1. Heart David Kachlík, Štěpán Jelínek

2. Heart situation

3. 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

4. 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.

5. Heart structure  endocardium = tunica intima  myocardium = tunica media working myocardium excitomotor apparatus (EA) = conducting m. fibrous skeleton of heart  pericardium

6. 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

7. 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

8. 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

9. Myocardium

10. Pericardium

11. 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)

12. Heart cavities  atrium dextrum + sinistrum  septum interatriale  septum atrioventriculare  ventriculus dexter + sinister  septum interventriculare (pars membranacea + muscularis)

13. 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

14. Atrium dextrum (right atrium)  auricula dextra  sinus venarum cavarum  crista terminalis  mm. pectinati  ostium atrioventriculare dextrum  trigonum nodi atrioventricularis Kochi

15. 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

16. 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

18. Right-sided compartments

19. Atrium sinistrum (left atrium)  auricula sinistra  ostia venarum pulmonalium  mm. pectinati  valvula foraminis ovalis (= former falx septi Parchappei)

20. 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)

23. Left-sided compartments

24. ECHO

25. 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

28. 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

29. Coronary arteries

30. 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)

33. 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

34. Coronary arteries

35. Arteria coronaria sinistra ACS in posteroanterior projection ACS in lateral projection (right to left) ACS in lateral projection (left to right)

36. Ponticulus

37. Stenosis in ACS

38. Arteria coronaria dextra ACS in posteroanterior projection ACS in lateral projection (right to left) ACS in lateral projection (left to right)

39. Collateral vessels

40. Heart veins  Sinus coronarius → atrium dextrum ← v. cardiaca (cordis) magna  ← v. interventricularis anterior  ← v. maginalis sinistra name 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

43. Heart veins  Vv. ventriculi dextri anteriores = vv. cardiace (cordis) anteriores → atrium dextrum  Vv. cadiace (cordis) minimae Thebesii → all cavities without any major clinical importance

44. 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

46. 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

47. 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

49. 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)

51. Purkyně fibres (HE + elastin)

52. artificial pacemaker

53. Physiology  Heart cycle systole diastole  Pulse and volumes  EKG curve  Arterial pulse curve with dicrotic notch  Endocrinne function - ANF

54. 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

55. Auscultation Testut‘s points = 4 auscultation points

56. 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

57. Systolic/ diastolic pressures in the heart chambers

59. 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

60. Heart X-ray

62. Rheumatic vegetations

63. Endocarditis

64. Valvular insufficiency (regurgitation) and stenosis

65. Myocardial infarction

66. Cardiac aneurysm

67. Pericarditis

68. Cardiac trauma

69. Cardiac tamponade

70. The heart during CPR

71. Basic therapeutic operations  PTCA (= percutaneous transfemoral coronary angioplasty)

72. 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

74. Valvular replacement

76. Cardiac transplantation

77. Practical training  X-ray of heart and lungs  Valve auscultation  Heart specimen – whole x dissected  Histological slides of heart muscle

78. 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