633805750b2a1 Introduction To The Circulatory System Consolidated

INTRODUCTION TO THE
CIRCULATORY SYSTEM
ANATOMY
A.N Malik:Department of Human Anatomy,
KMTC Nakuru.
2
 The circulatory system comprises both the

lymphatic and blood vascular systems.
 Components of the blood vascular system:
 Heart: pumps blood.
 Arteries: a series of efferent vessels from the heart that
supply nutrients and oxygen to the tissues.
 Capillaries: the smallest blood vessels. They form a
complex network of thin tubules and through their
walls exchange of materials happens.
A.N Malik: Department of Human Anatomy, KMTC Nakuru. 11-Mar-16

3
 Veins: they result from convergence of capillaries

into a system of channels. The channels become
larger as they approach the heart. They carry blood
to the heart for pumping again.

The lymphatic vascular system
4
 It begins in the lymphatic capillaries. These tubules

anastomose to form vessels of steadily increasing
size which later terminate in the blood vascular
system emptying their content into large veins near
the heart.
 The main function of the lymphatic system is to
return the interstitial fluid to the blood.

5
 Traditionally; the circulatory system has been

divided into macrovasculature and
microvasculature.
 Macrovasculature: vessels with a diameter
>0.1mm(large arterioles, muscular and elastic arteries
and muscular veins).
 Microvasculature: visible under a
microscope(arterioles, capillaries and post-capillary
venules)

6
 The microvasculature plays a great role in the

exchange of materials between blood and the
surrounding tissues both under normal conditions
and inflammation.
 NB: the internal surface of the lymphatic and blood
systems is lined by a single layer of squamous
epithelium i.e. endothelium.

The microvasculature(arterioles and
venules)
7

Tissue components of the vascular
8
wall
 There are three basic structural components:
 Endothelium
 Muscular tissue
 Connective tissue(it has elastic elements)
 The amount and arrangement of the above tissues
in a blood vessel is influenced by mechanical
factors(blood pressure) and metabolic factors
which reflect the local needs of the tissues.

9
 NB. The above tissue components are present in

the vascular wall in different proportions apart
from capillaries and post-capillary venules which
only have the endothelium, basal lamina and
pericytes.

Diagram of a muscular artery and an elastic
artery
10

Endothelium
11
 It is a specialized type of epithelium which acts as a

semipermeable barrier between blood plasma and the
interstitial fluid. Other functions of endothelium include:
 Conversion of angiotensin I to angiotensin II.
 Conversion of bradykinin, serotonin, prostaglandins,
norepinephrine, thrombin etc. to biologically inert compounds.
 Lipolysis of lipoproteins by enzymes located on the surface of
endothelial cells to yield triglycerides and cholesterol.
 Production of vasoactive factors that affect the vascular tone
e.g. endothelin, relaxin factor, nitric oxide.
Medical application
12
 The endothelium has antithrombogenic properties(prevents

blood from coagulation). Upon damage of the endothelium
e.g. by atherosclerotic lesions, the exposed subendothelial
connective tissue induces platelets aggregation which leads
to thrombus formation and blockage of the blood vessel and
eventually results in ischemia and infarction.
 Thus the integrity of the endothelial layer prevents contact
between platelets and the subendothelial connective tissue.
 Assignment: read on pathogenesis of myocardial
infarction and atherosclerosis with reference to
atherosclerotic plaque formation and subsequent rupture.
Vascular smooth muscle
13
 This tissue is present in all vessels except pericytic

venules. Smooth muscle cells(SMCs) are arranged in a
helical manner in the tunica media. Each SMC is enclosed
in a basal lamina and by variable amounts of connective
tissue secreted by it.
 Vascular SMC of arterioles and capillaries are frequently
connected by gap junctions.

Vascular connective tissue
14
 The amount of connective tissue varies as per the functional

requirements of the blood vessel.
 Collagen fibers are found in between muscle cells, in
adventitia(collagen I) and in some of the subendothelial layers.
Basement membrane has collagen type IV and the tunica media has
type III.
 Elastic fibers guarantee shrinkage of the expanded vascular wall.
These fibers predominate in large arteries e.g. aorta. They are
distributed throughout the tunica media.
 Ground substance forms a heterogeneous gel in the extracellular
space of the vessel wall. It affects diffusion and permeability across
the vessel wall. The concentration of glycosaminoglycan's is higher
in arterial than in venous tissue.???atherosclerosis.
Medical application
15
 With aging, the ECM is disorganized by increased

secretion of collagen type III and I and some
glycosaminoglycan's.
 Changes in the molecular conformation of elastin and
some glycoproteins also occurs and may enhance
deposition of lipoproteins and calcium ions in the tissue
resulting in calcification.
 Modifications of the components of the ECM may lead to
formation of atherosclerotic plaques.
 Assignment: review the pathogenesis of atherosclerosis.
Structural plan of blood vessels
16
 All blood vessels above a certain diameter have some

structural features in common and conform to a general
structural form.
 Blood vessels are generally composed of several layers:
 Tunica intima
 Tunica media
 Tunica adventitia

Layers of a blood vessel
17

Tunica intima
18
 Consists of a single layer of endothelial cells supported

by a subendothelial layer of loose connective tissue which
contains SMCs.
 In arteries, the intima is separated from the media by an
internal elastic lamina which is the most external part of
the intima.
 The internal elastic lamina is composed of elastin and has
gaps(fenestrae) that allows movement of substances in
and out of the vessel wall.

Cross section of a small artery
19
Due to absence of
blood pressure and
the contraction of the
vessel at death, the
tunica intima of
arteries show an
undulating appearance
in tissue sections. The
internal elastic lamina
is not stained.
20
Cross section of
a small artery
with the internal
elastic lamina
stained.

Tunica media
21
 It consists of concentric layers of helically arranged

smooth muscle cells. In between these cells are
elastic fibers, lamellae, reticular fibers(collagen
type III), proteoglycans and glycoproteins. This
ECM comes from the SMCs. Arteries have a
thinner external elastica lamina which separates it
from the tunica adventitia.

Tunica adventitia
22
 Consists mainly of collagen and elastic fibers.

 The collagen is type I.
 The adventitial layer becomes continuous with the
connective tissue of the organ through which the
vessel runs.

