Pericardium

(******Short Note)
Introduction: The pericardium is a fibroserous sae that contains the heart and the roots of the
great vessels.
Layers of Pericardium:
There are two layers to the pericardial sae:
L. fibrous pericardium
2. Serous pericardium.
1. Fibrous pericardium
• The fibrous pericardium is the most superficial layer of the pericardium
• It is a cone shaped bag with a truncated apex directed above
• It is a dense connective tissue, protecting the heart, anchoring it to the
surrounding
walls, and preventing it from overfilling w ith blood.
• Above, it fuses with the outer adventitial layer of the neighboring great blood
vessels
• Below it is firmly attached to the central tendon of the diaphragm
• In front it is attached to the upper & lower ends of the body of the sternum
by the superior & inferior sterno-pericardial ligaments
2.Serous pericardium
• The serous pericardium is deeper than the fibrous pericardium
• It is a closed sae & lies within the fibrous pericardium
• It contains two layers, both of which function in lubricating the heart to prevent
friction from occurring during heart activity
• The layer adherent to the fibrous pericardium is the parietal layer
• The layer deep to the fibrous pericardium is the visceral layer It is also called as
the
epicardium

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 • In betw een the parietal and visceral pericardial layers there is a space called
the pericardia1 cav”ty.
• It is normally lubricated by a film of pericardial fluid
• Applied aspect of Pericardial cavity: Too much fluid in the cavity(such as ”n
a pericardial effusions can result in pericardial tamponade, compression of the
heart within the pericardial sae.
• The continuity between parietal & the visceral layers is established in the form of
two
tubes
one tube surrounds the ascending aorta & the pulmonary trunk (arterial end of
the primitive hearty
the second tube surrounds the four pulmonary veins, the superior & the inferior
venae cava (venous end of the primitive heart)

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3.Pericardial sinus(Short note)
The pericardial sinuses are pockets in the pericardial cavity
There are two Pericardial sinuses:
• Tranwerse and
• Oblique.
Transverse Sinus: The passage betw een the venous and arterial mesocardia—i e , betw een the
aorta and pulmonary artery in front and the atria behind—is termed the transverse
sinus
Clinical Importance of tranwerse sinus: The catheter is passed through this sinus to
occlude the main vessels of heart during open heart surgery
Oblique 9nus: The cut-de-sae enclosed between the limbs of the inverted-j of the venous
mesocardium, lies behind the left atrium and is know n as the oblique sinus
Anatomical Importance of Oblique sinus: It acts as bursa for the frictionless movements
of
heart in the pericardium It is similar to lesser omentum of abdomen for the
stomach
.. › .. ..‹..*

s.

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Arterial Supply of the Pericardium
• Its main arteries are the pericardiacophrenic and musculophrenic arteries, which
are branches of the internal thoracic arteries
• It also receives pericardial branches from the bronchial, oesophageal, and
superior
phrenic arteries
• The epicardium is supplied by the coronary
arteries Venous Drainage of the Pericardium
• Its veins are tributaries of the azygos systems of veins
• Pericardiacophrenic veins also enter the internal thoracic veins
Nerve supply of the pericardium
• The fibrous pericardium and the parietal layer of the serous pericardium are
supplied by the phrenic nerves
• The visceral layer of the serous pericardium is supplied by the branches
from the sympathetic trunks and the vagus nerve
Applied Anatomy of the pericardium
• Applied aspect of Pericardial cavity: Too much fluid in the cavity(such as in
a perirardial effusion) can result in pericardial tamponade, compression of the
heart within the pericardial sae
• Oinical Importance of tranwerse sinus: The catheter is passed through this
sinus to occlude the main vessels of heart during open heart surgery

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 HEART
Question)

Introduction: Heart is vital organ and the central pump in the cardiovaSCular system.
It is a hollow, COniCal muSCUlar organ.
Location: It is situated in the middle mediastinum.
CDvering: Lies w ithin the periCardium.

External Features of heart (Short note):

Heart presents:
• Apex
• Base (Posterior surfaCe)
• Three surfaces
o Sternocostal, Diaphragmatic 6 Base(Posterior sUrfaC9)
• Three borders
• Right, Inferior 6 Left borders.

