize the cords sup- orientated in concavo-convex fashion. as do the outlets. This leaflet is separated from the septum by the Unequal support to the free edge is believed to be the subaortic vestibule. 17 The cast of the left atrium shows that the pectinate muscles are confined within the tubular appendage. 1985). and is supported by supero-laterally. with the leaflets porting the leaflets (Silver et al. antero-superior leaflets. As shown by either tomographic Thus.170 Cardiac anatomy. having fibrous continuity with two mechanism leading to prolapse of the leaflets (Van der of the leaflets of the aortic valve (Fig. R. Significantly. Important differences are also found in the structure ter to describe the two leaflets as being mural and aor. Currently. 1971). Tendinous cords attach each muscle and pulmonary valves. Because of the Bel-Kahn et al. a concept that dates back to Andreas Vesalius and anteriorly located pulmonary valve is lifted in its the birth of observation-based anatomy in Padova in entirety away from the ventricular base by the extens- the 16th century. The inlets also differ lateral’. it is bet. however. H. of the ventricular outlets. The difference in antero-posterior disposition. particularly for the guarding two-thirds of the valvar orifice. Because of this. these latter being either the strut or basal the parietal part of the atrioventricular junction. 22). 24). in our opinion it guarding markedly dissimilar proportions of the valvar is sufficient to distinguish those attached to the free- circumference (Fig. 22). Anderson et al. being coarsely trabeculated in comparison with the to both leaflets. being paired and positioned one at seen internally. 4). 21). and closing along a solitary zone of apposition been a matter of controversy. orifice. When also distinctive. the arrangement produces an extens- each end of the solitary zone of apposition between ive muscular shelf between the hinges of the tricuspid the valvar leaflets. 23) or cross-sectional echocardiograms. the so-called supraventricular © Anatomical Society of Great Britain and Ireland 2004 .

and is not marked by any terminal crest. the junction of the left atrial appendage with the atrium is narrow. Anderson et al. This muscular strap reinforces the septal surface of the © Anatomical Society of Great Britain and Ireland 2004 . important right ventricular landmark. 19 This cut in the short axis of the heart itself shows the triangular right atrial appendage (white star). or septal band (Fig. 18 Reconstruction from magnetic resonance images showing the interrelations of the systemic and pulmonary venous components from (a) the front and (b) the back. with a broad junction to the atrium (double-headed arrow). 25). Fig. In comparison. namely the septomarginal trabeculation. shows how the coronary sinus occupies crest (‘crista supraventricularis’ – Fig. and the middle cardiac vein at the crux. receiving the great cardiac vein aspect. marked by the prominent terminal crest (red star). Fig. 4). On the septal the left atrioventricular groove. 171 Fig. photographed to show the diaphragmatic aspect. R. Cardiac anatomy. 20 The cast of the cardiac chambers. H. this crest inserts between the limbs of another at its origin at the site of the oblique vein of the left atrium.

the last constructed by joining outlet is much reduced in size because of the fibrous together the nadir of the semilunar hinges of the three continuity between two of the leaflets of the aortic leaflets (Fig. namely the semilunar attachment of ships of the outflow tracts that can now be revealed by their leaflets. The two leaflets close along a solitary zone of apposition. The rings are the giving rise to a further series of septoparietal trabecu. This is the more significant. Anderson et al. Note the coarse trabeculations at the apex of the right ventricle in comparison with the smooth surface of the left ventricle. Fig. Original photograph reproduced by kind permission of Dr Val S. leaflets. The discrepancy between the anatomic valve and the aortic leaflet of the mitral valve. in fact. Armenia. the tomographic images. These arterial junction within the valvar complex. 5). has important consequences for the relation- ure in common. breaking up at the apex to form the found within the ventricular outlets. R. and haemodynamic ventriculo-arterial junctions. but none supports moderator band and the anterior papillary muscle. 21 The heart has been sectioned in its own long axis to reveal the four cardiac chambers (compare with Fig. they also have one feat. where the tual ring proximally. at least three rings to be within the ventricles to the sinutubular junctions. geons continue to describe these valves as possessing Because the semilunar attachments extend from an ‘annulus’. 22 The mitral valve is photographed from above to show its atrial aspect in closed position.172 Cardiac anatomy. sinutubular junction distally. with multiple slits in the larger leaflet ensuring competent coaptation. the anatomic ventriculo- lations that run to the parietal ventricular wall. There are. because sur. the Although the two ventricular outlets have important latter represented by the semilunar hingelines of the differences in their structure. Galstyan. and the hingelines of the valvar leaflets. right ventricle. and a vir- structures are absent from the left ventricle. 13). Fig. they © Anatomical Society of Great Britain and Ireland 2004 . H.

