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THE

HUMAN
HEART
DR. NWOSU C.I.A.,
MSc,MBBS,MD.

LEARNING OBJECTIVES
The heart is a 3-layered, 4-chambered double pump that,
in the embryo invaginated into a preexisting sac,
The surfaces and borders in the surface anatomy of the
heart enables accurate diagnosis in trauma and diseases,
The knowledge of the heart layers is helpful in the
appreciation of such diseases as rheumatic carditis,
The fibrous skeleton is dense connective tissue to which
structures of the heart are attached,
There are 4 heart valves, 2 A-V valves & 2 semilunar
valves: PAMT,
All 4 heart valves are located directly behind the sternum,
but the sound of their closure is heard in areas different
from their anatomical location,
The closure of the A-V valves is responsible for the first
heart sound, whereas the closure of the semilunar valves
is responsible for the second heart sound,
Venous return, stroke volume & cardiac output,
The cardiac cycle describes events from the beginning of
one beat to the beginning of the next,

THE HEART IN MIDDLE MEDIASTINUM

SURFACES & BORDERS


3 SURFACES:

Anterior or sternocostal : RT atrium , Rt ventricle & AVG


Posterior or base : mostly left atrium,
Diaphragmatic surface : RT & LT ventricles, and PIG,
3 BORDERS:
Superior border :from 3rd Rt CC to 2nd LT CC
Inferior border : RT atrium & RT ventricle; from 6 th CC to AB,
Rt border : Rt atrium ; from 3rd RT CC to 6th RT CC
Lt border : LT ventricle & LT auricle ;from 2 nd LT CC to AB
AB = apex beat = where maximum cardiac impulse is felt;
it is located on the 5TH left intercostal space, mid-clavicular
line (5th LT ICS, MCL)

CRUX = point of intersection between IAG, Iinter-atrial &


interventricular grooves/sunci ; AV nodal artery from RT coronary artery
takes off from here,
The Rt heart lies anteriorly & the left posteriorly, as a result of cardiac
folding in the 4th week of intrauterine life which brings the arterial and
venous ends together,

STERNOCOSTAL SURFACE &


THE 4 BORDERS

DIAPHRAGMATIC & POSTERIOR


SURFACES

Posterior
surface or
base

Diaphragmatic
surface

SURFACE ANATOMY OF THE


BORDERS OF THE
HEART/CARDIAC APEX

HEART FIBROUS SKELETON


Embryologically, the cardiac jelly forms the fibrous
skeleton of the heart : dense connective tissue to
which structures of the heart are attached
The fibrous skeleton consists of 4 rings (which
encircle 4 valves), 2 trigones, and membranous
portions of inter - atrial and inter - ventricular septa,
tendon of Todaro, and supraventricular crest,
The trigones connect the rings to the inter - atrial
and inter - ventricular septa
Functionally the fibrous skeleton
- keeps the valves open ,
- keeps the valves from being overstretched by large volumes,
- provides attachment points for the myocardium,
- provides electrical insulation to atria & ventricles = separates
atria from ventricles so they can contract independently
- membranous IVS provides a passageway for the AV bundle of His,

THE FIBROUS SKELETON OF


THE HEART

HEART CHAMBERS

EACH OF THE 4 HEART CHAMBERS HAS A SMOOTH & A ROUGH PART

RIGHT ATRIUM

Crista terminalis lies between sinus venerium & musculi


pectinati, and between the openings of SVC & IVC,
At the junction of SVC opening & superior end of crista
terminalis is the location of sinoatrial node (SAN),
OPENINGS :Superior vena cava, inferior vena cava (with
valve of Eustace), coronary sinus (with valve of
Thebesius), & tricuspid valve,
Fossa ovalis & annulus ovalis on inter-atrial septum,
Opening of coronary sinus lies between 3 structures :
fossa ovalis, IVC opening & tricuspid valve opening,
Tendon of Todaro runs from between the 2 valve to the
top part of septal leaflet of tricuspid valve,
Boundaries of triangle of Koch - the site of AVN :
tendon of Todaro
attachment of septal leaflet of tricuspid valve,
anteromedial margin of orifice of coronary sinus

TENDON OF TODARO

Tendon of Todaro runs from the valve of coronary sinus to the


margin of fossa ovalis ,
Is an extension of the fibrous skeleton of the heart,
this tendinous structure forms one of the boundaries of the
surgically important triangle of Koch
Pectinate muscle
Membranous part of IVS
Septal leaflet of tricuspid
Fossa ovalis in IAS