Apex of the heart

The apex Df the heart is the lowest superficial part of the heart.
• It is directed downward, forward, and to the left
• is overlapped by the left lung and pleura.
• it is a conical area formed only by the LED VENTR L.
• It lies behind the TiTth left intercostal space, 8to 9 cm. from the mid-eternal line, slightly
medial to the midClavicular line.
• Alternately, it can be found about 4 cm. below and 2 mm. to the medial side of the left
nipple

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Base of the heart
• It is formed mainly by thR left atrium, and, to a small Rxtent, by the back part of thR right
atrium.
• Somewhat quadrilateral in form.
• It is in rRldtion above with thR bifurcation of the pulmonary artery, and is boundRd below
by the posterior part of the coronary sulcus, containing thR Coronary sinus.
• On the right it is limited by the sulcus tRrminali5 Of the right atrium, and on the
left by the IigamRnt of thR IRft vRna cava and thR DbliquR vein Of thR left atrium.

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 • The four pulmonary veins, two on Rither side. opRn into thR IRft atrium, while the
supRrior vena cava opRns into the upper, and thR inferior vena cava into thR IowRr, part
Df the right atrium

RemocoRal surface(anterior surface of the heart)

• is directed forward, upward, and to thR left.
• Its IDwRr part is convRx, fDFITIRd d›iefly bythR right ventricle.
• traversRd nRar its IRft IT\argin bythR anterior intRrventricular groove.
• Anterior part of atrio-ventricular groove (Coronary sulcus) passRs downwards 6 to the
right betwRRn right atrium & right vRntridR

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 • The atria-ventricular grooVR (Coronary suIcus)Iodge5thR trunk of right coronary aFtRry and
anterior cardiac vein.
• Anterior intRrvRntricular groove is seRn bRtwRRn right and IRft vRntriClR5. It lodges
antRrior intRrvRntriCUldF branch of left coronary artery and great cardiac vRin.
This surface is formed by the following parts of thR heart:
• Anterior surfaCR Df right atrium & its auriclR.
• A part of IRft auride
• ADtRrior sUrfdCR DfthR right ventride (2/3)
• AntRrior sUFfaCR Of the IRft BtFiUIT\ (1 3)

Diaphragmatic surface of heart (inferiorsurfaoe)

• Is directed downward and slightly backward
• is formed by two vRntriClR5 -2/ 3 by left vRntriClR & 1 3 by the right vRntridR.
• rests upon the central tendon and a small part of the left muscular portion of the
diaphragm.
• It is separatRd from thR bB5R by the postRnor part Df thR atrio-vRntricular groove.
• is traversed obliquely by the posterior interventricular grOOVR.
• In postRnor interventricular groove run thR posterior intRrventricular artery and middlR
CdFdiac vein

• is directed upwards, backwards & to the IRft

• is formed by mainly thR left vRntricle 6 partial by the IRft Btrium 6 its auriclR.
• IRft part of the atria-ventricular groove intervenes bRtwRen IRft duriClR & left
ventricle. It contains left coronary drtRD/.
Right border of heart
• is formed by the right atrium.
• is roundRd and almost vertical
• Mends from the opening of supRrior vRnacava tD that of infRrior vRnacava.
• A shallow groove known as thR sukus terminalis accompanies the right boroer.
Inferior border
• Is sharp 6 nRdFI§ horizontal
• It extends from the opening of inferior vRnacava to the apex of the heart.
• CIOSR to the apRx it presents a notch, CBIIRd thR incisura apicis
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 • is named the acute
margin Left margin of
heart(obtuse margin)
• is shorter than the right border of heart
• full and rounded.
• it is formed mainly by the left ventricle, but to a slight extent, above, by the left
atrium.

Heart consists of four chambers:

• Right 6 Left atrium.
• Right 6 Left ventricle.

External Featuresofheart:

Right Atrium: (******Short Note)

It forms the right border and part of sternocostal surface of the heart. It is separatRd from the
right ventricle by atrioventricular sulcus (coronary sulcus).

Interior of the riQst atrium is divided into thee

parts:
. Rough part(Pe‹tinate part)
2. 9nooth part (9nus venarum)
3. Septal part (Interatrial septum)

. Rough had: (Peinate a (Anterior Pad)

It is formed by anterior wall of the right atrium and also formed by right auricle.
Featuresseen:
CriRa terminalis. It is sharp crest seen at the inner aspect of the right border of heart.
N usculi peztinati: This is comb like appearance of the rough part extending from the crista terminalis.
Right auride. It is small ear like part of right atrium containing rough trabeculae within it.
Rough part embryologically is derived from the primitive atrium.
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2. Smooth part(Since venamm(Posterior part):
It is formed by the postRrior wall Dfthe right atrium.
Faatures seen:
Smooth wdll rRceivRd openings of the vRin in to it.
Opening of Superior vena ‹ava in the uppRr part.
Opening of Inferior vena cava in thR lower part with vBIvR of InfRrior vRna cava.
Opening of coronary sinus and its valve located just adjacRnt to opening of Inferior vena
cava.
Smooth part Rmryologically is dRrived from the Sinus vRnosu5. HRnce it is known as Sinus
venarum.