23
Transverse
section of a
muscular artery.
Small blood
vessels(vasa
vasorum) are
seen in the
tunica
adventitia.

Vasa vasorum
24
 Large vessels have vasa vasorum(“vessels of vessels”)

within the adventitia and the outer part of the tunica
media.
 The vasa vasorum provide nourishment to these big
vessels since their walls are too thick to be dependent
on diffusion for nourishment.
 Vasa vasorum are more frequent in veins than in
arteries. Arteries of intermediate and large diameter,
the intima and most of the internal region of the tunica
media are devoid of vasa vasorum. These vessels are
nourished through diffusion of nutrients from the very
vessels.

Innervation of blood vessels
25
 Most vessels that have smooth muscles in their

walls have an extensive network of sympathetic
nerve fibers(vasomotor) with norepinephrine being
the neurotransmitter(NE).
 Release of NE results in vasoconstriction.
 These vasomotor nerves generally do not enter the
tunica media of arteries, thus the NE must diffuse
to reach the SMCs in the tunica media.

Medical application
26
 Diabetic neuropathy:

27
 In veins, the nerve endings are found in the tunica

adventitia and tunica media but the overall density of
innervation is less as compared to that of arteries.
 Arteries in muscles also have a cholinergic vasodilator
supply. The acetylcholine released acts on the vascular
endothelium with resultant release of nitric oxide
which is a potent vasodilator. This nitric oxide diffuses
to the SMCs and activates the cyclic Guanosine
Monophosphate(cGMP) second messenger system.
The muscle cells relax and the vessel lumen dilates.

Classification of arteries
28
 Generally, arterial blood vessels are classified

based on diameter into arterioles<muscular
arteries(arteries of medium diameter)<larger elastic
arteries.

Large elastic arteries
29
 They help stabilize blood flow.

 They include the aorta and its large branches.
 Characteristics
 Yellow in color due to accumulation of elastin in the
tunica media which is well developed.
 Have thicker intima than that of corresponding
muscular arteries.
 The internal elastic lamina is not clearly defined.
 Tunica adventitia is relatively underdeveloped.

30
Transverse
section of part
of a large artery
showing a well
developed
tunica media
containing
several elastic
laminas.
31
 The abundant elastic lamina of large arteries contribute

to the function of making blood flux more uniform.
 During systole the elastic lamina of large arteries are
stretched and reduce the pressure change. During
diastole the ventricular pressure drops to a low level but
the pressure is maintained by the elastic rebound of large
arteries.
 Consequently, arterial pressure and blood velocity
decrease and become less variable as the distance from
the heart increases .
Graph showing the
relationship between the
characteristics of blood
32
circulation (left) and the
structure of the blood vessels
(bottom). The arterial blood
pressure and speed of flow
decrease and become more
constant as the distance from
the heart increases. This
decrease coincides with a
reduction in the number of
elastic fibers and an increase
in the number of smooth
muscle cells in the arteries.
The graph illustrates the
gradual changes in the
structure of vessels and their
biophysical properties.
The graph was obtained from Basic Histology; text and atlas by Junqueuira 11 th edition.
Medical application
33
 During embryonic development of the vessels the

tunica media may develop abnormally with
subsequent focal weakening and dilation.
Progression of this dilation leads to an aneurysm
which is prone to rupture.

Carotid bodies
34
 These are chemoreceptors sensitive to changes in carbon

dioxide and oxygen concentration in the blood. They are
located near the bifurcation of the common carotid.
 They are richly supplied by fenestrated capillaries that
surround type I and II cells.
 Type I cells are supporting cells
 Type II cells have numerous vesicles containing
serotonin, dopamine and adrenaline.

Carotid bodies cont…..
35
 Most nerves of the carotid bodies are afferent(carry

impulses to the CNS).
 Carotid bodies are sensitive to low oxygen tension, high
carbon dioxide concentration and low arterial blood pH.
NB. The aortic bodies found at the arch of
aorta and the carotid bodies at the
bifurcation of the carotid arteries are
similar in morphology.
Carotid sinuses
36
 These are slight dilations of the internal carotid arteries.

 They contain baroreceptors that detect changes in blood
pressure and convey the information to the CNS.
 The arterial media layer of the sinus is thinner to allow it
to pick minute changes in blood pressure.
 The intima and adventitia are richly innervated.
 Afferent nerve endings relay impulses to the vasomotor
center resulting in vasoconstriction and maintenance of
blood pressure.
Arteriovenous anastomosis
37
 These are direct connections between arterioles and

venules. They play a great role in regulation of blood flow
in certain regions.
 Arteriovenous anastomosis are richly supplied by both
arms of the autonomic nervous system.

Medium(muscular)arteries
38
 They control the affluence of blood to organs by

contracting or relaxing the smooth muscle cells of the
tunica media.
 Their subendothelial layer is thicker than that of
arterioles.
 Their internal elastic lamina is prominent .
 The tunica media may contain up to 40 layers of smooth
muscle cells interminggled between elastic lamellae,
reticular fibers and proteoglycans. They are all
synthesized by SMCs.
Medium(muscular) arteries cont….
39
 The external elastic lamina, the last component of

the media is present only in large muscular arteries.
 The adventitia is made up of connective tissue. It
contains lymphatic capillaries, vasa vasorum and
vasa nervosa. These structures may penetrate the
outer parts of the tunica media.

Arterioles
40
 They are usually <0.5 mm in diameter with

relatively narrow lumens.
 The subendothelial layer is very thin.
 In the very small arterioles, the internal elastic
lamina is very thin and the media has one or two
layers of SMCs.

Cross section through an arteriole and its accompanying venule from the myometrium
of mouse uterus. Note the elongated, large nucleus (arrowhead) of a pericyte
surrounding the venule wall.
41

42
Cross section through a small

artery and its accompanying
muscular vein. Because of
vasodilatation, the arteriole is
unusually filled with blood. At
this stage the internal elastic
lamina is not distinguished. Many
other small arterial branches and
capillaries can be seen in the
surrounding connective tissue.
43
Oblique section of a
small artery from the
mesentery. Note the
transverse section of
the smooth muscle
cells of the media and
the endothelial layer
covering the lumen of
the vessel
A.N Malik: Department of Human Anatomy, KMTC (arrowheads
Nakuru. 11-Mar-16
A cross section of venules and
arterioles. Note the thickness of the
walls.
44

Capillaries
45
 They are composed of a single layer of endothelial cells

rolled up into a tube. Their average diameter is 7-9
micrometer with a length of nearly 50 micrometers. The
total length of all capillaries is 96,000 km.
 The endothelial cells normally rest on a basal lamina.
 The velocity of blood in the aorta averages 320mm/s; in
the capillaries it is 0.3mm/s. the low velocity and thin
walls allows exchange of materials between blood and
tissues i.e. they are exchange vessels.

