Cardiac Anatomy

Cardiac Orientation
Superior

Posterior Anterior

Inferior

2
 Cardiac Orientation
Superior

Right Left
Lateral Lateral

Inferior

3
 Cardiac Orientation
 If one considered the chest
a cube, then the heart is
located in its own cube
within the large cube. The
heart is pointing
downwards, to the left, and
anterior. Usually about 45
degree in each direction,
but there are considerable
individual variations.

http://brighamrad.harvard.edu/education/online/Cardiac/
4 anatomic-orient.html
 Position of the Heart

5
 Cardiac Orientation

http://brighamrad.harvard.edu/education/online/Cardiac/anatomic-
orient.html

6
 Myocardial Anatomy

7
 Dissection – Anterior View

Aorta

SVC Pulmonary
artery
RAA
LAA
RV
-RVOT LV
-RV apex -Base
-Apex

8
 Superior Aspect of the Heart

Aorta

SVC Bachman’s
Bundle
IVC
LAA
Right Atrial
Appendage Pulmonary
Artery

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 Abbreviations (for next slides)
LA = left atrium
RAA = right atrial appendage
LAA = left atrial appendage
SVC = superior vena cava
IVC = inferior vena cava
PA = pulmonary artery
RPA = right pulmonary artery
LPA = left pulmonary artery
LV = left ventricle
RV = right ventricle
CS = coronary sinus
Eso = esophagus
RSPV = right superior pulmonary vein
RIPV = right inferior pulmonary vein
LSPV = left superior pulmonary vein
LIPV = left inferior pulmonary vein
AO = aorta
TV = tricuspid valve
CSos = coronary sinus ostium
FO = fossa ovalis

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 AP View of the Heart

SVC
AO PA
LSPV
RSPV RAA RVOT
LIPV

RCA
LV
RA
RIPV RV

IVC

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 AP View of the Heart (Open View)

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 AP View

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 AP View of RA and CS

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 AP View of RA, LA and CS

15
 PA View of the Heart

LPA
RPA SVC
AO
LSPV

RSPV
LIPV Eso
RIPV
LA
LV CS
RA
RV IVC

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 RAO View of the Heart

AO
PA
SVC
RVOT
RSPV
RAA RCA
RA
RIPV RV

Eso LV

IVC

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 RAO View with View Inside RA and RV

TV

CSos

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 RAO View of RA and LA

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 RAO View of RA

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 Right Atrial Anatomy

ISTHMUS

The RA is composed of smooth and highly trabeculated (appendage) portions. Since catheter
stability is very poor in the smooth atrium, high right atrial catheters are usually placed in the
atrial appendage. The Crista Terminalis located on the border between the smooth atrium and
atrial appendage, is an important structure acting as a barrier to conduction during fast rates,
which helps reentrant arrhythmias form in the RA. Please note how the SVC passes very close
to the right PVs. Also note the Fossa Ovalis which is the targeted site for transseptal punctures.
You can also see the entrance (ostium) to the CS (CSos).
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 Su
pe
ri o
rV RA
en
aC
av
a

RAA
CT

Te
nd
on
of
To
da
Inf ro TA
eri
or
V en
aC
av
Eusta

a
Co
ro
c

na
h

r
i

y
a n

Si
nu
Ridge

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 Fast and Slow AV Nodal Pathways

https://www.hrsonline.org/uploadDocs/AndersonHo_Anatomy_AVNode.pdf
The Anatomy of the Atrioventricular Node. Robert H. Anderson BSc, MD, FRCPath. Cardiac Unit, Institute of Child Health
University College, London, Siew Yen Ho PhD, FRCPath, Cardiac Morphology, National Heart & Lung Institute, Imperial College
School of Medicine, London, Educational Content from the Heart Rhythm Society website:
www.HRSonline.org/professional_education/learning_categories/articles/

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 RA - Crista Terminalis

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 Right Atrial Anatomy

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 Right Atrial Anatomy

3mm
thick/
10mm
long

This shows the EV (cross hatched) and triangle of Koch (hatched). The open arrow is the slow
pathway and solid the fast pathway. The septal isthmus is targeted for slow pathway
ablation. Note the SA node is subepicardial and lies on top of the terminal crest, somewhat
isolated from the endocardium and difficult to ablate endocardially.