at its deepest cross the circular anatomic ventriculo-arterial junctions between the attachments of the pulmonary veins to where the musculature of the ventricles supports the the left atrium and the caval veins to the right (Fig. 23 The magnetic resonance images in frontal (a) and that interpose between chambers but incorporate within short axis (b) planes across the body show that the paired them extracardiac tissues (Anderson & Brown. anterior and posterior rims of the oval fossa. 26). also be a parie- tal structure? The answer is simple. Cardiac anatomy. 26). 173 of fibrous tissue. along with the antero-inferior buttress that leaflets are supported by the muscular infundibulum anchors the flap to the atrioventricular junctions (Fig. as opposed to folds Fig. How can such a fibrous membrane. The same arrange- ment is then found in the left ventricular outflow tract. The base of each leaflet is supported by muscle (Anderson et al. this area is continuous with the membranous septum. R. and posteriorly and superiorly (red star with yellow line). so-called ‘septum secundum’. the tomographic proximal to the anatomic junction. 27). Subsequent to formation and maturation of the arterial valvar sinuses and leaflets. rather than being parietal walls. H. and separate the ventricular outflow tract from the pericardial cavity. Structure of the septal components The tomographic images also serve to clarify the arrangement of those parts of the heart that are directly interposed between adjacent chambers. with the fibrous interleaflet triangles immediately beneath the sinutubular junction separating the left ventricular cavity from the pericardial cavity (Fig. 1998). and also from the tissue plane existing between the back of the subpulmonary infundibulum and the aortic root (Anderson. is no more than an infolding of the atrial walls. 1996). where all the valvar foramen. forming the superior. 5). at its base. The fibrous triangle interposes between the left ventricular outflow tract and the right side of the transverse sinus of the pericar- dium (Fig. the muscular sleeve regresses to the level of the anatomic ventriculo- arterial junction. This arrangement The true atrial septum is the flap valve of the oval is best seen in the right ventricle. This is the definition we have suggested to distinguish between partitions that sep- arate directly adjacent chambers. Anderson et al. part of the septal components of the heart. this part of the developing heart was encased in a muscular sleeve that extended to the sinutubular junction (Ya et al. papillary muscles supporting the mitral valves are positioned The tomographic images show exquisitely how the adjacent to the septum and inferiorly (yellow star with red line). This process then leaves the fibrous walls of the outflow tract interposed between the ven- tricular cavities and extracardiac space (Fig. Initially. 2000). while the triangles images then clarify the arrangement of the atrial and between the distal attachments of the leaflets are made ventricular musculatures in the floor of the triangle of © Anatomical Society of Great Britain and Ireland 2004 . fibro-elastic walls of the arterial trunks. The triangle formed between the non-coronary and right coronary leaflets of the aortic valve is of particular interest because. Significantly. 26). 1999).

the mural leaflet (red) being long and shallow whereas the aortic leaflet (blue) is short and deep. in reality. we thought that this important area. 1982). with an extension from the inferior atrioven.174 Cardiac anatomy. R. the two limbs clasping the insertion of the supraventricular crest ( yellow dotted line). Fig. We have now come As already discussed. the images also confirm that to appreciate that. 28). Also positioned between the cavities of the two ventricles significant is the fact that. H. Anderson et al. because of the deeply (Fig. both supported all along their free edge by tendinous cords. was a muscular atrioventricular at the level of the sinutubular junction (Fig. Only a very small part layers (Fig. Note also the septoparietal trabeculations and the moderator band. 26). Fig. septum (Becker & Anderson. 25 The photograph of the septal aspect of the right ventricle shows the arrangement of the muscle bundles. triangle that separates the attachments of the non- which contains the atrial components of the atrioven. coronary and right coronary leaflets of the aortic valve tricular conduction axis. The remainder of the membranous septum is tum separates the apical ventricular components. The aspect of the hinge of the septal leaflet of the tricuspid larger part of the extensive muscular ventricular sep- valve. the area is a muscular the subpulmonary infundibulum. guard markedly dissimilar lengths of the valvar orifice. with the supraventricular crest inserting between the limbs of the septomarginal trabeculation. Koch. The septomarginal trabeculation has a body (blue star) and superior (red star) and inferior (yellow star) limbs. The true atrioventricular septum is that of this structure is positioned as a true septum between part of the membranous septum positioned on the atrial the subpulmonary and subaortic outflow tracts. 24 The two leaflets of the mitral valve. is for its tricular groove interposed between the myocardial most part a free-standing sleeve. The medial papillary muscle arises from the inferior limb. Initially. the limbs of the septomarginal trabeculation. and is continuous superiorly with the fibrous wedged location of the subaortic outflow tract within © Anatomical Society of Great Britain and Ireland 2004 . inserting between sandwich. 12).