Three dimensional representation of a
capillary
46

Medical application
47
 The endothelial cells of the venules have the loosest

junctions, thus during an inflammatory process fluid leaks
out to the interstitial space leading to oedema.
 Pericytes; which are mesenchymal in origin surround
some endothelial cells of some capillaries and post
capillary venules. The pericytes have actin, myosin and
tropomyosin which are contractile proteins.
 Upon tissue injury; pericytes proliferate and differentiate
and form new blood vessels and connective tissue cells
thus they are important in the repair process.
Classification of capillaries
48
 Capillaries have structural differences that reflect the level

of metabolic exchange that happens.
 Continuous/somatic capillaries: their walls
are not fenestrated.
 Location:
 Muscle tissue
 Connective tissue
 Exocrine glands
 Nervous tissue
49
 Fenestrated/visceral capillaries: they are

characterized by several circular transcellular openings in
the endothelium membrane i.e. fenestrae.
 The fenestrae are limited by the cell membrane and
obliterated by a diaphragm that is thinner than the cell
membrane and it is not lipid bi-layered.
 Location:
 kidney

50
 Discontinuous sinusoidal capillaries:
 Characteristics:
 They have a tortuous path with a large diameter that slows down
circulation of blood.
 The endothelial cells form a discontinuous layer and are separated
from one another by wide spaces.

 The cytoplasm of endothelial cells has multiple fenestrations
without a diaphragm
 Macrophages are located either among or outside the endothelial
cells.
 The basal lamina is discontinuous.

Discontinuous sinusoidal capillaries cont…
51
 Location:
 Liver
 Hematopoietic organs e.g. bone marrow and spleen.

52
 Capillaries anastomose freely to form a rich network

interconnecting small arteries and veins.
 Arterioles branch into small vessels i.e. metarterioles
which branch further to form capillaries.
 Constriction of metarterioles(they have a discontinuous
layer of smooth muscle) regulates circulation into
capillaries.
 Some tissues have arteriovenous anastomoses that help
arterioles to empty directly into venules. This is another
mechanism for regulation of capillary circulation.
53
 Contraction of the arteriovenous anastomosis leads

to channeling of blood away from the capillary
network and vice versa when they relax.
 Tissues of high metabolic activity have very rich
capillary network as compared to tissues of low
metabolic activity.

Types of microcirculation formed by small blood vessels
54
Types of microcirculation
formed by small blood
vessels. (1) The usual
sequence of arteriole
metarteriole capillary
venule and vein. (2) An
arteriovenous anastomosis.
(3) An arterial portal
system, as is present in the
kidney glomerulus. (4) A
venous portal system, as is
present in the liver.
Post capillary venules
55
 Transition from capillaries to venules is gradual rather

than abrupt.
 The immediate postcapillary venules(pericytic venules)
have pericytes. Their tunica intima has an endothelium
and a thin subendothelial layer.
 It has the loosest endothelial junctions along the entire
vascular system.
 Postcapillary venules have functional similarity with the
capillaries i.e. exchange of materials and participate in
inflammation.
Histology of the cardiovascular
56
system video link
https://www.bing.com/videos/search?
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ew=detail&mid=D9D4E15166B070F49612D9D4E151
66B070F49612&FORM=VIRE

Assignment
57
 Read and make notes on muscular arteries under

the following headings:
 General structure
 Classification and the structural differences.
 Clinical correlation.

THE HEART and GREAT BLOOD
VESSELS
58

59
There’s no doubt that the proper functioning

of our pipes and pumps does have an
immediate urgency well beyond that of
almost any of our other bits and pieces.
…Steven Vogel (Vital Circuits, 1992)

60

Histology of the heart
61
 Review the notes on basic histology discussed

earlier on.

Objectives
62
 Learn the structure of the heart and its conducting

system.
 Learn the basic anatomy of the great blood vessels
linking the heart and the peripheral circulation.
 Clinical anatomy of the heart and the great blood
vessels.

63
The anterior
surface of the
heart with fibrous
and parietal serous
pericardium
removed.

Assignment
64
 Review the embryology of the heart and great

blood vessels.
 Seek embryological explanation of the various
congenital heart defects.

The pericardium
65
 This is a fibroserous membrane that covers the heart and the

beginning of its great vessels.
 Location: middle mediastinum surrounding the heart and the
beginning of its great vessels.
 Structure:
 A closed sac composed of two layers i.e.
 Fibrous pericardium: a tough external fibrous layer.
 Serous pericardium: composed of mesothelium( a single layer

of flattened cells forming an epithelium) that lines the internal
surface of the fibrous pericardium and the external surface of the
heart.
The pericardium cont….
66
 Parietal pericardium: a glistening serous membrane lining

the internal surface of the fibrous pericardium. This layer is
reflected onto the heart at the great vessels as the visceral
layer of the serous pericardium.
 Visceral pericardium: overlies the myocardium on the
external surface.

67

A. The heart occupies the middle mediastinum and is enclosed by the pericardium,
composed of two parts. The tough, outer fibrous pericardium stabilizes the heart and
helps prevent it from overdilating. Within the fibrous pericardium is a œcollapsed sac,
the serous pericardium. The embryonic heart invaginates the wall of the serous sac (B)
68
and soon practically obliterates the pericardial cavity (C), leaving only a potential space
between the layers of serous pericardium. C and D. The continuity of the fibrous
pericardium with the central tendon of the diaphragm constitutes the
pericardiacophrenic ligament.

69
 Fibrous pericardium: continuous superiorly with tunica

adventitia of the great vessels and with the pretracheal layer
of the deep cervical fascia.
 Anteriorly it attaches to the posterior surface of the sternum
through the sternopericardial ligaments.
 Posteriorly it is bound to loose connective tissue to
structures in the posterior mediastinum.
 Inferiorly it is continuous with the central tendon of the
diaphragm through the pericardiacophrenic ligament.

70
 The fibrous pericardium protects the heart against

sudden overfilling; it is very non yielding and
closely related to the great blood vessels.

