SURFACE ANATOMY OF THE HEART

 Approximately in the middle of the thorax

 Laterally & posteriorly by the lungs
 Anteriorly by sternum & central part of thoracic cage
 Borders of the heart
 Variable and depend on position of diaphragm & build and physical condition of person
 Superior border
 Line connecting inferior border of 2nd costal cartilage to superior border of 3rd right costal
cartilage
 Right border
 Line drawn from 3rd right costal cartilage to 6th right costal cartilage
 Slightly convex to the right
 Inferior border
 Line drawn from inferior end of right border to a point in 5th intercostal space
 Close to left MCL
 Left end corresponds to location of apex of heart and apex beat
 Left Border
 Line connecting left ends of the lines representing superior & inferior borders
 Valves -> located posterior to sternum
 Sounds produced are projected to areas (see figure)
 Where stethoscope is placed to avoid intervening bone
 APEX BEAT
 Mitral Area
 Results from apex of heart forced against anterior thoracic wall when LV contracts
 Located in 4th or 5th intercostal spaces, 6-10cm from anterior median line
 AUSCULTATORY AREAS
 Aortic Area
 Pulmonary Areas
 Tricuspid Area
 Mitral Area

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PERICARDIUM
 Found in middle mediastinum
 Fibroserous membrane
 Covers heart & beginning of great vessels
 Aortic aorta carries pericardium superiorly beyond heart to level of sternal angle
 Situated obliquely approximately 2/3 to left and 1/3 to right of median plane
 Closed sac composed of two layers
 Bare area of pericardium ->
 Serous pericardium
 Composed mainly of mesothelium
 Parietal layer
 Lines internal surface of fibrous pericardium
 Visceral layer
 Reflects parietal layer onto heart at great vessels
FIBROUS PERICARDIUM
 Tough, external layer
 Continuous with central tendon of diaphragm
 Continuous superiorly with tunica adventitia of great vessels entering & leaving heart
 Also with pretracheal layer of deep cervical fascia
 Attached anteriorly to posterior surface of sternum by sternopericardial ligaments
 Bound posteriorly by loose connective tissues to structures in posterior mediastinum
 Continuous inferiorly with central tendon of the diaphragm
 Inseparable; firmly attached and confluent
 Tethers heart in place inside fibrous pericardial sac
 Floor of diaphragm
 Pericardiacophrenic ligament -> site of continuity
 Influenced by movement of heart & great vessels, sternum, and diaphragm
 Protects heart against sudden overfilling
 Due to being unyielding and relation to great vessels piercing it superiorly
 Transverse pericardial sinus
 Transversely running passage between these 2 groups of vessels and reflections of serous
pericardium around them
 Oblique pericardial sinus
 Reflection of serous pericardium around 2nd group of vessel
 Folding of primordial heart tube
 Formation of pericardial sinuses during development of heart
 Venous end moves posterosuperiorly; end lies adjacent to arterial end
 Separated by transverse pericardial sinus
 Posterior to intrapericardial parts of pulmonary trunk & ascending aorta
 Anterior to superior vena cava
 Superior to atria of heart
 Developing veins of heart
 Surrounded by pericardial reflection forming oblique pericardial sinus
 Wide pocket-like recess in pericardial cavity posterior to base of heart
 Formed by left atrium
 Bounded laterally by pericardial reflections around pulmonary veins & IVC
 Posteriorly by pericardium overlying anterior aspect of esophagus
 Can be entered inferiorly & admit several fingers
 Cannot pass around any of these structures because sinus is blind sac

PERICARDIAL CAVITY / SINUSES

 Potential space between opposing parietal & visceral layers of serous pericardium
 Contains fluid enabling heart to move & beat in a frictionless environment
 Visceral layer
 Forms epicardium
 Extends onto beginning of great vessels
 Continuous with parietal layer in locations where:
 Aorta & pulmonary cavity leave heart
 Superior vena cava, inferior vena cava and pulmonary veins enter heart