26 The magnetic resonance image (upper) and anatomic section (lower) show the relationships produced because of attachment of the leaflets of the aortic valve at the sinutubular junction. a fibrous extension of the aortic root separates the outflow tract from the transverse sinus of the periciardium (yellow double-headed arrow). 175 Fig. however. often described as the ‘septum secundum’. H. Conclusions There are many important aspects of cardiac anatomy that we have ignored in our review. © Anatomical Society of Great Britain and Ireland 2004 . most of the septum beneath the sep- tal leaflet of the tricuspid valve separates the right ven- tricular inlet from the subaortic outlet (Fig. Cardiac anatomy. R. The yellow double-headed arrow is through the floor of the oval fossa. Because of the height of this attachment (red arrows). the left ventricle. 27 The long axis (oblique axial) image across the atrial chambers shows the structure of the atrial septum. The supero-posterior rim of the fossa. is shown by the image to be a deep infolding between the connections of the pulmonary veins to the left atrium and the caval veins to the right atrium. such as the Fig. The blue arrow shows the attachment of the wall of the right atrium. Note that the septum itself is directly related to the aorta. This area is better described as the interatrial groove (green and red arrow). 29). Anderson et al.

If we are to rational- mic myocardial disease (Fig. Fig. separates the inlet of the right ventricle from the subaortic outlet of the left ventricle (green and red arrow). The hingepoint of the tricuspid valve. emphasized by the blue dotted line. R. even if its usage will remain in such matters great precision. parts in isolation. In reality. will be greatly is better than the one it is intended to replace. divided the fibrous part of the septum into atrioventricular (red arrow) and interventricular ( yellow arrow) components. it is an ‘inlet–outlet’ septum. all display cardiac why. making it possible to identify the site as the description of the direction of shunting of blood of any atherosclerotic lesions that might cause ischae.176 Cardiac anatomy. and all other images. It is easy to understand three-dimensional echocardiography. computerized tomography and of the anatomical position. shows that the muscular septum itself. There is now no reason to continue The sophistication of tomographic imaging is now such to use a system of anatomical description based on this that these features can also be demonstrated with approach. however. H. in the past. Such investigations ize nomenclature. and by demonstration that the new system tation of these. The enhanced in future if students learn cardiac anatomy. Fig. This there- removed the heart from the body. through the part of the muscular septum that supports the membranous septum (yellow arrow) and the aortic root. 30). morphologists and anatomists structure in its appropriate bodily context. Previously. 29 This frontal section. in the setting resonance imaging. we had considered this part of the septum to be an ‘inlet septum’. between the cardiac components. Anderson et al. and described its fore needs to be the context for a logical revision of © Anatomical Society of Great Britain and Ireland 2004 . arrangement and disposition of the coronary arteries. by virtue of the deeply ‘wedged’ location of the left ventricular outflow tract. this can only be done by have great potential for preventive medicine. advent of the new techniques for imaging. consensus. such as as with the anatomy of all other organs. Interpre. 28 The section through the aortic root shows the relationships of the membranous part of the septum.