The pericardial cavity
71
 This is the potential space between the opposing layers of the visceral
and parietal pericardium. It contains a thin film of pericardial fluid
that allows frictionless movement of the heart.
 The visceral layer of the serous pericardium makes up the epicardium(
the outer most of the three layers of the heart wall). It extends to the
beginning of great vessels then becomes continuous with the parietal
layer of the serous pericardium. This is where the aorta and the
pulmonary trunk leave the heart and superior and inferior vena cavae
together with the pulmonary veins enter the heart.

Arterial supply to the pericardium
72
 Mainly through a small branch of the internal thoracic artery

i.e. the pericardiacophrenic artery. It either accompanies
or parallels the phrenic nerve to the diaphragm.
 Some arterial supply also comes from:
 Musculophrenic artery: terminal branch of internal
thoracic artery.
 Bronchial, oesophageal and superior phrenic arteries:
branches of the thoracic aorta.

 Coronary arteries: the visceral layer only( this is the
first branch of the aorta.

Arterial supply and venous drainage of the pericardium
73

Venous drainage of the pericardium
74
 Pericardiacophrenic veins: tributaries of the( or

internal thoracic vein)brachiocephalic veins.
 Variable tributaries of the azygos venous system.

Innervation of the pericardium
75
 Phrenic nerves: primary source of the sensory fibres. Pain

sensations conveyed by these nerves oftenly are referred
to the skin(C3C5: top of the shoulder).
 Vagus nerve: ??function.
 Sympathetic trunks: vasomotor.

Medical application
76
 Pericarditis, pericardial rub and pericardial

effusion.
 Cardiac tamponade
 Pericardiocentesis.

The heart and great blood vessels
77

Flow of blood through the heart
78

THE HEART
79
 Size: slightly larger than a clenched fist.

 It’s a four chambered muscular pump.
 The right side receives deoxygenated blood from
the body through the superior and inferior vena
cavae then pumps it to the lungs through the
pulmonary trunk and the left receives oxygenated
blood through the pulmonary veins and pumps it
into the aorta for distribution to the rest of the
body.

The heart cont….
80
 The four chambers of the heart are the atria(2, the

right and left) and the ventricles(2, right and left).
 Read on the cardiac cycle.

Layers of the heart
81
 Endocardium: a thin internal layer of the heart and

also covers the heart valves.
 Myocardium: thick helical middle layer composed
of cardiac muscle.
 Epicardium: a thin external layer(mesothelium)
formed by the visceral layer of the serous
pericardium.

Anchorage of the heart muscle fibers
82
 The muscle fibers of the heart are anchored to the fibrous skeleton of
the heart.
 It is a framework of collagen fibers to form fibrous rings which
surround valvular orifices.
 Functions of the fibrous skeleton of the heart:
 Keeps orifices of the artrioventricular and semilunar valves patent
and prevents them from over-distention due to increased volume.

 Attachment for valve leaflets and cusps.
 Attachment for the myocardium
 An electrical insulator(prevents simultaneous contraction of the
ventricles and atria)

The fibrous skeleton of the heart
83
The fibrous skeleton of

the heart is made up of
four fibrous rings each
encircling a valve, two
trigones and the
membranous portions
of the interartrial,
interventricula and
artrioventricular septa.
External demarcations of the heart
84
 Coronary/
atrioventricular
groove: demarcates
the atria from the the
ventricles.
 Anterior and
posterior
interventricular
grooves: demarcates
right and left
ventricles.

External appearance of the heart
85
 Anterior and posterior views: trapezoidal

 3 D: shaped like a tipped over pyramid with an
apex(directed anteriorly and to the left), a
base(opposite the apex) and four sides.

86

The apex of the heart
87
 Formed by the inferolateral part of the left ventricle.

 It is found posterior to the 5th intercostal space in adults
approximately 9cm from the median plane.
 Remains motionless throughout the cardiac cycle.
 Mitral valve sounds are best heard here upon auscultation.
 Medical application: in conditions of the heart that
lead to hypertrophy, dilation of the left ventricle,
pericardial effusion and a left shift of the mediastinum;
the apex beat may be displaced away from the 5th ICS
MCL. A.N Malik: Department of Human Anatomy, KMTC Nakuru. 11-Mar-16
88

The base of the heart
89
 It is the posterior aspect opposite the apex.

 It is mainly formed by the left atrium with some
little contribution from the right atrium.
 It faces posteriorly towards the vertebral
bodies(T6-T9) and it is separated from them by
the pericardium, oblique pericardial sinus .
Esophagus and the aorta.
 Extent: superiorly to the birfurcation of the
pulmonary trunk and inferiorly to the coronary
groove.
 Receives the pulmonary veins on the right and
left sides of the left atrial portion and the SVC
and IVC at the superior and inferior ends of its
right atrial portion.

Surfaces of the heart
90
 Anterior/sternocostal surface:
formed mainly by the right
ventricle.
 Diaphragmatic/inferior surface:
formed mainly by the left ventricle
and partly by the right ventricle. It is
related to the central tendon of the
diaphragm(relate tubular
mediastinum and COPD).
 Right pulmonary surface: formed
mainly by the right atrium.
 Left pulmonary surface: formed
mainly by the left ventricle. It forms
the cardiac impression on the lung.

Borders of the heart
91
 Right border: formed by the

right atrium.
 Inferior border: formed mainly
by the right ventricle and to a
lesser extent by the left ventricle.
 Left border: formed mainly by
the left ventricle and to a lesser
extent by the left auricle.
 Superior border: formed by the
atria and auricles.

The pulmonary trunk
92
 It is 5cm long and 3cm

wide.
 It is the arterial
continuation of the right
ventricle and divides into
right and left pulmonary
arteries.
 The trunk and the arteries
carry deoxygenated blood
to the lungs.

Medical application
93
 Dextrocardia: reversal in position of the heart so that

the apex is directed to the right rather than the left side.
This follows abnormal folding of the embryonic heart.
 Dextrocardia is associated with mirror image positioning
the great vessels and the aortic arch. This anomaly may be
associated with situs inversus or be an isolated
dextrocardia which is more frequently associated with
severe cardiac anomalies.

94
Ectopia cordis:
give an embryological
explanation for the
condition.

Pulmonary circulation
95

Note the arrangement of the great
vessels from the posterior view
96

The right atrium
97
 It forms the right border of the heart and receives

venous blood from the SVC, IVC, and coronary
sinus.
 It has an ear like right auricle(a muscular pouch)
that handles increased right atrial volume.

