1

AGT Notes

On

Applied Anatomy

Of

Heart and Allied Structures

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Preface
As I have grown older, my love for learning anatomy of heart has increased. Over the years, I
have realised that only a thorough knowledge of anatomy carries you through many critical
surgical steps. Today, for me, anatomy is no more the deadly demon of undergraduate days
but a friendly fairy helping me at every stage during an operation.

This may be because as a surgeon you get a chance to look at anatomy in a more practical
way. Instead of remembering 36 odd branches of an artery, you know the exact location and
course of just 6 branches and you carry out your work effortlessly and safely!!

That was the idea behind this book: to share knowledge to understand anatomy better and
help you perform surgery.

The words ‘applied anatomy’ ‘surgical anatomy’ ‘clinical anatomy’ were introduced to me
in 1971, when i was a first MBBS student, by Dr. Ramesh Rege. Rege sir (as we would say in
India) while teaching anatomy would always make a point to tell us (his students) the
surgical and applied aspect of the anatomy. Frankly, I did not realise the importance then.

Later, while working as a faculty at KEM Hospital, Mumbai, thanks to Dr. Lopa Mehta, the
then HOD Department of Anatomy, I started conducting ‘open book fun quiz in cardiac
anatomy’, for 1st MBBS students ,every year. With all modesty, the quiz was a great success.

The popularity of that programme made me realise that anatomy can be very interesting if the
usefulness of the knowledge is understood & appreciated. This note book is the result of that
realisation.
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Foreword
The reason behind calling this book as ‘notes’, is to stress the fact that this is mere a
compilation of literature already published. All that I have done is to go through individual
articles, edit them and present in an orderly manner, as much as possible.

I have avoided descriptive anatomy, unless, i felt that a particular topic is not at all described
in textbooks of anatomy.

These notes are prepared with a postgraduate student in mind who, would have to write short
notes in theory exams.

Like the other two books of mine, these notes too, are not intended to replace a standard book
of anatomy.
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Dedicated to

All my anatomy teachers

With reverence

Anil
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Ascending Aorta
1. Normal relation: Aorta is right and posterior to MPA and the aortic valve is inferior to
pulmonary valve. This is also called ‘solitus’ relation.
2. Aortic Root Widening: The aortic root is the initial part of the ascending aorta which
provides the supporting structures for the aortic leaflets. It extends from the basal
attachments of the leaflets within the left ventricle to the sinutubular junction.

In a patient with aortic stenosis (AS), the aortic annulus is narrow (i.e. small in diameter).
This would permit implantation with only a small sized prosthesis. The size of the prosthesis
may be small from point of view of size (w.r.t. Body Surface Area: BSA) of the patient. In
such a situation, the surgeon cuts across the aortic annulus, widens the annulus with a patch
and then implants an aortic prosthesis. This procedure is called ‘aortic root widening’.
The important structures around aortic annulus are as shown in figure 1

Figure 1: Structures around Aortic Annulus

1. Right Coronary Artery 2. Right Coronary Cusp 3. A-V node 4. Non Coronary Cusp
5.Left Coronary Cusp 6. Common Annulus 7. Main Pulmonary Artery 8. Left Coronary Artery

The spots for root widening are shown in figure 2.

1) LCC-NCC commissure (A). This spot can be extended inferiorly from annulus into the
AML as to achieve an extra widening
2) into the annulus of NCC (B)
3) to the left of the origin of RCA (C).Inferior extend of this incision intends into IVS.
At other places, cutting the annulus is not feasible because of
1) damage to the RCA
2) damage to AV node
3) root is covered by RVOT
4) inaccessible due to MPA
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Figure 2: Sites Where root could be widened: shown with black circles
(legends as in fig 1)

3.Aneurysm of Sinus of Valsalva: The aneurysm of Sinus of Valsalva ( ASOV) grows

inferiorly . Hence the relevant anatomy is shown in figure 3 & 4.

Figure 3: Superior view of structures around aortic root

(Red arrows depict the sites of growth/ rupture)
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Figure 4: Longitudinal sections of structures around aortic root

Combining figures 1to 4, the ASOV cause the following hemodynamic problems by
i) pressure compression of adjoining structures or by ii) rupture
(the problems are described superior to inferior, not in accordance to frequency).

a) Pulmonary regurgitation: due to distortion of pulmonary valve by aneurysm of RCC. As

aortic valve is inferior to pulmonary valve, an aneurysm of SOV can never rupture into MPA.
b) RVOT Obstruction: by aneurysm of RCC.
c) Myocardial ischemia due to compression of RCA.
d) Conduction disturbances by both aneurysms of RCC & NCC
e) Tricuspid valve incompetence: by aneurysm of RCC
f) Rupture of ASOV from posterior part of NCC occurs typically at the anterior superior
margin of fossa ovalis (FO).
4. Subaortic Membrane: (Please refer to fig 1, also.) The safe area for excision of a
subaortic membrane is to the left of RCC-NCC commissure and proceeding counter-clock
wise till the AML attachment (Fig5 green line). This is a safe area as this corresponds to free
LV wall. Further counter clock wise excision should be continued very cautiously and may
result in
a) perforation of AML producing acute MR b) perforation of membranous septum
producing iatrogenic VSD c) damage to AV node producing complete heart block.

Figure 5: Safe site for excision of Sub Aortic Membrane

1. RCC 2. AV node 3. NCC 4. IVS ( red curved line) 5. LCC 6. AML.

The green semicircle is the safe area for excision of subaortic membrane
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5.Second Heart Sound: The commencement of ascending aorta is on a level of lower border
of third left costal cartilage. Hence aortic second heart sound, normally (i.e. with undilated
aorta), is best audible in the left third space. Dilatation of aortic root results in shifting of this
position to the right and superiorly. Hence, ‘second’ aortic area is to the right of sternum in
the second intercostal space.

6.Aneyrysm Of Ascending Aorta: Aneurysm results in pressure and stretch on structures

which are in close proximity to aorta as shown in figure 6.

Figure 6: Transverse section through thorax At T3-4 level

1 Thymic fat 2 Ascending aorta 3 SVC 4. Paratracheal space

5Trachea (just bifurcating) 6. Pericardial space 7. Left Pulmonary Artery
8 Esophagus 9. Descending aorta

Aneurysm of ascending aorta results in pressure on SVC (producing SVC syndrome), trachea
(producing hemoptysis, strider) pressure-erosion of sternum. Ascending aorta is
intrapericardial hence, leak of ascending aortic aneurysm results in hemopericardium.
Esophagus and vertebrae are too posterior to get compressed hence symptoms of dysphagia,
hematemesis and back ache are rare in ascending aortic aneurysm.

7. Aortic Annulus: (Also see ‘Aortic Valve’)The arterial surface of the closed leaflets of the
aortic valve is directed not only upwards but also right ward at an angle of at least 450 to the
median plane. The plane of the aortic valve tilts inferiorly at an angle to the pulmonary valve.
The nadirs of the aortic sinuses lie in a plane at an angle of 30° from the horizontal. Hence,
the RCC annulus (near to pulmonary valve) is the easiest to view while the diagonally
opposite NCC-LCC commissure is the deepest. Hence, excision of aortic valve is begun at
the RCC-NCC commissure.

The fibrous skeleton of the heart is the thickest or dense most in between aorta and the two
AV valves and becomes thin anteriorly and posteriorly. As a result, the RCC annulus is the
thinnest and the annulus becomes thicker towards the NCC- LCC commissure.
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Figure 7: Aortic annulus and Fibrous Skeleton

(Grey shaded area is fibrous skeleton)

8. Aorta- MPA separation: Aorta and MPA are covered by a continuous layer of
pericardium. Separation of the two vessels is required for partially clamping aorta for placing
proximal anastomosis of OM grafts, and for cross-clamping aorta during an open heart
operation.
Proximity of aorta with MPA is utilised for constructing systemic- pulmonary artery
anastomosis in patients with cyanotic heart diseases like Tetralogy of Fallot (using PTFE
graft: Gazzaniga shunt, direct anastomosis: Davidson’s shunt).

9. RPA – aorta relation; RPA is closely related to the posterior surface of ascending aorta.
a) Cross clamping of aorta during open heart surgery can pinch/ damage RPA. This is more
likely in the presence of intrapericardial adhesions.
b) Waterston shunt is a systemic pulmonary artery shunt between anterior surface of RPA and
posterior surface of ascending aorta. This was performed through right thoracotomy. Cooley
later used median sternotomy and ‘Cooley clamp’ to construct a quick and measured shunt.
3) Managing RPA ostial stenosis/ RPA stenosis: Though RPA is intrapericardial and anterior
as compared to the LPA, extensive mobilisation, even transsection of ascending aorta, may be
required.
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Arch of Aorta
1. Aneurysm Of Aortic Arch : In aneurysm of arch of aorta, structures like trachea and left
bronchus get easily compressed / eroded, resulting in strider, and later hemoptysis. The left
recurrent laryngeal nerve courses around the arch of aorta and stretch on the nerve results in
hoarseness of voice (fig. 8). As the left pleura is in contact with the arch, leak of the
aneurysm results in left hemothorax.

Figure.8: Structures around arch of the aorta

Tracheal tug: (Oliver’s sign): is downward displacement of cricoid cartilage with ventricular
systole. The sign is elicited by gently grasping the cricoid cartilage and applying upward
pressure while the patient stands with his or her chin extended upward. Due to the anatomic
position of the aortic arch, which overrides the left main bronchus, a downward tug of the
trachea may be felt if an aneurysm is present.

The arch of aorta and trachea with its main bronchi are enclosed in the same pretracheal
fascia. Expansion of the aneurysm during systole pushes the left bronchus, which is in close
proximity to arch, inferiorly resulting in a downward tug on the upper respiratory tree. This
tug is perceived through the tug on the cricoids cartilage. To elicit the sign, the patient’s
mouth is closed, neck is extended & the cricoids cartilage is pushed up – all these
manoeuvres bring the left bronchus in contact with the arch.
The sign was first described by English military surgeon William Silver Oliver in 1878.

