NATOMY DEPARTMENT

ANATOMY OF THE HEART

Dr. Wael Amin Nasr El-Din
Associate Prof. of Anatomy
CMMS - AGU
INTENDED LEARNING OUTCOMES
At the end of the lecture, the students should be able to:
• State the site of the heart and the layers of its wall.
• Describe the shape, the surfaces and borders of the heart.
• Describe the internal structure of the heart.
• State the lymphatic drainage and nerve supply of the heart.
• Describe the surface anatomy and areas of auscultations of
the heart.

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 HEART
• Is a muscular pump, located in middle
mediastinum and is slightly larger than a
closed fist.
• Covered by pericardium which is composed
Heart of outer fibrous pericardium and inner serous
pericardium.

Fibrous pericardium

Parietal layer of
serous pericardium

Pericardial cavity
(containing thin
film of fluid)
Pericardium
Visceral layer of
serous pericardium inferior
(epicardium) cornu
Dr: Wael Amin
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 LAYERS OF WALL OF THE HEART
• Consists of 3 layers (from outside inwards):
1. Epicardium: visceral layer of serous pericardium and composed of
mesothelium (simple squamous epithelium).
2. Myocardium: composed of cardiac muscle.
3. Endocardium: endothelium lining heart chambers and covers the
valves.

Epicardium
Epicardium (visceral layer
of serous pericardium)

Myocardium Myocardium

Endocardium

Endocardium

Dr: Wael Amin

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 HEART
Left atrium Base
Left atrium

Right atrium

Sternocostal surface
Right ventricle Diaphragmatic
Left ventricle
surface

Apex

Anterior view of the heart Posterior view of the heart

• Consists of 4 chambers:
A. Two atria (right and left) that receive blood.
B. Two ventricles (right and left) that pump blood.
• Heart is pyramidal in shape, having:
1. Apex.
2. Base (posterior surface). inferior
3. Sternocostal (anterior) surface. cornu
4. Diaphragmatic (inferior) surface. Dr: Wael Amin
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 APEX OF THE HEART
• Directed downwards, forwards and to the
left. Lowermost and outermost point.
• Formed by left ventricle only.
• Lies at level of left 5th intercostal space 9
cm from midline at midclavicular line
below the left nipple.

Midclavicular
Midline line Clavicle

Left ventricle

inferior
Apex
cornu
Anterior view of the heart
Dr: Wael Amin
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(Apex at left 5th intercostal space)
 Left pulmonary
artery
Right pulmonary
artery BASE (POSTERIOR
2 left
pulmonary
SURFACE) OF THE HEART
Left 2 right pulmonary
veins
Posterior
atrium veins • Formed by the 2 atria mainly left
Part of Right atrium, into which open 4
coronary atrium
sulcus Coronary sinus pulmonary veins.
• Directed backwards and to right.
Diaphragmatic
surface Posterior view of • Lies opposite T6-T9 vertebrae.
the heart • Separated from vertebral
column by descending aorta,
esophagus and oblique sinus of
pericardium.
• Bounded inferiorly by posterior
part of coronary sulcus, which
lodges coronary sinus.
Oblique
sinus of
pericardium Descending
aorta
Esophagus
Vertebral Coronary sulcus
Azygos column
vein
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Transverse section of the heart
STERNOCOSTAL (ANTERIOR) SURFACE
• Divided by coronary (atrio-
Right coronary artery ventricular) sulcus into:
1. Atrial part: formed mainly by
Left auricle right atrium and left auricle.
2. Ventricular part: right 2/3 is
Right
atrium
formed by right ventricle,
Anterior Part of
Coronary sulcus while left 1/3 is formed by left
Great cardiac vein
ventricle.
• The 2 ventricles are separated
Anterior
Right ventricle interventricular
sulcus
by anterior interventricular (IV)
Left Anterior
ventricle interventricular sulcus, which lodges:
artery
1. Anterior interventricular
artery
Anterior view of the heart 2. Great cardiac vein.
• Coronary sulcus lodges right
inferior
coronary artery.
cornu
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STERNOCOSTAL (ANTERIOR) SURFACE
• Lies behind sternum, 2-6 costal
cartilages and thymus gland.
• Overlapped by anterior border
2 of both lungs and pleurae.
Sternum 3
4
5
6