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HEART EXTRAS

APEX OF HEART  Coronary Sulcus -> demarcates atria from ventricles

 Anterior & Posterior Interventricular Sulci -> demarcates right & left ventricle
 Formed by inferolateral part of left ventricle
 Lies posterior to left 5th intercostal space in adults (insert pictures here)
 9cm from median plane
 Remains motionless throughout cardiac cycle
 Sounds of mitral valve closure are maximal -> apex beat
 Underlies mitral area

BASE OF HEART

 Posterior aspect of heart; opposite of apex

 Formed mainly by left atrium; right atrium has small contribution
 Posteriorly faces bodies of T6-T9 vertebrae
 Separated by pericardium; oblique pericardial sinus & aorta
 Extends superiorly to bifurcation of pulmonary trunk &
inferiorly to coronary sulcus
 Receives
 Right & left side of left atrial portion: pulmonary veins
 Superior & inferior ends of right atrial portion: SVC & IVC

SURFACES OF THE HEART

 Anterior (Sternocostal): formed by right ventricle

 Diaphragmatic (Inferior): formed mainly by left ventricle & partly by right ventricle
 Related to central tendon of diaphragm
 Right Pulmonary: formed by right atrium
 Left Pulmonary: formed by left ventricle
 Forms cardiac impression of left lung

BORDERS OF THE HEART

 Right: right atrium extending between SVC & IVC; slightly convex
 Inferior: right ventricle & little left ventricle; nearly horizontal
 Left: left ventricle & little left auricle; oblique; nearly vertical
 Superior: right & left atria and auricles in anterior view
 Ascending aorta & pulmonary trunk emerge from this border
 SVC enters right side of this border
 Forms inferior boundary of transverse pericardial sinus

© AKMH, Kromos 2023

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CHAMBERS OF THE HEART LEFT ATRIUM

RIGHT ATRIUM  Forms most of the base of the heart

 Valveless pairs of right & left pulmonary veins enter the atrium
 Forms right border of the heart  Wall of embryonic pulmonary vein & 4 of its tributaries -> incorporated into wall of left atrium
 Receives venous blood from SVC, IVC & coronary sinus  Part derived from embryonic pulmonary vein -> smooth walled
 Right auricle  Left auricle
 Projects from right atrium; conical muscular pouch  Wall trabeculated with pectinate muscles
 Increases capacity of atrium as it overlaps ascending aorta  Forms superior part of left border of heart
 Interior of right atrium contains:  Remains of left part of primordial atrium
 Sinus venarum  Semilunar depression in interatrial septum -> floor of oval fossa
 Vena cavae & coronary sinus open  Valve of oval fossa -> surrounding ridge of semilunar depression
 Bringing poorly oxygenated blood into heart  Interior of left atrium contains:
 Pectinate muscles  Larger smooth-walled part & smaller muscular auricle containing pectinate muscles
 Composes rough, muscular anterior wall  4 pulmonary veins entering smooth posterior wall
 Right AV orifice  Thicker wall than right atrium
 Poorly oxygenated blood into right ventricle  Interatrial septum
 Smooth & rough parts of atrial wall are separated by:  Sloping posteriorly and to the right
 Sulcus terminalis (terminal groove) externally; shallow vertical groove  Left AV orifice
 Crista terminalis (terminal crest) internally; vertical ridge  Oxygenated blood from pulmonary veins into left ventricle
 Superior vena cava
 Opens into superior part at level of right 3rd costal cartilage
 Inferior vena cava
 Opens into inferior part at level of 5th costal cartilage; almost in line with SVC
 Opening of coronary sinus
 Between right AV orifice and intraventricular orifice
 Interatrial septum
 Separates atria
 Oval fossa
 Oval, thumbprint-size depression
 Remnant of oval foramen & its valve in fetus

