1. HEART & PERICARDIUM Dr.S.Nizamudeen

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5. Pericardium and its sinuses

6. Development

7. Developmental stages

8. Layers of pericardium

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10. Relations (Ligaments and attachments)

11. Contents of pericardium Heart with cardiac vessels, nerves Ascending aorta Pulmonary trunk Superior vena cava (lower half) Inferior vena cava (terminal part) Pulmonary veins (terminal parts)

12. Sinuses of pericardium

14. Transverse sinus

15. Transverse and oblique sinuses

16. Arterial supply Branches of Internal thoracic artery Musculophrenic artery Descending thoracic aorta

17. Nerve supply Phrenic nerve: Fibrous & Parietal pericardium (Pain sensitive) Autonomic nerves of heart: Visceral pericardium or epicardium (Not pain sensitive)

18. Clinical anatomy Pericardial effusion Drainage 1) 5 th or 6 th ICS (lateral to apex beat) 2) Angle (Xiphoid process & LT costal margin)

19. Introduction Conical muscular organ situated in middle mediastinum within the pericardium. Cardia- Greek term, Cor- Latin. Measurements- 12X9 cm. Weight- 300g in males, 250g in females.

20. Circulation:: Overview  Size of a Fist  250 – 350 grams  Double Pump  Oxygenated and deoxygenated blood  About 16,000 liters/day!  Pulmonary circuit  Systemic Circuit

21. Location of the Heart Posterior to the Sternum Within the Mediastinum Apex vs. Base

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24. sectional view: position immediately posterior to sternum...

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26. Surface Anatomy Auricle of atria (expandable) Coronary sulcus (between atria & ventricles) Ant. & post. interventricular sulcus Base (3 rd costal cartilage) vs. apex (5 th intercostal space) Vessels entering & leaving the heart

27. External features Chambers Grooves/ Sulci Surfaces Borders

29. Grooves/ Sulci ATRIOVENTRICULAR GROOVE INTER VENTRICULAR GROOVE ATRIOVENTRICULAR GROOVE

30. INTERATRIAL GROOVE

31. Apex APEX

32. Base

33. Borders Upper border Lower border Right border Left border

34. Surfaces Anterior/ sternocostal Inferior/ diaphragmatic Left surface

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39. INTERNAL STRUCTURE OF HEART (EXTERNAL STRUCTURE OF HEART)

40. HEART OF FIBROUS SKELETON

41. 22-41 Functions of the Fibrous Skeleton of the Heart Located between the atria and the ventricles Formed from dense irregular connective tissue. – separates the atria and ventricles – anchors heart valves by forming supportive rings at their attachment points – provides electrical insulation between atria and ventricles ensures that muscle impulses are not spread randomly throughout the heart prevents all of the heart chambers from beating at the same time Provides a rigid framework for the attachment of cardiac muscle tissue.

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47. Right atrium Right auricle Sulcus terminalis Crista terminalis SA node

48. Interior SMOOTH PART ROUGH PART INTERATRIAL SEPTUM

49. Smooth posterior part SUPERIOR VENACAVA INFERIOR VENACAVA CORONARY SINUS THEBASIAN VEIN OPENINGS

50. Rough anterior part CRISTA TERMINALIS MUSCULI PECTINATI

51. Interatrial septum FOSSA OVALIS LIMBUS FOSSA OVALIS

52. Left atrium Auricle PV Fossa lunata

53. Right ventricle Smooth part Rough part Supraventricular crest

54. Chorda tendinae Posterior Papillary muscle Ridge Septal papillary muscle Moderator band Anterior Papillary muscle Bridge

55. Atrioventricular orifice Pulmonary orifice Infundibulum

56. Left ventricle Anterior papillary muscle Auricle Posterior papillary muscle

57. Valves of the heart

59. Conducting system

60. 22-60 Conduction System of the Heart Exhibits autorhythmicity – the heart itself (not external nerves) is responsible for initiating the heartbeat. Certain cardiac muscle fibers are specialized to conduct muscle impulses to the contractile muscle cells of the myocardium. Specialized cells are part of the heart’s conduction system.

