USLS COLLEGE OF MEDICINE (3) Descending Thoracic aorta

b) Pulmonary Trunk
ANATOMY 2. Large Thoracic Veins
a) Brachiocephalic Veins
b) Superior Vena Cava
Heart and Pericardium c) Azygos Veins
DATE: 10/26,28,29/20 (1) Inferior Hemiazygous
LECTURER: Fernandez, MD (2) Superior Hemiazygous
d) Inferior Vena Cava
(asynchronous) e) Pulmonary Veins

I. Pericardium
A. Fibrous ● fibroserous sac that encloses the heart and the roots of the
great vessels
B. Serous
C. Pericardial Sinuses ● within middle mediastinum
D. 
Nerve Supply
● function:
○ restrict excessive movements of the heart as a whole
II. Heart
A. Orientation ○ serve as a lubricated container in which the different parts
1. Surfaces of the heart contract
● location:
2. Borders
B. Structures ○ anterior - T5 to T8
1. Layers ○ posterior - body of the sternum and the 2nd to 6th costal
cartilage
2. Chambers
○ superior - great blood vessels
a) Right Atrium
○ inferior - diaphragm
(1) Openings
(2) Fetal Remnants
b) Right Ventricle ● strong fibrous part of
c) Left Atrium the sac
(1) Openings ● firmly attached below
d) Left Ventricle to the central tendon
3. Heart Valves of the diaphragm
4. Fibrous Cardiac Skeleton ● apex fuses with outer
C. Action coats of great blood
D. Conducting System of the Heart vessels passing
1. Sinoatrial Node through the:
2. Atrioventricular Node ○ Aorta
3. Atrioventricular Buncles (Bundle of His) ○ Pulmonary Trunk
a) Bundle Branches ○ Superior &
b) Subendocardial Branches Inferior Venae
c) Internodal Conduction Paths Cavae
E. Nerve Supply ○ Pulmonary veins
1. Extrinsic ● Sternopericardial
2. Intrinsic ligaments - attaches
F. Arterial Supply pericardium in front to the sternum
1. Right Coronary Artery
2. Left Coronary Artery
● lines the fibrous pericardium and coats the heart
3. Coronary Artery Anastomoses
● divided into:
G. Venous Drainage
○ Parietal Layer - lines the fibrous pericardium
1. Great Cardiac Vein
■ reflected around the roots of the great vessels to
2. Middle Cardiac Vein
become continuous with the visceral layer of serous
3. Small Cardiac Vein
pericardium that closely covers the heart
H. Great Vessel
○ Visceral Layer “Epicardium”
1. Large Thoracic Arteries
a) Aorta
(1) Ascending aorta
(2) Aortic arch

TRANSCRIBER: ANTOLO, P., ARDIENTE, J., CARAM, M., ESTANOL, A., GONZAGA, E., KRAFT, R., TABABA, R.
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 ● Pericardial cavity -
○ bulbus cordis and ventricular parts of the tube - elongate more rapidly
slit like space than the remainder of the tube
between the ○ arterial and venous ends are fixed by the pericardium -> tube begins to
parietal and visceral bend (Fig. 5.41)
layers ■ bend soon becomes U-shaped -> forms a compound S shape
● Pericardial fluid - ● with the atrium lying posterior to the ventricle -> venous
small amount of and arterial ends are brought close together as they are in
tissue fluid (about the adult
○ passage between the atrium and the ventricle narrows -> form
50ml) inside the
atrioventricular canal
cavity which acts as ○ as these changes occur: heart tube gradually migrates from the neck
lubricant to region -> become the thoracic region
facilitate movement
of the heart

● spaces posterior to the heart formed by the reflections of the

serous pericardium around the great vessels
● formed as a consequence of the way the heart bends during
development
○ extensions of the pericardial cavity and not separate
compartmental spaces
● no clinical significance
● Oblique Sinus
○ reflection around the large veins forms an inverted
U-shaped cul-de-sac ●
○ runs along the long axis of the heart (apex to the
ascending aorta)
● Transverse Sinus
○ short horizontal space
○ between reflection of the serous pericardium around the
aorta and pulmonary trunk and reflection around the large
veins
Embryology Notes
Heart Tube Development
● clusters of cells - arise in the mesenchyme at the cephalic end of the
embryonic disc, cephalic to the site of the developing mouth and the
nervous system
○ form a plexus of endothelial blood vessels that fuse to form the right
and left endocardial heart tubes
● paired tubes soon fuse -> form a single median endocardial tube (Fig. 5.39)
● as head fold of the embryo develops -> endocardial tube and pericardial
cavity rotate on a transverse axis through almost 180° = come to lie ventral ● Phrenic Nerves - sensory fibers to fibrous pericardium and
to (in front of) the esophagus and caudal to the developing mouth parietal layer of serous pericardium
● endocardial tube starts to bulge into the pericardial cavity (Fig. 5.39) ->
● Branches of the Sympathetic and Vagus Nerve - visceral layer
becomes surrounded by a thick layer of mesenchyme -> differentiate into
of serous pericardium
myocardium and visceral layer of the serous pericardium
○ establishes primitive heart tube with:
■ cephalic end as the arterial end Clinical Notes
■ caudal end as the venous end Pericarditis
○ arterial end of the primitive heart - continuous beyond the ● inflammation of the pericardium
pericardium with a large vessel “aortic sac” (Fig. 5.40) ● excessive pericardial fluid may accumulate in the pericardial cavity
● heart - begins to beat during the 3rd week ○ compress the thin-walled atria and interfere with the filling of the heart
○ heart tube then undergoes differential expansion -> formation of 4 during diastole
dilatations: (separated by grooves) ○ such compression of the heart - “cardiac tamponade”
■ bulbus cordis ■ can also occur secondary to stab or gunshot wounds when the
■ ventricle chambers of the heart have been penetrated
■ atrium ● blood escapes into the pericardial cavity and can restrict the
■ sinus venosus (including right and left horns) filling of the heart