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It is formed by interatrial septum.
Features seen:
FDSSd 0Valis. It is oval shaped depression. It is embryological remnant of Septum primum.
Limbus fossa ovalis. It IS CF9SC90tiC margin of the fossa ovalis. It is embryological remnant of Septum
secondum.

4. At io entri ar value: Tri u pid value): at:s ommunicating ight atrium

to right ventFICIP dnd formed by thFee Cusps.

Right Ventricle note):

It forms the part of sternocostal surface and diaphragmatic surface of the heart. It is separated
from the right atrium by atrioventriCular sulcUS (coronary sulcus) and from the left ventricle by
anterior and posterior parts of interventriCular sulCuS.
W all the right ventricle is three times thinner than the wall of left ventricle. (Thin walled)

Interior of the rigkt Ventricle is divided into two

parts:
. RDugh part (Trabeculae camZR)

2. Smooth part (Infundibulum)

. Rough pad: Trabe u ae a nae)

It is formed by ridges, bridges and papillae.

Features seen:
Ridges: It is raised elevations from the Wall of ventFlClE.
BridgRS. It is raised elevations attached at two ends and Tree in between. Example of
bridges is N oderator band from interventricular septum to base of anterior papillary
muscle.

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Papillae: It is conical nipplR IikR projRctions from the wall of ventriClR. There arR three papillae in
right
ventridR.
The papillae are also known as papillary musdez
interior papillary muscle
Po&erior papillary musde
Septal papillary muscle (formed by small multiple papillae)
From thR apex of thR papillary musclRS thR thin strand Rxtend to thR margin DfthR IeaflRt (cusp)
of thR atriovRntriculaF (tricuspid) VBIVR. RSR thin strands arR known as ChoFdae Tendinae.
Rough part Rmbryologically is derivRd from thR primitive ventricle.

2. Smooth part( n n ibulum):

It is formRd bythR DUt-flowing smooth part whirl IRads to pulmonary trunk. At its tRFlTiination
thRFR i5
pulmonary valve with thrRe cusps.

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Smooth part embryologically is derived from the bulbus C0rdis.

right atrium to right VPFtFlCle and formed by thFee Cusps.

Ventricle:
It forms the part of steFn0Costal surfaCe and diaphragmatic surfaCe of the heart. It is separated from
the left atrium by atrioventricular sulcus (coronary sulcus) and from the right ventricle by anterior
and posterior parts of interventriCular sulcus
W all the left ventricle is three times thicker than the wall of right VPFtFlC P. (Thick walled)

Interior of the Ventricle is divided into two

. Rough part (Trabeculae camae)
2. tooth part (Vestibule)

. Rough pad: Trabe u ae larvae)

It is formed by ridges, bridges and papillae.

Features seen:
Ridges: It is raised elevations from the wall of ventricle.
Bridges: It is raised elevations attached at two ends and free in between.
PB}iil BR: It is conical nipple like projections from the wall of ventricle. There are tw o papillae
in left
VPFtFl Cl P.

Thh {iBpillae are also knDwn as Capillary muscles

AntRriDF Capillary muscle

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Po&erior papillary musde
From thR apex of thR papillary IT\U5/R5 thR thin strand extRnd to the margin ofthR IRdflRt (cusp) of
thR atrioventricular (Mitral) valVR. ThRSR thin strands are known as Chordae Tendinae.
Rough part embryologically is dRrived from the primitive ventricle.

2. Smooth part(Veibule):
It is formRd bythR DUt-flowing smooth part whirl IRads to AscRnding aorta. At its tRrmination thRre is
Aortic valve with three cusps.
Smooth part RIT\bF}/OlDgicall}/ iS dRrived from the bulbus cordis.

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 . Aortic valve at the junction of smooth pad of right
ventric e and Amending ao a.

4. Led Atrioventric ar valve: N itra valve): it isommuni ating Ie t at

ium
to left ventricle and formed by three cusps.

Left Atrium:
It forms the base of the heart or posterior surface of heart.