61. 22-61 Conduction System of the Heart – Sinoatrial (SA) Node Heartbeat is initiated by the cardiac muscle fibers of the sinoatrial (SA) node. – located in the posterior wall of the right atrium, adjacent to the entrance of the superior vena cava Act as the pacemaker. – rhythmic center that establishes the pace for cardiac activity Initiates impulses 70 - 80 times per minute.

62. 22-62 Conduction System of the Heart – Atrioventricular (AV) Node Impulse travels to both atria, stimulating atrial systole. And via an internodal conduction pathway through an opening in the fibrous skeleton to the atrioventricular (AV) node. – located in the floor of the right atrium between the right AV valve and the coronary sinus

63. 22-63 Conduction System of the Heart – Atrioventricular (AV) Bundle Cardiac impulse then travels from the AV node to the atrioventricular (AV) bundle(bundle of His). – extends into the interventricular septum and then divides into one right and two left bundle branches. Conduct the impulse to conduction fibers called Purkinje fibers in the heart apex. – Purkinje fibers are larger than other cardiac muscle fibers. Muscle impulse conduction along the Purkinje fibers is extremely rapid. The impulse spreads immediately throughout the ventricular myocardium.

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66. Fibrous Skeleton

67. Clinical anatomy 1 st heart sound- produced by closure of atrio-ventricular valves, 2 nd by closure of semilunar valves. Stenosis of valves Incompetence or regurgitation

68. RADIOGRAPH OF CHEST -- PA view

69. The Chambers Separated by – Interatrial Septum – Interventricular Septum – Externally, the septa appear as shallow sulci Right Atrium – Receives blood from superior and inferior venae cavae and the coronary sinus – Right auricle is prominent externally – Pectinate Muscles

70. The Chambers Right Ventricle – Receives blood from the right atrium via the right AV valve, AKA tricuspid valve Supported by chordae tendinae and papillary muscles – Thin wall – Network of trabeculae carneae

71. The Chambers Left Atrium – Receives blood from R and L Pulmonary Veins Left Ventricle – Receives blood from the Left AV valve (AKA mitral AKA bicuspid) Chordae tendinae and papillary muscles – Thick wall Pumps to body via Aortic Semilunar V alve

72. Sectional (Internal) Heart Anatomy Atria & ventricles Interatrial & interventricular septa 9981621 Valves (fibrous tissue) Pectinate muscles (auricles & ant. atria) Trabeculae carneae (ventricles) Chordae tendinae & papillary muscles

73. Left vs. Right Ventricle Left: high pressure pump - Right: low pressure pump  right chamber is thinner walled than left Ventricles separated by interventricular septum

74. Structure and Function of Valves (prevent backflow) = Mitral valve = Right AV valve 4 sets of valves Each cusp is C.T. covered with endothelial cells Close passively under blood pressure Heart sounds produced by valve closure

75. picture taken from R ventricle, looking toward R atrium (see fig 21.6) Support for AV valves: Valves are restrained by chordae tendinae which are in turn attached to papillary muscles (prevention of backflow!)

76. Fig 21.6 a

77. Coronary Circulation Coronary arteries: branch off the ascending aorta, immediately distal to the aortic valve

78. coronary veins to coronary sinus to right atrium (inferior to opening of inferior vena cava) posterior view Coronary Circulation, cont’d

79. HEART AND ITS BLOOD SUPPLY AND NERVE SUPPLY CORONARY ARTERIES CORONARY SINUS AND TRIBUTARIES CARDIAC PLEXUS

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81. VENOUS DRAINAGE OF HEART ( 3 GROUPS) -CORONARY SINUS AND ITS TRIBUTARIES -ANTERIOR CARDIAC VEINS -THEBESIUS VEINS (VENAE CORDIS MINIMAE)

82. CORONARY SINUS AND ITS TRIBUTARIES GREAT CARDIAC VEIN SMALL CARDIAC VEIN MIDDLE CARDIAC VEIN POSTERIOR VEIN OF LEFT VENTRICLE OBLIQUE VEIN OF MARSHALL

83. ANTERIOR CARDIAC VEINS

84. THEBESIUS VEINS MANY IN THE RIGHT ATRIUM (2MM IN DIAMETER0 A FEW IN THE RIGHT VENTRICLE(0.5MM IN DIAMETER) OCCASIONAL OR ABSENT IN LEFT ATRIUM RARE IN LEFT VENTRICLE

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86. Myocardial Infarction (MI) ~ 1.3 x 10 6 MIs / year in US Most commonly due to severe CAD (coronary thrombosis) Ischemic tissue degenerates → nonfunctional area = infarct Predisposing factors?