TRANSCRIBER: ANTOLO, P., ARDIENTE, J., CARAM, M., ESTANOL, A., GONZAGA, E., KRAFT, R., TABABA, R.
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● Pericardial friction rub - roughening of the visceral and parietal layers of
○ also formed by inferior surface of the right atrium
serous pericardium by inflammatory exudate in acute pericarditis ■ where inferior vena cava opens
○ felt on palpation and heard through a stethoscope ● posterior - Base of the heart
● Constrictive pericarditis - fibrous pericardium becomes too rigid because of ○ formed by the left atrium
inflammation ■ where 4 pulmonary veins opens
○ results in heightened resistance to movements of the heart and blood ○ lies opposite to the apex
flow ○ heart is pyramid shaped, does not rest on its base
● excessive amounts accumulate in pericarditis of pericardial fluid - can be
■ rests on its diaphragmatic (inferior) surface
aspirated from the pericardial cavity
○ process - “paracentesis”
○ needle can be introduced to the left of the xiphoid process in an upward
and backward direction at an angle of 45° to the skin
■ when performed at this site: pleura and lung are not damaged
because of the presence of the cardiac notch in this area

● hollow muscular organ, somewhat pyramid shaped

● unique and dominant functional feature: myocardial layer
composed largely of cardiac muscle
● lies within the pericardium and mediastinum
● connected at its base to the great blood vessels but otherwise
lies free within the pericardium
● has 2 functional circuits
○ pulmonary circuit pump - right heart (right atrium and
right ventricle)
■ blood travels a relatively short distance to the lungs
and back against low peripheral resistance
○ systemic circuit pump - left heart (left atrium and left
ventricle)
■ blood travels a long distance through the body against
high peripheral resistance

● heart - aligned obliquely

within the thorax
○ 2/3 - left of the midline
○ 1/3 - right of the midline
● with an apex directed
downward, forward, and to
the left
○ formed by left ventricle
○ at the level of the 5th
left intercostal space,
3.5 in. (9 cm) from the
midline
○ apex beat - usually be
seen and palpated in
the living patient
● right: right atrium
○
○ 3rd to 6th right intercostal space
● left: left auricle
● anterior - Sternocostal surface ○ 2nd to 5th left intercostal space
○ formed by right atrium and right ventricle ● superior: great vessels of the heart
■ separated by vertical atrioventricular groove ○ 3rd right costal cartilage to 2nd left costal cartilage
(coronary sulcus) ● inferior: right ventricle (mainly) and right atrium and apex
○ right and left ventricles - separated by anterior ○ 6th right intercostal space to 5th left midclavicular
interventricular groove intercostal space
● inferior - Diaphragmatic surface
○ formed by right and left ventricles
■ separated by posterior interventricular groove

TRANSCRIBER: ANTOLO, P., ARDIENTE, J., CARAM, M., ESTANOL, A., GONZAGA, E., KRAFT, R., TABABA, R.
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 ● Openings:
1. Superior vena cava
■ returns blood to the heart from the upper half of
● heart walls has 3 layers: the body
1. visceral layer of serous pericardium (epicardium) - external ■ opens into the upper part of the right atrium
layer ■ no valve
2. Cardiac muscle (myocardium) - primary constituent of the 2. Inferior vena cava (larger than superior vena cava)
middle layer ■ returns blood to the heart from the lower half of
3. layer of endothelium (endocardium) - lines the inner the body
surface and forms the internal layer ■ opens into the lower part of the right atrium
■ guarded by a rudimentary, nonfunctioning valve
“valve of the inferior vena cava” ay ambot
3. Coronary sinus
■ drains most of the blood from the heart wall
■ opens into right atrium between the inferior
vena cava and the atrioventricular orifice
■ guarded by a rudimentary, nonfunctioning valve
“valve of the coronary sinus”
4. Right atrioventricular orifice
■ anterior to inferior vena caval opening
■ guarded by tricuspid valve
5. Anterior cardiac veins
■ drains directly to right atrium
● Fetal Remnants - lie on the atrial septum (separates right
atrium from left atrium)
○ Fossa ovalis - shallow depression
■ site of the fetal foramen ovale
■ upper margin of the fossa - Anulus ovalis
● forms from lower ridge of the septum
● contains 4 chambers secundum
○ atria and ventricles - connected via atrioventricular valves ■ floor of the fossa - represents the persistent
■ atria - receive venous blood, pump blood only to the septum primum of the embryonic heart
immediately adjacent ventricles 2. Left atrium
● low-pressure chambers ● consists of main cavity and left auricle
■ ventricles - pump arterial blood out of the heart, ● behind right atrium
must impart pulmonary and systemic pulses of blood ● forms greater part of the base or posterior of the heart
● high-pressure chambers ● blique sinus of the serous pericardium lies behind it
● major sources of energy for the circulation of ● separated from esophagus by the fibrous pericardium
blood ● interior is smooth
1. Right atrium ○ left auricle possesses muscular ridge
● 2 parts: ● Openings:
○ main cavity (atrium proper) 1. 4 pulmonary veins (2 from each lung) - open through
■ posterior to the ridge the posterior wall and have no valves
■ smooth walled 2. Left atrioventricular orifice - guarded by mitral valve
■ embryologically from sinus venosus 2. Right ventricle
○ auricle - a small earlike outpouching ● communicates with right atrium through right
■ in front of the ridge atrioventricular orifice and pulmonary trunk through
■ roughened or trabeculated by bundles of muscle pulmonary orifice
fibers, musculi pectinati ● infundibulum (conus arteriosus) - funnel-shaped
● run from the crista terminalis to the auricle narrowing of the ventricular cavity where the cavity
■ embryologically from primitive atrium approaches the pulmonary orifice
● Sulcus terminalis ○ constitutes right ventricular outflow tract
○ vertical groove on the outside at the junction ● in cross section: crescentic
between the right atrium and the right auricle ● thicker walls than right atrium
○ on the inside forms a ridge - crista terminalis ● trabeculae carneae - internal projecting ridges that give
■ boundary between between atrium proper and ventricular wall a sponge like appearance, composed of 3
auricle types:
1. papillary muscles