van den Hoff MJB. because the catheters are manoeu. 539– phology of the human tricuspid valve. Ho SY. J. 83. Standardized myocardial segmentation and nomenclature Silver MD. The tomographic images Anderson RH. 15. 547. Circulation 100. humans. 362–374. Cardiol. ments in imaging. Ho SY (1998) What is a ventricle? Ann. septal structures. and the three-dimensional structure What’s in a name? J. 647–652. and potentially producing myocardial ischaemia. (1998) Normal devel- Surg. has demonstrated the advantage of the anato- the coronary sinus musculature and the left atrium in mist keeping abreast of these remarkable achieve. de Boer PA. Heart 87. Wigle ED (1971) Mor- for tomographic imaging of the heart. (2004) Characterization of a new pulmonary vein variant using magnetic resonance References angiography: incidence. 512–531. et al. Circulation 107. 716–720. 538–543. Brown NA (1999) Clinical anatomy of electrophysiologists. Ya J. expanded in the inset. H. Heart 85. Brechen- macher C (2002) The anatomic basis of connections between hope. Marcellin L. (2003) Pulmonary vein the Institute of Child Health and Great Ormond Street anatomy in patients undergoing catheter ablation of atrial Hospital for Children NHS Trust benefits from R & D fibrillation. J. such as the arrangement of the Becker AE. Coll. R. Haissaguerre M. Lessons learned by use of magnetic resonance funding received from the NHS Executive. indebted to our colleagues in the United States of Knauth A. MD (Mayo Clinic. cardiac morphology. et al. et al. Circulation 105. opment of the outflow tract in the rat. 464–472. Anderson RH (1982) Atrioventricular septal defects. Webb S. 503–506. Thorac. Car- America and Belgium for permission to reproduce Fig. Brecker SJ (2001) Anatomic basis of also serve to clarify some of the more difficult areas of cross-sectional echocardiography. Lam JHC. Lickfett L. we Chauvin M. Reproduced by kind permission of Dr Ronald Kuzo. Circulation 101. We are also imaging. (2002) Interatrial com- munication through the mouth of the coronary sinus. PhD (Gasthuisberg University Hospital. It might be argued Anderson RH. Thorac. Working Group of Arrhythmias. anatomic terminology for the heart. Circulation 43. Duren DR. significantly reducing the calibre of the vessels. FL. MD. Anat. Cardiovasc. A Consensus. 33–48. 5. Circ. USA). Cardiovasc. Surg. 12. the heart is a ‘stand-alone’ organ. 364–372. Lickfett L. Car- diol. Res. 30. Nomenclature Study Group. Van der Bel-Kahn J. Kuck K. 82. 66. Statement from the Cardiac The research on which this review is based was sup. and interventional im- American Heart Association Writing Group on Myocardial plications of the ‘right top pulmonary vein’. Ranganathan N. 1335–1340. Meininger G. Leuven. tion in children with congenitally malformed hearts. Anderson RH (2000) Clinical anatomy of the aortic root. older patients. 670–673. 616–620. 461–469. 1–7. from the stance of the interventional cardiologist. vred into the heart using the standard anatomical coor. Clin. Cardiac anatomy. ponents. 1999). Webb S. The image. Research at Kato R. and Professor Jan Bogaert. The experiences of Anderson RH. Anderson RH. Cosio FC. Shah DC. Jacksonville. Brown NA (1998) Defective lateralisa- that. Our review. © Anatomical Society of Great Britain and Ireland 2004 . diol. Young 8. (1999) Living Anatomy Acknowledgements of the Atrioventricular Junctions. however. Webb S. and the Task Force on Cardiac Nomenclature from NASPE. Heart 84. 246. et al. 2004–2010. 177 Fig. Cook AC. and relationships of the arterial roots. McCarthy KP. Attitudinally correct nomenclature. E31-E37. Rec. has revealed the presence of a calcified. Segmentation and Registration for Cardiac Imaging (2002) Electrophysiol. Anderson RH (2002) Editorial. Becker AE (1985) Isolated mitral Anderson RH. 30 Computed tomography section through the right coronary artery shows the potential for the new imaging techniques. black arrow shows calcification). et al. Anat. Am. A Guide to Electrophysio- logical Mapping. Kato R. Belgium). Tandri H. dinates (Cosio et al. ported by grants from the British Heart Foundation European Society of Cardiology. Brown NA (1996) The anatomy of the heart valve prolapse: chordal architecture as an anatomic basis in revisited. Anderson et al. together with the Joseph Levy Foundation. have demonstrated that the atrial septum with reference to its developmental com- this is not the case. imaging. Anderson RH. atherosclerotic plaque (white arrows. Young 12.