Heart - Univerzita Karlovaanatomie.lf3.cuni.cz/centralni_prezentace/Srdce1_eng.pdf · Conducting system of the heart - parts nodus sinuatrialis (Keith-Flack) right atrium near foramen

Heart

David Kachlík, Štěpán Jelínek

© David Kachlík 30.9.2015

Heart situation


Heart development

sinus venosus

common atrium

ventricle

bulbus cordis

truncus arteriosus

atrium - sinus venarum cavarum

atrium (separated with crista

terminalis)

ventricle (inflow part)

ventriculus (outflow part separated

with crista supraventricularis)

aorta + truncus pulmonalis

© David Kachlík 30.9.2015© David Kachlík 30.9.2015

Heart description

basis x apex

facies sternocostalis s.anterior

facies diaphragmatica s. inferior

/=posterior wall in clinic/

facies pulmonalis dx. + sin.

margo dexter /former acutus/

margo sinister /former obtusus/

incisura apicis cordis

auricula dextra et sinistra

sulcus coronarius

sulcus interventricularis ant. + post.


Heart structure

endocardium = tunica intima

myocardium = tunica media

working myocardium

excitomotor apparatus (EA) = conducting m.

fibrous skeleton of heart

pericardium


Endocardium

continuous with vessels´ tunica intima

4 layers:

endothelial

subendothelial – collagenous fibres

fibromuscular - collagenous, elastic connective tissue, smooth muscle cells – thicker in atria

subendocardial – containing conducting myocardium, loose connective tissue

endocardium forms heart valves


Heart valves

duplication of endocardium

Internal fibrous lamina

– collagenous + elastic fibres

endothelium superficially

attached to fibrous anuli

without blood or lymph vessels

cuspidal, semilunar, other leaflets


Myocardium

cardiomyocytes

3 layers in ventricles

spiral (vortex), circular, longitudinal

2 in atria – internal layer = mm. pectinati

3x thicker in left ventricle than in right

one

conducting system is different in both

function and structure


Myocardium


Pericardium


Pericardium

Pericardium fibrosum – ligg. sternopericardiaca, membrana bronchopericardiaca

Pericardium serosum

lamina paretalis = pericardium

lamina visceralis = epicardium = tunica serosa = mesothel

tela subserosa (fat tissue, vessels)

Cavitas pericardii

Sinus obliquus + transversus

Liquor pericardii - 20 ml

N. phrenicus, a.+ vv. periacardiacophrenicae

puncture (in case of tamponade)

below processus xiphoideus (dorsocranially)

4th / 5th intercostal space left of sternum (less frequently)


Heart cavities

atrium dextrum + sinistrum

septum interatriale

septum atrioventriculare

ventriculus dexter + sinister

septum interventriculare (pars membranacea +

muscularis)


Atrium dextrum (right atrium).

ostium v. cavae inferioris

valvula v.c.i. Eustachii

ostium v. cavae superioris

tuberculum intervenosum Loweri

ostium sinus coronarii

valvula s. coronarii Thebesii

ostia vv. ventriculi dx. anteriorum

foramina venarum minimarum

fossa ovalis / foramen ovale cordis

limbus fossae ovalis


Atrium dextrum (right atrium)

auricula dextra

sinus venarum cavarum

crista terminalis

mm. pectinati

ostium atrioventriculare

dextrum

trigonum nodi

atrioventricularis Kochi


Ventriculus dexter (right ventricle)

ostium atrioventriculare dextrum

valva tricuspidalis

cuspis anterior, posterior, septalis

mm. papillares

anterior, posterior, septalis

chordae tendineae chordae tendineae falsae s. spuriae

trabeculae carneae

trabecula septomarginalis


Ventriculus dexter (right ventricle)

crista supraventricularis

pars glabra = infundibulum =

conus arteriosus = outflow part

ostium trunci pulmonalis

valva trunci pulmonalis

valvulae semilunares dx., sin.,

ant. /semilunar cusps/

noduli Aranzii

lunulae

commissurae



Right-sided compartments


Atrium sinistrum (left atrium)

auricula sinistra

ostia venarum pulmonalium

mm. pectinati

valvula foraminis ovalis

(= former falx septi Parchappei)