2. Right Aortic Arch: When aorta arches over the left lung hilum, it is called left aortic
arch. Arching over right hilum is called right aortic arch. Right aortic arch is observed in
congenital heart disease (CHD) and is associated with severe forms of CHD. In right aortic
arch, the descending aorta is initially on the right of the vertebral column, but always reaches
to the left of the vertebral column by the level of diaphragm. If the descending aorta
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continues to lie on the right of vertebral column even below the diaphragm the condition is
then called situs inverses. The most common branching pattern of arch vessels in right aortic
arch is a ‘mirror image’ of normal branching pattern, i.e. (left) innominate artery – right
common carotid artery – right subclavian artery.
Importance of right aortic arch:
a) presence of right arch suggests a complex cardiac conditions ( common in Truncus
Arteriosus and severe forms of Tetralogy of Fallot)
b) direction of aortic cannula : normally the aortic cannula is directed towards the left
shoulder of the patient (i.e. directed towards transverse arch). In a case with right aortic arch
the cannula should be directed towards the right shoulder of the patient.
c) construction of BT shunt: while constructing a BT shunt in a case with right aortic arch it
should be remembered that the left subclavian artery is a branch of innominate artery and the
right subclavian artery directly originates from the arch.
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Mitral Valve
1. Mitral annulus: The structures around the mitral valve are shown in figure 9 & the fibrous
skeleton around the mitral valve is shown in figure 10.

Figure 9: Structures around mitral annulus

Figure 10: Fibrous skeleton around mitral annulus

a) Mitral annuloplasty: i) Mitral annuloplasty rings are bean shaped to restore the 3:4
proportion of AP: Lateral diameters of the annulus.
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ii) Mitral annulus is the thickest between 10 & 2 o’clock position and is also called the
common annulus. The annulus thins out towards the 6 o’clock position on either side. Mitral
annulus being a part of LV, it dilates along with the LV dilatation. The fibrous common
annulus does not contract during systole and being very thick, does not dilate. The rest of the
annulus is muscular and contracts towards the center of the annulus during systole. This is the
reason of making ‘physiological’ annuloplasty rings flexible posteriorly. One of the earliest
bioprosthesis was ‘Carpentier – Edward’ valve and the prosthesis had a flexible ring.

iii) The annulus dilates as per the fibrous tissue content, with maximum dilatation at 6
o’clock position. Hence, mitral annuloplasty is restricted to the posterior 2/3 part. That is the
idea behind designing a ‘C’ shaped mitral annuloplasty rings with the open part
corresponding to the common annulus. Even in complete rings, plicating sutures are avoided
in the anterior part, i.e., corresponding to the common annulus.

iv) In the classic Carpentier ring the slots on the ring measurer and the two markers on the
ring correspond to the respective fibrous trigones which remain fixed or undisplaced in their
position (fig 11). The sutures corresponding to these spots should be tied first for accurate
matching. The rest of the sutures (2 o’clock to 10 o’clock, clockwise) are adjusted for
plication.

Figure 11: Mitral annuloplasty rings

v) As the aortic pressure rises during systole, the common annulus bulges into LA. Thus,
while the rest of the mitral annulus moves towards the center, the common fibrotic annulus
moves away from the center. Hence in many of the ‘Physio’( physiological!) rings, the part of
the ring corresponding to the common annulus has a bulge towards the LA ( shown with an
arrow in the fig 12) – called ‘anterior saddle’.

Figure 12 : Physio ring

b) Mitral Valve Replacement: i) Referring to figure 9 , while passing sutures through annulus
during MVR, care should be taken to protect aortic cusps ( 10 to 1 o’clock) , conduction
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bundle ( 2 o’clock) , coronary sinus ( 4 to 6 o’clock) and left circumflex artery (6 to 10

o’clock).

ii) During MVR with a bioprosthetic valve, the stent posts of bioprosthesis should be placed
on either sides of the common annulus, i.e. at 10 and 2 o’clock positions as to avoid a
subaortic obstruction due to the stent posts.

iii) As vital structures are all around the mitral annulus (fig 9), ‘mitral annular widening’
(similar to aortic root widening) is not feasible.
2. Mitral leaflets: i) AML occupies 66% of orifice area but has only 33% of the annular
attachment. Hence, the intactness of AML is the key to MV repair. Most of the valve repairs
aim at ‘monocuspidisation’ of valve, with AML doing most of the work. Hence while
deciding the size of the annuloplasty ring, not only the two slots should correspond to the two
trigones (green sutures at 11 & 1 o’clock in figure 13.)

Figure 13: Measurements for Annuloplasty

but the antero-posterior length of AML should be longer than the sizer ( Fig 13 : AML is
stretched under the sizer with two hooks)

ii) During systole the mitral valve closes not by edge to edge meeting of AML & PML but
the leaflets coapt with each other over an area corresponding to the rough zones of AML &
PML (like the Indian Namaskaar! Shown with arrows in figure 14)

Figure 14: Coaptation of AML & PML

(shown with arrows)

Thus, for a MV repair to be successful, an adequate area for coaptation should be provided.
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iii) Description of mitral leaflets: Carpentier has referred the leaflets into 3pairs for
describing the leaflet proplapse or tethering. The PML has three indentations dividing the
PML into two lateral commissural cusps and one central cusp. They are referred from left to
right as P1, P2& P3 scallops. The corresponding apposing AML is divided (fig 15 top) into
A1, A2 & A3 scallops.

Figure 15: Leaflet segments by Carpentier

Leaflet segments by Duran

Duran has classified AML and PML according to the chordal attachment to the respective
papillary muscles (fig15 bottom). Thus AML has A1 & A2 segments while the PML has P1,
PM1, PM2, P2 segments. The A1, P1 & the PM1 chordae are attached to the AL papillary
muscle, while A2, P2 & PM2 chordae are attached to the PM papillary muscle.

The P1 leaflet segment is supposed to maintain its level of coaptation and is used as a
reference for deciding the lengthening or shortening of chordae or prolapse of other leaflet
segments. Hence, to detect chordal length status, a nerve hook in the left hand determines the
‘level’ of P1 while a nerve hook in the right hand compares other segment ‘level’ with the P1
( fig 16).
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Figure 16: Checking for segmental prolapse with two hooks

iv) a cleft in AML is distinguished from commissure by the fact that, in case of cleft, the
chordae on either sides of the cleft are attached to two different groups of papillary muscles.
In case of a commissure, the chordae arise from the same group of papillary muscles (fig 17).

Figure 17: Chordal arrangement in a MV cleft and a commissure

3. Papillary Muscle (PM) : i) Dysfunction: The anterior PM is provided with a dual blood
supply from D1 & OM1 while the posterior PM , usually, has a single supply either from
RCA or the last OM, depending on the dominance. Due to the single blood supply,
dysfunction of posterior PM is far more common in ischemic MR.
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ii) Depolarisation: The left posterior fascicle is relatively short and broad, with dual blood
supply, making it particularly resistant to ischemic damage. The left posterior fascicle
transmits impulses to the PM. As the left posterior fascicle is shorter and broader than the
right, impulses reach the PM just prior to depolarization, and therefore contraction, of the left
ventricle myocardium. This allows pre-tensioning of the chordae tendinae, increasing the
resistance to flow through the mitral valve during left ventricular contraction. This
pretensioning is absent during ventricular premature contraction (VPC), when the impulse
travels to PM muscle through muscle, giving rise to MR (‘ectopic induced MR’).

iii) Papillary muscle alignment: when a surgeon visualises the subvalvar structures, i.e.
through LA via a paraseptal incision, the tips of the two papillary muscles should be seen at
the junction of P1-P2 and P2-P3. LV Dilatation results in displacement of papillary muscles
laterally, towards the commissures (fig.18)

Figure 18: Papillary muscle alignment

Normal After infarction After annuloplasty

Ischemic LV dysfunction results in LV dilatation and functional MR (FMR). Causes of FMR

are: a) annular dilatation and b) abnormal displacement of the PM leading to excessive
tension on chordae. The tethering of leaflets restricts mitral leaflet mobility, and results in
MR.
Treating FMR with only annuloplasty may increase the distance to the posterior annulus and
worsen the tethering (fig 18 right & fig 19 A). Thus correction of functional MR should
involve, apart from annuloplasty, some form of interventricular remodelling directed to
relieve tension on chordae.

Figure 19: Effect of annuloplasty on functional MR

A B
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‘Papillary Muscle Sling’ (fig 19B) operation has been proposed which encircles the
trabecular base of both PMs. Tightening and securing this sling anchors the base of the PMs
together.
Re-establishing a more normal annulus-to-papillary muscle alignment relieves the excess
tethering on the mitral leaflets, and significantly restores leaflet mobility.

iv) splitting of muscles during mitral valve repair: Papillary muscles receive a large central
artery which courses through the entire papillary muscle to its apex, dividing dichotomously
to supply the papillary muscle. In rheumatic mitral stenosis, there is fusion of papillary
muscles. Repair of rheumatic mitral stenosis involves splitting of these fused papillary
muscles to clear the subvalvar fusion. The splitting should be done exactly in the center as to
avoid infarction of the papillary muscle.

4. Mitral valve apparatus on chest radiograph: sufficiently calcified mitral valve apparatus
can be visualised on chest x ray. Usually, the annulus and the leaflets calcify. As annulus is at
the A-V groove, mitral valve apparatus is roughly situated ( fig 20) inferior to a line joining
right cardiophrenic angle to MPA segment –LAA junction ( anterior end of third rib).