TRANSCRIBER: ANTOLO, P., ARDIENTE, J., CARAM, M., ESTANOL, A., GONZAGA, E., KRAFT, R., TABABA, R.
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 ● project inward, attached by their bases to the
ventricular wall
● apices connected by the chordae tendineae to
the cups of the tricuspid valve
2. septomarginal trabecula (moderator band)
● attaches at the ends to the ventricular wall, free
in the middle
● crosses the ventricular cavity from the septal to
the anterior wall
● conveys the right branch of atrioventricular
bundle (part of the conducting system)
3. prominent ridges
4. Left ventricle
● communicates with the left atrium through the
atrioventricular orifice and with the aorta through the
aortic orifice
● walls are 3x thicker than right ventricle
○ left intraventricular pressure is 6x higher
● in cross section: circular
● well developed trabeculae carneae: 2 large papillary
muscles
● aortic vestibule - part of the ventricle below the aortic
orifice
Embryology Notes
Atria Development
● single primitive atrium divides into 2 separate right and left atria
○ atrioventricular canal widens transversely (Fig. 5.42A)
○ ventral and dorsal endocardial (atrioventricular) cushions form and
fuse -> form “septum intermedium”
■ divides the canal into right and left halves
○ another septum “septum primum” - develops from the roof of
primitive atrium and grows down to fuse with the septum intermedium
○ opening between the lower edge of septum primum and septum
intermedium that occurs before fusion - “foramen primum”
○ atrium now is divided into right and left parts
● degenerative changes occur in the central portion of the septum primum
before complete closure of the foramen primum takes place (Fig. 5.42B)
○ breakdown in the septum primum forms a second foramen, “foramen
secundum” - allows the right and left atrial chambers to communicate
(Fig. 5.42C)
○ another, thicker, septum “septum secundum” - grows down from the
atrial roof on the right side of the septum primum (Fig. 5.42C,D)
■ its lower edge overlaps foramen secundum in the septum primum
but does not reach floor of the atrium and does not fuse with
septum intermedium
○ space between the free margin of the septum secundum and the
septum primum - “foramen ovale” (Fig. 5.42D,E)
● before birth: foramen ovale allows oxygenated blood that has entered the
right atrium from the inferior vena cava to pass into the left atrium
○ lower part of the septum primum - serves as a flaplike valve to prevent
blood from moving from the left atrium to the right atrium
● at birth: owing to raised blood pressure in the left atrium -> septum primum
is pressed against the septum secundum and fuses with it = foramen ovale is
closed -> two atria are separated from each other
○ lower edge of the septum secundum in the right atrium -> becomes
annulus ovalis
■ depression below this - “ fossa ovalis”
● right and left auricular appendages later develop as small diverticula from
the right and left atria
TRANSCRIBER: ANTOLO, P., ARDIENTE, J., CARAM, M., ESTANOL, A., GONZAGA, E., KRAFT, R., TABABA, R.
Ventricle Development
● muscular partition projects upward from the floor of the primitive ventricle
-> form ventricular septum (Fig. 5.42C,D)
● space bounded by the crescentic upper edge of septum and he endocardial
cushions -> forms interventricular foramen
○ spiral subendocardial thickenings “bulbar ridges” - appear in the distal
part of the bulbus cordis -> grow and fuse -> form “spiral
aorticopulmonary septum” (Fig. 5.43)
● interventricular foramen closes - result of proliferation of the bulbar ridges
and the fused endocardial cushions (septum intermedium)
○ newly formed tissue grows down and fuses with the upper edge of the
muscular ventricular septum -> form membranous part of the septum (
Fig. 5.42D)
○ shuts off the path of communication between the right and left
ventricles
○ also ensures that the right ventricular cavity communicates with the
pulmonary trunk and the left ventricular cavity communicates with the
aorta
■ right atrioventricular opening - connects with right ventricular
cavity
■ left atrioventricular opening - connect with left ventricular cavity
Atrial Septal Defects
● after birth: foramen ovale closes completely as the result of the fusion of the
septum primum with the septum secundum
● in 20% to 25% of hearts: small opening (probe patency) persists
○ has no clinical significance
○ occasionally, opening is much larger and results in oxygenated blood
from the left atrium passing over into the right atrium
Ventricular Septal Defects
● ventricular septum is complete when the membranous part fuses with the
muscular part
● most common congenital cardiac malformation
● occur in either the membranous or muscular part
○ more common - muscular part
○ more serious - membranous part
● blood under high pressure passes through the defect from left to right ->
enlargement of the right ventricle
● larger VSDs - shorten life if corrective surgery is not performed
Tetralogy of Fallot
● bulbus cordis divides into the aorta and pulmonary trunk because of the
formation of the spiral aorticopulmonary septum
○ septum forms by the fusion of the bulbar ridges
● if bulbar ridges fail to fuse correctly -> unequal division of the bulbus cordis
with consequent narrowing of the pulmonary trunk = interference with the
right ventricular outflow
○ resulting congenital anomaly “tetralogy of Fallot” - most common
defect in the conotruncal region
● 4 anatomic abnormalities:
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REFERENCES: SNELL’S CLINICAL ANATOMY BY REGIONS 10TH
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1. stenosis of the pulmonary trunk (narrowing of the right ventricular
outflow)
2. large ventricular septal defect (mainly in the membranous part)