87. The EKG

88. 22-88 Innervation of the Heart Innervated by the autonomic nervous system. Consists of both sympathetic and parasympathetic components. – referred to as the coronary plexus Autonomic innervation by autonomic centers in the hindbrain doesn’t initiate heartbeat, but it can increase or decrease the heartbeat. Rich innervation to SA and AV nodes, but also to myocardial cells.

89. 22-89 Sympathetic Innervation Sympathetic innervation increases the rate and the force of heart contractions arises from T1-T5 segments of spinal cord enter sympathetic trunk, ascend and pass through ganglia travel through heart via cardiac nerves

90. 22-90 Innervation

91. 22-91 Parasympathetic Innervation Parasympathetic innervation decreases heart rate, but tends to have no effect on the force of contractions, except in special circumstances comes off of the medulla oblongata via right and left vagus nerves (CN X)

92. 22-92 Coronary Circulation Left and right coronary arteries travel in the coronary sulcus (atrioventricular groove) of the heart to supply the heart wall. – the only branches of the ascending aorta Located immediately superior to the aortic semilunar valve. The right coronary artery typically branches into the – marginal artery supplies the right border of the heart – posterior interventricular artery supplies both the left and right ventricles

93. 22-93 Coronary Circulation Left coronary artery typically branches into the anterior interventricular artery. – also called the left anterior descending artery – supplies the anterior surface of both ventricles and most of the interventricular septum Circumflex artery. – supplies the left atrium and ventricle Arterial pattern can vary greatly among individuals.

95. INTERIOR OF RIGHT ATRIUM Opening of Superior vena cava Opening of Inferior vena cava ---- Eustachian valve Opening of Coronary sinus Foramina venarum minimarum Intra venus tubercle Crista terminalis Musculi pectinati

96. INTERATRIAL SEPTUM Foss ovalis Limbus fossa ovalis Triangle of koch Torus aorticus Vestibule of the tricuspid valve

97. INTERIOR OF RIGHT VENTRICLE Ventricle proper ( inflowing rough part) --Right AV orifice -- tricuspid valve -- chordae tendineae Conus arteriosus ( infundibulum). Supraventricular crest Trabeculae carneae. ---Papillary muscle. Septomarginal trabecula (Moderator band)

98. OUT FLOW TRACT Infundibulum Pulmonary orifice

99. INTERIOR LEFT VENTRICLE Inflow tract (ventricle proper) Left AV orifice Mitra valve complex Trabeculae carneae. Papillary muscle. Out flow tract Aortic vestibule Siminular valve.

100. CONDUCTING SYSTEM SA node AV node AV bundle of His.

101. BUNDLE OF HIS

102. CORONARY ARTERIES THERE ARE 2 CORONARIES BOTH ARISE FROM ASCENDING AORTA BOTH DEVELOP AS VASA VASORUM OF THE HEART. TRADITIONALLY CONSIDERED AS END ARTERIES

103. RIGHT CORONARY ARTERY ARISES FROM THE ANTERIOR AORTIC SINUS CALIBER IS LESS THAN THE LEFT CORONARY SUPPLIES LESSER HEART TISSUES 65% OF THE CASES SUPPLIES THE S-A NODE 80% OF THE CASES SUPPLIES THE A-V NODE 80% OF THE CASES HAS RIGHT DOMINENCE

104. COURSE OF RIGHT CORONARY

105. BRANCHES OF THE FIRST SEGMENT CONUS ARTERY ANTERIOR VENTRICULAR RAMI (2- 4) RIGHT MARGINAL ARTERY ANTERIOR AND LATERAL ATRIAL RAMI NODAL ARTERY

106. NODAL ARTERY FROM RIGHT CORONARY ( 65 % )

107. BRANCHES OF SECOND SEGMENT OF RIGHT CORONARY POSTERIOR VENTRICULAR RAMI POSTERIOR ATRIAL RAMI POSTERIOR INTERVENTRICULA R BRANCH A-V NODAL BRANCH