Figure 20: position of mitral valve on chest x-ray PA view

(a postoperative x ray is intentionally chosen)
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Left Atrium
i) Identification of LA: left atrium is also known as pulmonary atrium. It is recognised by its
filiform (i.e. finger like) appendage (as against broad, pyramidal RA appendage).

ii) LA enlargement: LA is the posterior and superior heart chamber (fig 21). LA is bound
anteriorly by ventricle, inferiorly by diaphragm, superiorly by carina and left bronchus, and
posteriorly by the oesophagus, thoracic aorta & vertebrae. Thus dilatation of LA is possible
laterally, to the left and the right, only.
a) The appendage (LAA) is free in the pericardium and is comparatively thin walled.
Hence it is the first to dilate in response to rise in LA pressure.
b) When the body of LA dilates towards the right, the enlargement of LA body is seen
as a rightward convex shadow on a plane chest radiograph. This shadow touches the
diaphragmatic shadow at an acute angle.
c) superior dilatation of LA results in widening of carinal angle ( > 750) and even
compression of left bronchus. (fig. 21)
d) Posterior distension results in stretching of esophagus over the LA with concavity
anteriorly. This is appreciated on a barium swallow as an arc like indentation (small arc of a
large circle = MR, large arc of a small circle = MS)
e) Further posterior enlargement brings LA in close proximity to the rigid vertebrae.
In such a situation, and in the presence of gross mitral regurgitation, the systolic pulsations of
LA result in the entire heart being pushed forwards with each systole! This is called ‘Herz
Ptosis’

Figure 21: Modes of LA enlargement

Normal LA Enlarged LA

Legends as per text above

iii) LA Maze procedure: one of the sites for application of radiofrequency Maze is from left
inferior pulmonary vein to mitral annulus (line K in figure 22) Energy output should be
decreased on this line as to avoid damaging coronary sinus.
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Figure 22: LA Maze incisions

iv) Otner’s Syndrome: The syndrome was originally described in three patients with severe
mitral stenosis. Otner explained the hoarseness on basis of compression of the left recurrent
laryngeal nerve by the enlarged left atrium. Pathophysiological mechanism of this syndrome
is thought to be compression of the left recurrent laryngeal nerve between the aorta and
dilated pulmonary artery.
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Inter Atrial Septum( IAS)

Viewed from right side, which is the surgical view of IAS, the structures around fossa ovalis
are as shown in the figure 23.

Figure 23: Structures around Fossa Ovalis (surgeon’s view)

i) Primum versus secundum septum: an imaginary line, parallel to SVC & IVC and passing
through the anterior margin of FO demarcates anterior septum primum from the posterior
septum secundum. Thus, coronary sinus (CS) forms the postero-inferior relation of a primum
ASD and antero- inferior relation of a secundum ASD. An IVC type of ASD, like a primum
ASD, is also an inferiorly placed ASD but the CS will be along the antero-inferior margin of
the ASD.

Figure 24: Trans Septal Incisions

Red interrupted line: transseptal incision

Saffron interrupted lines: 1. T shaped incision
2. Extended vertical transseptal incision
3. Incision for trans-septal approach to LA Myxoma
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ii) trans-septal approach for MV: transseptal approach is used for operations of mitral valve
and for excision of LA myxoma. As can be seen from figure 21, the safe part on the IAS for
incision is the fossa ovalis itself and the part of IAS postero-superior it.
Hence, all the transseptal approaches, like, Dubost T shaped approach, exclusive
transseptal approach, extended vertical trans septal approach (Berreklouw - Guiraudon)
evolve around this area in the IAS.
In Leutembacher’s syndrome if the ASD is ‘small’ to operate on mitral valve, the
ASD is enlarged by one of the extensions shown in figure 24.
LA myxoma pedicle is attached to the fossa ovalis. The myxoma with the fossa ovalis
is excised together. The incision is begun at the safest spot i.e. center of the posterior margin
of fossa ovalis, and is then extended on either sides, along the margins of fossa ovalis.

iii) Balloon Mitral Valvotomy (BMV): BMV is performed by transseptal approach. The IAS
is required to be punctured in the in posterior – inferior part. To ensure this, interventionist
places a (pigtail) catheter in the aortic root to indicate the position of torus aorticus, and the
IAS is punctured posteroinferior to it (fig 25).

Figure 25: Septal puncture during BMV

iv) Rupture of Aneurysm of Sinus of Valsalva: The aneurysm of noncoronary sinus ruptures
into RA at the anterior- superior margin of the fossa ovalis as shown in figure 18 (also refer
to figure 4).

v) Atrial switch operations: like Senning or Mustard operations involves routing of caval
blood to LV and PV blood to RV. Key to operative success is unobstructed flow of venous
blood & this is achieved by enlarging the ASD, cutting the septum to use as partition
(Senning’s operation). All the septal excision is restricted to ‘secundum septum’, i.e.
posterior and inferior to taurus aorticus and coronary sinus (fig 24)
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Sinu-Atrial Node
Relevant Anatomy: the 5mm x 2.5 mm x 1mm sized node lies, in more than 85% cases, in
the groove between the right atrial appendage and the lateral atrial wall (fig 26). In the rest of
the cases, it straddles the SVC-RA junction. The ‘head’ of the node is subepicardial.

Figure 26: Position of the A) Sinu-Atrial Node & B) its blood supply

The artery to the node could be anterior or posterior in equal (40-45%) number of cases. In
rest of the cases, the arteries form a circle around the SVC and anastomose in the SA node.
The SA nodal artery is branch of right coronary artery in 66% cases and a branch of left
coronary artery in 34% cases.
When the SAN artery is from RCA it could be posterior or anterior, but when the SAN artery
is from LCA it is passes along the anterior surface of the LA, crosses the posterior interatrial
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sulcus and encircles the SVC posteriorly. This course is vulnerable to damage during
incisions or suturing involving superior LA /RA wall, e.g., the superior septal approach to
mitral valve.

i) Subepicardial position: due to its subepicardial position, the node gets easily damaged by
a) epicardial diseases like constrictive pericarditis:
b) handling of heart during direct SVC cannulation & snaring :
c) anoxic rewarming of heart during any open heart procedure: Rewarming of anterior
epicardium occurs first and is maximum in a cardioplegically arrested heart.
d) clamping of proximal SVC during construction of Glenn shunt or TCPC can crush
the node in the clamp.
ii) Surgical damage: Incisions that can directly damage SA nodal region (i.e. SA node and or
its artery) are
a) atriocavopexy to widen narrowed SVC following right PAPVC repair
b) Superior septal approach of Berreklouw & Guiraudon: particularly when the SAN
artery is from LCA (fig27).
c) longitudinal posterior atriotomy: This incision ,used for correction of right
PAPVC , in its superior part can directly damage SAN or a posteriorly encircling
artery.
iii) SA nodal artery can get damaged during procedures mentioned above. In addition, the
artery can get damaged during suturing of superior (SVC) limb of baffle of Senning or
Mustaard operation.

Figure 27: Damage to SAN artery during superior septal approach

The superior part of the incision crossing roof of LA &RA (dashed line) damages SAN artery
(solid red line) when it originates from LCx artery
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Venous Drainage of the Heart

Veins draining heart are shown in figure 28.
Figure 28: Veins draining into RA

i) Beck’s operations: partial ligation of coronary sinus (with abrasion of epicardium +

application of asbestos to myocardium+ application of mediastinal pedicled fat) was part of
Beck’s 1st operation to improve myocardial blood supply. Beck’s 2nd operation consisted of
grafting median basilica vein between descending aorta and CS. A suture loop was passed
around CS but was left open (fig 29). Three weeks later the opening of CS was closed
externally. This was possible because coronary sinus lies in the right side end of the posterior
AV groove and is easily visible.

ii) Retrograde perfusion of heart: is possible because all the veins of heart are almost devoid
of valves. There is one valve (valve of Vieussen), mostly nonocclusive, at the junction of
great cardiac vein with CS.
There is an extensive communication between the three venous systems of the heart. Hence
not more than 40% retrograde perfusate reach the myocardium, when only coronary sinus is
perfused.

iii) Retrograde cardioplegia: delivered into coronary sinus (CS) does not reach free RV wall
as it is drained by anterior cardiac veins which directly open into RA. Free RA wall, IAS and
SA node, AV node are drained by Thebesian veins, which directly open into RA. These parts
too, are poorly perfused by retrograde cardioplegia into CS (Fig 28).
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Figure 29: Beck II Procedure

Middle cardiac vein, accompanying PD and draining posterior IVS, and, Small cardiac vein
draining RA, open too close to the opening of CS. The balloon of the retrograde cardioplegia
(RCP) catheter easily blocks these two veins and prevents perfusion of the posterior part of
the IVS (fig 30). If the RCP catheter is excessively passed inside it enters great cardiac vein
which is aligned to the longitudinal axis of CS.

Figure 30: RCP catheter balloon & opening of middle and small cardiac veins

iv) retrograde cardioplegia through RA: Fabiani & Carpentier proposed retrograde perfusion
through right atrium, instead of coronary sinus, which would perfuse all the three venous
systems of heart.

v) LA desaturation: The blood in LA is never 100% saturated. One of the reasons is the
Thebesian veins open into LA also. The coronary venous blood is the most desaturated blood
in the body (saturation of 25%). This blood when mixes with the fully saturated blood in the
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pulmonary veins, brings down the oxygen saturation. The other reason of LA desaturation is,
50% of bronchial (desaturated) venous blood drains into pulmonary veins.

vi) simultaneous antegrade and retrograde cardioplegia: is feasible because of extensive

communication between the three venous systems of heart. The Thebesian veins, the anterior
cardiac veins and the right marginal veins perform the job of draining the cardioplegia into
RA.

vii) CS also has been used to deliver tissue-type plasminogen activator to achieve
thrombolytic, deliver stem cells into infracted myocardium.

viii) CS is thin walled, is subepicardial and lies in the AV groove i.e. adjoining both atrium as
well as ventricles. Thus, CS cannulation allows access to the LA and LV epicardium,
enabling a spectrum of diagnostic and mapping maneuvers to aid in the determination of the
type of arrhythmia as well as permit the delivery of ablative energy. The CS position also
allows, LV epicardial lead placement to achieve biventricular pacing and thereby providing
cardiac resynchronization therapy for patients with CCF.

ix) The coronary sinus is a commonly cannulated structure in patients undergoing

electrophysiology studies, catheter ablation of arrhythmias, implantation of resynchronization
therapy devices and, more recently, percutaneous mitral valve repair (Fig 31).