Interior of the leR atrium is divided into three

parts:
. Rough part
2.tooth part
3.Septal part

It is formed bt left auriCl£'.

Left auricle. It is small ear like part of right atrium containing rough trabeCulae w ithin it.
Rough part embryologiCally iS derived from the primitive atrium.

2. Smooth pad
It is formed by the posterior wall of the left atrium.
It receives two pulmonary veins on each side. HeFCe four pulmonary veins open into left atrium.
Smooth part embryologically is derived from absorption of pulmonary veins.

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It is formed by interatrial septum.

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Features seen:
Fossa lunata. It is counterpart of fossa ovalis of right atrium.

4. Led Atrioventricu a value: N itra value): ir is ommuni ating right

atrium to right ventricle and formed by thFee Cusps.

Valves of the heart (viva)

. Right ZtriDvRntricular (Tricuspid) valve. It is between right atrium and right ventricle.
It has three cusps: Anterior, Posterior and septal.
It is best auscultated at left fourth intercostal space just lateral to left sterna border.
2. Aft atriovRntricular (Nitral valve). It is between left atrium and left ventricle.
It has tw0 Cusps: Anterior and posterior.
It is best auscultated at left fifth intercostal space at midclaviCular line.
. Aortic valve: It is between left ventricle and ascending aorta.
It has three cusps: Anterior left, anterior right and posterior.
It is best auscultated at right second intercostal space just lateral to right stern a border.
4. lmDnary valve: It iS between right ventricle and pulmonary trunk.
It has three cusps. Anterior left, anterior right and posterior.
It is best dUSCultated at left SECOFd IFltercostal spaCe just lateral to left sterna border.

General Structure of the Cardiac Wall

• It consists of three layers.
• The endocardium, the internal layer. This layer is continuous w ith the endothelium of the great
vessels.
• The M/DCardium, the muscular layer.
• The R{iicardium, the subepicardial fat and c0FFECtive tissUe beneath the visceral layer
of the serous pericardium.

Gmat vessels of the heart (Viva)

Ascending Ao a: Originating from the left ventricle.
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Pulmonary trunk: Originating from thR right ventride.
Superior Vena cava: Opening in the upper part of right atrium.
Inferior vena cava: 0pRning in the IowRr part of right atrium
Pulmonary veins: Four pulmonary veins. Two opens on each sidR Df IRft atrium

Blood wpply of heart (******Short Note)

Arterial supply:
HRdrt is suppliRd by right and left coronary BrtRFiRs. Coronary drtRriRs arR functional Rnd artRries.
That means even though it has anastomosis with RdCh other in circumstances of blockage they are
not abIR tD supply the arRa of blDckRd vessel and IRads to infarction.

Right corona
ryanterior aortic sinus of ascRnding aorta.
Origin: Right
Zeurse:
• It emerge between right auride and pulmonary trunk.
• It runs obIi§URIy in the antRrior part Df thR Btriventricular (coronary sulcus).
• At thR IowRr bordRF Df hRdFt, it turns posteriorly on thR diaphragmatic surface in the
posterior part of coronary sulcus.
• It gives posterior interventricular branch.
• It tRrminates by anastomosing with circumflex branch of the left coronary artery.
Brandies:
• Nodal branr : supply in 80P• peoplR SP node.
• Conal branr : supply aorta and pulmonary trunk.
• Right marginal branch
• Posterior intRrventricular branch which runs in postRrior intRrVRDtricular sulcus and
tRrminates
by anastomosing with anterior interventricular branch of IRft coronary artery.
Area of di&ribution:
• Right atrium

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 • WhOIR Of right ventriClR RxcRpt small part adjacent to anterior intRrvRntricular sulcus.
• Small part of left vRntricle nRar thR postRrior interventricular sulcus.
• Posterior half of intervRntricular sRptum.

Wimonary trunk
Left coronary artary

R@ht
Anterior interventricuiar a.
coronary Left marginal a.
Atrioventricuiar nooal a
Post interventficular a.
Right may

Origin: Left antRrior aortic sinus of ascending aorta.