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RIGHT VENTRICLE  Inferiorly -> interventricular septum
 Superiorly -> atrioventricular septum
 Largest part of anterior surface of heart  Separates right atrium from left ventricle
 Small part of diaphragmatic surface; entire inferior border of heart  Septomarginal trabecula -> curved muscular bundle
 Conus arteriosus  Traverses right ventricular chamber from inferior part of IVS to base of APM
 Leads into pulmonary trunk  Carries part of right branch of AV bundle
 Interior of right ventricle contains  Part of conducting system of heart to APM
 Trabeculae carneae -> irregular muscular elevations  Facilitate conduction time -> coordinated contraction of APM
 Supraventricular crest -> thick muscular ridge  Empty & relaxed right ventricle -> contraction of right atrium
 Separates ridged muscular wall of inflow part from smooth wall of conus arteriosus  Blood forced through () orifice into right ventricle
 Inflow part  Cusps pushed aside like curtains
 Receives blood from right atrium into right AV (tricuspid) orifice  Inflow tract -> inflow of blood into right ventricle
 Located posterior to body of sternum at level of 4th-5th intercostal spaces  Enters posteriorly
 Surrounded by one of fibrous rings of fibrous skeleton of the heart  Contracting right ventricle
 Keep caliber of orifice constant -> large enough to admit tips of three fingers  Outflow tract -> outflow of blood into pulmonary trunk
 Resist dilation that result from blood being forced through at varying  Leaves superiorly and to the left; U-shaped path through right ventricle, 1400
pressures  Supraventricular crest deflects:
 Tricuspid valve  Incoming flow into main cavity of ventricle
 Guards right AV orifice  Outgoing flow into conus arteriosus towards pulmonary orifice
 Bases of valve cusps are attached to fibrous ring around orifice  Pulmonary valve -> at apex of conus arteriosus -> level of left 3rd costal cartilage
 Contact each other in same way with each heartbeat
 Tendinous cords
 Attach to anterior, posterior & septal cusps -> cords attaching to parachute
 Arise from apices of papillary muscles
 Tightened -> prevent separation of cusps & inversion during systole
 Prevent cusps from prolapsing
 Valve Cusps
 Blocks backward flow of blood from right ventricle back to right atrium
 During ventricular systole
 Papillary muscles
 Conical muscular projection with bases attached to ventricular wall
 Begin to contract before contraction of right ventricle,
 Tightening tendinous cords & draw cusps together
 Anterior papillary muscle
 Largest & most prominent
 Arises from anterior wall of right ventricle
 Cords attach to anterior & posterior cusps
 Posterior papillary muscle
 Smaller than APM (see above)
 Arises from inferior wall of right ventricle
 Cords attach to posterior & septal cusps
 Septal papillary muscle
 Arise from interventricular septum; cords attach to anterior & septal cusps
 Interventricular septum -> composed of muscular & membranous parts
 Partition between right & left ventricles -> forming part of walls of each
 Muscular part
 Majority of septum
 Thickness of remainder of the wall of left ventricle (2-3x thicker than wall of RV)
 Bulges into cavity of right ventricle
 Membranous part
 Found superiorly & posteriorly; smaller
 Part of fibrous skeleton of heart
 Septal cusp attaches to middle of membranous part
© AKMH, Kromos 2023
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LEFT VENTRICLE SEMILUNAR VALVES