Figure 31: percutaneous insertion of MV annuloplasty device

The mean diameter of the orifice of the coronary sinus is 9.6 mm. The size of the orifice is
definitely related to the configuration of the Thebesian valve, heart weight and the presence
of congestive heart failure.
The Thebesian valve is situated at the orifice of CS and may prevent cannulation of the sinus.
The main variations of the Thebesian valve are: 1) absent in 15% 2) small and crescentic in
38% 3) large and covering the entire orifice of the coronary sinus in 31% .The anatomic
variations of the orifice of the coronary sinus is considered to be important from the
standpoint of catheterization.
Some 16% cases have a valve morphology (covering 75% of the ostium, a fibrous,
fibromuscular, or muscular composition, and devoid of fenestrations) that makes them a
‘potentially complicating’ structure interfering with the cannulation of the CS.
 28

From intervention point of view, next to the type of Thebesian valve, the size of the orifice
and morphology of CS determines the ease of cannulation. In patients with severe heart
failure and massive ventricular and RA dilatation, the CS is dilated and is best visualized. If
the ostium is located more superiorly, towards the mid-atrial septum, in a more central area of
Koch’s triangle, it may be especially difficult to identify the ostium without resorting to
angiographic contrast.
The most difficult situation for coronary sinus ostium cannulation is referred to as the “pipe-
shaped” ostium, which is a narrow pipe mouth pointing cranially before the remainder of the
coronary sinus turns inferiorly at an angle and continues in the cranio-lateral direction (fig.
32).The most difficult obstacle for cannulating the CS tends to be a very tight upward
angulation next to a very low posterior venous tributary. Another technically demanding
variation of the coronary sinus morphology with a potential for higher complication rates is
pronounced systolic compression of the posterolateral-posterior coronary sinus segment,
especially in the elderly. It is very easy to advance the guiding catheter far into the subintimal
plane without any noticeable resistance. Extensive dissection of the entire coronary sinus may
result.

Figure 32: ‘Pipe shaped’ coronary sinus

x) Implantation of the coronary sinus lead usually involves cannulation of the Left marginal
vein or the Posterior vein of the LV (fig 33). The angle between the tributaries and the
proximal coronary sinus decides the ease of cannulation –more obtuse the angle easier the
cannulation. The length of these veins with a caliber > 2 mm (lead is 6 F) also decides the
choice of the vein. Pacing through a laterally placed vein may result in stimulating left
phrenic nerve.

xi) Intermittent Coronary Sinus Occlusion: In both, acute myocardial infarction (AMI) and
chronic stable disease, is performed when standard therapeutic approaches may fail to restore
tissue perfusion. As a consequence, the long pursued strategy of augmenting myocardial
perfusion by diverting blood from the coronary venous system to an ischemic region (venous
retroperfusion) has again gained attention during recent years. Occlusion of the coronary
sinus (CSO) was introduced to provide retroperfusion by transient augmentation of coronary
venous pressure. Different devices using CSO have been invented and evaluated in animal
models and in small clinical trials, e.g. intermittent CSO (ICSO) and pressure-controlled
intermittent CSO (PICSO) which seem to be effective for myocardial salvage
 29

Figure 33: Veins of LV used for cannulation

 30

Azygos Vein
i) Azygos vein forms an important communication between IVC & SVC. Azygos vein
usually communicates with IVC indirectly through ascending lumbar veins or right renal
vein. Rarely, it can communicate directly with IVC. The dilated azygos vein may be
misinterpreted as a paracardiac or mediastinal mass on chest radiography (fig. 34). Isolated
dilatation of azygos vein is the first indication of interrupted IVC.
Figure 34: Azygos vein shadow in a case with interrupted IVC
(shown with a white arrow)

ii) Azygos vein joins SVC at the level where extrapericardial distal SVC becomes
intrapericardial. It joins SVC bang on the posterior surface of SVC. These facts help in
distinguishing it from right upper (RULPV) and middle lobe (RMLPV) pulmonary veins
involved in partial anomalous pulmonary venous connection (PAPVC) anomaly. The
RULPVs & RMLPVs are always intrapericardial and open into SVC laterally.
iii) While correcting right PAPVC, snugging of SVC during CPB, should be done proximal
to the azygos opening.
iv) azygos vein is divided during Glenn shunt to prevent late ‘stealing’ of blood from the post
Glenn high pressure SVC to IVC. Azygos vein has many valves. One valve is at the azygos
SVC junction. With dilatation, vales become incompetent.
v) dividing azygos vein increases the mobility of SVC, and facilitates Glenn anastomosis.
The distal end of azygos vein requires extra care while ligation as after division, the distal
stump retracts posteriorly and is invisible (operating through median sternotomy). The
proximal stump of the divided azygos vein acts as marker in preventing axial rotation or
twisting of SVC during Glenn anastomosis.
vi) azygos principle: In the early experimental days of CPB, it was observed during canine
experiments that if the azygos vein was not clamped but all other inflows to heart were
clamped, the flow through the azygos vein( 8 to 14 ml /kg/min ) was sufficient to sustain the
vital organs safely for 30 minutes at normothermia. This was the beginning of low flow
principle in CPB.
 31

Vii) azygos lobe: results from an anomalous lateral course of the azygos vein in a pleural
septum within the upper lobe. This is a congenital variation of the upper lobe of the right
lung. The azygos lobe has no bronchi, veins and arteries of its own; hence, it is not a true, or
even accessory, pulmonary lobe, but rather an anatomically separated part of the upper lobe.
It is usually an incidental finding on chest x-ray or CT scan (fig. 35) and is as such not
associated with any morbidity but can cause technical problems in thoracoscopic procedures.
Figure 35: Azygos Lobe on chest x-ray and CT scan

\
 32

Inferior Vena Cava

i) Situs determination: Relation of IVC to the vertebral column is an important finding in
determining the situs of a case. With the help of 2D echocardiography the situs is determined.
In situs solitus, IVC is to the right of the vertebral column and at the level of diaphragm, is in
a plane anterior to the aorta.

ii) IVC cannulation during CPB: When IVC is cannulated through a low RA purse-string; the
anteriorly placed Eustachian valve obstructs the cannula. To avoid the Eustachian
obstruction, the cannula is first passed left words-posterolaterally, till the tip touches & is
seen through the free RA wall and then it is rotated towards the IVC (fig36).

Figure 36: Obstruction to IVC cannulation by Eustachian valve

iii) Accidentally suturing of ASD patch to the margins of Eustachian valve: when CPB is
conducted with an IVC cannula passed through the anterolateral RA wall, the Eustachian
valve gets automatically retracted away by the cannula and what you see is as in figure 23
(above).
But, when ASD is closed without a cannula in IVC ( early era of ‘inflow occlusion’ , total
circulatory arrest, or distal IVC cannulation with snugging of ‘empty’ IVC ) the superior
margin of Eustachian valve could be mistaken for inferior margin of an IVC type of ( low
lying) ASD, and sutured according. This produces an iatrogenic right to left shunt after ASD
closure. (anatomically the free margin of Eustachian valve ends in two cornua. The left or the
medial cornua is in continuity with the anterior limb of the fossa ovalis.) (fig37)

iv) Malplacement of IVC cannula: the hepatic veins open into IVC just few centimeters
away from the RA – IVC junction. A straight IVC cannula (typically passed through RA
appendage) or a curved long tip cannula easily lodges into one of the hepatic veins making
the venous drainage inadequate.
 33

Figure 37: Low placed ASD and Eustachian valve margin

v) Right heart margin: The IVC forms the lower most part of right heart border (RHB) on
chest x-ray. The IVC pierces diaphragm at right angle and there is a very short segment of
intrathoracic IVC. Hence, on chest x-ray, a prominent RHB always touches the diaphragm
and touches it at right angles (fig 38).

Figure 38: RHB on chest x-ray

vi) large Eustachian valve: There is a large variability in size, shape, thickness, and texture of
the persistent Eustachian valve, and in the extent to which it encroaches on neighbouring
structures such as the atrial septum. It can persist as a mobile, elongated structure projecting
several centimeters into the RA cavity & may be confused with RA tumour, thrombi, and
vegetations. It may mimic cor triatriatum dexter (divided RA) echocardiographically.
Occasionally, a Eustachian valve is large enough to obstruct IVC inflow to RA.

vii) IVC looping: during CPB may injure right inferior pulmonary vein
 34

viii) IVC interruption: During embryogenesis, the IVC is made up of the hepatic, prerenal,
renal, and postrenal segments, which by segmental fusion, regression, and midline
anastomosis form the IVC (fig 39).

Figure 39: Embryologic formation of IVC

Failure of the hepatic and prerenal segments to fuse is the most common developmental
anomaly of the IVC and results in infrahepatic IVC interruption. The infrahepatic IVC may
continue as the azygos vein, as the hemiazygos vein to the left SVC, intrathoracic veins, or
anomalous intrahepatic veins. The hepatic segment of the IVC drains directly into the RA.

Interrupted IVC is associated with congenital heart disease in approximately 85% of cases,
and frequently with the polysplenia syndrome .The clinical implications could be a) recurrent
deep vein thrombosis of the lower limbs b) sick sinus syndrome c) procedural difficulties
during right heart catheterisation, electrophysiological studies, femoral vein catheter
advancement, IVC filter placement, and temporary pacing.

From CPB point of view, IVC interruption is a classic example where IVC cannula is smaller
than the SVC cannula. For the drainage of hepatic portion of IVC, placement of cannula tip in
RA, rather than in IVC, may be required.