Course:
• It RmergR bRtweRn IRft auricle and pulmonary trunk
• It gives antRrior interventricular branch which runs in antRrior interventricular sulcus.
• Further continuation of IRft Coronary artRry is known as circumflRx coronary artery which runs
in the postRrior part of coronary sulcus.
• It tRrminatRS by anastomosing with right coronary
artery. Brandies:
• Nodal branch: supply in 20a pRoplR SA nodR.
• Conal branch: supply aorta and pulmonary trunL

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 • Anterior interventricular branch which runs in anterior interventricular sulcus and
terminates by anastomosing with poterior intervRntricular branch of right coronary artery.
This artery further gives diagonal branches for the left ventricle.
Area of diRribution:
• Left atrium
• Whole of left ventricle except small part adjacent to posterior interventricular sulcus.
• 5maII part of right vRntricle near the antterior interventricular sulcus.
• Anterior half of interventricular septum.

Types of coronarycirculation to the heart:

R ht dominance! When the posterior interventricular artery is branch from the right coronary
artery. This type of circulation is present in most of the individuals.
Left dominance: W hen the posterior interventricular artery is branch from the left coronary artery.
This type of circulation is present in few individuals. This pattern is more prone to lead to M
yocardial infarction (Heart Attack)
Balanced type: When the posterior interventricular artery is branch from both right and left
coronary artery.
Applied Anatomy of Arterial supply:
As the coronary arteries are functional end arteries, blockage of any of the artery or its branch leads to
loss of blood supply to area of heart supplied by it. It leads to M yocardial infaction. (Heart
Attack).

Venous
Veins of the heart:
Coronary sinus(Short note)
largest vein of the heart.
Located in the posterior part of the coronary sulcus.
Tributaries:
Great cardiac vein
Middle cardiac vein
AFltRrior cardiac

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 veins 5maII cardiac
veins

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 Vein of left atrium
Termination. It opens in the right atrium of heart.
Greatcardiac vein: Located in anterior interventricular sulcus drains in to coronary sinus.
N iddle cardiac vein: Located in posterior interventricular sulcus drains in to coronary
sinus. Anterior cardiac veins: Located in coronary sulcus drains in to coronary sinus.
Small cardiac veins: drain into coronary
sinus. Vein of left atrium. drains in to
coronary sinus.
Venae cordis minimi. 5maII veins directly open in to the chamber of heart.

Aortc arch

Pulmonary trunk

Left alrium

Right atrium

Middle cardiac vein

Small cardiac vtin

night vontricle
Lelt ventricle

Conducting system of Heart (Short note)

Sinuatrial node (SA node):
Located in the upper part of crista terminalis. Beating rate is 60-80 beats per minute. It is
known as pacemaker of heart.

Atrioventricular node (AV node):

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Located just besides the atrioventricular valve in right atrium .

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Bundle of His:
Located in the membranous part of interventricular septum. Transmit impulses from AV node to
ventricles.

Right and left bundle branches:

Right and left branches of bundle of his respectively enter the right and left ventricles through
interventricular septum

Purkinje fibers:
Final terminal branches in the wall of the ventricles.

Iriternodal Tracts
SA
Node
Left
A-V Posterior Foscicle

Lefi
Anterior Fascicie

Bundle
of His Left
Septol Fibers

R. Bundle Purkinje
Branch Fibers

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Nerve supply of heart(viva)
Parasympathetic nerve supply: Vagus nerve (10* cranial nerve)
Stimulation of vagus is responsible for the decrease in the heart ratR.

Sympathetic nerve supply: Cervical sympathetic chain containing

fibers from TI-T4thoracic segments of spinal cord.
5timulatiDn of sympathRtic nervRs is respDnsible fDFthR increasR in the heart rate.

Applied Anatomy of heart(Viva)

Angina pectoris. temporary narrowing of the coronary arteries leads to severe excruciating pain in the
precordial region radiating to chin and left arm.
Nyocardial infarction: It is serious condition due to sudden blockage of coronary artery or its branches
leading to loss of blood supply to myocardium causing ischemia of the sam.
CongRnital heart diseases.
Atrial septal defect: DRfect in the atrial septum which IRdds to mixing of oxygenated and
deoxygenated blood.
Vantricular septal defect: Defect in the interventricular septum which leads to mixing of oxygenated
and deoxygenated blood.
Valvular diseases of heart.
Narrowing of valves is known as stenosis e.g. Mitral stenosis
Incompetence of valve is known as regurgitation e.g. M itral
regurgitation.
Coronary angiongraphy: radiological study of vascular pattern of coronary arteries to identify any
blockage in the artery.
Coronary angioplasty. Repair of the block of the artery by putting stent in the coronary
artery.
Bypass surgery for heart: Blocked coronary artery is bypassed by putting venous, arterial graft or by
transposition of vessel.

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