108. POSTERIOR INTERVENTRICULAR BRANCH AND RIGHT DOMINENCE

109. AREA OF HEART SUPPLIED BY RIGHT CORONARY ENTIRE RIGHT ATRIUM ENTIRE RIGHT VENTRICLE EXCEPT A SMALL AREA NEAR THE ANTERIOR INTERVENTRICULAR GROOVE A PART OF LEFT VENTRICLE NEAR THE POSTERIOR INTERVENTRICULAR GROOVE POSTERIOR ONE THIRD OF I-V SEPTUM ENTIRE CONDUCTING SYSTEM EXCEPT LEFT BUNDLE BRANCH 65% -S-A NODE 80% - A-V NODE

110. COURSE OF LEFT CORONARY

111. BRANCHES OF ANTERIOR INTERVENTRICULAR ARTERY ANTERIOR RIGT VENTRICULAR RAMI (VERY FEW) ANTERIOR LEFT VENTRICULAR RAMI DIAGONAL ARTERY ANTERIOR I-V SEPTAL ARTERIES CONUS ARTERY

112. BRANCHES OF CIRCUMFLEX ARTERY POSTERIOR VENTRICULR RAMI LEFT MARGINAL ARTERY LEFT ATRIAL RAMI (ANTERIOR, LATERAL AND POSTERIOR)

113. NODAL ARTERY FROM LEFT CORONARY

114. LEFT DOMINENCE

115. AREA OF HEART SUPPLIED BY LEFT CORONARY ENTIRE LEFT ATRIUM ENTIRE LEFT VENTRICLE EXCEPT AN AREA NEAR THE POSTERIOR INTER VENTRICULAR GROOVE A SMALL PART OF RIGHT VENTRICLE NEAR THE ANTERIOR I-V GROOVE ANTERIOR 2/3 OF I-V SEPTUM LEFT BUNDLE BRANCH 35% S-A NODE 20% A-V NODE

116. CARDIAC PLEXUS SUPERFICIAL CARDIAC PLEXUS DEEP CARDIAC PLEXUS

117. SUPERFICIAL CARDIAC PLEXUS LIES SUPERFICIAL TO ARCH OF AORTA INFRONT OF RIGHT PULMONARY ARTERY MADE UP OF AUTONOMIC NERVES

118. COMPONENTS OF SUPERFICIAL PLEXUS CARDIAC BRANCH OF LEFT SUPERIOR CERVICAL SYMPATHETIC GANGLION INFERIOR CARDIAC BRANCH OF LEFT VAGUS

119. BRANCHES OF SUPERFICIAL PLEXUS RIGHT PULMONARY PLEXUS RIGHT CORONARY PLEXUS CONTINUOUS WITH DEEP PLEXUS

120. DEEP CARDIAC PLEXUS LIES DEEP TO THE ARCH OF AORTA INFRONT OF BIFURCATION OF TRACHEA MADE UP OF AUTONOMIC NERVES CONTNUOUS WITH THE SUPERFICIAL PLEXUS

121. COMPONENTS OF DEEP PLEXUS CARDIAC BRANCHES OF ALL CERVICAL AND UPPER FOUR THORACIC SYMPATHETIC GANGLION(WITH EXCEPTION OF LEFT SUPERIOR GANGLION) CARDIAC BRANCHES OF LEFT AND RIGHT VAGI EXCEPT INFERIOR CARDIAC BRANCH OF LEFT VAGUS

122. IMPULSES FROM THE HEART

128. Right ventricle Smooth part Rough part Supraventricular crest

129. Chorda tendinae Posterior Papillary muscle Ridge Septal papillary muscle Moderator band Anterior Papillary muscle Bridge

130. Atrioventricular orifice Pulmonary orifice Infundibulum

131. Left atrium Auricle PV Fossa lunata

132. Left ventricle Anterior papillary muscle Auricle Posterior papillary muscle

133. Valves of the heart

135. P A M T

136. Conducting system

137. Fibrous Skeleton

138. Clinical anatomy 1 st heart sound- produced by closure of atrio-ventricular valves, 2 nd by closure of semilunar valves. Stenosis of valves Incompetence or regurgitation

139. RADIOGRAPH OF CHEST -- PA view