26

S.Y. Ho et al./Cardiovascular Research 54(2002)325-336

 LAO View of the Heart

SVC
AO
LPA
LSPV
RA LAA
CS
RV LIPV

LV

IVC

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 LAO View with View Inside Ventricles

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 Orientation for Accessory Pathways

Current used but inaccurate Terminology Unused but accurate Terminology

Left Right Right

Left

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 LAO View of the RA and CS

30
 LAO View of RA. LA and CS

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 PA View of RA. LA and CS

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 AP View of the LA

Mitral Valve
LSPV

LAA

RSPV
LIPV

RIPV

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 PA View of the LA

LAA

LSPV

RSPV
LIPV

RIPV

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 Posterior View of RA. LA and CS

LAA

35
 LAO View Inside the LA

36
 LAA Ridge and PV Carina
 The LAA ridge is defined
as a prominent ridge
interposed between the
LAA and LPV orifice. The
PV carina is defined as
the area between the
superior and inferior PVs
(intervenous ridge).

37
 LAA Ridge and PV Carina

PV Carina
LSPV
LAA

LIPV

LAA Ridge

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 LAA Ridge and PV Carina
 The intervenous ridge (PV carina) is the greatest transmural
myocardial thickness of the PV-atrial junction and epicardial atrial
fibers may act as an electrical connection across the ablation line,
which could lead to difficulties in obtaining transmural block.

 Muscular folds between the LPVs and LAA, and the LA and LIPV are
complex with easy misinterpretation of far field LAA activity, which may
contribute to incomplete circumferential ablation, and form slow
conduction and an obstacle that can maintain a reentrant circuit.

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 Atrio-esophageal Fistula

©The art on this page is reproduced with permission from Prentice Hall, Inc.
Link: http://www.biosbcc.net/b100cardio/htm/heartant.htm
Video of esophagus with heart beat. http://www.gihealth.com/html/education/video/esophagusHeartbeat.html

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 Close Proximity of the LA to Esophagus

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 Cardiac Venous Anatomy

Ho et al. Vagaries of the Vagus Nerve.J Cardiovasc Electrophysiol, Vol. 17, pp. 330-331, March
2006.

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 Left Atrial Wall

Left Right

The four pulmonary veins (right and left inferior and superior) open into the posterior wall of the
left atrium. The tissue surrounding the pulmonary vein (PV) ostia may be the origin of atrial
tachyarrhythmias.
• The left atrial wall has a larger smooth-walled area and a smaller muscular area.
• Focal ablation in and around the ostia of the pulmonary veins isolates the veins and prevents
the AT/AF trigger from entering the left atrium.
• Please note in this picture how close the SVC is to the right superior PV. If a multipole
catheter is placed in the SVC, it can possibly record far-field signals form the right superior PV
assisting the doctor in diagnosing the location of the ectopic site. You can also see that the right
and left pulmonary arteries also come very close to the right and left PVs, respectively.

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 Cardiac Venous Anatomy

 Note the close

proximity of the
phrenic nerve to the
RSPV.

 The Phrenic nerve

can be damaged
during PV ablation.

Bunch, TJ, et al. Mechanisms of phrenic nerve injury during radiofrequency ablation at the
pulmonary vein oriface. J Cardiovasc Electrophysiol, Vol. 16, pp. 1318-1325, December
2005

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 AP View of LV and Ao

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 RAO View of LV and Ao

46
 LAO View of LV and Ao

47
 LAO View of LV and Ao

 Catheters tend to
fall to the left lateral
wall and not the
septum for VT
ablation

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 AP View of the RV and Pulmonary Arteries

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 AP View of the RV and Pulmonary Arteries

 The RVOT is a roundish structure, ideal for placing a circular loop type
catheter

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 PA View of the RV and Pulmonary Arteries

 It is rare, but VT ectopic sites can originate just inside the pulmonary
artery.