 Forms apex; nearly all left (pulmonary) surface & most diaphragmatic surface  Cusps -> concave when viewed superiorly
 Performs more work than left ventricle -> systemic pressure > pulmonary pressure  Do not have tendinous cords for support
 Interior of left ventricle  Smaller in area than AV valve cusps
 Walls 2-3x thicker than walls of right ventricle  Force exerted on them is less than half of tricuspid & mitral valve cusps
 Walls covered with trabeculae carneae finer & numerous than right ventricle  Project into the artery
 Conical activity longer than right ventricle  Pressed toward walls as blood leaves ventricle
 Anterior & posterior papillary muscles -> larger than in right ventricle  Diastole -> relaxation of ventricle
 Aortic vestibule  Elastic recoil of wall of pulmonary trunk / aorta forces blood back toward heart
 Smooth-walled, nonmuscular, supero-anterior outflow part  Cusps snap catching reverse blood flow
 Leading from ventricular cavity to aortic orifice & aortic valve  Close orifice; support each other as edges meet
 Mitral valve -> double leaflet  Prevent blood from returning to ventricle
 Guards left AV orifice  Lunule -> thickened edge of cusp in region of contact
 Aortic orifice  Nodule -> further thickened apex of angulated free edge
 Lies in right posterosuperior part  Aortic sinuses & sinuses of pulmonary trunk
 Surrounded by fibrous ring  Formed superior to semilunar cusps; dilated wall of origins of aorta & pulmonary artery
 Right posterior & left cusps are attached  Spaces at origin of pulmonary trunk & ascending aorta between dilated wall of vessel and each
 Beginning of ascending aorta cusp of semilunar valves
 Mitral valve  Blood in sinuses & dilation of wall prevent cusps from sticking to the wall of vessel, which
 Located posterior to sternum at level of 4th costal cartilage might prevent closure
 Two cusps: anterior & posterior  Right aortic sinus -> mouth of right coronary artery
 Recieves tendinous cord from more than 1 papillary muscle  Left aortic sinus -> mouth of left coronary artery
 Support mitral valve, allows cusps to resist pressure during contractions of LV  Posterior aortic sinus -> no artery
 Cords become taut -> before & during systole -> cusps resist pressure in contraction
 Bloodstream undergoes two right angle turns, result in 1800 change in direction
 Takes place around anterior cusp of mitral valve; reversal of flow
 Aortic valve -> semilunar valve
 Between left ventricle & descending aorta
 Located posterior to left side of sternum at level of 3rd intercostal space

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ABNORMALITIES, DISEASES & INJURIES INVOLVING HEART & PERICARDIUM
POSITIONAL ABNORMALITIES OF HEART
 Dextrocardia
 Apex misplaced to right instead of left
 Complete reversion of heart position
 Due to abnormal folding of embryonic heart tube to left instead of right
 Most common positional abnormality of heart; still relatively uncommon
 Situs inversus; part of general transposition of thoracic & abdominal viscera
 Low incidence of accompanying cardiac defects; heart functions normally
 Isolated dextrocardia; transposition only affects heart
 Complicated by severe cardiac anomalies (e.g. transposition of great arteries)
PERICARDITIS, PERICARDIAL RUB & PERICARDIAL EFFUSION
 Pericarditis
 Inflammation of pericardium
 Make serous pericardium rough -> calcify -> hamper cardiac efficiency
 Pericardial friction rub -> rustle of silk over left sternal border & upper ribs
 Pericardial effusion
 Passage of fluid from pericardial capillaries into pericardial cavity (pus accumulation)
 Often occur with congestive heart failure
 Venous blood returns to heart at rate exceeding cardiac output
 Producing right cardiac hypertension
CARDIAC TAMPONADE
 Heart compression
 Increasingly compromised heart volume by fluid outside heart but inside pericardial cavity
 Extensive pericardial effusion -> compromised sac volume
-> heart receives limited amount of blood -> reduced cardiac output
 Hemopericardium -> blood in pericardial cavity -> produces cardiac tamponade
 Result from perforation of weak heart muscle area from previous myocardial infarction
 High pressure involved & rapidity of fluid accumulation -> lethal situation
 Increasingly compressed heart & circulation fails
 Veins become engorged due to blood backup, begins where SVC enters pericardium
 Pneumopericardium -> air in pericardial sac
 Complication of pneumothorax (air or gas in pleural cavity)
 Always result of a valve abnormality; always a chronic process
 Insufficiency or regurgitation -> failure of valve to close completely
 Owing to nodule formation on cusps -> edges do not meet or align
 Result from pathology of valve itself or its supporting structures
 Acutely -> suddenly (e.g. rupture of cords)
 Chronically -> over a relatively long time (e.g. scarring and retraction)
 Both result in increased workload for the heart
 Produces turbulence
 Set up eddies (small whirlpools) -> produce vibrations audible as murmurs
 Superficial vibratory sensations (thrills) felt over area of turbulent skin
 Clinical significance
 Ranges from slight & insignificant to severe & rapidly fatal
 Factors (e.g. degree, duration & etiology) -> affect secondary changes in heart, blood vessels &
other organs, both proximal / distal to valve lesion
 May be congenital or acquired
 Mechanical problem
 MITRAL VALVE INSUFFICIENCY / MITRAL VALVE PROLAPSE
 Insufficient valve with 1 or both leaflets enlarged extend back to LA during systole
 Blood regurgitates into LA when LV contracts -> producing murmur
 PULMONARY VALVE STENOSIS
 Fused valve cusps -> forms dome with narrow central opening
 Infundibular pulmonary stenosis -> underdeveloped conus arteriosus
 Produce restriction of right ventricular outflow
 PULMONARY VALVE INCOMPETENCE
 Lunules of cusps of a semilunar valve thicken -> become inflexible/damaged by disease ->
incomplete closure of valve
 Results in backrush of blood under high pressure into right ventricle during diastole
 Produces pulmonic regurgitation -> heard through stethoscope
 AORTIC VALVE STENOSIS -> most frequent valve abnormality
 Result of degenerative calcification; coms to clinical attention in 6th decade of life
 Results in left ventricular hypertrophy
 AORTIC VALVE INSUFFICIENCY
 results in aortic regurgitation -> produces heart murmur & collapsing pulse