Anterior border of
lung and pleura
Heart

Dr: Wael Amin

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 DIAPHRAGMATIC (INFERIOR) SURFACE

• Formed by 2 ventricles, mainly

left ventricle (left 2/3).
• Directed inferiorly and backward.
• Separated from the base by
Posterior
Part of posterior part of coronary sulcus.
coronary
sulcus
• The 2 ventricles are separated by
posterior IV sulcus which lodges:
Left Middle cardiac
vein
1. Posterior interventricular
ventricle artery.
Right Posterior
ventricle interventricular 2. Middle cardiac vein.
artery

Posterior interventricular
sulcus
Posterior view of the heart

Dr: Wael Amin

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 DIAPHRAGMATIC (INFERIOR) SURFACE

Heart
• Diaphragm separates this surface
from left lobe of the liver and
fundus of the stomach.
Central tendon
of diaphragm

Fundus of
Left lobe of stomach
the liver
Dr: Wael Amin
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 BORDERS OF THE HEART
Ascending aorta

1. Upper border:
• Formed by 2 the atria (mainly
Pulmonary trunk
left).
Left • Masked by ascending aorta and
auricle
Right
atrium
pulmonary trunk.
Right
2. Right border (surface):
border • Formed by right atrium.
Right Left
ventricle
border 3. Lower border:
Left • Formed by right ventricle and
ventricle apex of left ventricle.
4. Left border (surface):
Lower border • Formed by left ventricle and left
Anterior view of the heart auricle.

Dr: Wael Amin

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 BORDERS OF THE HEART
• Right and left borders (surfaces) are related to corresponding
lung, pleura, phrenic nerve and pericardiophrenic vessels.

Phrenic nerve
Pericardiophrenic vessels

Left lung
Right lung and pleura
and pleura

Dr: Wael Amin

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 SURFACE ANATOMY OF THE
BORDERS OF THE HEART
• Point A: inferior border of left 2nd
costal cartilage, 4 cm from midline.
• Point B: superior border of right 3rd
costal cartilage, 3 cm from midline.
A
2 • Point C: right 6th costal cartilage, 3
B cm from midline.
3 • Point D: left 5th intercostal space, 9
Right Border

cm from the midline.

• Upper border: A-B.
5 • Right border: B-C.
6 C Lower Border
• Lower border: C-D.
D
6 • Left border: D-A.
• 1/3 of the heart is to the right and
2/3 to the left of median plan.
13 Dr: Wael Amin
 CAVITY OF THE RIGHT ATRIUM
Limbus fossa ovalis
Interatrial
septum (annulus ovalis) • Crista terminalis (between SVC
Right auricle
and IVC) divides right atrium
S.V.C.
Pectinate into:
muscles
Crista terminalis 1. Anterior rough part:
(terminal crest)
trabeculated and contains
pectinate muscles extending
Sinus to the auricle.
venarum 2. Posterior smooth part (sinus
venarum).
Fossa ovalis
• Interatrial septum shows fossa
I.V.C.
ovalis that surrounded by
annulus ovalis.

Sulcus terminalis corresponds to crista

terminalis from external surface

Dr: Wael Amin

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 OPENINGS OF THE RIGHT ATRIUM
S.V.C.
1. SVC: has no valve (opens at level of
right 3rd costal cartilage).
2. IVC: guarded by Eustachian valve
(embryologic remnant of IVC valve
and appears like a thrombus during
echocardiography). Opens at level of
right 5th costal cartilage.
3. Coronary sinus: has a well-defined
valve.
Right 4. Right atrioventricular (tricuspid)
I.V.C. ventricle orifice: guarded by tricuspid valve
Opening of and guide blood to right ventricle.
coronary sinus
Valve (Eustachian)
Tricuspid opening
of I.V.C. Valve (Thebesian)
(guarded by
of coronary sinus tricuspid valve)

Dr: Wael Amin

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 CAVITY OF THE LEFT ATRIUM

2 left • Its wall is smooth except for

pulmonary
veins
Left 2 right pulmonary small pectinate muscles in the
veins
atrium left auricle.
• Receives 4 valveless pulmonary
veins.
• Sends blood to left ventricle via
left atrioventricular (mitral)
orifice which is guarded by
Left auricle mitral valve.
Left ventricle
Semilunar depression in
interatrial septum
(opposite fossa ovalis)