3. overriding aorta (exit of the aorta immediately above the VSD instead
of from the left ventricular cavity only)
4. severe hypertrophy of the right ventricle (because of the high blood
pressure in the right ventricle)
● although not necessarily fatal = congenital cyanosis and do considerably limit
activity
○ most children can be successfully treated surgically
● most children: squatting position after physical activity relieves
breathlessness
○ reduces the venous return by compressing the abdominal veins
○ increasing the systemic arterial resistance by kinking the femoral and
popliteal arteries in the legs
■ both of these tend to decrease the right-to-left shunt through the
ventricular septal defect and improve the pulmonary circulation
Semilunar Valves
1. Pulmonary valve
○ guards the pulmonary orifice at right ventricle
○ consists of 3 semilunar cusps
■ 1 posterior - left cusp
■ 2 anterior - anterior and right cusps
○ curved lower margin and sides of cusps are attached to the
arterial wall
○ open mouths of the cusps are directed upward into the
pulmonary trunk
○ with sinuses - 3 dilatations at the root of the pulmonary
trunk; 1 situated external to each cusp
■ systole: cusps are pressed against the wall of
pulmonary trunk by the outrushing blood
■ diastole: blood flows back to the heart and enters the
sinuses -> cusps fill -> come into apposition in the
center of the lumen and close the pulmonary orifice
2. Aortic valve
○ guards the aortic orifice at left ventricle
○ similar in structure to pulmonary valve
■ 1 anterior - right cusp
TRANSCRIBER: ANTOLO, P., ARDIENTE, J., CARAM, M., ESTANOL, A., GONZAGA, E., KRAFT, R., TABABA, R.
■ 2 posterior - left and posterior cusps
○ behind each cusps, aortic wall bulges to form aortic sinus
■ anterior aortic sinus - gives origin to right coronary
artery
■ left posterior sinus - gives origin to left coronary
artery
Embryology Notes
Development of the Semilunar Valves of the Aorta and Pulmonary Arteries
● after the formation of the aorticopulmonary septum -> 3 swellings appear at
the orifices of both the aorta and the pulmonary artery
○ each swelling consists of a covering of endothelium over loose
connective tissue -> gradually become excavated on their upper surfaces
-> form the semilunar valves
Atrioventricular valve
1. Tricuspid valve
○ guards the atrioventricular orifice at right ventricle
○ consists of 3 cusps (leaftlets) formed by folds of
endocardium with some connective tissue
■ anterior - lies anteriorly
■ septal - lies against the ventricular septum
■ inferior (posterior) cusps - lies inferiorly
○ bases of the cusps - attached to the fibrous ring of the
skeleton of the heart
○ free edges and ventricular surfaces - attached to the
chordae tendineae
■ connect the cusps to the papillary muscles
○ systole: papillary muscle contract and prevent the cusps
from being forced into the atrium and turning inside out as
intraventricular pressure rises
2. Mitral valve
○ guards the atrioventricular orifice
○ consists of 2 cusps (similar to cusps of tricuspid valve)
■ anterior - larger and intervenes between
atrioventricular and aortic orifices
■ posterior
○ attachment of chordae tendineae and papillary muscles -
similar to tricuspid valve
Embryology Notes
Atrioventricular Valve Development
● after the formation of the septum intermedium -> atrioventricular canal
becomes divided into right and left atrioventricular orifices
● raised folds of the endocardium appear at the margins of these orifices ->
folds become invaded by mesenchymal tissue -> becomes hollowed out from
the ventricular side
○ 3 cusps - formed about the right atrioventricular orifice and constitute
the tricuspid valve
○ 2 cusps - formed about the left atrioventricular orifice to become the
bicuspid (mitral) valve
● newly formed cusps enlarge -> their mesenchymal core becomes
differentiated into fibrous tissue
○ cusps remain attached at intervals to the ventricular wall by muscular
strands
○ muscular strands become differentiated into papillary muscles and
chordae tendineae
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Clinical Notes ○ current evidence: blood flows in CPR because the whole thoracic
Surface Projections and Auscultation of the Heart Valves cage is the pump
● cardiac valves are located deep to the sternum ■ heart functions merely as a conduit for blood
○ each valve has an ■ external chest compressions create an extrathoracic pressure
anatomical projection gradient in which the pressure in all chambers and locations
to a place on the within the chest cavity is the same
thoracic wall that ● with compression: blood is forced out of the thoracic cage
immediately overlies ○ flows out the arterial side of the circulation and
its position back down the venous side because the venous
○ sounds produced by valves in the internal jugular system prevent a
the valves are useless oscillatory movement
projected to ● with release of compression: blood enters the thoracic
auscultation areas cage
that are removed ○ down the venous side of the systemic circulation
from the anatomical
projections and
widely separated
from each other
● consists of 4 interconnected fibrous rings that surround the
● blood carries sound along
the direction of its flow atrioventricular, pulmonary and aortic orifices
○ each auscultation area is located superficial to the heart chamber or ● continuous with membranous upper part of ventricular septum
great vessel into which the blood flows after passing each valve ● fibrous rings - around the atrioventricular orifices
○ separate the muscular walls of the atria from the ventricles
but provide attachment for the muscle fibers
○ support the bases of valve cusps and prevent them from
stretching and becoming incompetent
● forms the basis of electrical discontinuity between the atria and
ventricles