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 RAO View of the RV and Pulmonary Arteries

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 RAO View of the RV and Pulmonary Arteries

 The RVOT is a roundish structure, ideal for placing a circular loop type
catheter

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 Right Ventricular Anatomy

RVOT

Due to the highly trabeculated wall of the right ventricle (RV), stability of RV apex catheters
placed in the RV is very good. However, due to that trabeculation, larger french sized catheters
will have trouble making contact with the RV wall.
Please note the moderator band. In a healthy heart this will be very small or non-existent. This is
a muscular structure and assists in ventricular contraction, so with RV dysfunction, this will be
large since it must work harder. Also to note is that the right bundle branch passes through the
moderator band when one is present.
Please note the RVOT. This is where much RV VT occurs.

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 Ventricular Components

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 RVOT

al ve
onic V
Pu lm

Ri
gh
tV
en
tr i
cu
la
rO
ut
fl ow
Tr
ac
t(
RV
O
T)

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 RV Outflow Tract

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 Left Ventricle Anatomy

Interventricular
Membraneous Right Coronary Cusp
Septum

Left Coronary Cusp

Tricuspid valve annulus
Non-Coronary Cusp

Atrioventricular
Apex Membraneous Septum

Netter, F. Clinical Symposia. Novartis Pharmaceuticals Corporation, Summit, NJ,

1997.

58
 Septal Anatomy

http://en.wikipedia.org/wiki/Interventricular_septum

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 LVOT Endocardial Structures

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 Left Ventricle

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 Orientation of the Left Ventricular Walls

http://brighamrad.harvard.edu/education/online/Cardiac/anatomic-orient.html

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 Aortic Valve Cusps

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 Orientation of the Left Ventricular

http://brighamrad.harvard.edu/education/online/Cardiac/anatomic-orient.html
 The LV is commonly divided in a basal third, a middle third, and an apical
third, plus apex.

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 Left Ventricle Anatomy

65
 Embryological Development

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 Cardiac Venous Anatomy

• Coronary Sinus (CS) – Great Cardiac Vein (GCV)

• Vein (Ligament) of Marshall (VOM or LOM)
• Left and Right Superior and Inferior Pulmonary Veins (RSPV, RIPV, LSPV,
LIPV)
• Superior Vena Cava (SVC)
• Inferior Vena Cava (IVC)
• Pulmonary artery (PA)
• Middle Cardiac Vein (MCV)
67 • Posterior Descending Artery (PDA)
 Venous structures

J Anat. 2004 September; 205(3): 159–177. doi:10.1111/j.00218782.2004.00330.x.

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 Coronary Sinus Structure
Coronary sinus (CS) is the cardiac venous system that begins at its
ostium in the RA and ends at the origin of the great cardiac vein.
Major tributaries of the CS:
 Great cardiac vein (anterior cardiac vein)
 Left obtuse marginal vein
 Posterior (or inferior) left ventricular vein
 Middle cardiac vein
 Right coronary vein
 Atrial veins, notably, the vein of Marshall (or oblique left atrial vein)
also enter the coronary sinus
The CS provides access to epicardial atrioventricular pathways and
arrhythmogenic foci of both atrial and ventricular arrhythmias and
represents a potential source of atrial arrhythmias

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 Coronary Sinus Structure

70
 CS Anatomy Variations

71
 CS Anatomy Variations

Large with
inferior
angulation

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 CS Anatomy Variations

RAO

Wafer-shaped

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 Special Structures Of Interest

Associated Arrhythmia /
Structure Reason for Interest

 Crista Terminalis  Atrial Tachycardia

 Fossa Ovalis  Transseptal puncture
 Tricuspid Isthmus  Atrial Flutter
 Eustachian Ridge/Valve  Atrial Flutter
 Pulmonary Veins
 Atrial Fibrillation
 RVOT
 RVOT Tachycardia

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THE END.