Left atrium

Left atrioventricular Dr: Wael Amin

(mitral) orifice
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 CAVITY OF THE RIGHT VENTRICLE
Pulmonary
trunk
• Its wall is 9 mm thick.
Pulmonary orifice guarded
• Communicates with right
by pulmonary valve atrium via tricuspid orifice.
Outflowing smooth
part
• Communicates with
Supraventricular
crest
pulmonary trunk through
Right
pulmonary orifice.
atrium
Right ventricle
• The cavity is divided into:
Tricuspid
1. Inflowing rough part.
orifice
guarded by
2. Outflowing smooth part.
tricuspid • The 2 parts are separated by
valve
supraventricular crest.

Inflowing rough
Dr: Wael Amin
part
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 CAVITY OF THE RIGHT VENTRICLE
I. Rough inflowing part:
A. Trabeculae carnae: small
sponge muscular projections.
Septal papillary B. Papillary muscles: large
muscle
conical muscular projections.
Interventricular
septum
1. Anterior papillary muscle.
Chorda tendinea
2. Posterior papillary muscle.
Tricuspid
valve (tendinous cords) 3. Septal papillary muscle.
• Each papillary muscle is
Anterior papillary attached to two cusps of
muscle tricuspid valve by chordae
tendinae.
Moderator band
(septomarginal C. Moderator band: connects
Posterior papillary trabecula)
Interventricular septum to
Trabeculae carnae muscle
anterior papillary muscle.
Papillary muscles and chordae tendineae • Prevents overdistension of
prevent the cusps from being everted into right ventricle and transmit
the atrium during ventricular contraction. right branch of AV bundle.
18 Dr: Wael Amin
 PAPILLARY MUSCLE
• The attachments of papillary muscles to the cusps look like a
Parachute:
1. The cusps = the fabric.
2. Chordae tendineae = the ropes.
3. Papillary muscles = the person controlling it.

The fabric = cusps

Tricuspid
valve
Ropes = Chorda tendinea

Chorda tendinea
(tendinous cords)

Anterior papillary
muscle
The Person = Papillary muscles

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CAVITY OF THE RIGHT VENTRICLE
Pulmonary
trunk
• Blood leaves right ventricle to
pulmonary trunk through
Pulmonary orifice guarded
by pulmonary valve
pulmonary orifice.
II. Smooth outflowing part:
Infundibulum
(conus arteriosus)
• Infundibulum (conus arteriosus)
has smooth conical-shaped wall.

Dr: Wael Amin

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 RIGHT ATRIO-VENTRICULAR (TRICUSPID) ORIFICE
• Guarded by tricuspid valve,
admitting tips of 3 fingers.
Septal cusp
• The valve has 3 triangular cusps
(anterior, posterior and septal)
surrounded by fibrous ring.
• Cusps give attachment to chordae
tendinea.
Anterior cusp

Chorda tendinea
Posterior cusp

Anterior cusp

Anterior papillary Fibrous ring

muscle
Structure of tricuspid valve Septal cusp

Posterior cusp

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Dr: Wael Amin Superior view of the valves
(the two atria are cut)
 PULMONARY ORIFICE
Pulmonary trunk
• 3 cm in diameter, surrounded by fibrous
Pulmonary orifice ring which attaches to cusps of
guarded by
pulmonary valve
pulmonary valve.
• The valve is formed of 3 semilunar
cusps: (anterior, right and left).
• No chordae tendineae or papillary
muscles are attached to cusps.
Anterior semilunar cusp Right semilunar cusp
Left semilunar cusp

Fibrous ring

Structure of pulmonary valve

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Dr: Wael Amin Superior view of the valves
(the two atria are cut)
 CAVITY OF THE LEFT VENTRICLE
Chorda tendinea • Its wall is 27 mm thick.
Anterior papillary
muscle • Receives blood from left atrium
through mitral orifice, guarded by
Left ventricle
mitral valve.
I. Inflowing part:
A. Trabeculae carnae: numerous and
Mitral valve
fine than in right ventricle.
B. Two large papillary muscles:
Posterior papillary (anterior and posterior), attached
muscle
Trabeculae carnae
by chordae tendinea to cusps of
mitral valve.
C. No moderator band.

