1. SHANDONG UNIVERSITY Liu Zhiyu
Angiology
SHANDONG UNIVERSITY
Liu Zhiyu

2. Angiology
Composition
Cardiovascular system
Lymphatic system

3. The cardiovascular system
Organization
Heart
A muscle pump to maintain the flow of blood
Consist of four chambers (right and left atria, right and left ventricles)
Artery (a.)
carry blood away from the heart
Veins ( v.)
carry blood back to the heart
Capillary
microscopic vessels, the area of exchange between blood and tissue fluid

4. The cardiovascular system
Blood circulation
Systemic circulation left ventricle→aorta and its branches→capillaries of body→superior and inferior vena cava→right atrium
Pulmonary circulation right ventricle→pulmonary a.→capillaries of lung → pulmonary v. →left atrium

5. The cardiovascular system
Vascular anastomosis
Anastomosis between a.
Anastomosis between v.
Arteriolovenular anastomosis
Collateral vessels
Collateral circulation

6. The Heart

7. The heart Position Lies within the pericardium in middle mediastinum
Behind the body of sternum and coastal cartilages 2 to 6
In front of thoracic vertebrae 5 to 8
A third of it lies to the right of median plan and 2/3 to the left

8. Surfaces of the heart

9. Surfaces of the heart
Pyramidal in shape, somewhat larger than a closed fist
One apex
One base
Two surface
Three borders
Four sulcuses

10. Cardiac apex Formed by left ventricle
Directed downwards, forward, and to the left
Lies at the level of the fifth left intercostal space, 1~2 cm medial to the left midclavicular line (9cm from the midline)

11. Cardiac base
Formed by the left atrium and to a small extent by the right atrium.
Faces backward, upward and to the right

12. Sternocostal surface
Formed mainly by the right atrium and right ventricle, and a lesser portion of its left is formed by the left auricle and ventricle
Directed forwards and upwards

13. Diaphragmatic surface
Formed the ventricles－chiefly the left ventricle
Directed backwards and downwards, and rest upon the central tendon of the diaphragm

14. Borders of the heart Right border Left border Inferior border Vertical
Formed entirely by right atrium
Left border
Round
Mainly formed by the left ventricle and partly by the left auricle
Inferior border
Horizontal
Formed by the right ventricle and cardiac apex

15. Sulcuses of the heart
Coronary sulcus (circular sulcus) which marks the division between atria and ventricles, contains the trunks of the coronary vessels and completely encircles the heart
Interatrial sulcus －separates the two atria and is hidden by pulmonary trunk and aorta in front

16. Sulcuses of the heart Anterior interventricular groove
Posterior interventricular groove
Mark the division between ventricles (which separates the RV from the LV)
Cardiac apical incisure
Atrioventricular crux

17. Chambers of the heart

18. Chambers of the heart Consists of four chambers Left and right atria
Left and right auricle
Left and right ventricles

19. Right atrium (RA) Three inlets
Orifice of superior vena cava returns blood to the heart from the upper half of the body
Orifice of inferior vena cava returns blood to the heart from the lower half of the body
Orifice of coronary sinus returns blood to the heart from the cardiac muscle
One outlet －right atrioventricular orifice

20. Right atrium (RA)
Crista terminalis －vertical ridge that from superior vena cave to inferior vena cave
Sulcus terminalis－groove on exterior of heart that corresponds to crista terminalis
Two parts －separated externally by sulcus terminalis and internally by the crista terminalis
Atrium proper
Sinus venarum cavarum

21. Right atrium (RA) Atrium proper Sinus venarum cavarum
In front of the ridge
Pectinate muscles in wall
Sinus venarum cavarum
Smooth walls
Fossa ovalis － an oval depression, a remnant of the fetal foramen ovale, on the lower part of interatrial septum, the most common location of atrial septal defects (ASD)
Aortic mound

22. Right ventricle (RV) One inlet －right atrioventricular orifice
One outlet 　　－orifice of pulmonary trunk

23. Right ventricle (RV)
Supraventricular crest (a muscular ridge between right atrioventricular orifice and orifice of pulmonary trunk )
Two parts
Inflow tract
Outflow tract

24. Right ventricle (RV) Inflow tract
Trabeculae carneae irregularly arranged bundles of myocardium
Septomarginal trabecula －extends from interventricular septum to base of anterior papillary muscle, contains right bundle branch
Papillary muscles
Conical-shaped
Three: anterior, posterior and septal

25. Right ventricle (RV) Outflow tract —Conus arteriosus
Cone-shape , smooth area leading upward to orifice of pulmonary trunk
Pumps blood through pulmonary orifice to pulmonary trunk

26. Tricuspid valve Guards right atrioventricular orifice
Three triangular cusps:
anterior, posterior and septal
Base of cusps are attached to fibrous ring surrounding the atrioventricular orifice.
To their free edges and ventricular surfaces are attached chordae tendineae , which connect the cusps to the papillary muscles.