Ventriculus sinister (left ventricle) ostium atrioventriculare sinistrum

valva mitralis s. bicuspidalis

cuspis anterior, posterior

(cc. commissurales)

mm. papillares

anterior, posterior

chordae tendinaeae

trabeculae carneae

vestibulum aortae

ostium aortae

valva aortae

valvulae semilunares dx., sin., post. /semilunar cusps/

noduli Aranzii, lunulae, commissurae

sinus aortae Valsalvae (correspond to valvulae)© David Kachlík 30.9.2015




Left-sided compartments


ECHO


Fibrous skeleton of heart

anulus fibrosus dexter + sinister

trigonum fibrosum dextrum /= central fibrous body/ + sinistrum

anulus aorticus + a. trunci pulmonalis

tendo infundibuli

tendo valvulae venae c. inf. Todaroi

pars membranacea septi interventricularis

fibrous connective tissue

valve support

myocardium insertion

electric isolation of atrial and ventricular myocardium




Heart supply

arteries – 2 coronary arteries (ACS, ACD)

vinculum, ponticulus

veins – 3 systems, without valves

lymph drainage – 3 plexuses, 2 truncs (right one to ductus thoracicus, left one to ductus lymphaticus dexter !)

nerves – automatical impulses

autonomic system (sympathetic, parasympathetic)

viscerosensory fibers© David Kachlík 30.9.2015


Coronary arteries


Arteria coronaria dextra (ACD)

sinus aortae (Valsalvae) dexter → ACD

r. coni arteriosi → Vieussens´ circle

r. nodi sinuatrialis (65%)

rr. atriales

r. marginalis dexter (RMD)

r. interventricularis posterior (RIP)

r. nodi atrioventricularis (80%)

r. posterolateralis dexter (RPLD)




Arteria coronaria sinistra (ACS)

sinus aortae (Valsalvae) sinister → short (2-3cm) → ACS

r. interventricularis ant. (RIA) – clinically „left anterior descending“ (LAD)

r. coni arteriosi → Vieussens´ circle

r. diagonalis (RD)

r. circumflexus (RC)

rr. atriales

r. marginalis sinister (RMS)

r. posterolateralis sinister (RPLS)

r. intermedius (RIM) – 25%, from ACS bifuraction© David Kachlík 30.9.2015


Coronary arteries


Arteria coronaria sinistra

ACS in

posteroanterior

projection

ACS in lateral

projection

(right to left)

ACS in lateral

projection

(left to right)


Ponticulus


Stenosis in ACS


Arteria coronaria dextra

ACS in

posteroanterior

projection

ACS in lateral

projection

(right to left)

ACS in lateral

projection

(left to right)


Collateral vessels


Heart veins

Sinus coronarius → atrium dextrum

← v. cardiaca (cordis) magna

← v. interventricularis anterior

← v. maginalis sinistraname change when crossing left border (Vieussens´valve !)

← v. ventriculi sinistri posterior

← v. obliqua atrii sinistri Marshalli

← v. cardiaca (cordis) media (= v. interventricularis post.)

← v. cardiaca (cordis) parva

← v. marginalis dextra




Heart veins

Vv. ventriculi dextri anteriores = vv. cardiace

(cordis) anteriores → atrium dextrum

Vv. cadiace (cordis) minimae Thebesii → all

cavities

without any major clinical importance


Nerves – autonomic system

Sympathetic – nn. cardiaci cervicales sup.+ medii + inf., thoracici

positive dromotropic, bathmotropic, inotropic, chronotropic effect

β1 receptors

Parasympathetic – n. X → rr. cardiaci cervicales sup.+inf., thoracici

negative effect

Viscerosensory fibres (T1-T4)