Dr: Wael Amin

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 CAVITY OF THE LEFT VENTRICLE
Chorda tendinea
Anterior papillary
muscle

• Blood leaves left ventricle

to ascending aorta through
aortic orifice.
Mitral valve II. Outflowing part:
• Called aortic vestibule. Its
Posterior papillary
wall is fibrous and smooth.
muscle
Trabeculae carnae

Ascending aorta

Aortic orifice

Left ventricle
Aortic vestibule

Dr: Wael Amin

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 LEFT ATRIO-VENTRICULAR (MITRAL) ORIFICE

Anterior papillary Chorda tendinea

• Guarded by mitral valve,
muscle admitting tips of 2 fingers.
• Fibrous ring gives attachment to
cusps of mitral valve.
• Mitral valve is composed of 2
Anterior cusp
cusps (anterior and posterior).
• The cusps give attachment to
Posterior cusp chordae tendinea.

Structure of
mitral valve

Anterior cusp

Fibrous ring
Posterior cusp
Superior view of the valves
(the two atria are cut)
Dr: Wael Amin
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 AORTIC ORIFICE
Ascending aorta • 2.5 cm in diameter, surrounded by
Aortic orifice
fibrous ring which gives attachment
to cusps of aortic valve.
• Aortic valve is formed of 3 semilunar
cusps being (posterior, right and left).

Right semilunar cusp

Structure of aortic valve
Aortic sinuses Left semilunar cusp Posterior semilunar
cusp
Fibrous ring

Left semilunar
cusp Superior view of the valves
Posterior semilunar
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Right semilunar
cusp Dr: Wael Amin (the two atria are cut)
cusp
 INTERVENTRICULAR SEPTUM
Membranous part of

• Lies between right and left

interventricular septum

ventricles.
1. Muscular part: lower long part,
bulges into cavity of right
ventricle due to higher pressure
in left ventricle.
2. Membranous part: short thin
upper part, forms part of
fibrous skeleton of the heart.
Muscular part of
interventricular septum
• It is the site of VSD.
Interventricular septum

Left ventricle

Right ventricle
Interventricular septum Dr: Wael Amin
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LYMPHATIC DRAINAGE OF THE HEART

Inferior tracheobronchial
(carinal) lymph nodes

• Subepicardial lymphatic plexus

will join then drain into right
inferior tracheobronchial
(carinal) lymph nodes.

Dr: Wael Amin

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 NERVE SUPPLY OF THE HEART
• Superficial and deep cardiac plexus
Vagus nerve
situated anterior to tracheal
bifurcation and behind aorta.
1. The sympathetic fibres: arise from
the cervical and upper thoracic
Sympathetic
trunk ganglia of sympathetic trunks
(accelerate heart rate).
2. The parasympathetic fibres: arise
from the vagus nerves (reduce
heart rate and induces
Cardiac plexus
vasoconstriction of coronary
arteries).

Dr: Wael Amin

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 Surface Anatomy of the cardiac valves

Pulmonary valve: at the level of left

3rd costal cartilage
Aortic valve: posterior to the left margin of
the sternum at level of 3rd intercostal space

Mitral valve: posterior to the sternum at

level of 4th costal cartilage

Tricuspid valve: posterior to the body of sternum

at level of 4th and 5th intercostal space

Dr: Wael Amin

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 Areas of auscultation

Aortic area Pulmonary area

Aortic valve sounds heard in 2nd

intercostal space at right sternal margin Pulmonary valve sounds heard in
2nd intercostal space at left
Pulmonary valve sternal margin
Aortic valve
Mitral valve Tricuspid valve sounds typically
Tricuspid valve heard in left sternal margin of 5th
intercostal space
Mitral valve sounds heard over
heart apex (in the left 5th intercostal
space) in line with middle of clavicle
(apex beat)

Blood tends to carry the sounds in

the direction of its flow.

Mitral area Dr: Wael Amin

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Tricuspid area