Glenn shunt when performed in the presence of IVC interruption gives very satisfying
improvement in oxygen saturation (Kawashima’s procedure). The azygos vein should not be
ligated/ divided during this type of Glenn Shunt as it is a conduit for IVC drainage.

ix) IVC clamping: IVC carries 66% of venous turn to heart. Also, IVC drains an area which
is resilient to tissue edema. Hence, IVC can be temporary clamped to acutely reduce the
systemic pressure.
 35

Tricuspid Valve
i) Echocardiographic view of TV: Since the valve is nearly vertical (approximately 45
degrees to the sagittal plane), the anterior leaflet is also referred to as superior/ anterosuperior
or infundibular leaflet. The posterior leaflet has also been called inferior or marginal leaflet &
the septal leaflet is also called medial leaflet. Posterior leaflet is most difficult to visualise.
Unlike aortic and mitral valve, all three leaflets are not simultaneously visualised. Septal
leaflet is the hallmark of tricuspid valve (MV has no septal leaflet).

ii) Tricuspid annulus: a) is a very dynamic structure and can change markedly with loading
conditions. Also, tricuspid annulus, with more of its circumference in contact with the
myocardium than that of the mitral valve, exhibits increased systolic reduction. There is
approximately 19% of reduction in annular circumference or 33% reduction in annular area
with atrial systole and early ventricular systole.
b) Tricuspid annulus: The tricuspid annulus is not uniformly thick throughout its
circumference and it is contributed by 1) the right half of right fibrous trigone b) right and left
long, tapering subendocardial fibrous bands - the fila coronaria - passing laterally from the
right fibrous trigone c) a very thin layer of connective tissue between the distal ends of the
fila coronaria laterally (fig 40). Attachment of various leaflets corresponding to the annulus is
shown in figure 41.

Figure 40: Components of Tricuspid valve annulus

 36

Figure 41: Attachment of various leaflets to the annulus

The dilatation of annulus following RV failure is mainly in the thinner part of the annulus,
i.e. along ATL & PTL region. Hence the classical annuloplasty of De Vega is restricted to
this region (fig 42)

Figure 42: De Vega Annuloplasty

Annuloplasty sutures: suturing is restricted between the antero- septal commissure and
postero-septal commissure. The posterior leaflet has many scallops, making it difficult to
identify the postero septal commissure. The commissure is indicated by the coronary sinus.

iv) in a normal heart, the tricuspid valve is located slightly closer to the apex than the mitral
valve. The space in between the septal insertion of the tricuspid valve and the septal insertion
of the anterior leaflet of mitral valve belongs to the membranous septum that separates the
LV from the RA (Fig 43). The apical displacement is expressed as ‘displacement index’ and
is calculated by finding the difference of the linear distances between septal insertions of the
tricuspid and mitral valves and then dividing it by the patient’s body surface area. The
excessive apical displacement of tricuspid valve, i.e. the displacement index > 8 mm/m2, is
associated with the Ebstein’s anomaly.
 37

Figure 43:
Levels of insertion of mitral (red coloured) and tricuspid (blue coloured) valves

v) A real-time three dimensional echocardiography (RT3DE) demonstrates the normal

tricuspid annulus as a bimodal or saddle-shaped structure with the highest points in an antero-
posterior orientation and the lowest points in a medio-lateral orientation. There are two high
points, oriented superiorly toward the RA and there are two low points, oriented inferiorly
toward the RV (fig 44 & 45A).

Figure 44: Saddle shaped tricuspid annulus with high and low points

A B

With the development of functional TR the tricuspid annulus becomes more planer and
circular, with greater increase in anteroposterior diameter than the mediolateral one.
There are 2 types of annular shapes noted with functional TR, which are termed
‘intermediate’ and ‘advanced’. These two varieties are actually continuation of pathology.
The intermediate shape has 1distinct high point located anteriorly (corresponding to the right
trigone), with the posterior edge becoming flat relative to the anterior high point (fig 45B).
The advanced shape is more uniformly flat in both anterior and posterior locations (fig 45C)
 38

Figure 45: TV annulus in normal and during functional TR

vi) functional tricuspid regurgitation: Each A-V valve (i.e. tricuspid or mitral valve) is a part
of the corresponding ventricle and the A-V annulus dilates along with the dilatation of the
ventricle. Thus, when the RV fails & dilates due to severe pulmonary hypertension the
tricuspid annulus dilates. This results in failure of coaptation of leaflets with resultant
regurgitation. It is suggested that the flattening of the annulus potentially alters the normal
papillary muscle to leaflet and annulus relationship. With flattening of the annulus, the low
points of the annulus may be stretched away from the papillary muscles, thereby increasing
tethering.

vii) annuloplasty rings:

Figure 46: Tricuspid annuloplasty ring A Classic B: Physio

A B

Original or ‘classic’ variety of commercially available tricuspid annuloplasty rings confirmed

only to shape of the annulus and is uniplaner (Fig.46A). With the understanding of
physiology mentioned above, the rings are made confirming to the physiological shape of
annulus (Fig 46B). The ‘open space’ in all the rings corresponds to the position of A-V node.

viii) the septal aspect of the tricuspid annulus is attached to the fibrous skeleton of heart.
Hence, it is relatively spared from annular dilation. Because of this property, tricuspid
annular sizing algorithms have been based on the dimension of the base of the septal leaflet.

ix) perimembranous VSD in RA approach: Membranous septum is confluent with the right
fibrous trigone & is an integral part of the aortic root, where it forms the base of the fibrous
triangle between the right and the non-coronary leaflets of the aortic valve. Perimembranous
VSD is the most common type of VSD. The VSD is visualised in the antero-septal
commissure by retracting the ATL anteriorly and cranially and STL caudally and to the right
 39

(fig 47). Detachment of STL from the annulus can also help in visualising a perimembranous
VSD.
Inadequate leaflet tissue at the ATL-STL commissure also helps in visualising a
perimembranous VSD.

Figure 47: Relationship of the membranous septum (blue coloured ) to TV

x) Spontaneous closure of VSD: due to its relationship with the STL, a perimembranous VSD
most commonly closes by adhesions between STL & VSD to the margins.

xi) Tricuspid Valve Replacement (TVR): (ref to figure 23 on page 21) Protecting A-V node
is of cardinal concern during TVR. This done either by
a) placing sutures, to the left of CS, in the partly excised or plicated STL ( fig 48A) or
b) by placing sutures supra-annularly from CS to ATL- STL commissure. (fig 48B)

Figure 48: Techniques of Tricuspid valve Replacement

A : Annular B: Supra annular

Most of the TV annulus is thin. Hence TVR is usually performed with interrupted pledgeted
sutures. During TVR, care also should be taken of RCA ( right circumflex artery!!) which
courses along the annulus (fig 49)
 40

Figure 49: Course of RCA and Tricuspid Valve (blue arrow)

When a bilogical valve is used, to avoid RVOT obstruction by the stent posts, the stents posts
should be at 12, 4 & 8 o’clock positions in the tricuspid annulus (fig 50.)

Figure 50: Orientation of bioprosthesis in tricuspid position

xii) TV repair &variations in the elements of TV: While performing TV repair the variations
in anatomy of cusps and papillary muscles should be borne in mind.

The TV is not consistently tricuspid, but is observed to present with 2, 4, 5 or 6 cusps in 72%
of cases; moreover, additional “commissural cusps” are found in 64% cases independent of
the number of “supernumerary cusps”.

According to a more recent functional terminology for the TV, the papillary muscles can be
grouped according to the distribution of their cords to a definite commissure and its
contiguous main leaflets. Therefore, the APM becomes the anteroposterior, the PPM the
posteroseptal and the SPM the anteroseptal papillary muscle, respectively

Like the MV, the papillary muscles of TV, too, contract just before contraction of the RV so
as to tighten the chordae tendinae and draw the cusps at the time ventricular contraction
begins. This prevents ventricular blood from passing back into the right atrium

The variability of the papillary muscles is a normal characteristic of the tricuspid valve. They
can number from 2-9, but usually 2 or 3 papillary muscles can be seen. The APM and PPM
are present in all cases, while the SPM is absent in 21.5% of cases. The APM and PPM
could be mutiheaded and vary in morphology (V or H shaped).
(septal papillary muscle is described separately, later)
 41

Three types of connections can be found between TV leaflets and the papillary muscles:
1) muscular : direct connection between the leaflet and the papillary muscles (30.27%),
2) membranous : in some 6.54%.
3) tendinous chordal connection: all cases
Obviously , more than one type of connection exists in a single case.
 42

Right Ventricle
i) in a normal heart, the RV is the most anteriorly situated cardiac chamber and lies
immediately behind the sternum & the left 3rd to 5th costal cartilages and adjoining ribs.
Thrust of a pressure or volume overloaded RV is appreciated clinically on inspection and
palpation, initially, as intercostal activity and later as ‘heave’, felt on palpation.
The anterior position makes RV prone for injury during sternotomy.

ii) traditionally RV is divided into sinus and conus components.

RV is also described in 3 components (fig 51): (1) the inlet, which consists of the tricuspid
valve, chordae tendinae, and papillary muscles, i.e., TV valve and its tension apparatus, (2)
the trabeculated apical myocardium and (3) the infundibulum, or conus, which corresponds to
the smooth myocardial outflow region. It is a region between the two arterial valves.

This nomenclature of RV divisions is used to classify VSDs. This classification helps surgeon
in choosing the approach for closing VSD e.g., an infundibular VSD is best closed through an
infundibular or pulmonary approach.

The RV can also be divided into anterior, lateral, and inferior walls, as well as basal, mid, and
apical sections.

iii) Under normal loading and electrical conditions, the septum is concave toward the LV in
both in systole and diastole. RV is a volume handling ventricle. Hence, the volume of the RV
is larger than the volume of the LV, whereas RV mass is approximately one sixth that of the
LV.

iv) distinguishing anatomic features of the RV as compared to LV: anatomic RV is defined

by its structure rather than by its position or connections. The morphological features that
best differentiate anatomic RV from LV or indeterminate ventricle are: 1) the more apical
hinge line of the STL relative to the AML 2) the presence of a moderator band 3) the
presence of 3 or more papillary muscles 4) the presence of coarse trabeculations and 5) the
presence of a muscle fold (ventriculo-infundibular fold) separating the a-v valve (tricuspid
valve) from the valve of the great vessel (pulmonary valve).

Figure 51: Parts of RV

 43

The various muscles, folds and landmarks in RV are as follows: (there is a variation in the
exact definition of each in various articles)

a) Ventriculo-Infundibular Fold ( VIF) : The muscle intervening between tricuspid valve and
pulmonary valve . As Tricuspid and Pulmonary valves are in different planes, this fold is
partly in the free RV wall and, partly in the septal plane. (fig 52A)
b) Crista Supraventricularis (CSV): is part of the VIF over-hanging the ATL (RV inflow).
(some call VIF as crista).Crista is more of a specific point, on the parietal side of VIF. The
crista supraventricularis gives origin to two large muscular bands, the septal band (SB),
which courses along the interventricular septum and, the larger, parietal band (PB), which is
located along the free wall of the right ventricle (fig 52B). PB forms the superior margin of
membranous septum (fig 52A).
Some consider parietal band and infundibular septum as crista supraventricularis.