Valvular Heart Disease ● Normal heart beat:

● inflammation of a valve = edges of the valve cusps to stick together ○ 70-90 bpm - resting adult
○ fibrous thickening occurs ○ 130 to 150 bpm - newborn child
○ loss of flexibility and shrinkage ● cardiac cycle - 1 complete heartbeat composed of two phases:
○ narrowing (stenosis) and valvular incompetence (regurgitation) 1. systole - ventricular contraction
○ heart ceases to function as an efficient pump 2. diastole - ventricular relaxation)
● in rheumatic disease of the mitral valve: ● each phase consists of a series of characteristic changes within
○ cusps undergo fibrosis and shrink and chordae tendineae shorten =
preventing closure of the cusps during ventricular systole
the heart as it fills with blood and empties
Valvular Heart Murmurs
● apart from typical lub–dub sounds of the valves closing, blood passes 1. Atrioventricular Valves
through the normal heart silently ● closed during ventricular systole (contraction)
● when valve orifices become narrowed or the valve cusps distorted and ○ blood is temporarily accommodated in the large veins
shrunken by disease -> rippling effect = turbulence and vibrations that are and atria
heard as heart murmurs ○ Atrial systole - occurs when the ventricles are nearly
Traumatic Asphyxia
full -> forces the remainder of the blood in the atria
● sudden caving in of the anterior chest wall associated with fractures of the
into the ventricles
sternum and ribs = dramatic rise in intrathoracic pressure
● anatomy of the venous system - immediate evidence of respiratory ● open once ventricular diastole (relaxation)
distress ○ blood passively flows from the atria to the ventricles
○ plays a significant role in the production of the characteristic vascular ○ ventricular systole - blood begins to move back
signs of traumatic asphyxia toward the ventricles and immediately fills the
○ thinness of the walls of the thoracic veins and the right atrium = pockets of the semilunar valves
causes their collapse under the raised intrathoracic pressure, and ■ cusps float into apposition and completely close
venous blood is dammed back in the veins of the neck and head
the aortic and pulmonary orifices
■ produces venous congestion
■ bulging of the eyes - injected 2. Sinoatrial Node
■ swelling of the lips and tongue - cyanotic ● initiates wave of contraction in the atria -> commences
■ skin of the face, neck, and shoulders - purple around the openings of the large veins and milks the blood
Anatomy of Cardiopulmonary Resuscitation toward the ventricles
● Cardiopulmonary resuscitation (CPR) - achieved by compression of the ○ blood does not reflux into the veins
chest 3. Atrioventricular node - Cardiac impulse
○ originally believed to succeed: compression of the heart between the ● conducted to the papillary muscles by the atrioventricular
sternum and the vertebral column
bundle and its branches