The right atrium cont….
98
Interior
 The posterior part(sinus venerum) is smooth and thin walled. This
is where the SVC, IVC and the coronary sinus open into the right
atrium to bring in deoxygenated blood.
 Anterior wall is rough and muscular.
 It has the right atrioventricular orifice through which blood enters
the right ventricle.

 Crista terminalis/terminal crest separates the smooth and rough
surface of the right atrial wall.
Sulcus terminalis/terminal groove separates the smooth and rough

parts of the right atrial wall on the external aspect..
99
 SVC opens into the superior part of the right atrium at the
level of right 3rd costal cartilage whereas the IVC opens
into the inferior part of the right atrium at the level of the
5th right costal cartilage.
 The coronary sinus( a short venous trunk that receives
most of the cardiac veins) opens in between the right
atrioventricular orifice and the IVC orifice.

100
 Interartrial septum: separates the right and left atrium. The

interatrial septum has an oval depression(fossa ovale)
which is a remnant of fossa ovale.
 Sinuatrial node: located in front of the SVC orifice at the
superior end of crista terminalis.

Internal view of the right atrium
101

The right ventricle
102
 Forms the largest part of the antrerior surface of the heart,

a small part of the diaphragmatic surface and nearly the
entire inferior border of the heart.

The right ventricle
103
 The superior portion of the right ventricle tapers into an

arterial cone(conus arteriosus/infundibulum) which leads
into the pulmonary trunk.
 Trabeculae carneae: irregular muscular elevations inside
the right ventricle.
 Supraventricular crest: this is a thick muscular ridge
separating the ridged muscular wall of the inflow part of
the chamber from the smooth wall of conus arteriosus.
 The right ventricle receives blood from the right atrium
through the right atrioventricular orifice/tricuspid valve.
The right ventricle cont….
104
 The tricuspid valve is located posterior to the body of the

sternum at the 4th -5th intercostal spaces.
 The bases of the leaflets of the tricuspid valve are attached
to the fibrous skeleton.
 The tricuspid valve is surrounded by one of the fibrous
rings of the cardiac skeleton. It keeps the caliber of the
aperture constant, thus regardless of the varying right
ventricular pressures, it does not give in to the pressures
upon the tricuspid valve.

The right ventricle cont….
105
 Tendinous cords/chordae tendinae: these are strands

attaching to the free edges of the valve leaflets on the
posterior aspect.
 Tendinous cords arise from the apices of papillary
muscles(they are cornicular muscular projections attached
to the ventricular wall).
 This system of chordae tendinae and papillary muscles
prevent prolapsing of the tricuspid valve when ventricular
pressures rise i.e. they prevent regurgitation.

The right ventricle cont…
106
 Papillary muscles: they are three and correspond to the

three valvular cusps of the tricuspid valve.
 Anterior papillary muscle: the largest and most prominent. It
arises from the anterior wall of the right ventricle.
 Posterior papillary muscle: smaller than the anterior muscle
and may consist of several parts. It arises from the inferior
wall of the right ventricle.
 Septal papillary muscle: arises from the interventricular
septum.

The right ventricle interior view
107

The interventricular septum
108
 This is a strong obliquely placed partition between the

right and left ventricle.
 It has a muscular and membranous part.
 The muscular wall forms the largest portion of the septum.
 The muscular wall is three times the thickness of the right
ventricular wall and it also buldges into the right ventricle
cavity.
 Superiorly and posteriorly a thin membrane which is part
of the fibrous skeleton of the heart forms the membranous
interventricular septum.
109
Ventriculoseptal
defect(VSD)

The septomarginal trabecula/moderator band
110
 This is a curved muscular bundle that traverses the right

ventricular chamber from the inferior part of the
interventricular septum to the base of the anterior
papillary muscle.
 This structure carries a portion of the right branch of the
AV bundle.

Left atrium
111
 Forms most of the base of the heart.

 The valveless pairs of pulmonary veins drain into
the left atrium.
 The left auricle is muscular and its inner wall
trabeculated with pectinate muscles. It forms the
superior part of the left boarder of the heart.

The left atrium cont….
112
 Interior of the left atrium

 Has a larger smooth wall part and a smaller muscular
auricle that has pectinate muscles.
 There are 4 pulmonary veins entering its smooth
posterior wall.
 Has a thicker wall than that of the right atrium.
 Has a left atrioventircular orifice(mitral valve)
connecting into the left ventricle.

The interior of the left atrium
113

Left ventricle
114
 Forms the apex of the heart.

 It performs more work than the right ventricle.
 Interior of the left ventricle
 Thicker wall than the right atrium(2-3 times)
 Trabeculae carneae are numerous and finer than those in the
right ventricle.
 Its cavity is more conical and longer than the right venricles’.
 Has double leaflet mitral/ left atrioventricular valve.
 Has an aortic orifice on the right posterosuperior aspect.

The mitral valve
115
 Has 2 cusps; an anterior and a posterior.

 Located posterior to the sternum at the level of 4th
costal cartilage.
 Each cusp receives tendinous cords from more than
one papillary muscle for support

Interior of the left ventricle
116

The aortic valve
117
 A semilunar like valve between the left ventricle and the

ascending aorta.
 Located posterior to the left side of the sternum at the
level of the 3rd ICS.
NB: for the heart valves; take note of
the position of auscultatory areas in
the clinical setting.
The semilunar valves
118
 They are the pulmonary and aortic valves.

 Each has 3 cusps and do not have tendinous cords to
support them.
 They have a smaller surface area than that of the AV
valves.
 The cusps project into the arteries and prevent
backflow of blood into the ventricles.

The aortic valve, aortic sinuses and the
coronary arteries.
119

Medical application
120
 Valvular heart diseases

 Mitral valve regurgitation, mitral valve prolapse, mitral
valve stenosis.
 Pulmonary valve, aortic valve all can have stenosis or
insufficiency.

Vasculature and innervation of the
heart
121
 The endocardium and sub-endocardial tissue receive

oxygen and nutrients by diffusion or through
microvasculature directly form the heart chambers.
 The blood vessels of the heart are normally embeded in
fat overlying the epicardium.
 The blood vessels of the heart are affected by both
parasympathetic and sympathetic innervation.