27. Tricuspid valve

28. Tricuspid complex Tricuspid ring Tricuspid valve Chordae tendineae
Papillary muscles

29. Chordae tendineae
Papillary muscles

30. Function of tricuspid complex
Open during diastole to allow blood to enter ventricles from atria
Closed during systole to prevent regurgitation of blood into atria

31. Valve of pulmonary trunk
Guards the orifice of pulmonary trunk
Has three semilunar cusps – each with free border that has central modules called nodules of semilunar valve
Has three pulmonary sinuses —bulges in wall of pulmonary trunk at level of valve that correspond to cusps

32. Function of pulmonary valves
Opening during systole, with cusps pressed toward wall of vessel as blood is forced upward
Closed during diastole
Ventricular pressure drops in diastole
Floating together of valve cusps, with free borders meeting, thus closing the valve

33. Left atrium (LA) Four inlets－four orifices of pulmonary veins
One outlet－left atrioventricular orifice

34. Left ventricle (LV) One inlet left atrioventricular orifice
One outlet － aortic orifice
Two parts－divided by anterior cusps of mitral valve
Inflow tract－rough walls
Outflow tract
Aortic vestibule
Smooth area leading to aortic orifice

35. Mitral valve Guards left atrioventricular orifice
Two triangular cusps－anterior and posterior with commissural cusps between them (posteromedial and anterolateral commissures)

36. Mirtal complex Mitral ring Mitral valve Chordae tendineae
Papillary muscles

37. Function of mitral complex
Open during diastole to allow blood to enter ventricles from atria
Closed during systole to prevent regurgitation of blood into atria

38. Aortic valve Guards the aortic orifice
Three semilunar cusps (right, left and posterior)
Each with free border that has nodules of semilunar valve
Aortic sinus – bulges in aortic wall at level of valve that correspond to cusps
Right－contains opening of right coronary artery
Left－contains opening of left coronary artery
Posterior－no opening

39. Function of aortic valves
Opening during systole, with cusps pressed toward wall of vessel as blood is forced upward
Closed during diastole
Ventricular pressure drops in diastole
Floating together of valve cusps, with free borders meeting, thus closing the valve

41. Structures of the heart

42. Structures of the heart
Walls of heart
Endocardium
Inner coat of the heart wall
Continuous with the valve flaps
Myocardium
Arranged spirally
Attached to fibrous rings surrouding the four orifices of heart
The walls of left ventricle are about three times thicker than that of right
Epicardium
Outer
Visceral layer of serous pericardium

43. Structures of the heart
Interatrial septum
Located between right and left atria
Contains fossa ovalis
Interventricular septum
Located between right and left ventricles
Has upper membranous part
Has thick lower muscular part
Atrioventricular septum

44. Membranous part of interventricular septum

46. Ventricular Septal Defect
Note the large ventricular septal defect * which may be seen in this photo. * *

47. Fibrous skeleton of heart
Fibrous rings that surround the atrioventricular, pulmonary, and aortic orifices
Left and right fibrous trigones

48. Conduction system of heart

49. Conduction system of heart
Composed of specialized myocardial cells
Sinuatrial node
Internodal tract
Atrioventricular node
Atrioventricular bundle
Right and left bundle branches
Purkinje network

50. Conduction system of heart
Sinuatrial node (SA node)
Called the pacemaker cell (P cell)
Located at the upper part of the sulcus terminalis close to the superior vena cava, under the epicardium.

51. Conduction system of heart
Atrioventricular node (AV node)
Located in the lower part of interatrial septum, near orifice of coronary sinus and base of tricuspid valve
Under the endocardium
Lower part related to membranous part of interventricular septum

52. Conduction system of heart
Atrioventricular bundle (AV bundle)
Passes forward through right fibrous trigon to reach inferior border of membranous part
Divides into right and left bundle branches at upper border of muscular part of interventricular septum

53. Conduction system of heart
Right and left bundle branches
Right bundle branch－passes down on right side of interventricular septum to reach the septomarginal trabecular and into the base of anterior papillary muscle. Here it becomes continuous with the fibers of Purkinje fibres
Left bundle branch－passes down on left side of interventricular septum beneath the endocardium. It usually divides into two branches, which eventually become continuous with the Purkinje fibers
Purkinje network continuous with myocardium