Figure 52: View inside RV

A) View though anterior RV wall B) View though RV outflow

Y indicates position of TSM
 44

Figure 53: Crista Supraventricularis

c) Trabecula Septomarginalis (TSM): (some call the entire TSM as ‘septal band’) The TSM
is shown as a prominent muscle trabecula along the upper portion of the interventricular
septum. It runs obliquely on the septum (fig 54B). It has a body with a superior bifurcation
and an inferior bifurcation, which merges with RV apex. The superior bifurcation has two
limbs: antero-basal and postero-basal limbs. The postero-basal limb terminates beneath the
membranous septum. The antero-basal division extends in cephalad direction and reinforces
the surface of the sub-pulmonary infundibulum. Between these limbs is inserted the septal
root of the CSV.
When abnormally formed or hypertrophied, the septomarginal band can divide the ventricle
into 2 chambers (double-chambered RV).

Figure 54: Trabecula Septomarginalis

* indicated insertion of papillary muscle of Lancisi.
A B

d) Moderator Band: joins the inferior bifurcation of TSM with the base of anterior papillary
muscle (fig 52B). The right bundle branch travels along the moderator band.
 45

e) The medial papillary complex: is that group of muscles or tendinous cords that supports
the antero-septal commissure of the tricuspid valve. The concept of a medial papillary
complex is preferred by some because of multiple small papillary muscles around Lancisi's
muscle itself which contribute to commissural support,
The most prominent muscle of medial papillary complex is that originally described by
Lancisi. It has a free-standing belly which is rooted to the septum at the point where the
septomarginal trabeculation bifurcates into antero-basal and postero-basal limbs (fig 54A
& * in the figure 54B). There is a marked variation in the disposition of Lancisi's muscle
along with its supporting minor medial papillary muscles. Both Lancisi's muscle and minor
papillary muscles are intimately related to the postero-basal division of the septomarginal
trabeculation. They support the antero-superior portion of the septal leaflet of the tricuspid
valve.
In normal heart and in hearts with a perimembranous VSDs, the bifurcation and the right
bundle branch (RBB) lay about beneath a series of upper accessory papillary muscles
(AcPM) when these tension apparatuses are present(fig 55). The RBB descends beneath or
slightly anterior to the uppermost AcPM and postero- inferior to the medial papillary muscle
(MPM).

Figure 55: Relationship between RBB & MPM in a normal heart

(A& B marks are unrelated to this text)

In TOF, the bifurcation usually lays underneath the MPM, on the LV side of the septum.
Traversing the septum, the RBB descended slightly anterior to the MPM.

The relationship between RBB and PM is further modified by the grade of aortic overriding,
aspects of the TSM such as distribution and hypertrophy.
 46

Pulmonary Artery & Pulmonary Valve

Pulmonary valve relation to aortic valve: The normal relation of pulmonary valve to aortic
valve is: Pulmonary valve is anterior, to the left and superior to the aortic valve. Hence
aneurysms of sinuses of Valsalva, which grow inferior, never rupture into MPA.

Structures around pulmonary artery: Left main coronary artery, proximal LAD and the first
septal (S1) are closely related to the pulmonary artery root (fig 56 & 57). Hence, during Ross
procedure, while harvesting the autologous pulmonary artery as well as while suturing
allograft, the left main coronary artery and S1 artery can get damaged.

Figure 56: Relation of LCA to Pulmonary root

Fibrous skeleton of the heart is the thinnest around the pulmonary annulus (fig 7, page 9).
This fact is to be kept in mind while choosing & placing sutures during pulmonary valve
replacement.

As the MPA trunk totally covers the LM & the initial part of LAD coronary arteries, direct
coronary anastomosis in this region is not feasible.

The significant feature of the pulmonary root, emphasizing its distinction from the aortic root,
is that RV-PA ventriculoarterial junction is completely muscular. Thus, the entire pulmonary
valvar complex is lifted away from the base of the heart by the free-standing subpulmonary
infundibulum. The infundibulum, which is narrowest at the anatomic ventriculoarterial
junction, rises obliquely from the right ventricle so that it is longest below the right-facing
sinus, and shortest below the left facing sinus of pulmonary artery.
 47

Figure 57: Relationship of the two arterial roots

A: Space between hollow arrows indicates the groove between infundibulum and aortic sinuses. The solid black
arrow points to the 1st septal artery. The dotted line indicates the junction of infundibulum with the pulmonary
trunk.
B: The infundibulum has been dissected away from the base of the heart at the lowest point of attachment of the
pulmonary valvar hinges. The solid black arrow indicates the 1st septal artery.

A B

Nomenclature of pulmonary valve: Nomenclature of pulmonary (as well as aortic valve) is

according the position in which a specimen of the heart is oriented. This has resulted in
different nomenclatures.
a) Basle Nomina Anatomica (BNA) (ref to page 54 for details related to BNA) convention
specified that description of heart should be with IVS in anteroposterior plane. With this there
is one anterior pulmonary cusp and two posterior pulmonary cusps.
b) The British revision (BR) suggested the descriptions be as in situ, i.e., with IVS in 600 left
anterior oblique plane. This results in two anterior pulmonary cusps and one posterior cusp
(fig 58 ) .
c) The current nomenclature used by pediatric cardiac surgeons is
Right facing cusp: cusp facing RCC of aorta or right anterior cusp of BR classification
Left facing cusp: cusp facing LCC of aorta or posterior cusp of BR classification
Anterior cusp: left anterior cusp of BR classification

Figure 58: Nomenclature of Pulmonary Cusps

 48

Aortic Valve
(Please also refer to ‘Ascending aorta’ on page 5)

In the root there are aortic sinuses alternating with fibrous triangles (interdigitating
intersinusoidal fibrous triangles). The RC sinus and the LC sinus have ventricular muscle at
its nadir, i.e. bottom, (fig 59 & 60) while the NC sinus has the fibrous curtain attached to the
mitral valve. The inferior part of the intersinusoidal fibrous triangles (part inferior to the
yellow line), though structurally part of aorta, are subjected to ventricular pressure.

Aortic annulus: There has been a constant debate as to what constitutes aortic annulus.
Many call the leaflet attachment site as annulus. This is mere a hinge point of the leaflet
attachment. The three semicircular or semilunar (red line in Figure 59) lines join superiorly to
form a crown shaped ring. These semilunar lines extend throughout the aortic root, running
from their basal attachments within the left ventricle to their distal attachments at the
sinutubular junction.

Figure 59: Aortic Annuli

The discrete anatomic ventriculo-aortic (V-A) junction is a circular locus within the aortic
root, formed where the supporting ventricular structures give way to the fibro-elastic walls of
the sinuses of Valsalva ( yellow line in figure 59) . Thus, the ring of VA junction crosses the
crown shaped ring six times. During aortic valve replacement the suture line corresponds to
the green line (ventriculo-aortic junction as visible to surgeon during AV replacement) when
at the bottom of the cusp and corresponds to the yellow line in the intersinusoidal fibrous
triangle.
 49

Figure 60: Attachment of aortic valve leaflet

Aortic Cusps: The anatomy of aortic cusp is as shown below in figure 61. The leaflet is
thicker towards its base, due to extra layer of spongiosa (fig 61& 62), & free margin. On its
ventricular surface, is the zone of apposition, known as the lunule, occupying the full width
along the free margin and spanning approximately one-third of the depth of the leaflet. This is
where a leaflet meets the adjacent two leaflets during valvar closure. At the mid portion of
the lunule, the ventricular surface is thickened to form a nodule (called nodule of Arantius)
that extends along 60% of the inferior margin of the lunule.

Figure 61: Aortic Cusp Anatomy

With the valve is in closed position, the inferior margins of the lunules meet together,
separating blood in the left ventricular cavity from blood in the aorta. The total area of the
valvar leaflets is 40% greater than that of the aortic root.
 50

Figure 62: Layers of aortic Cusps

In cross-section, the cusp has three distinct layers: fibrosa, spongiosa and ventricularis. The
fibrosa is on the top surface of the cusp, if looking down from the aorta, with the ventricularis
on the bottom (fig 62A). The fibrosa is considered to be the primary structural layer and
contains a large amount of collagen organized into large bundles and fibers which are
oriented in a circumferential direction (fig 62B). This directionality results in a structure that
is considerably stiffer in the circumferential direction than the radial. A matrix of elastin
surrounds the collagen bundles to maintain the valve’s microstructure during unloading.
The ventricularis, while less organized than the fibrosa, contains a significant amount of
collagen and elastin. However, because the collagen is not oriented in any specific direction,
it tends to be less stiff than the ventricularis. The spongiosa is perhaps the least studied layer
because it is more of a gap between the other two than a definable structure on its own. It is
primarily water, but also contains glycosaminoglycans (GAG’s) and small amounts of
collagen and elastin which connect the fibrosa and ventricularis together.

i) Fenestrations in the lunules: these are common, especially in the elderly, but the valve
remains competent because they are above the closure line. Larger fenestrations that extend
beyond the zones of apposition, however, can lead to significant valvar regurgitation.

ii) Frater’s stitch: The three nodules of Arantius meet in the center of the aortic lumen during
the closure of the aortic valve. Hence while deciding the circumferential (free edge)
redundancy of aortic leaflets during aortic valve repair, an apposing suture of 6-0 Prolene
suture is passed through the three corpora and is pulled diagonally opposite to the
commissure being checked ( Fig.63, where the redundancy of right coronary and non
coronary cusp is being checked)
 51

Figure 63: Frater’s Stitch

iii) Caging or jailing of coronary ostia during AV Replacement and Implantation

Caging of coronary ostia is easily avoided during surgery by placing the stents of biological
valves corresponding to the commissures. A Mechanical Valve causes caging if a relative
large sized valve is placed suprannularly. Caging mainly occurs of the left coronary ostium.