Arterial supply of the heart
122
 Coronary arteries
 They are the1st branches of the aorta. Supply both the
myocardium and epicardium.
 The right and left coronary arteries arise from the
corresponding aortic sinuses superior to the aortic valve
and pass around the opposite sides of the pulmonary
trunk.
 Coronary arteries supply both the ventricle and atria.
 The ventricular distribution of the coronary arteries is not
sharply demarcated.
The coronary arteries
123
 Right coronary artery(RCA)

 Arises from right aortic sinus and passes to the right side
of the pulmonary trunk to run in the coronary groove.
 Branches:
 Sinuatrial node branch: given off near its origin and supplies
the sinuatrial node.
 Right marginal branch: supplies the right border of the heart
towards the apex but does not reach the apex.
 Atrioventricular nodal branch: given off at the crux(cross)
of the heart from the posterior aspect and supplies the
atrioventricular node.
RCA branches Cont….
124
 Posterior interventricular branch: it descends in

the posterior interventricular groove towards the
apex. It supplies adjacent areas of both ventricles
and gives off perforating interventricular septal
branches into the IVS.

The RCA territory
125
 The right atrium.

 Most of the right ventricle.
 Part of the left ventricle (the diaphragmatic
surface).
 Part (usually the posterior third) of the IV septum.
 The SA node (in approximately 60% of people).
 The AV node (in approximately 80% of people).

Coronary arteries cont…
126
 The left coronary artery(LCA)

 Arises from the left aortic sinus to pass between the left
auricle and the left side of the pulmonary trunk. It runs in
the coronary groove as well but on the posterior aspect of
the heart.
 Branches:
 SA node branch
 Anterior interventricular/left anterior descending(LAD)
branch: supplies the right and left ventricles and anterior two
thirds of the IVS.
 Circumflex branch: supplies the left atrium and left ventricle
LCA branches cont….
127
 Left marginal: supplies the left ventricle.

 Posterior interventricular: supplies the right and
left ventricles and the posterior third of IVS.

Arterial supply of the heart
128

The LCA territory
129
 Part of the right ventricle.

 Most of the IVS (usually its anterior two thirds),
including the AV bundle of the conducting system
of the heart, through its perforating IV septal
branches.
 The SA node (in approximately 40% of people).
 The left atrium.
 Most of the left ventricle.

Arterial supply of the heart cont….
130

The right coronary artery and its territories
131

The left coronary artery and its territories
132

Coronary collateral circulation
133
 Branches of the coronary arteries are considered to

be end arteries.
 Anastomosis between the terminal branches of the
right and left coronary arteries do exist but are not
sufficient to provide adequate blood supply in the
event of occlusion of a major branch.
 Sudden occlusion leads to myocardial infarction

Arterial supply to the heart
134

Summary of the overall arterial supply to the heart in most
individuals(an excerpt from clinical anatomy by R. Snell 8th ed.)
135
 The right coronary artery supplies all of the right ventricle (except for
the small area to the right of the anterior interventricular groove), the
variable part of the diaphragmatic surface of the left ventricle, the
posteroinferior third of the ventricular septum, the right atrium and
part of the left atrium, and the sinuatrial node and the atrioventricular
node and bundle. The LBB also receives small branches.
 The left coronary artery supplies most of the left ventricle, a small
area of the right ventricle to the right of the interventricular groove,
the anterior two thirds of the ventricular septum, most of the left
atrium, the RBB, and the LBB.

A. Posterior view of the
heart showing the
origin and distribution
136
of the posterior
interventricular artery
in the right dominance.
B. Posterior view of the
heart showing the
origin and distribution
of the posterior
interventricular artery
in the left dominance.
C. Anterior view of the
heart showing the
relationship of the
blood supply to the
conducting system.
Medical application
137
 Coronary artherosclerosis and coronary artery

disease.
 Myocardial infarction.
 Angina pectoris.
 Coronary bypass graft.
 Coronary angioplasty.

138
Percutaneou
s
transluminal
angioplasty

Common sites of coronary artery occlusion.
139

Cardiac veins
140
 Most of the veins that drain the heart drain into the
coronary sinus and partly into the right atrium.
 The coronary sinus: the main vein of the heart. Found
in the posterior aspect of the coronary groove.
 Tributaries:
 The great cardiac vein at its left. It’s the main tributary.
 Middle and small cardiac veins at its right.
 The left ventricular vein
 The left marginal vein.

Cardiac vein cont….
141
 Other cardiac veins

 Anterior cardiac veins
 Smallest cardiac veins
The above veins drain into the atria.

The cardiac veins
142

The conducting system of the heart
143
 This system coordinates the cardiac cycle.

 Comprises of the cardiac muscles and specialized
conducting fibers that initiate the electrical
impulses and distribute them to the rest of the
cardiac muscle.
 Nodal tissue initiates the heart beat and coordinates
contractions of the chambers.

The sinuatrial node
144
 Location: anterolaterally deep to the epicardium at

the junction of the SVC and right atrium near the
superior end of sulcus terminalis.
 It is the pacemaker of the heart(initiates and
regulates heart contractions).
 Its contraction signal spreads myogenically to the
atria.
 Arterial supply: sinuatrial nodal artery; a branch of
the RCA(60% of people) or LCA(40% of people)
The sinuatrial node cont….
145
 It is stimulated by the sympatheitic division of

ANS to accelerate the heart and by the
parasympathetic division to inhibit and return to or
towards its basal rate.

146

The atrioventricular node
147
 Location: posteroinferior region of the interatrial septum

near the opening of the coronary sinus.
 Signals from the SAN move through cardiac muscle and
reach the AVN which then distributes the signal to the
ventricles through the AV bundle.
 The AV bundle is the only bridge between the atrial and
the ventricular myocardium.
 Arterial supply to AVN: AV nodal artery.

The right and left bundle branches
148
 At the junction of the membranous and muscular

parts of the ventricles the AV bundle divides into a
left bundle and a right bundle.
 These branches pass on each side of the muscular
IVS deep to the endocardium and then ramify into
subendocardial branches(Purkinje fibers).

Distribution of the right bundle
branch
149
 The muscular IVS.

 Anterior papillary muscle through the moderator band.
 Wall of the right ventricle.

Distribution of the left bundle branch
150
 It divides to give off nearly six smaller branches to

supply:
 IVS
 Anterior and posterior papillary muscles
 Wall of the left ventricle.