SEPTAL DEFECTS

 Atrial Septal Defect (ASD)

 Congenital anomaly of interatrial septum
 Incomplete closure of oval foramen; patency present in 15-25% of adults
 Cause no hemodynamic abnormalities by themselves
 No clinical significants and not considered form of ASD by themselves
 Clinically significant ASD -> large opening
 Ventricular Septal Defect -> membranous part of IVS -> common site


VALVULAR HEART DISEASES

 Disturbs pumping efficiency of heart; produces either

 Stenosis -> failure of valve to open fully / slowing blood flow from a chamber
© AKMH, Kromos 2023
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VASCULATURE OF HEART  Left coronary artery
 Arises from left aortic sinus of ascending aorta
CORONARY ARTERIES  Passes between left auricle & left side of pulmonary trunk; runs in coronary sulcus
 Typically supplies:
 First branch of aorta  Left atrium; most of left ventricle; part of right ventricle
 Supply myocardium & epicardium  Most of IVS
 Right & left coronary arteries arise from corresponding aortic sinuses
 AV bundle of conducting system of heart, via perforating IV septal branches
 At proximal part of ascending aorta, superior to aortic valve, opposite sides of PT
 SA node (40% chance)
 Supply both atria & ventricles
 SA nodal branch
 Atrial branches are small and not readily apparent in cadaver
 Arises from circumflex branch (40% chance)
 Ventrical distribution not sharply demarcated
 Divides into two branches at superior end of anterior IV groove
 Right coronary artery
 Anterior IV branch / LAD
 Typically supplies:
 Passes along IV groove to apex of heart
 Right atrium; most of right ventricle
 Turns around inferior border of heart
 Diaphragmatic surface (left ventricle); posterior third of IV septum (part only)
 Commonly anastomoses with posterior IV branch of RCA
 SA node (60% of people); AV node (80% of people)
 Supplies adjacent parts of both ventricles
 Arises from right aortic sinus of ascending aorta
 Passes to right side of pulmonary trunk, running in coronary sulcus  Also anterior 2/3 of IVS via IV septal branches
 Sino-atrial nodal branch; ascending  Gives rise to lateral branch -> descends on anterior surface of heart
 Given off near origin  Circumflex branch
 Supplies SA node  Follows coronary sulcus around left border of heart to posterior surface of heart
 Right marginal branch  Left marginal border -> follows left margin of heart; supplies left ventricle
 Given off in descent of RCA in coronary sulcus  Terminates in coronary sulcus, but 1/3 continue to supply branch running or adjacent to
 Supplies right border of heart as it runs toward apex of heart posterior IV groove
 Atrioventricular nodal branch  Variations of Coronary arteries
 At junction of interatrial & interventricular septa between 4 heart chambers (cross)  67% -> right dominant pattern -> RCA & LCA share equal blood supply of heart
 Supplies AV node  15% -> dominant LCA -> posterior IV branch is from circumflex artery
 Posterior interventricular branch  18% -> codominance -> artery reach crux & give rise to branches near posterior groove
 67% chance -> dominance is typical  Few only have 1 coronary artery; 4% have accessory coronary artery
 Supplies areas of both ventricles  Coronary Collateral Circulation
 Sends perforating interventricular septal branches into IV septum  Functional end arteries -> coronary arteries
 Supply regions of myocardium lacking sufficient anastomoses from other large branches
 Maintain viability of tissue should occlusion occur
 Anastomoses exist between
coronary arteries (subepicardial / myocardial) & extracardiac vessels (thoracic vessels)
 Between terminations of right & left coronary arteries in coronary sulcus & between IV
branches around apex of heart in 10% of hearts
 Potential for development of collateral circulation exists in all hearts