Any percutaneous (PC) aortic valve consists of metal frame to which is attached a trifoliate,
pericardium heart valve. The upper third of the frame (i.e., outflow portion) exerts low radial
force and usually sits within the ascending aorta and functions to orient the prosthesis in the
direction of the aortic root and blood flow (fig 64). The middle third of the frame is
constrained to avoid jailing of the coronary arteries. In addition, this portion of the prosthesis
hosts the valve leaflets and has high hoop force to resist deformation and thus maintain
normal leaflet function. The lower third of the frame (i.e., inflow portion) sits within the left
ventricular outflow tract/annulus of the native aortic valve and exerts high radial force.
Although the prosthesis is anchored within the annulus, its function is supraannular.

Figure 64: Percutaneous Aortic Valve Replacement

iv) Function of sinus of Valsalva: Each Sinus of Valsalva with its corresponding aortic cusp
is considered as one functional unit. Stiffening of aortic wall at the level of sinus results in
stress overload of the aortic cusps. There is evidence that the vortices created in the sinuses
lead to stress reduction on the aortic leaflets and support coronary flow. In valve sparing
aortic valve surgery, maintenance or recreation of the sinuses has been shown to effectively
recreate the vortices in the sinuses and may be beneficial in terms of normal leaflet
movement and valve durability.
 52

During systole sinuses distend by 16% to keep leaflets distended and flat

v) Under each commissure lies one of the three interleaflet triangles. Although histologically
they consist of thinned aortic wall, hemodynamically they are extensions of the ventricular
outflow tract and reach the level of the sinutubular junction in the area of the commissures.
The triangle between the right and noncoronary sinuses faces the right atrium (fig 65). It is in
direct continuity, proximally, with the membranous septum, which contains the His bundle.
Under the left and non-coronary triangle, the aorto-mitral curtain leads to the anterior mitral
valve leaflet.

Fig 65: Interleaflet triangles

vi) widening of sinutubular junction (STJ) can give rise to aortic regurgitation. Under non-
pressurised conditions (i.e. in autopsied hearts) aortic annulus is bigger than STJ by a ratio of
1.15:1. The ratio gets reversed to an Annulus: ST ratio of 1:1.3 when the dimensions are
studied (by 2D Echocardiography) under pressurised conditions.

vii) The LCA is situated in a caudal plane as compared to the RCA ostium. This makes LCA
vulnerable to embolism by calcium or particulate debris while operating a case with calcific
AS. RCA is prone to air embolism whenever air enters cross-clamped aortic root during an
open heart procedure.

Similarly, the LCA ostium can get ‘caged’ by sewing ring of a prosthetic valve while, the
RCA can be caged by the stent post of a biological valve
 53

Left Internal Mammary artery

In 1895 the Basilea Nomina Anatomica (congress of anatomist held in Basel, Switzerland) denominated the ITA
as the “internal mammary artery”. In 1936, in the Jena Nomina Anatomica, (conference held in the German
university town of Jena) the denomination was changed to “internal thoracic artery”, which also was referred
to in 1955 in the Paris Nomina Anatomica.
Sternal artery, Parasternal artery and Vineberg artery are some of the other names of IMA.

i) Coronary steal: LIMA passes posterior to left subclavian vein before entering the thorax
and start branching. Hence, while harvesting LIMA, disconnecting branches upto the left
subclavian vein is essential to ensures all branches are clipped as to prevent coronary steal.
In 70% cases LIMA originates directly from the subclavian artery. Out of the remaining 30%
cases, the frequent variations are as common trunk with supra scapular and /or transverse
cervical arteries. These vessels are impossible to disconnect during LIMA harvesting.

As compared to LIMA harvested through median sternotomy, harvesting LIMA through left
thoracotomy has higher incidence of unclipping of 1st anterior intercostal artery and 1 mm
diameter unnamed branches.

ii) Left Phrenic nerve Palsy: The left phrenic nerve should be protected while harvesting
LIMA. The nerve crosses LIMA lateral to medial, at a point where the artery enters the
thorax, i.e., where the artery passes posterior to the subclavian vein. Phrenic nerve crossing
LIMA anteriorly is more frequent. LIMA also gives a pericardiophrenic branch which runs
along the phrenic nerve. This artery is clipped during LIMA harvesting. This can produce
ischemia of phrenic nerve, resulting in diaphragm palsy.

iii) Distance from the lateral sternal margin: The LIMA runs on an average 13-14 mm lateral
to the sternal margin. It is closer to the lateral sternal margin in the 1st space (10mm) and the
distance increases in the lower spaces (20 mm at 6th ICS). This fact should be borne in mind
while passing peristernal wires during sternal closure.

iv) Laterally placed origin: in 8% of cases LIMA originates from the 2nd or 3rd part of
subclavian artery and the LIMA is deviated laterally at the proximal or upper end. . In such
cases harvesting the proximal (upper) end poses difficulty. The vessel origin may pose
traction on LIMA.

v) Termination of LIMA: is most frequent at 6th IC space. A termination at 7th space provides
a longer LIMA, favourable for sequential anastomosis, while termination at 5th space
provides a short LIMA. In general, the length of LIMA is proportional to the length of the
chest. Hence, in men LIMA is of longer length.

vi) Sternal collateral blood supply: A total of six varieties of branches are seen w.r.t. sternal
collateral supply (fig 66). The three top panel arteries are ‘non collateral’ branches and
number, on an average, 5- sternal, 2- perforating and 7- intercostals on each side. The three
bottom panel arteries are ‘collateral’ types and are responsible for maintaining blood supply
to sternum after IMA harvesting. Of these, sternal-perforating and sternal-costal arteries are
branches of IMA, while, persistent posterior IC arteries are branches of descending thoracic
aorta.
 54

Figure 66: Branches of IMA

An angiographic study has reported an additional variety of IMA branch: a sterno-

costo-perforating branch, (fig 67) i.e., all three branches arising from a common
trunk.

Figure 67: Branches of IMA: Sterno-costo-perforating branch

1: sternum 2: IMA 3: sternal branch 4: perforating branch 5: costal branch
6: Pectoralis major 7: intercostal muscle

a) on each side there are, on an average, 3 sternal- perforating branches, 2 sterno-costal

branches and 1 persistent posterior intercostal artery.
b) there is, on an average, 1 collateral vessel in each intercostals space. The incidence
collateral vessel per space is high (>1) in the upper fours intercostals spaces (highest in the
2nd space) and the lowest in the 6th space. The lower three spaces have only 30% of the
collaterals. This is one of the causes why sternal dehiscence is common in the lower part.
c) the length of the common trunk is less than 5 mm in majority of cases. Hence clipping of
IMA branches should be done at a distance less than 5 mm from IMA, so as to preserve blood
supply to sternum.
Thus, after IMA harvesting, blood supply to sternum can only be through
 55

1) posterior intercostal arteries , supplying either directly or through anterior intercostals –

sternocostal branch anastomosis.
2) thoracoacrominal arteries (branch of axillary artery supplying Pectoralis major) ,
anastomosing with sterno-perforating branches.
This supply will be facilitated if IMA branches are clipped close to IMA. Harvesting
skeletonised LIMA and RIMA thus protects the collateral blood supply and provides better
sternal healing.

The sternal branches form a vascular plexus along the sternum. The plexus is at superficial as
well as deeper sternal level. The deeper plexus is formed by the sternal branches of IMA
which form an arcade on the posterior surface of sternum (fig 68), while the superficial one is
formed by perforating branches of IMA and is between intercostal externus and internus.

Figure 68: Sternal Arcade

In addition to IMA harvesting with a thick pedicle, sternal closure by peristernal wiring
technique too, damages this vascular plexus.

vii) Part of collateral supply in coarctation of aorta: Both the IMAs are an important channel
in establishing flow in descending aorta distal to coarctation. This task is accomplished
through
a) superior epigastric artery – inferior epigastric artery- external iliac artery
b) musculophrenic artery- lower posterior intercostals- post coarct thoracic aorta. Also,
musculophrenic artery – inferior phrenic artery – post coarct (abdominal ) aorta.
c) anterior intercostals- posterior intercostals from 3rd space onwards - post coarct thoracic
aorta.
In the first two intercostal spaces, the posterior intercostals come from costo-cervical artery,
a branch of subclavian artery, which is a precoarct branch. Hence rib notching is not seen in
the first two intercostal spaces.
Both the IMAs take equal part in establishing collateral circulation in a classic case of
congenital juxta-ductal coarctation of aorta. Hence, the rib notching (which is because of
posterior and lateral perforating branches of posterior intercostal arteries) is bilateral,
symmetrical, starts from 3rd space and is best seen in the upper spaces. Any deviation from
this pattern should raise the suspicion of abnormal branching pattern.

viii) Inter mammary collaterals : Following a classic Blalock -Taussig (BT) Shunt or
following occlusion of proximal left subclavian artery , flow in the affected IMA is
 56

maintained through the sternal branches & mediastinal branches ( anterior mediastinal artery,
pericardial branches ) of the two IMAs.
These collaterals bleed during sternotomy and during dissection for instituting CPB.
 57

Coronary Artery
Non coronary blood supply of myocardium: The heart may receive perfusion not only from
the coronary arteries but also from the bronchial arteries, the internal thoracic artery, and the
mediastinal vessels and is called ‘extra coronary myocardial blood supply’. This flow can be
seen coming out of coronary orifices (particularly left one) during AVR and flood the LCC
annulus with blood. Also, this flow washes away cardioplegia and rewarms the myocardium
during cardioplegic arrest.

1) Left main (LM)

a) Angiography: LM coronary artery has a transverse or slight caudo-cranial course towards
the left (fig 69). Hence LM is profiled in a PA or shallow LAO view without any cranial or
caudal angulations.

b) Cannulation of LM: LM could be 1 to 25 mm in length. In a short (< 5mm) LM, a cardiac

catheter is likely to lodge in LAD (which is in line with LM) and may give a false impression
of 100% LCx block.
c) In a short LM, flexible cardioplegia cannula enters LAD and LCx remains under perfused.
d) LM is closely related to the posterior margin of pulmonary artery trunk and should be
protected while harvesting main pulmonary artery for Ross procedure.
e) The position of LM (origin from posterior aortic sinus and coursing behind MPA) makes it
inaccessible for direct bypass grafting.