Tendon of Todaro
Valve of IVC (Eustace)
Valve of coronary sinus
(Thebesius)

Crista terminalis

RIGHT VENTRICLE
Inlet & outlet valves,
Inlet part is roughened by trabeculae carnae, ridges, 3
papillary muscles attached to tendinous cords,
Outlet part is the smooth, arterial infundibulum = conus
arteriosus
Supraventricular crest supports the following structures
- anterosuperior leaflet of tricuspid valve,
- septomarginal band (septomarginal trabecula = moderator band)
- separating the attachments of tricuspid & pulmonary
valves,

Moderator band (septomarginal trabecula) =a curved


muscular bundle that stretches from the inferior part of IVS
to anterior papillary muscle
Functions of Moderator band :
wall,

- re-inforces the septal surface and anterior papillary muscle,


- conveys the Rt bundle branch (or part of it) to the anterior
- embraces & is strengthened by the supraventricular crest,
- may prevent overdistension of RT ventricle

When the ventricular muscle contracts during the second phase


(ejection) of systole, the ventricular volume reduces, and there is a
tendency for the atrio-ventricular valves to prolapse into the atria. The
papillary muscles prevent this.

RIGHT VENTRICULAR OUTFLOW = CONUS


ARTERIOSUS = INFUNDIBULUM
Supporting &
separating the ridged
inflow part from the
smooth arterial
outflow part is a
thick, arched
muscular structure,
the supraventricular
crest,
Supraventricular
crest : a muscular
arch/ridge between
the smooth and
rough parts of RT
ventricle that
accommodates the
140 degrees change
of direction of flow of
blood between the
inflow & outflow of RT
ventricle

INTERVENTRICULAR
SEPTUM
Indicated externally by AIVG and PIVG,
In cross section, the interventricular septum bulges into the RT ventricle

Right ventricle
Left
ventricle

Interventricular
septum

LEFT ATRIUM & LEFT AURICLE


auricle

atrium

LEFT VENTRICLE
Rough inlet and smooth outlet (aortic
vestibule)
Like the Rt ventricle, the inlet is roughened
by trabeculae carnae, ridges,and 2 papillary
muscles attached to their tendinous cords,
No Moderator band,
Wall 3 X as thick as the wall of the Rt
ventricle
During systole, the papillary muscle begins
to contract before the general myocardium:
a mechanism to tighten the cords & pull
together the valve cusps to avoid prolapse

Trabeculae carnae

HEART VALVES
The cardiac valves are 2 ATRIOVENTRICULAR & 2 SEMILUNAR,
Each heart valve consists of a core of connective tissues covered by endocardium ;
thus whatever affects the endocardium affects the heart valves e.g bacterial
endocarditis

VALVE
P
A
M
MCL)
T
ICS)

ANAT. LOCATION
3rd CC
3rd ICS
4th CC
4th ICS
(3344)

AUSCULTATION SITE
2 nd LT ICS
2 nd RT ICS
cardiac apex (5th Lt ICS
Rt inferiormost ST (? 5th RT
(2255)

A 10 YO boy had group A beta heamolytic streptococcal pharyngitis and in 6


weeks developed pan-carditis and arthritis. What does that mean to you in terms
of heart structure?

Ascending
aorta
RT coronary
ostium

Coronary
sinuses

LT coronary
ostium

HEART VALVES

HEART VALVES
& HEART
SOUNDS
Normal heart
valves produce
sounds only when
they close
Where might specific
valves be best
heard?
remember that
the sounds are
produced by
BLOOD FLOW
hitting/moving
each structure
project the most
likely passage of
soundwaves ie. the
direction of blood flow
through each gate

HEART VASCULATURE &


INNERVATION
VESSELS: 2 coronary arteries, cardiac
veins/coronary sinus, and cardiac lymphatics,
NERVES: autonomic & visceral afferents;
- sympathetic from all cervical ganglia and T1-5,
- parasympathetic by the 2 vagus nerves
- both form the superficial (on the ligamentum
arteriosum) and deep (posterior to arch) cardiac
plexuses,
- from here mixed autonomic nerves innervate the
conducting tissue of the heart ; the right supplies
the SAN, while the left supplies the AVN

