EMBRYOLOGY OF HEART AND LUNGS

Introduction

The development of heart and lungs begin early in pregnancy. The heart is the first functional
organ in an embryos At around 2 to 3 weeks after fertilization, the heart starts to form, and
begins to beats spontaneously by week 4 of development

Definition

Embryology of heart refers to the process of heart development during fetal life.

Primitive development

The heart derives from embryonic mesodermal germ-layer cells that differentiate into the

myocardium. Mesothelial pericardium forms the outer lining of the heart. The inner lining of
the heart, lymphatic and blood vessels, develop from endothelium.

Endocardial tubes
On either side of the neural plate, which is formed by ectodermal tissue and forms the basis
of nervous system, a horseshoe-shaped area develops as the cardiogenic region. The heart
begins to develop near the head of the embryo in the cardiogenic area. Two cords begin to
form in the cardiogenic region. As these form, a lumen develops within them, at which point,
they are referred to as endocardial tubes. The two tubes migrate together and fuse to form a
single primitive heart tube, the tubular heart which quickly forms five distinct regions which
are the truncus arteriosus, bulbus cordis, primitive ventricle, primitive atrium, and the sinus
venosus.

The truncus arteriosus will divide to form the aorta and pulmonary artery

The bulbus cordis will develop into the right ventricle

The primitive ventricle will form the left ventricle

The primitive atrium will become the front parts of the left and right atria and their
appendages.

And the sinus venous will develop into the posterior part of the right atrium, the sinoatrial
node and the coronary sinus.
Layers of the heart

The myocardium thickens and secretes a thick layer of rich extracellular

matrix containing hyaluronic acid which separates the endothelium.

The inner endothelium layer forms the endocardium.

The pericardium and epicardium are formed byt mesothelial cells.

Formation of heart chambers

During the fourth week, the sinus receives venous blood from the poles of right and left sinus.
Each pole receives blood from three major veins: the vitelline vein, the umbilical vein and the
common cardinal vein.

Tissue masses called endocardial cushions develop into atrioventricular regions. It helps in

the formation of auricular septum, ventricular conduits, atrio-ventricular valves and aortic
and pulmonary channels.

A single pulmonary vein develops in the form of a bulge in the back wall of the left atrium.
This vein will connect with the veins of the developing lung buds.

Development of the pacemaker and conduction system

The rhythmic electrical depolarization waves that trigger myocardial contraction is myogenic,
which means that they begin in the heart muscle spontaneously and are then responsible for
transmitting signals from cell to cell. 

Myocytes initiate rhythmic electrical activity. Myocytes forms the Sinoartrial node (SA
node). The superior endocardial cushions begin to form the atrioventricular node. With the
development of the SAN, a band of specialized conducting cells forms the Bundle of His that
sends a branch to the right ventricle and one to the left ventricle.

The embryonic heart rate beats at approximately 165-185 beats per minute nearing 7th week
of gestation. After the 13 week heart rate decelerates to an average of 145 beats per minute.
Fetal circulation

During the 8th week of gestation, circulatory blood through the placenta is well established.
Three physiological diversions are present in the form of shunts, these are:

1. Ductus venosus: Connects the umbilical vein to the inferior vena cava
2. Ductus arteriosus: connects the main pulmonary artery to the aorta
3. Foramen ovale: Anatomical opening between right and left atrium

Circulation before birth

Oxygenated blood enters the fetal body through the umbilical vein. About half of the blood
enters the liver through portal sinus, with the remainder entering the inferior vena cava
through ductus venosus. Blood from the inferior vena cava enters the right atrium, and passes
directly into the left atrium through foramen ovale. A small amount of blood is pumped to the
lungs by the right ventricle. The remaining blood from the right ventricle joins the left
ventricle through the ductus arteriosus.

Circulation after birth:

Umbilical arteries become occluded by contraction of muscles and remain in adults as medial
umbilical ligaments.

Left umbilical vein also gets occluded just a few minutes after birth. It remains in adults as
ligamentum teres of liver

The ductus venous closes when the cord is cut and blood flow form umbilical cord ceases. It
remains in adults as ligamentum venosum in depth of the inferior sulcus of liver.

With rise in infant oxygen levels in blood the ductus arteriosis constricts and closes at 3
weeks after birth. It remains in adults as ligamentum arteriosum.

The foramen ovale closes by 3 months of age because pressure in the right side of the heart
falls as the lungs become fully inflated.
Features of heart development in embryonic and fetal life.