TRANSCRIBER: ANTOLO, P., ARDIENTE, J., CARAM, M., ESTANOL, A., GONZAGA, E., KRAFT, R., TABABA, R.
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 ● Papillary muscles - contract and take up the slack of the
chordae tendineae
● spread of the cardiac impulse along the AV bundle and its
terminal branches including Purkinje fibers - ensures that
myocardial contraction occurs at almost the same time
throughout the ventricles
● 2 sounds (“lub–dub”) - associated with each heartbeat (cardiac
cycle) when listening to the heart with a stethoscope
○ 1st sound (“lub”) - contraction of the ventricles and the
closure of the tricuspid and mitral valves
○ 2nd sound (“dub”) - sharp closure of the aortic and
pulmonary valve
● network of specialized
cardiac muscle cells
● generate rhythmic cardiac
impulses
● conduct and coordinate
the intrinsic contractions
of the myocardium
● both atria contracts first
-> simultaneous
contractions of both
ventricles
● functions:
○ pacemaker function -
initiate excitation of
the atria
○ delay excitation of
the ventricles -> allows time for the atria to empty their
blood into the ventricles before the ventricles contract
○ penetrate the fibrous cardiac skeleton
○ spread excitation across the ventricles
● components:
1. Sinuatrial (SA) node “pacemaker” of the heart
● located in the wall of the right atrium, at the junction
of the crista terminalis and superior vena cava
● spontaneously gives origin to rhythmic electrical
impulses that spread in all directions through the
cardiac muscle of the atria and cause the muscle to
contract
● relatively slow conduction velocity: atrial excitation
wave traveling at ~1 m/s
● derived from the embryonic sinus venosus
● frequency with which the SA node generates impulses
- determined by heart rate
● activity to adjust and balance heart rate as needed -
modulated by the autonomic input
2. Atrioventricular (AV) Node
● located on the right, lower side of the atrial septum,
between the attachment of the septal cusp of the
tricuspid valve and the opening of the coronary sinus
● stimulated by the excitation wave as it passes through
the atrial myocardium
● speed of conduction: about 0.1 seconds
○ allow sufficient time for atria to empty their
blood into the ventricles before systole
3. Atrioventricular Bundle (Bundle of His)
TRANSCRIBER: ANTOLO, P., ARDIENTE, J., CARAM, M., ESTANOL, A., GONZAGA, E., KRAFT, R., TABABA, R.
● from the AV node
● sescends behind the septal cusp of the tricuspid
valve, and extends into the membranous part of the
ventricular septum
● pierces the fibrous skeleton of the heart
● sole myocardial connection between the atria and the
ventricles
○ only route which cardiac impulse can travel from
the atria to the ventricles
4. Bundle Branches
● AV bundle divides into branches (one for each
ventricle) at the upper border of the muscular part of
the ventricular septum:
○ right bundle branch (RBB) - passes down on the
right side of the ventricular septum to reach the
moderator band
■ crosses to the anterior wall of the right
ventricle
■ becomes continuous with the fibers of the
Purkinje plexus
○ left bundle branch (LBB) - pierces the ventricular
septum and passes down on its left side beneath
the endocardium.
■ divides into 2 branches: anterior and
posterior
○ Eventually become continuous with the fibers of
the Purkinje plexus of the left ventricle.
5. Subendocardial Branches (Terminal Conducting Fibers,
Purkinje Fibers)
● terminal branches of the conducting system ramify
throughout the ventricular myocardium in a plexiform
fashion
● have the highest conduction velocity: 4 to 5 m/s
Internodal Conduction Paths
● impulses from the sinoatrial node travel to the atrioventricular
node more rapidly than they can travel by passing along the
ordinary myocardium
○ special internodal pathways in the atrial wall - mixture of
Purkinje fibers and ordinary cardiac muscle cells
● anterior internodal pathway - leaves the anterior end of the
sinoatrial node and passes anterior to the superior vena caval
opening
○ descends on the atrial septum and ends in the
atrioventricular node
Clinical Notes
Failure of the Conduction System of the Heart
● sinuatrial node - spontaneous source of the cardiac impulse
● atrioventricular node - responsible for picking up the cardiac impulse from
the atria
● atrioventricular bundle - only route by which the cardiac impulse can spread
from the atria to the ventricles
○ failure of the bundle to conduct the normal impulses = alteration in the
rhythmic contraction of the ventricles (arrhythmias)
○ complete bundle block = complete dissociation between the atrial and
ventricular rates of contraction
● atherosclerosis of the coronary arteries - common cause of defective
conduction through the bundle or its branches
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 ○ results in a diminished blood supply to the conducting system
Commotio Cordis
● ventricular fibrillation and sudden death - caused by blunt non penetrating D. Conducting System of the Heart
blow to the anterior chest wall over the heart
○ occurs most commonly in the young and adolescents and is often
sports-related Clinical Notes
■ sports-related: sudden blow is produced by a baseball, baseball Cardiac Pain
bat, lacrosse ball, or fist or elbow ● pain originating in the heart as the result of acute myocardial ischemia -
■ common incidence in the young: due to the compliant chest wall caused by oxygen deficiency and accumulation of metabolites, which
because of the flexible ribs and costal cartilages and the thin stimulate the sensory nerve endings in the myocardium
undeveloped chest muscle ○ afferent nerve fibers ascend to the central nervous system through the
● timing of the blow relative to the cardiac cycle is critical cardiac branches of the sympathetic trunk and enter the spinal cord
○ ventricular fibrillation - most likely to occur if the blow occurs during through the posterior roots of the upper four thoracic nerve
the upstroke of the T wave of the electrical activity of the cardiac ○ nature of the pain varies: from severe crushing pain to nothing more
muscle than a mild discomfort
■ not felt in the heart but is referred to the skin areas supplied by
the corresponding spinal nerves
■ skin areas supplied by the upper four intercostal nerves and by
● extrinsic nerve supply - both sympathetic and parasympathetic the intercostobrachial nerve (T2) intercostobrachial nerve
fibers of the autonomic nervous system communicates with the medial cutaneous nerve of the arm and is
distributed to the skin on the medial side of the upper part of the
● intrinsic nerve tract - conducting system of the heart
arm
■ certain amount of spread of nervous information must occur
A. Sympathetic Supply - originates in upper thoracic spinal cord within the central nervous system - sometimes felt in the neck
segments and the jaw
○ routes: ● Myocardial infarction involving the inferior wall or diaphragmatic surface of
the heart - gives discomfort in the epigastrium
■ through the cervical and upper thoracic sympathetic
○ afferent pain fibers from the heart ascend in the sympathetic nerves
chain ganglia and enter the spinal cord in the posterior roots of the seventh, eighth,
■ descends through sympathetic cervical and thoracic and ninth thoracic spinal nerves and give rise to referred pain in the T7
cardiac nerves to 9 thoracic dermatomes in the epigastrium
■ enters the cardiac plexuses situated below the arch of ● heart and the thoracic part of the esophagus - have similar afferent pain
the aorta around the base of the heart pathways
○ Postganglionic sympathetic fibers - terminate on the: ○ painful acute esophagitis can mimic the pain of myocardial infarction
■ sinuatrial and atrioventricular nodes
■ cardiac muscle fibers
■ coronary arteries
■ activation:
● cardiac acceleration ● arises from the right
● increased force of contraction of the cardiac aortic sinus of the
muscle ascending aorta
● dilatation of the coronary arteries ● runs forward between
B. Parasympathetic supply the right side of the
○ comes from the vagus nerves pulmonary trunk and
○ Vagal cardiac nerve branches the right auricle
○ arise in the neck, descend into the thorax, and join into the ● descends almost
cardiac plexuses vertically in the right
○ Postganglionic parasympathetic fibers - terminate on the: atrioventricular groove
■ sinuatrial and atrioventricular nodes ● continues posteriorly
■ coronary arteries along the
■ activation: atrioventricular groove
● reduction in the rate and force of contraction of to anastomose with the left coronary artery in the posterior
the heart interventricular groove
● constriction of the coronary arteries ● branches:
● Afferent fibers ○ Right Conus Artery - supplies
○ run with the sympathetic nerves ■ anterior surface of the pulmonary conus
■ carry nervous impulses that normally do not reach ■ upper part of the anterior wall of the right ventricle
consciousness ○ Anterior Ventricular Branches (2 or 3) - supply the anterior
■ blood supply to the myocardium becomes impaired: surface of the right ventricle
pain impulses reach consciousness via this pathway ■ RIght Marginal Artery - largest; runs along the right
○ run with the vagus nerves margin of the anterior surface toward the apex
■ cardiovascular reflexes