Impulse generation and conduction
151
 The SA node initiates an impulse that is rapidly conducted to

cardiac muscle fibers in the atria, causing them to contract.
 The impulse spreads by myogenic conduction, which rapidly
transmits the impulse from the SA node to the AV node.
 The signal is distributed from the AV node through the AV
bundle and its branches (the right and left bundles), which
pass on each side of the IVS to supply subendocardial
branches to the papillary muscles and the walls of the
ventricles .

Impulse generation and conduction
152

Innervation of the heart
153
 Supplied by autonomic fibers from the cardiac plexus.

 Sympathetic supply:
 presynaptic fibers of T1-T5/6
 postsynaptic fibers from cervical and superior thoracic
paravertebral ganglia of sympathetic trunks and terminate in
AV and SN nodes.
 Effects of stimulation of the sympathetic supply to the heart:
 Increased heart rate
 Increased impulse conduction
 Increased force of contraction
 Increased blood flow to coronary vessels
Medical application
154
 Read and make a brief summary

 Electrocardiography(ECG)
 Coronary occlusion and the heart conducting system.
 Artificial cardiac pacemaker.
 Cardiopulmonary resuscitation.
 Fibrillation of the heart and defibrillation.
 Cardiac referred pain.

Innervation of the heart cont….
155
 Parasympathetic supply:
 Comes from presynaptic fibers of the vagus
nerve.
 Effects of Parasympathetic stimulation of the
heart:
 Slows the heart rate.
 Reduces cardiac contractility.
 Constricts the coronary arteries.

Surface anatomy of the heart
156
 The tricuspid valve lies behind the right half of the sternum opposite the 4th
intercostal space.
 The mitral valve lies behind the left half of the sternum opposite the 4th costal
cartilage.
 The pulmonary valve lies behind the medial end of the third left costal cartilage
and the adjoining part of the sternum.
 The aortic valve lies behind the left half of the sternum opposite the 3rd
intercostal space.

Where to listen for heart sounds
157
 The tricuspid valve is best heard over the right half of the lower end of the body
of the sternum.
 The mitral valve is best heard over the apex beat, that is, at the level of the fifth
left intercostal space, 3.5 in. (9 cm) from the midline.
 The pulmonary valve is heard with least interference over the medial end of the
second left intercostal space
 The aortic valve is best heard over the medial end of the second right intercostal
space.

158
Auscultatory
areas of the
heart

The great blood vessels
159
 Read and make notes on the great

vessels(brachiocephalic veins,artery trunk, aorta,
IVC and SVC, common carrotid artery, subclavian
arteries and veins)
 Give clinical correlations with reference to the
above.
Read and make notes on the azygous and
hemiazygous system of veins.

160
A 61-year-old man was seen in the emergency department complaining of a feeling of pressure within his
chest. On questioning, he said that he had several attacks before and that they had always occurred when
he was climbing stairs or digging in the garden. He found that the discomfort disappeared with rest after
about 5 minutes. The reason he came to the emergency department was that the chest discomfort had
occurred with much less exertion.
The following comments concerning this case are correct except which?
(a) The diagnosis is a classic case of angina pectoris.
(b) The sudden change in history, that is, pain caused by less exertion, should cause the physician concern
that the patient now has unstable angina or an actual myocardial infarction.
(c) The afferent pain fibers from the heart ascend to the central nervous system through the cardiac branches
of the sympathetic trunk to enter the spinal cord.
(d) The afferent pain fibers enter the spinal cord via the posterior roots of the 10th to the 12th thoracic nerves.
(e) Pain is referred to dermatomes supplied by the upper four intercostal nerves and the intercostal brachial
nerve.

161
 Answer D. The afferent pain fibers from

the heart enter the spinal cord via the
posterior nerve roots of the upper four
thoracic spinal nerves.

162
A 55-year-old woman has severe aortic incompetence, with the blood

returning to the cavity of the left ventricle during ventricular diastole.
To hear the aortic valve with the least interference from the other heart
sounds, the best place to place your stethoscope on the chest wall is
(a) the right half of the lower end of the body of the sternum.
(b) the medial end of the second right intercostal space.
(c) the medial end of the second left intercostal space.
(d) the apex of the heart.
(e) the fifth left intercostal space 3.5 in. (9 cm) from the midline.

163
 Answer: B

164
A 33-year-old woman was jogging across the park at 11 p.m. when she was attacked by a gang of youths.
After she was brutally mugged and raped, one of the youths decided to stab her in the heart to keep her
silent. Later in the emergency department she was unconscious and in extremely poor shape. A small
wound about 0.5 in. in diameter was present in the left fifth intercostal space about 0.5 in. from the lateral
sternal margin. Her carotid pulse was rapid and weak, and her neck veins were distended. No evidence of
a left-sided pneumothorax existed. A diagnosis of cardiac tamponade was made.
The following observations are in agreement with the diagnosis except which?
(a) The tip of the knife had pierced the pericardium.
(b) The knife had pierced the anterior wall of the left ventricle.
(c) The blood in the pericardial cavity was under right ventricular pressure.
(d) The blood in the pericardial cavity pressed on the thin-walled atria and large veins as they traversed the
pericardium to enter the heart.
(e) The backed-up venous blood caused congestion of the veins seen in the neck.
(f) The poor venous return severely compromised the cardiac output.
(g) A left-sided pneumothorax did not occur because the knife passed through the cardiac notch.

165
 Answer 8. B. The knife had pierced the

anterior wall of the right ventricle.

166
A 50-year-old man with chronic alcoholism was told by his physician that he had
cirrhosis of the liver with portal hypertension.
The following statements explain why the patient recently vomited a cupful of blood
except which?
(a) The lower third of the esophagus is the site of a portalâ€“systemic anastomosis.
(b) At the lower third of the esophagus the esophageal veins of the left gastric vein
anastomose with the esophageal veins of the inferior vena cava.
(c) In cirrhosis of the liver, the portal circulation through the liver is obstructed by
fibrous tissue, producing portal hypertension.
(d) Many of the dilated veins that lie within the mucous membrane and submucosa are
easily damaged by swallowed food.
(e) Copious hemorrhage from these veins is difficult to treat and is often terminal.

167
 Answer B. The esophageal veins of the azygos

system of veins anastomose with the
esophageal veins of the left gastric vein.