Weeks Features
Week 2-3 Heart is tubular and begins to beat
Week 5 Double heart chambers are visible
Week 8 Circulatory system through umbilical cord is established
Week 10- 12 Heart beat is detected by Doppler transducer
Week 20 Heartbeat is detected by regular (non-electronic) fetoscope
Week 29-32 Rhythmic beating movements occur
Embryology of the lungs

Introduction

The lung bud forms from the respiratory diverticulum  as an

embryological endodermal structure that develops into the respiratory tract organs such as
the larynx, trachea, bronchi and lungs

Early development

At 4th week of gestation, the respiratory diverticulum, starts to grow from the ventral (front)
side of the foregut (the anterior part of the alimentary canal, from the mouth to
the duodenum), into the mesoderm that surrounds it, forming the lung bud.

Larynx development
The endoderm form the epithelium of the larynx. The laryngeal cartilages are formed by
the mesenchyme(mucus connecting tissue) of the fourth and sixth pharyngeal arches.

The 4th pharyngeal arch forms the epiglottis and the 6th pharyngeal arch forms the thyroid,
cricoids cartilages. Later, it recanalizes leaving two membrane-like structures: the vocal
folds and the vestibular folds.

Trachea and bronchi

The lung buds form the trachea and the two lateral outpouchings called bronchial buds. At 5th
week, each bud enlarges to form the right and left main bronchi. The right then forms three
secondary bronchi giving rise to three lobes, and the left forms two secondary bronchi giving
rise to two lobes.

Lung development stages

Pseudoglandular stage: The first stage of alveolar development, spanning between the 5th and
the 16th week of development. The primitive alveoli resemble glandular tissue.

Canalicular stage: From 16th to 25th week. Bronchioles are produced, increasing number of
capillaries in close contact with epithelium and the beginning of alveolar epithelium
development and production of surfactant.
Saccular stage: From 25th to 40th week. The terminal tubes narrow and give rise to small
saccules, which become increasingly associated with capillaries as to make gas exchange
possible. 

Alveolar stage: It is seen in late fetal life. The alveolar epithelium begins to differentiate into
two distinct types of cells: type I pneumocytes and type II pneumocytes, as well as
the respiratory epithelium of the trachea and bronchial tree.

Features of lung development

Stages Weeks Features

Embryonic Week 4 to 5 Lung buds originate as an outgrowth from the ventral
wall of the foregut where lobar division occurs
Pseudoglandular Week 5 to 17 Conducing epithelial tubes surrounded by thick
mesenchyme are formed, extensive airway branching
Canalicular Week 16 to 25 Bronchioles are produced, increasing number of
capillaries in close contact with epithelium and the
beginning of alveolar epithelium development
Saccular Week 24 to 40 Alveolar ducts and air sacs are developed

Alveolar Late fetal life Secondary septation occurs, marked increase of the
number and size of capillaries and alveoli

Prenatal diagnostic tests for cardiac and pulmonary anomalies

1. Four chamber view

This is the most important view in both fetal echocardiography as well as on a

standard second trimester anatomy scan, which is easy to obtain and shows many features of
both normality and abnormality. It is assessed on an axial (transverse) plane through the fetal
thorax.

Features to evaluate:

 Situs: establish heart on the left side, same side as fetal stomach
 Axis:  cardiac apex normally points to the left, at an angle of 45°+/-20°
 Heart size: should occupy approximately 1/3rd of the thoracic area
 Heart location: any mediastinal shift or ectopia cordis
 Heart rate: normal 120-160 bpm
 Bradycardia below 100 beats can be assessed which indicates fetal distress
 Tachycardia above 200 beats per minute
 atrial chambers: similar in size, with foramen ovale flap opening to the left atrium

2. Pulse Doppler

This techniques records the relationship between atrial and ventricular contractions. The
Doppler is positioned over the superior vena cava and the ascending aorta

3. M- mode

Pathological arrhythmias such as complete heart block and supraventricular tachycardia is

assess using this method of echocardiography

4. Spatio temporal image correlation and rendering (STIC)

Three dimensional fetal echocardiography using high quality 3D equipment. It is acquired in

a transverse sweep through fetal thorax at level of descending aorta

5. Ultrasound with tomographic display for lung abnormalities

The lung length, development can be best appreciated showing typical convex shaped upper
border and the concave shaped lower border being the hypoechoic line of the diaphragm.