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VENOUS DRAINAGE OF HEART
 Drained mainly by veins emptying into coronary sinus & small veins emptying right atrium
 Coronary sinus -> main vein of heart
 Runs from left to right in posterior part of coronary sulcus
 Left end: great cardiac vein
 Right end: middle cardiac vein & small cardiac veins
 Left posterior ventricular vein & left marginal veins also open into sinus
 Great cardiac vein -> main tributary of coronary sinus
 Anterior interventricular vein -> first part
 Begins near apex of heart & ascends with anterior IV branch (LAD) of LCA
 Turns left at coronary sulcus -> second part
 Runs around left side of heart w/ circumflex branch of LCA to reach coronary sinus
 Same direction of blood flow within paired artery & vein
 Drains areas of heart supplied by LCA
 Middle cardiac vein -> accompanies posterior IV branch
 Small cardiac vein -> accompanies right marginal branch of RCA
 Oblique vein of the left atrium (of Marshall) -> relatively unimportant postnatally
 Descends over posterior wall of left atrium
 Merges with great cardiac vein to form coronary sinus
 Remnant of embryonic left SVC; atrophies during fetal period
 Occasionally persists in adults; replacing / augmenting SVC
 Some veins do not drain via coronary sinus
 Anterior cardiac vein
 Begin over anterior surface of right ventricle, cross coronary sulcus
 End directly in right atrium; sometimes enter cardiac vein
 Smallest cardiac vein
 Begin in capillary beds of myocardium & open directly into chamber of heart (atria)
 Valveless communications with capillary beds of myocardium
 Carry blood from heart chambers to myocardium
LYMPHATIC DRAINAGE OF HEART
 Subepicardial lymphatic plexus
 Lymphatic vessels in myocardium & subendocardial connective tissue pass here
 Pass to coronary sulcus and follow coronary arteries
 Lymphatic vessel -> formed by union of various lymphatic vessels of heart -> ascends between
pulmonary trunk & left atrium -> ends in interior tracheobronchial lymph nodes (right side)
© AKMH, Kromos 2023
INNERVATION OF HEART
 Cardiac plexus -> supplies heart with autonomic nerve fibers
 Lies on anterior surface of bifurcation of trachea (carina)
 Commonly observed in dissection after removal of ascending aorta & bifurcation of
pulmonary trunk
 Formed of both sympathetic & parasympathetic fibers en route to heart
 As well as visceral afferent fibers - convey reflexive & nociceptive fibers from heart
 Divided into:
 Superficial
 Deep
 Sympathetic supply
 From presynaptic fibers
 Cell bodies in intermediolateral cell column of superior 5/6 thoracic segments
 Also from postsynaptic sympathetic fibers
 Cell bodies in cervical & superior thoracic paravertebral ganglia of sympathetic
trunks
 Traverse cardiopulmonary splanchnic nerves & cardiac plexus
 End in SA & AV nodes in relation to terminations of parasympathetic fibers
on coronary arteries
 Sympathetic stimulation results to:
 Increased heart rate; impulse conduction
 Force of contraction
 Increased blood flow through coronary vessels -> support increased activity
 Adrenergic stimulation of SA node & conductive tissue
 Increases pacemaker depolarization rate while increasing AV conduction
 Direct adrenergic stimulation + indirect suprarenal hormone stimulation
 Increases atrial and ventricular contractility
 Coronary blood vessel adrenergic receptors = B2 receptorsd