THE HEART IN HEALTH &


DISEASE

THE HEART IN HEALTH &


DISEASE

CARDIAC
CYCLE

Describes events from the beginning of one beat to the beginning


of the next,
It consists of diastole (ventricular filling) and systole (ventricular
emptying),
The cardiac cycle is best begun from diastole :
DIASTOLE :
Step 1 : semilunar valves close,
Step 2 : the atrio-ventricular valves open to receive venous
return,
Step 3 : atrial; contraction : the atria squeeze out the last drops,
SYSTOLE :
Step 4 : ventricles begin to contract thereby causing the closure
of atri-ventricular valves,
Step 5 : isometric contraction of ventricles when all 4 valves are
closed,
Step 6 : further increase in ventricular pressure forces open the
semilunar valves,
1st & 2nd Heart Sounds are caused by valve closure : atrioventricular, then semilunar.

Cardiac referred pain

THANK YOU

PRACTICE QUESTIONS

What mediates the anginal pain of cardiac origin that radiates


across the precordium, neck, shoulder, medial arm?
Where is the mitral valve sounds best heard, and why is this
different from the location of the valve itself?
What are the circulatory changes that occur at birth?
What is the location of the apex beat?
An injury that damages the interventricular septum involves which
cardiac valve?
An artificial pacemaker is implanted to remedy the function of
which conducting tissue of the heart?
Which veins open into the right ventricle?
What are the unique characteristics of the right atrium and right
ventricle?
Looking at the A-P radiagraph of the chest, what structures form
the right boundary of the cardiac silhouette from the clavicle
downward?
Describe the events of the cardiac cycle.

EMBRYOLOGIC SUMMARY

Begins as angiogenic cell clusters in splanchnic mesoderm ; these


become 2 endocardial tubes which fuse during body foldings,
The single endocardial tube which emerges becomes segmented
into 5 dilatations : TBVAS,
The segmented dilated endocardial tube folds into a U-shaped
structure with the arterial and venous ends moving upward and the
venous end moving caudally and to the left,
T = truncus arteriosus, becomes ascending aorta and pulmonary
trunk,
B = bulbus cordis forms conus arteriosus & aortic vestibule,
V = primitive ventricle, forms the rough part of the 2 definitive
ventricles,
A = primitive atrium, forms the rough part of the 2 definitive atria
and the auricles,
S = sinus venosus, forms sinus venerium, coronary sinus and
oblique vein of left atrium,
The smooth part of left ventricle is formed from absorption of the
primitive pulmonary vein into the left atrium

EKG BASICS
When one part of cardiac muscle depolarizes and becomes
electronegative relative to other parts,electrical current also
spreads from the electronegative part into adjacent tissues
(electropositive) all the way to the surface ; recordable on
electrocardiograph,
Electrocardiographic leads are bipolar limb leads, precordial
(chest) leads & augmented unipolar limb leads,
The basic electrocardiographic waves are :
P due to atrial depolarization,
QRS complex due to ventricular depolarization, contraction,
and atrial repolarization (atrial T wave obscured by QRS
complex) ,
T wave due to ventricular repolarization,
P-R interval is about 0.16 second.

VALVULAR INSUFFICIENCY

Common causes of valvular insufficiency are rheumatic fever, ischemic heart


disease, congestive cardiac failure, prolapse, degerative or age-related(as in
calcific aortic stenosis),infective endocarditis, non-bacterial thrombotic
endocarditis etc, etc.
Rheumatic fever affects mostly the left heart valves; mitral valve is the most
frequently damaged by disease processes,
Age related changes occur most commonly in the aortic valve,
Non-bacterial thrombotic endocarditis results from deposition of blood
products on previously normal valves: common in malignancies, especially
adenocarcinoma,
Bacterial endocarditis occurs in previously damaged valves ; acute type by
high virulence bacteria e.g Staph. aureus, whereas subacute is by low
virulence organisms e.g @-hemolytic Strep.
Libman-Sacks endocarditis consists of sterile vegetation on cardiac valves of
SLE patients,
MECHANISM : the disease process usually excites an endocardial
inflammation, which produces necrosis with deposits e.g. Aschoff bodies in
rheumatic pan-carditis; healing produces fibrosis that deforms the valve(s) +
++, and predisposis to formation of vegetation & embolization.