Figure 69: Coronary artery anatomy (shallow LAO+ cranial view)

Please note 1) the direction of left main is leftwards and the LM, initial parts of LAD & LCx
are in a transverse plane 2) all diagonals are to the left and in the same plane as the mid and
distal LAD
 58

Figure 70: Course of LCA in a PA view of heart

Please note: 1) LM & LCx are well ‘opened up’
2) Diagonal (hollow arrow) forms margins of the left cardiac silhouette

f) Left coronary ostium is in front of the surgeon when viewed through an aortotomy. Hence
left ostial cardioplegia cannulae are straight or slightly angled (fig 71). The easy visibility of
left ostium is one of the reasons why ostial cardioplegia is first delivered into the left ostium.

Figure 71: Design of left ostial cardioplegia cannula

g) ‘Take off’ of coronary arteries: Coronary orifice could be above the sinutubular junction
and is called ‘high takeoff’. A high left coronary orifice is usually associated with a long
LCA and is therefore at a greater risk of injury during surgery, either due to a low clamping
of the aorta or due to the incision of the aorta wall during valve replacement.
 59

A high or low coronary orifice (i.e. at the bottom of the sinus) represents an added difficulty
in cannulation during coronary angiography

2) Left Anterior Descending (LAD):

a) Angiography: from its origin behind the MPA till it reaches the superior end of the
interventricular sulcus, the LAD passes left anteriorly and is in a transverse plane (fig 70 &
72). Hence an LAO view fore-shortens it while an RAO - cranial view opens the proximal
LAD fully. In a PA view, the vessel which corresponds with the left cardiac silhouette is a
diagonal artery (fig 70).
All the diagonal branches are to the left of LAD and all pass in a longitudinal (descending)
plane, parallel to LAD (Fig 68 & 70). Hence, in an RAO view there is an overlap of the
arteries; while, in an LAO view the angles between LAD and Diagonals are opened up (fig
72)

Figure 72: LAO view of the heart without cranial angulation

Please note: 1) foreshortening of proximal LAD
2) there is no overlap of LAD & Diagonals
3) there is an overlap of OMs & distal 2/3 of LCx

b) Left Anterior Descending (LAD) artery (also called anterior interventricular artery, artery
of Vieussen) passes behind the MPA trunk and then between MPA and LA appendage to
enter the superior end of interventricular sulcus. This part of proximal LAD is difficult to
access surgically to place an anastomosis or to perform endarterectomy
c) Type of LAD: Depending upon the area of distribution (Fig 73) LAD is called Type I:
falling short of apex, Type II: reaching apex Type III: coursing beyond the apex, continuing
through the posterior interventricular groove, where it is known as posterior recurrent
interventricular artery of Mouchet.

Larger territory of distribution increases the importance of LAD, for that matter, any artery.
 60

Figure 73: Types of LAD

d) Intramyocardial LAD: upto 23% cases could have of intramyocardial LAD. As LAD runs
over IVS, dissection to search for LAD on right side can result in opening of RVOT (in a
coronary artery disease with normal pulmonary pressures the RVOT wall is thin).
e) Application of a stabilising device like ‘Octopus’ during off-pump CABG can cause
RVOT obstruction.
3) Left Circumflex Artery (LCx)
a) Angiography: LCx initially is in a transverse plane. Thus, the LM, proximal LAD and
proximal LCx are in a transverse plane (fig 69). Hence a caudal view (with LAO), also called
a ‘spider view’ (fig 74), is for detecting blocks in the LM and proximal parts of LAD & LCx.

Figure 74: LAO-caudal or ‘Spider’ view of LCA

Please note: LM, proximal LAD & proximal LCX, being in a transverse plane, are best
visualised

The rest of the LCx forms a ‘C’ shaped curve in the left a-v groove. The groove is at right
angles to the long axis of the heart, which is directed in an LAO direction. Hence a PA view
opens the C (fig 75) but the OM branches running towards the apex are foreshortened (angio
below fig 75A). While in RAO, C is viewed through its ‘mouth’ and makes it look like ‘I’
(fig 75B) but, the OM are seen sideways, i.e. are ‘opened up’ (angio below fig 75B).

b) LCx after forming behind the MPA passes along the antero-medial base of LA appendage
to enter the left (posterior) a-v groove or sulcus. The LCx, over here, is covered by great
cardiac vein. All these factors (deep, in a posterior a-v grove, covered with vein) make LCx
inaccessible for placing distal anastomosis during CABG.
 61

Figure 75: View of LCx

4) Right Coronary Artery (RCA)

a) Angiography: The first part of RCA passes transversely from aortic sinus to reach base of
RA appendage (fig76). The second part passes in longitudinal plane till acute margin of heart.
RCA, in its 3rd part, then passes in a transverse plane leftward to reach crux and becomes
posterior descending artery (PD). PD runs antero-laterally in a transverse plane
(corresponding to diaphragmatic surface of heart) to reach apex. Hence, in an RAO view (fig
76) the 1st and 3rd parts of RCA gets fore-shortened, while, the PD is ‘opened- up’.

In an LAO view 1st and 3rd parts of RCA open-up while PD is fore-shortened.

As the 3rd part of RCA and PD (and also the PLV branches) are in a transverse plane, a
cranial angulation gives an excellent view of the 3rd part of RCA, PD and PLV without any
overlap (fig 77).
 62

Figure 76: RAO view of heart

Please note: 1) 2 part of RCA is well seen but 1st and 3rd parts are fore shortened
nd

2) PD is fully opened.
3) there is overlap of acute marginal (AM), PD and PLV

Figure 77: RCA angiogram in a LAO-cranial view

Please note: 1) the 1st and the 3rd parts are opened-up
2) there is no overlap of AM, PD and PLV branches.

b) The 1st and 2nd part of RCA are deep in the fat and are not graftable.

c) In about 50% of humans conal artery arises from a separate ostium (‘third coronary
artery’). Up to 5 ostia (RCA+ conal + RV branches) may be present in the right coronary
sinus. Ostial cardioplegia may not perfuse these small (< 1.5 mm diameter) branches.

While preparing right coronary button during Bental operation, one should be careful about
including all these small branches in the button.

d) During aortotomy, RCA with an intramural aortic course may get opened.
 63

Sternum
1. Dividing sternum in the center: The sternum is covered anteriorly by the right and left
pectoralis major muscles except for a narrow margin in the median plane (fig78).

Figure 78: Sternal origin of pectoralis major muscle

This ‘amuscular’ area guides a surgeon in maintaining the median plane during sternotomy.

2. Sternal fixation: Manubrium sternum is thick and broad (fig79). Hence, while closing the
sternum after sternotomy, sternal wires are passed always transsternally for manubrium.
Body of the sternum is narrow. Hence, sternal wires could be passed peristernally also.

Figure 79: Costal attachment of sternum

 64

3. Sternal spreader: The spreading blades of a Finochietto sternal spreader are angled
appropriately to confirm to sternal angle (white hollow arrows in fig 80). The surgeons who
place the ratchet of the spreader superiorly (across the neck), the blades should be
appropriately curved.

Figure 80: Finochietto Chest Spreader

4.Need of a changeable IMA retractor : The natural inclination of the sternum is oblique from
above, downward and forward (fig79). In addition, due to sternal angle the manubrium is in a
posterior plane to the body of the sternum. Hence, of the two blades of an IMA retractor, the
one at the cranial end is long while the one at caudal end is short (fig81A & B). Thus, a
‘LIMA retractor’ cannot be used for RIMA harvesting, simply by applying in a mirror image
manner.

Figure 81: Changeable mammary retractor

A
 65

Mechanics of sternal closure: Immobilisation is cardinal to a bone healing and sternal healing
is no exception. Unfortunately, sternal halves can never be immobilised in a true sense.

Figure 82: General Sternal Motion

Common daily activities like normal breathing, coughing, sneezing, walking, lifting a glass of
water, exert distracting shear force on the two sternal halves. This results in movement of the
two halves in a) antero posterior direction b) lateral direction or c) longitudinal or superior-
inferior direction (fig 80).This shear force could be as high as 1500Newtons (1 Newton is
1Kg mass moved with an acceleration of 1meter/sec, every second = Mass x Distance x sec-2)

The displacement produced by the shear force is not uniform. It is maximum at xiphi sternum
and in the lower part of the body of the sternum and; the displacement is the least in the
manubrium sternum (fig 83). This distracting force is proportional to the number of ribs
attached to the part of the sternum. Manubrium is thicker and broader than the body of the
sternum but has only 1&1/2 ribs attached (fig 79). The upper body has 3&1/2 (half of second
rib +3rd, 4th &5th) ribs attached while the lower part of the body has 5rib attachments (6th rib
+ conjoint 7-10 cartilage). Thus separation of the sternum is more in the lower half than in
the upper half of sternum, requiring more wires to immobilise the lower half of sternum
(common practice is to place more wires in the manubrium and upper half of the sternum!!!)
Also, the chance wires cutting -through sternum is more in the lower half, where, the sternum
is thinner and narrower, but is subjected to more distracting force.
The attachment of shoulder girdle to manubrium has a stabilising effect on the manubrium.
 66

Figure 83: Regional Sternal Motion

Placing more sternal wires reduces the distracting force per wire and reduces the chance of
wires cutting-through sternum. A twisted wire or a sternal band, due to their width, reduce
the force exerted by wire per unit area on the bone and also reduces the chance of cut-
through.

Sternal Blood Supply: Please refer page 53.

 67

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 68

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 69

A free e- book
By
Dr. Anil G Tendolkar
Professor and Unit Chief , Department of CVTS, KEM Hospital, Parel, Mumbai , India ( 1989-99)
Professor & Head, Department of CVTS, LTMG Hospital , Sion, Mumbai, India ( 1999-2006)

Communication: atendolkar@yahoo.com