54. Atrioventricular bundle Atrioventricular node★
Sinuatrial node
Atrioventricular bundle
Right and left bundle branches
Atrioventricular node
Purkinje network

55. Arterial supply of the heart

56. Arterial supply of the heart
Left coronary artery
Course
Arises from left aortic sinus
Runs between pulmonary trunk and left auricle into coronary sulcus
Branches
Anterior interventricular branch －runs downward in anterior interventricular groove around inferior margin of heart to posterior interventricular groove
Circumflex branch －travels to left in coronary sulcus to posterior aspect
Distribution－supplies left atrium and ventricle, lesser portion of anterior wall of right ventricle, and anterior 2/3 of interventricular septum

57. Arterial supply of the heart
Right coronary artery
Course
Arises from the right aortic sinus
Runs forward between right auricle and pulmonary trunk into coronary sulcus
Branches
Right marginal branch travels along inferior border
Posteror interventricular branch －travels downward in posterior interventricular groove, it anastomosises near the apex with the anterior interventricular branch of the left coronary artery
Distribution: supplies right atrium and ventricle, posterioinferior 1/3 of interventricular septum, posterior wall of left ventricle, the sinuatrial node and atrioventricular node

58. Thrombus in Coronary Artery Angiogram
冠状动脉造影显示动脉血栓

60. Coronary artery bypass grafting (CABG)
Precutaneous translaminal
coronary angioplasty (PTCA)
Stent in an artery

61. Venous drainage of the heart

62. Venous drainage of the heart
Coronary sinus
Lies in posterior part of coronary sulcus
Carries most of venous blood from myocardium to right atrium
Tributaries
Great cardiac vein
Middle cardiac vein
Small cardiac vein

63. Pericardium 心包

64. Pericardium 心包 Fibrous pericardium 纤维心包 Serous pericardium 浆膜心包
Attached to central tendon of diaphragm inferiorly
Blends with outer coat of great vessels superiorly
Serous pericardium 浆膜心包
Visceral layer (epicardium)
Parietal layer
Pericardial cavity 心包腔
Potential space between visceral and parietal layes
Contains film of pericardium fluid as a lubricant to facilitate cardiac movements

65. Pericardium 心包 Pericardium sinus
Formed by reflection of serous pericardium
Transverse sinus of pericardium 心包横窦
Posterior to ascending aorta and pulmonary trunk
Anterior to superior vena cava and left atrium.

66. Pericardium sinus
Oblique sinus of pericardium 心包斜窦－cul-de-sac , posterior to heart, bounded by pulmonary veins on either side
Anterior inferior sinus of pericardium 心包前下窦

67. Venous drainage of heart
Anterior cardiac veins －3~4 small vessels, drain into right atrium
Smallest cardiac veins －drain into all chambers, mainly atria

68. Surface markings of heart

69. Surface markings of heart
R. superior point－ lies on the upper border of right third costal cartilage ±1.2cm from the margin of sternum
R. inferior point － lies on the sixth sternocostal joint
L. superior point － lies on lower border of left second costal cartilage ±1.2cm from sternal margin
Cardiac apex－in the fifth left intercostal space 7~9cm from the midline

70. Surface markings of heart
Right border－corresponds to a line running from the upper border of right third costal cartilage ±1.2cm from the margin of sternum, downwards to sixth sternocostal joint
Apex－in the fifth left intercostal space 7~9cm from the midline
Left border－represented by a line running from apex upwards and medially to a point on lower border of left second costal cartilage ±1.2cm from sternal margin
Lower border－represented by a line joint the lower end of right border to apex

71. ★You must identify follow structures！
Vessels of heart
Left coronary artery
Anterior interventricular branch
Right coronary artery
Posteror interventricular branch
coronary sinus
Right atrium
Orifice of superior vena cava
Orifice of inferior vena cava
Orifice of coronary sinus
Sulcus terminalis
Fossa ovalis
Pectinate muscles
Shape of heart
Cardiac apex
Cardiac base
Coronary sulcus
Anterior interventricular groove
Posterior interventricular groove
Cardiac apical incisure
Atrioventricular crux
Right and left auricle
Pulmonary trunk

72. ★You must identify follow structures！
Left atrium
Orifices of pulmonary veins
Left atrioventricular orifice
Left ventricle
Aortic vestibule
Mitral valve
Aortic vavle
Aortic sinus
Right ventricle
Right atrioventricular orifice
Tricuspid valve
Chordae tendineae
Papillary muscles
Supraventricular crest
Trabeculae carneae
Septomarginal trabecula
Conus arteriosus
Valve of pulmonary trunk