168
A 5-year-old boy was seen in the emergency department after an attack of breathlessness during which he had
lost consciousness. The mother said that her child had had several attacks before and sometimes his skin
had become bluish. Recently, she had noticed that he breathed more easily when he was playing in a
squatting position; he also seemed to sleep more easily with his knees drawn up. An extensive workup,
including angiography, demonstrated that the patient had severe congenital heart disease.
The following observations in this patient are consistent with the diagnosis of tetralogy of Fallot except
which?
(a) The child was thinner and shorter than normal.
(b) His lips, fingers, and toes were cyanotic.
(c) A systolic murmur was present down the left border of the sternum.
(d) The heart was considerably enlarged to the left.
(e) Pulmonary stenosis impairs the pulmonary circulation so that a right to left shunt occurs and the arterial
blood is poorly oxygenated.
(f) A large ventricular septal defect was present.
(g) The aortic opening into the heart was common to both ventricles.

169
 Answer D. Because of the pulmonary

stenosis and the ventricular septal defect, right
ventricular hypertrophy is causing the heart to
enlarge to the right.

170
On performing a routine examination of a 7-year-old girl, a pediatrician heard a continuous

machinery-like murmur in the second left intercostal space. The murmur occupied both
systole and diastole. The child was not cyanotic, the heart was of normal size, and there was
no clubbing of the fingers. Radiographic examination of the chest revealed slight enlargement
of the left atrium, left ventricle, and pulmonary trunk. A diagnosis of patent ductus arteriosus
was made.
Based on the clinical history and the diagnosis, the following statements concerning the case are
correct except which?
(a) The patent ductus represents the distal portion of the sixth left aortic arch artery.
(b) The ductus connects the right pulmonary artery to the descending thoracic aorta.
(c) The ductus in fetal life is the normal bypass of blood to the aorta from the pulmonary trunk.
(d) At birth, the ductus arteriosus normally constricts in response to a rise in arterial oxygen.
(e) The ductus arteriosus closes to become the ligamentum arteriosum.

171
 Answer B. The ductus arteriosus represents

the distal portion of the sixth left aortic arch
artery and connects the left pulmonary artery
at its origin from the pulmonary trunk to the
junction of the aortic arch and the descending
thoracic aorta.

172
Thank you!

THE ABDOMEN
173
INTRODUCTION:

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INTRODUCTION TO THE

 The circulatory system comprises both the

A.N Malik: Department of Human Anatomy, KMTC Nakuru. 11-Mar-16

 Veins: they result from convergence of capillaries

A.N Malik: Department of Human Anatomy, KMTC Nakuru. 11-Mar-16

 It begins in the lymphatic capillaries. These tubules

A.N Malik: Department of Human Anatomy, KMTC Nakuru. 11-Mar-16

 Traditionally; the circulatory system has been

A.N Malik: Department of Human Anatomy, KMTC Nakuru. 11-Mar-16

 The microvasculature plays a great role in the

A.N Malik: Department of Human Anatomy, KMTC Nakuru. 11-Mar-16

A.N Malik: Department of Human Anatomy, KMTC Nakuru. 11-Mar-16

A.N Malik: Department of Human Anatomy, KMTC Nakuru. 11-Mar-16

 NB. The above tissue components are present in

A.N Malik: Department of Human Anatomy, KMTC Nakuru. 11-Mar-16

A.N Malik: Department of Human Anatomy, KMTC Nakuru. 11-Mar-16

 It is a specialized type of epithelium which acts as a

 The endothelium has antithrombogenic properties(prevents

 This tissue is present in all vessels except pericytic

A.N Malik: Department of Human Anatomy, KMTC Nakuru. 11-Mar-16

 The amount of connective tissue varies as per the functional

 With aging, the ECM is disorganized by increased

 All blood vessels above a certain diameter have some

A.N Malik: Department of Human Anatomy, KMTC Nakuru. 11-Mar-16

A.N Malik: Department of Human Anatomy, KMTC Nakuru. 11-Mar-16

 Consists of a single layer of endothelial cells supported

A.N Malik: Department of Human Anatomy, KMTC Nakuru. 11-Mar-16

A.N Malik: Department of Human Anatomy, KMTC Nakuru. 11-Mar-16

 It consists of concentric layers of helically arranged

A.N Malik: Department of Human Anatomy, KMTC Nakuru. 11-Mar-16

 Consists mainly of collagen and elastic fibers.

A.N Malik: Department of Human Anatomy, KMTC Nakuru. 11-Mar-16

A.N Malik: Department of Human Anatomy, KMTC Nakuru. 11-Mar-16

 Large vessels have vasa vasorum(“vessels of vessels”)

A.N Malik: Department of Human Anatomy, KMTC Nakuru. 11-Mar-16

 Most vessels that have smooth muscles in their

A.N Malik: Department of Human Anatomy, KMTC Nakuru. 11-Mar-16

A.N Malik: Department of Human Anatomy, KMTC Nakuru. 11-Mar-16

 In veins, the nerve endings are found in the tunica

A.N Malik: Department of Human Anatomy, KMTC Nakuru. 11-Mar-16

 Generally, arterial blood vessels are classified

A.N Malik: Department of Human Anatomy, KMTC Nakuru. 11-Mar-16

 They help stabilize blood flow.

A.N Malik: Department of Human Anatomy, KMTC Nakuru. 11-Mar-16

 The abundant elastic lamina of large arteries contribute

 During embryonic development of the vessels the

A.N Malik: Department of Human Anatomy, KMTC Nakuru. 11-Mar-16

 These are chemoreceptors sensitive to changes in carbon

A.N Malik: Department of Human Anatomy, KMTC Nakuru. 11-Mar-16

 Most nerves of the carotid bodies are afferent(carry

 These are slight dilations of the internal carotid arteries.

 These are direct connections between arterioles and

A.N Malik: Department of Human Anatomy, KMTC Nakuru. 11-Mar-16

 They control the affluence of blood to organs by

 The external elastic lamina, the last component of

A.N Malik: Department of Human Anatomy, KMTC Nakuru. 11-Mar-16

 They are usually <0.5 mm in diameter with

A.N Malik: Department of Human Anatomy, KMTC Nakuru. 11-Mar-16

A.N Malik: Department of Human Anatomy, KMTC Nakuru. 11-Mar-16

Cross section through a small

A.N Malik: Department of Human Anatomy, KMTC Nakuru. 11-Mar-16

 They are composed of a single layer of endothelial cells

A.N Malik: Department of Human Anatomy, KMTC Nakuru. 11-Mar-16