TRANSCRIBER: ANTOLO, P., ARDIENTE, J., CARAM, M., ESTANOL, A., GONZAGA, E., KRAFT, R., TABABA, R.
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 ○ Posterior Ventricular Branches - supply the diaphragmatic
surface of the right ventricle
■ Atrioventricular Nodal Branch - supplies the AV node
○ Posterior Interventricular Artery - runs toward the apex in
the posterior interventricular groove
■ gives off branches to the right and left ventricles,
including its inferior wall
■ supplies branches to the posterior part of the
ventricular septum but not to the apical part
■ artery may originate from the circumflex branch of
the left coronary artery
○ Atrial Branches - supply the anterior and lateral surfaces of
the right atrium
■ Sinoatrial Nodal Artery - supplies the SA node and
the right and left atria
● usually larger than the right coronary artery
● supplies the major part of the heart
● arises from the left aortic sinus of the ascending aorta
● passes forward between the left side of the pulmonary trunk
and the left auricle
● enters the atrioventricular branch and a circumflex branch
● branches:
○ Anterior Interventricular Artery (left anterior descending
artery, LAD) - supplies the right and left ventricles
■ run downward along the ventricular septum in the
anterior interventricular groove to the apex of the
heart
■ passes around the apex of the heart to enter the
posterior interventricular groove and anastomose
with the terminal branches of the posterior
interventricular branch of the right coronary artery
■ numerous branches that also supply the anterior two
thirds of the ventricular septum
● Lateral or Diagonal Artery - larger ventricular
branch may arise directly from the trunk of the
left coronary artery
● Left Conus Artery - supplies the pulmonary
conus
○ Circumflex Artery - winds around the left margin of the
heart in the atrioventricular groove
■ Left Marginal Artery - large branch that supplies the
left margin of the left ventricle down the apex
■ Anterior and Posterior Ventricular Branches - supply
the left ventricle
■ Atrial Branches - supply the left atrium
● collateral circulation between the terminal branches of the
right and left coronary arteries
● not large enough to provide an adequate blood supply to the
cardiac muscle
● considered functional end arteries
TRANSCRIBER: ANTOLO, P., ARDIENTE, J., CARAM, M., ESTANOL, A., GONZAGA, E., KRAFT, R., TABABA, R.
Clinical Notes
Coronary Artery Disease
● myocardium receives its blood supply through right and left coronary arteries
○ coronary arteries have numerous anastomoses at the arteriolar level ->
essentially functional end arteries
○ sudden block of one of the large branches of either coronary artery =
necrosis of the cardiac muscle (myocardial infarction) in that vascular
area
■ often, patient dies
■ acute thrombosis on top of a chronic atherosclerotic narrowing of
the lumen - most cases of coronary artery blockage
● Arteriosclerotic disease of the coronary arteries may present in 3 ways
(depending on the rate of narrowing of the lumina of the arteries):
1. general degeneration and fibrosis of the myocardium - occur over many
years and are caused by a gradual narrowing of the coronary arteries
2. Angina pectoris - cardiac pain that occurs on exertion and is relieved by
rest
■ coronary arteries are so narrow that myocardial ischemia occurs
on exertion but not at rest
3. Myocardial infarction - occurs when coronary flow is suddenly reduced
or stopped and the cardiac muscle undergoes necrosis
■ major cause of death in industrialized nations
● Coronary bypass surgery, coronary angioplasty, and coronary artery stenting -
commonly accepted methods of treating coronary artery disease
○ Coronary bypass surgery - harvesting a segment of blood vessel and
using that to circumvent a blockage in a coronary artery
○ use great saphenous vein from the lower limb as the donor vessel
because of its size and surgical ease of access
○ emerging techniques increasingly use the internal thoracic artery from
the neighboring chest wall to revascularize the heart wall
● a large, dilated vein
● lies in the posterior part of
the atrioventricular groove
(coronary sulcus)
● empties into the right
atrium just to the left of
the inferior vena cava
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● tributaries:
○ Great Cardiac Vein - drains most of the areas of the heart
supplied by the left coronary artery
■ joins left end of the coronary sinus
○ Middle Cardiac Vein & Small Cardiac Vein - drain most of
the areas normally supplied by the right coronary artery
■ drain into the right end of the coronary sinus
○ Small Anterior Cardiac Veins - drain the anterior surface of
the heart and empty directly into the right atrium
■ note: not all venous blood drain into the coronary
sinus
A. Aorta
● main arterial trunk
● delivers oxygenated blood from the left ventricle of the
heart to the tissues of the bod
1. Ascending Aorta
○ begins at the base of the left ventricle
○ runs upward and forward to come to lie behind the
right half of the sternum at the level of the sternal
angle -> becomes continuous with the arch of the
aorta
○ lies within the fibrous pericardium and is enclosed
with the pulmonary trunk in a sheath of serous
pericardium
○ at its root, possesses 3 bulges (sinuses of the aorta)
■ one behind each aortic valve cusp
○ Branches:
TRANSCRIBER: ANTOLO, P., ARDIENTE, J., CARAM, M., ESTANOL, A., GONZAGA, E., KRAFT, R., TABABA, R.
■ Right Coronary Artery - from anterior aortic
sinus
■ Left Coronary Artery - from left posterior aortic
sinus
2. Arch of the Aorta
○ continuation of the ascending aorta
○ lies behind the manubrium sterni and arches upward,
backward, and to the left in front of the trachea (its
main direction is backward)
○ passes downward to the left of the trachea and, at
the level of the sternal angle, become continuous
with the descending aorta
○ Branches:
■ Brachiocephalic Artery - arises from the convex
surface of the aortic arch
● passes upward and to the right of the
trachea and divides into the right subclavian
and right common carotid arteries behind
the right sternoclavicular joint
■ Left common Carotid Artery - arises from the
convex surface of the aortic arch on the left side
of the brachiocephalic artery
● runs upward and to the left of the trachea
and enters the neck behind the left
sternoclavicular joint
■ Left Subclavian Artery - arises from the aortic
arch behind the left common carotid artery
● runs upward along the left side of the
trachea and the esophagus to enter the root
of the neck
● arches over the apex of the left lung
3. Descending Thoracic Aorta
○ lies in the posterior mediastinum
○ begins as a continuation of the arch of the aorta on
the left side of the lower border of the body of the
4th thoracic vertebra
○ runs downward in the posterior mediastinum,
