Anatomy

Pericardium

- Fibrous pericardium (FP)

- Thick, continuous with adventitia of great vessels

- Attached to central tendon of diaphragm

- Phrenic nerve, pericardiacophrenic vessels pass through FP along their course  supply

- Innervated by phrenic nerve (C3-C5)

- Serous pericardium (SP)

- Parietal serous pericardium (PSP):

- Continuous with VSP around roots of great vessels (serous reflection) at two sites:

- Superior reflection: surround arteries (ascending aorta, pulmonary trunk)

- Inferior reflection: surround veins (SVC/IVC/PVs)

- Transverse pericardial sinus:

- Pericardial cavity between superior reflection and inferior reflection

- Lined by serous pericardium (PSP at posterior wall, VSP at other walls, which formed by
great vessels

- Separate great arteries (AA, PA) from veins (SVC/IVC/PVs)

- Oblique pericardial sinus:

- Pericardial cavity posterior to left atrium

- Between Left/right PVs

- Innervation: sensory (phrenic nerve) ~ FP

- Visceral serous pericardium (VSP):

- VSP = VSP at root of great vessels (continuous with PSP) + epicardium (VSP covering heart)

- Lack sensory innervation

- Pericardial cavity

- Serous fluid space between VSP and PSP, lubricating function

- Normally ~ 20ml serous fluid

- Rupture of coronary arteries (traffic accident), aorta (retrograde aortic dissection), pericarditis 
cardiac tamponade

- Parietal pericardium (fibrous + PSP) sensory  phrenic nerve  C3-C5  supraclavicular/lateral neck pain

- Blood supply:

- Artery: internal thoracic branches, pericardiophrenic, thoracic aorta

- Vein: internal thoracic, azygos

Heart

- Gross:

- 5 Surfaces:

- Anterior:

 RA+RV >>> LV

- Base:

 LA + PV, SVC/IVC of RA, esophagus immediately posterior to base (LA)

 Right PVs run posterior to SVC-part of RA

- Diaphragmatic

 LV >> RV, posterior interventricular groove, rest on diaphragm

 Separate from base by coronary sinus

 Continue to apex

- Right pulmonary:

 RA

- Left pulmonary

 LA, part of LA

- 1 Apex

- Left 5th intercostal space, 7~8cm from midsternal line

- Apex beat can be felt

- Anteriorly, inferiorly, left, formed by left ventricle

- Margin (important for radiology)

- Inferior margin: horizontal, RV, little LV near apex

- Right margin: SVC (upper)  RA (middle)  IVC (lower)

- Obtuse margin (left margin): LV mostly, left auricle

- Sulci:

- Coronary sulcus:

- Separate atrium from ventricle

- Coronary sinus, small cardiac vein, right coronary artery (RCA), left circumflex coronary a
(LCC)

- Anterior interventricular sulci (AIS)

- Anterior surface

- LAD, great cardiac vein

 - Posterior interventricular sulci (PIS)

- Diaphragmatic surface

- Posterior interventricular artery (usually from RCA), middle cardiac vein

- Continuous with AIS at apex

- Regional anatomy

- Right atrium (右心房)

- RA

- RA= Sinus of vena cavae + atrium proper (contain right auricle) (2 embryonic s
tructures)

 Separate externally by sulcus terminalis cordis 分界溝

 Separate internally by crista terminalis 分界稜

 Smooth muscular ridge

 Extend from roof of LA just anterior to SVC opening  anterior lip of

IVC

- Sinus of vena cavae (大静脈洞)

 Right horn of sinus venosus

 Smooth, thin wall, posterior, IVC/SVC enters

- Atrium proper:

 Contain right auricle

 All covered by pectinate muscles

- IVC, SVC, coronary sinus opening, openings of smallest cardiac veins (many)

- SVC opening: no valve (JVP!)

- IVC and coronary sinus have valves

 IVC valves help shunting blood to foremen ovale

- Interatrial septum is posterior wall of RA

- Fossa ovalis 卵円窩 + limbus fossa ovalis (just above IVC opening)

- Right ventricle 右心室

- Blood from RA  RV in horizontal, to the left direction

 AV opening is posterior-superior to RV

- Outflow to pulmonary trunk: (CA) conus arteriosus 動脈円錐 (infundibulum) (bulbus cordis
embryology)
  Separated from RV by supraventricular crest 室上稜(muscular ridge)

 CA is anterior-superior to RV

- Trabeculae carneae(TC) 肉柱: muscular, rougher than LV

- Form ridge: attach its whole length to RV walls

- Form bridge: two ends attached to RV walls

- Bulged TC is papillary muscles: one end attached to RV walls

- Papillary muscles 乳頭筋  chordae tendineae 腱索  free edge of cusps of tricuspid valves