 Activated -> causes relaxation of vascular smooth muscle -> dilation of artery
 more oxygen & nutrient supply to myocardium during increased activity
 Parasympathetic supply
 From presynaptic fibers of vagus nerve
 Postsynaptic parasympathetic cell bodies (intrinsic ganglia)
 Located in atrial wall & interatrial septum near SA & AV nodes & along CA
 Release acetylcholine -> binds with muscarinic receptors
 Decreases pacemaker polarization rate & AV conduction
 Decrease atrial contractility
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STIMULATING, CONDUCTING & REGULATING SYSTEM OF HEART  Lies on right side of superior mediastinum, anterolateral to trachea & posterolateral to
ascending aorta
 Generates & transmits impulses producing coordinated contractions of cardiac cycle
 Consist of
 Nodal tissue -> initiates heartbeat & coordinates contractions
 Conducting fibers -> conduct impulses rapidly to different areas of heart
 -> impulses propagated by cardiac striated muscles -> simultaneous contraction
 Sino-atrial node
 Located anterolaterally, deep to epicardium at junction of SVC & RA, near superior end of
sulcus terminalis
 Small collection of nodal tissue, specialized cardiac muscle fibers & associated fibro-elastic
connective tissue
 Pacemaker of heart
 Initiates and regulates impules for contractions of heart
 Gives off an impulse 70x/min
 Contraction signal spreads myogenically of both atria
 Supplied by sino-atrial nodal artery
 Arises either from RCA (60%) or LCA (40%)
 Stimulated by sympathetic division of autonomic nervous system
 To accelerate heart rate
 Inhibited by parasympathetic division to return to / approach its basal rate
 Atrioventricular node
 Smaller than SA node
 Located in postero-inferior region of interatrial septum near opening of coronary sinus
 Signal from SA node -> wall of RA + cardiac muscle propagation -> AV node
 Distributes signal to ventricles through AV bundle
 Supplied by AV nodal artery
 Largest & usually first IV septal branch of posterior IV artery
 Branch of RCA in 80% of people
 RCA usually supplies both SA & AV nodes
 AV bundle / Bundle of His
 Only bridge between atrial & ventricular myocardium
 Passes from AV node through fibrous skeleton of heart along membranous part of IVS
 Divides into left & right bundle at junction of membranous & muscular parts of IVS
 Proceed on side of muscular IVS deep to endocardium
-> ramify into subendocardial branches -> extend into walls of respective ventricle
 Right -> stimulate muscle of IVS, anterior papillary muscle through septomarginal
trabecula, wall of right ventricle
 Left -> divides into 6 smaller tracts -> subendocardial branches
 Stimulate IVS, anterior & posterior papillary muscles & wall of LV
 Traverses center of IVS, anterior two thirds supplied by septal branches of LAD
 1. SA node -> AV node -> AV bundle (Bundle of His)

GREAT VESSELS

 Brachiocephalic veins (right & left)

 Formed posterior to SC joints by union of IJV & subclavian veins
 Unite to form SVC at level of inferior border of 1st right costal cartilage
 Shunt blood from head, neck, & upper limbs to right atrium
 Left is twice as long as right ->
 Superior vena cava
 Returns blood from all structures superior to diaphragm EXCEPT lungs & heart
 Passes inferiorly and ends at level of 3rd costal cartilage -> enter right atrium
© AKMH, Kromos 2023
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