inclining forward and medially to reach the anterior
surface of the vertebral column
○ at T12: passes behind the diaphragm (through the
aortic opening) in the midline and becomes
continuous with the abdominal aorta
○ Branches:
■ Posterior intercostal arteries - given off to the
lower nine intercostal spaces on each side
■ Subcostal Arteries - given off on each side and
run along the lower border of the 12th rib to
enter the abdominal wall
■ Pericardial, Esophageal and bronchial Arteries -
small branches that are distributed to these
organs
4. Pulmonary Trunk
○ conveys deoxygenated blood from the right ventricle
of the heart to the lungs. It leaves the upper part of
the right ventricle and runs upward, backward, and to
the left
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 ○ It is about 2 in. (5 cm) long and terminates in the
concavity of the aortic arch by dividing into right and
left pulmonary arteries
○ Together with the ascending aorta, it is enclosed in
the fibrous pericardium and a sheath of serous
pericardium
○ Branches:
■ Right Pulmonary Artery - runs to the right
behind the ascending aorta and superior vena
cava to enter the root of the right lung
■ Left Pulmonary Artery - runs to the left in front
of the descending aorta to enter the root of the
left lung
● Ligamentum Arteriosum - fibrous band that connects the
bifurcation of the pulmonary trunk to the lower concave
surface of the aortic arch
○ remains of the ductus arteriosus
Embryology Notes
Development of the Roots and Proximal Portions of the Aorta and the
Pulmonary Trunk
● distal part of the bulbus cordis - “truncus arteriosus”
● spiral aorticopulmonary septum divides the truncus -> form roots and
proximal portions of the aorta and pulmonary trunk
● with the establishment of right and left ventricles -> proximal portion of the
bulbus cordis becomes incorporated into:
○ right ventricle as the definitive conus arteriosus or infundibulum
○ left ventricle as the aortic vestibule
● just distal to the aortic valves, 2 coronary arteries arise as outgrowths from
the developing aorta
Clinical Notes
Aneurysm and Coarctation of the Aorta
● arch of the aorta lies behind the manubrium sterni
○ gross dilatation of the aorta (aneurysm) - pulsatile swelling in the
suprasternal notch
○ Coarctation of the aorta - congenital narrowing of the aorta just
proximal, opposite, or distal to the site of attachment of the
ligamentum arteriosum
TRANSCRIBER: ANTOLO, P., ARDIENTE, J., CARAM, M., ESTANOL, A., GONZAGA, E., KRAFT, R., TABABA, R.
■ result from an unusual quantity of ductus arteriosus muscle tissue
in the wall of the aorta
● when ductus arteriosus contracts:
○ ductal muscle in the aortic wall also contracts
○ aortic lumen becomes narrowed
■ when fibrosis takes place: aortic wall also is involved, and
permanent narrowing occurs
● cardinal sign of aortic coarctation: absent or diminished pulses in the femoral
arteries of both lower limbs.
○ to compensate for the diminished volume of blood reaching the lower
part of the body -> an enormous collateral circulation develops, with
dilatation of the internal thoracic, subclavian, and posterior intercostal
arteries
■ dilated intercostal arteries erode the lower borders of the ribs =
producing characteristic notching
● seen on radiographic examination
Patent Ductus Arteriosus
● ductus arteriosus - distal portion of the sixth left aortic arch
○ connects the left pulmonary artery (near its origin from the pulmonary
trunk) to the beginning of the descending aorta
● fetal life: blood passes through it from the pulmonary artery to the aorta =
bypassing the lungs
● after birth: normally constricts -> closes -> becomes ligamentum arteriosum
○ failure of the ductus arteriosus to close - isolated congenital
abnormality or associated with congenital heart disease
● persistent patent ductus arteriosus - results in high-pressure aortic blood
passing into the pulmonary artery = pulmonary hypertension and
hypertrophy of the right ventricle
● life threatening and should be ligated and divided surgically
A. Brachiocephalic Veins
1. Right Brachiocephalic Vein
○ formed at the root of the neck by the union of the
right subclavian and the right internal jugular veins
2. Left Brachiocephalic Vein
○ same origin
○ passes obliquely downward and to the right behind
the manubrium sterni and in front of the large
branches of the aortic arch
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 ○ joins the right brachiocephalic vein to form the
End of Transcription
superior vena cava
B. Superior Vena Cava
● contains all the venous blood from the head and neck and
both upper limbs
● formed by the union of the two brachiocephalic veins
● passes downward to end in the right atrium of the heart
● vena azygos joins the posterior aspect of the superior vena
cava just before it enters the pericardium
C. Azygos Veins
● drain blood from the posterior parts of intercostal spaces,
posterior abdominal wall, pericardium, diaphragm,
bronchi, and esophagus
1. Main Azygos Vein
○ origin is variable
○ formed by the union of the right ascending lumbar
vein and the right subcostal vein
○ ascends through the aortic opening in the diaphragm
on the right side of the aorta to the level of the fifth
thoracic vertebra
○ arches forward above the root of the right lung to
empty into the posterior surface of the superior vena
cava
○ tributaries:
■ eight lower right intercostal veins
■ right superior intercostal vein
■ superior and inferior hemiazygos veins
■ numerous mediastinal veins
2. Inferior Hemiazygos Vein
○ formed by the union of the left ascending lumbar vein
and the left subcostal vein
○ ascends through the left crus of the diaphragm and,
at about the level of the eighth thoracic vertebra,
turns to the right and joins the azygos vein
○ receives as tributaries some lower left intercostal
veins and mediastinal veins
3. Superior Hemiazygos Vein
○ formed by the union of the fourth to the eighth
intercostal veins
○ joins the azygos vein at the level of the seventh
thoracic vertebra
D. Inferior Vena Cava
● pierces the central tendon of the diaphragm opposite the
eighth thoracic vertebra and almost immediately enters
the lowest part of the right atrium
E. Pulmonary Veins
● 2 pulmonary veins leave each lung carrying oxygenated
blood to the left atrium of the heart

Clinical Notes
Azygos Veins and Caval Obstruction
● obstruction of the superior or inferior venae cavae: azygos veins provide an
alternative pathway for the return of venous blood to the right atrium of the
heart
○ possible because these veins and their tributaries connect the superior
and inferior venae cavae

TRANSCRIBER: ANTOLO, P., ARDIENTE, J., CARAM, M., ESTANOL, A., GONZAGA, E., KRAFT, R., TABABA, R.
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REFERENCES: SNELL’S CLINICAL ANATOMY BY REGIONS 10TH