- Anterior 前, posterior 後, septal 中隔

- Contract prior to other cardiac muscles to tighten chordae tendinae

- Septomarginal trabecula 中隔縁柱 (moderator band): connect interventricular septum  anterior

RV wall nears base of anterior papillary muscle  part of right bundle branch  anterior RV walls

- Tricuspid:

- Anterior, posterior, septal cusps 前・後・中隔尖

- Cusps are anchored to fibrous ring 線維輪

- Continue with each other at base (commissure)

- Pulmonary valve:

- 3 semilunar 半月弁 cusps (anterior, right, left)

- Each has a nodule 半月弁結節, a lunule (lateral V edge)  better close of valve

- Left atrium:

- LA = posterior half + anterior half (two embryonic structures)

- Posterior half: smooth, 4 PVs

- Anterior half: pectinate muscles, have left auricle

- Interatrial septum is anterior wall of LA

- No crista terminalis separate two portions

- Valve of foramen ovale (valve derived from LA)

- Left ventricle:

- Outflow to aorta: aortic vestibule (bulbus cordis), posterior to infundibulum

- Trabeculae carneae; fine, more delicate than RV, also form ridges, bridges

- Papillary muscles

- Anterior
 - Posterior

- Interventricular septum forms anterior wall of LV (b/c LV is posterior to RV)

- Muscular part: thick, RV-LV

- Membranous part: thin

- Seen from LV: just below aortic cusps

- Seen from RV: just below fibrous ring of tricuspid  interventricular part

- Seen from RA: just above fibrous ring of tricuspid  atrioventricular part

- Interventricular part: RV-LV

- Atrioventricular part: RA-LV (superior to attachment of tricuspid)

- Mitral valve:

- Anterior, posterior cusps

- Anchored to fibrous ring

- Continuous at commissure at base

- Aortic valve: 3 semilunar valves, right – left (coronary cusp) and posterior (non-coronary)

- Cardiac valves structure:

- Atrial/blood vessel surface + ventricular surface

- All covered with endocardium/endothelium

- Under endocardium, 3 layers:

 Atrial/blood vessel surface: spongiosa

 Middle: fibrosa – the extension of fibrous ring

 Ventricular surface: ventricularis, continuous with chorda tendineae

- Chordae tendinae from two papillary muscles attach to each cusp  prevent cusps separation

- Necrosis of papillary muscle (AMI)  prolapse of valves

- Elasticity of PA, Ao  force blood back to semilunar valves  close them

- Cardiac skeleton

- Dense, fibrous connective tissue

- Nearly coincide with sagittal section (to the left: R/LV, to the right: R/LA)

- 4 rings (annulus fibrosus) + 2 interconnecting area (2 trigone)

- 4 annulus fibrosus: PA valve ring, Ao valve ring, left/right AV ring

- Interconnecting area:

- Right fibrous trigone (between Ao ring and right AV ring)

- Left fibrous trigone (between Ao ring and left AV ring)

 - Electrical isolation

- Attachment of membranous part of interventricular septum

- Attachment of atrial/ventricular myocytes

- Prevention of dilation of valves (regurgitation)

- AV bundle (bundle of HIS) is the electrical connection only

- Cardiac microscopic structure: (inner to outer)

- Endocardium: single layer of endothelium

- Subendocardial: connective tissue, containing veins, nerves, part of conducting system

- Myocardium:

- Epicardium: VSP + underlying adipose tissue + VAN embedded in it.

- Coronary arteries

RCA LCA
- RA - LA (LCX)
- RV
- SA node (60% of time) - SA node from LCX (40%), sometimes both!
- AV node
- Posterior 1/3 interventricular septum - Anterior 2/3 interventricular septum  bundle
of His + LB/RB
- LV - LV
 Posterioinferior surface: RCA  PIB  Anterior surface: LAD DB
in 60% (right heart dominant)  Lateral surface: LCX  LMA, PL
 Posterioinferior surface: LCX  PL, LCX  PIB
in 30% (left heart dominant)

Other notes: - Posterioinferior wall of LV in 10% of time receive

both RCA-PIB and LCX-PL
- Posterioinferior wall contains LV posterior
papillary muscle
- Anterior and lateral LV wall both contributes to
anterior papillary muscle
- Either from RCA or LCA (only <10% of people
have both supply), posterior papillary muscle is
supplied by PIB/PDA  prone to AMI  Mitral
regurgitation (MR)
- Anterior papillary muscle is less affected by AMI
b/c it is supplied by both LAD/LCX
 - RCA:

- From right aortic sinus (Valsava sinus) (right cusp)

- Descend in part of coronary sulcus between RA/RV  turn to diaphragmatic surface

- Follow it courses inferiorly:

- RCA  atrial branch  SA nodal branch  goes posteriorly, near SVC  SA node

- RCA  right marginal branch (RMB) (inferior margin)

- RCA  AV branch (in diaphragmatic surface)

- RCA  posterior interventricular branch (PIB/PDA) (final, in PIS)

- LCA:

- Left aortic sinus (left cusp)

- From aorta  posterior to pulmonary trunk  between PT and left auricle  branches

- LCX: in coronary sulcus  left marginal artery (LMA)  posteriolateral branch (PL) end
before PIS or give PIB

- LAD: AIS, curve at apex to reach near PIS, may give diagonal branch (DB) x 1-2

- Cardiac veins

- No valves

- Two pathways:

 Arteries (epicardium)  capillaries (myocardium)  veins (epicardium)  coronary sinus

or RA directly (anterior cardiac veins)

 Arteries (epicardium)  capillaries (myocardium)  Thebesian veins (subendocardium)

 RA > RV > LA > LV

- 60% venous enters coronary sinus  RA:

 Great cardiac vein: apex  AIS (with LAD)  up  coronary sulcus  CS

-  Middle cardiac vein: apex  PIS (with PIB)  up  CS

 Small cardiac vein: coronary sulcus at inferior margin of RV  CS

 Right marginal vein may enter it or directly to RA

 Accompany RMB
  Posterior vein of left ventricle: lateral edge of LV  CS

 Oblique vein of left atrium:

- Other veins:

 Anterior cardiac vein: anterior surface of RV  cross coronary sulcus  RA

 Thebasian veins (smallest cardiac veins): backflow of oxygenated blood directly from
heart may supply subendocardial myocardium

- Conduction:

- SA node: inside RA, superior end of crista terminalis, to the right of opening of SVC

- Internodal tract: SA AV, not clear yet

 Anterior

 Middle

 Posterior

- Interatrial tract (Bachmann bundle):

 Branch of anterior internodal tract

 SA  LA

- AV node:

Just above coronary sinus, septal leaflet of tricuspid, in interatrial septum

 Beneath endocardium, in subendothelial

- Bundle of His:

 Pierce right fibrous trigone  enter membranous part of IVS

Follow inferior border of membranous part of interventricular septum (IVS)

 Divide to two bundle at the beginning of muscular part of IVS

- Right bundle:

 Cord-like, thick

 Buried in muscle of IVS  near apex it becomes subendocardial  bifurcate

 One enters moderator band  Purkinje fibers (subendocardial plexus)

 Other  tip of RV  Purkinje fibers

- Left bundle:

 Sheet-like

 Immediately divide to 2 fascicles: anterior, posterior

 Anterior: travel to apex  to anterior papillary muscle  Purkinje fibers

 Posterior: travel to posterior papillary muscle  Purkinje fibers

  One septal branch: innervate IVS muscular part

- Purkinje fibers: subendocardium

- Innervation:

- Superficial cardiac plexus + deep cardiac plexus

- PNS:

- Vagal cardiac branches  plexus  synapse in plexus ganglion or not  target  synapse
in ganglion in atrial walls

- (Superior/middle/inferior cervical, thoracic) cardiac branches

- SNS:

- T1-T4  preganglionic SNS 

 Thoracic ganglia (1st  4th)  synapse  thoracic cardiac nerves (post-

ganglionic SNS)  plexus

 Thoracic SNS trunk  upward  superior/middle/inferior cervical sympathetic

ganglion  synapse  sup/mid/inf cervical cardiac nerves  post ganglionic SNS
 plexus

- Visceral afferent:

- Afferent with vagal nerve:

- Sense BP: aortic arch, atria

- Sense blood chemistry: aortic body

 involve in cardiac reflex

** In IHD, stimulation of vagal afferent  brain vomit center  nausea/vomit

- Afferent with sympathetic:

 Sense pain of tissue damage: C7-8, T1-T4 dermatome

- PNS/SNS distribution and function on heart

SNS PNS
Distribution Everything in heart SA node, AV node, LA/RA muscles
HR ↑ ↓
Contractility ↑ ↓ (mild)
Coronary arteries Dilate (↑ demand) Constrict (↓ demand)
-

Vessel

- Artery

- Vein

- Capillary

- Lymphatic