Head´s zone behind sternum and in ulnar edge of left upper limb



Conducting system of heart

Complexus stimulans cordis

Systema conducens cordis

„Excitomotor apparatus“

enables generation of heart automatic impulse

formed with modified cardiomyocytes:

less myofibrils placed in periphery

no intercalar discs

connections by desmosomes and nexuses

different size

glycogen gathered around the nucleus


Conducting system of the heart - parts

nodus sinuatrialis (Keith-Flack)

right atrium near foramen v. cavae superioris

interatrial connections (fasciculi atriales)

fasciculus interatrialis (Bachmann)

další svazky sporné

anterior (James), medius (Wenckebach), posterior (Thorel)

nodus atrioventricularis (Aschoff-Tawara)

right atrium in Koch‘s triangle near ostium atrioventriculare

dextrum

myocytes smaller than those of working myocardium

rich blood supply



Conducting system of heart

fasciculus atrioventricularis (atrioventricular bundle) His-Kent-Gaskell

AV blockage of 1st-3rd grade

truncus f.a.

crus f.a. (Tawara)

dextrum

sinistrum

limbus anterior

limbus posterior

rami subendocardiales (Purkyně)

larger than typical cardiomyocytes

with lighter cytoplasma

quick impulse conduction towards heart apex

accessory connections → preexcitation syndrom WPW (Wolf-Parkinson-White)© David Kachlík 30.9.2015



Purkyně fibres (HE + elastin)


artificial

pacemaker


Physiology

Heart cycle

systole

diastole

Pulse and volumes

EKG curve

Arterial pulse curve with dicrotic notch

Endocrinne function - ANF


Examination

physical examination (aspection, percussion,

palpation, ausculatation)

EKG, Holter

echocardiography, oesophageal echok.

(X-ray of heart and lungs)

coronarography

nuclear medicine

biochemistry: troponins, CK MB, myoglobin


Auscultation

Testut‘s points

=

4 auscultation

points


Auscultation – Testut´s points

4 auscultation points

Valva mitralis – 5th intercostal space left of strenum in

medioclavicular line

Valva tricuspidalis – 4th intercostal space left (or right)

of strenum

Valva aortae – 2th intercostal space right of sternum

Valva trunci pulmonalis – 2th intercostal space left of

sternum

Erb´s point (3rd intercostal space left of sternum) -

murmurs© David Kachlík 30.9.2015


Systolic/

diastolic

pressures in

the heart

chambers



Basic clinical units

Endocardium: endocarditis, valvular defects

(inborn, acquired)

Myocardium: ischmeic heart disease (AP, IM),

myocarditis, cardiomyopathy

Pericardium: pericarditis, tamponade

Conducting system: arrythmia

Developing defects: septal defects, transposition

of large vessels, Fallot´s tri-, tetra-, pentalogy,

opened Botallo´s duct, aorta coarctation


Heart X-ray


Heart X-ray


Rheumatic

vegetations


Endocarditis


Valvular

insufficiency

(regurgitation)

and

stenosis


Myocardial

infarction


Cardiac

aneurysm


Pericarditis


Cardiac

trauma


Cardiac

tamponade


The heart

during CPR


Basic therapeutic

operations

PTCA (= percutaneous transfemoral coronary angioplasty)


Basic therapeutic operations

by-passing

venous grafts (v. saphena magna)

arterial grafts (a. radialis)

artery lifting (a. thoracica interna, a. gastroomentalis sinistra)

a.thoracica interna (clinically „a. mammaria interna – left/right = „LIMA, RIMA“)

valve replacement (porcine, plastic)

transplantation



Valvular replacement


Valvular replacement


Cardiac

transplantation


Practical training

X-ray of heart and lungs

Valve auscultation

Heart specimen – whole x dissected

Histological slides of heart muscle


Thank you for attention…..

... and finaly several important notes:

speciality of the cnducting system

the worst blood supply of subendocardial

layers - ↑ risk of hypoxia

The thickest muscular wall of left ventricle - ↑

risk of hypoxia


Documents

Heart - Univerzita Karlovaanatomie.lf3.cuni.cz/centralni_prezentace/Srdce1_eng.pdf · Conducting system of the heart - parts nodus sinuatrialis (Keith-Flack) right atrium near foramen