1. Cardiovascular Anatomy and Physiology AFAMS Residency Orientation April 16, 2012 ARMED FORCES ACADEMY OF MEDICAL SCIENCES

2. Heart Facts Human heart is 13 x 9 cm Weighs about 1 kg Beats 100, 000 times a day Pumps 7600 L of blood daily Circulates blood completely about 1000 x a day Pumps blood through 100,000 km of vessels Cardiovascular Death is most common cause of death worldwide ARMED FORCES ACADEMY OF MEDICAL SCIENCES

3. Purpose of Cardiovascular System Deliver blood to tissues and organs – Nutrients – Oxygen Remove used blood from organs and tissues – Deoxygenated hemoglobin Deliver deoxygenated blood to lungs for re- oxygenation ARMED FORCES ACADEMY OF MEDICAL SCIENCES

4. Cardiac Anatomy ARMED FORCES ACADEMY OF MEDICAL SCIENCES

5. Cardiac Anatomy ARMED FORCES ACADEMY OF MEDICAL SCIENCES

6. Cardiac Anatomy: Chambers Right Atrium (RA) – Receives deoxygenated blood from venous circulation – Pumps blood to RV Right Ventricle (RV) – Receives deoxygenated blood from RA – Pumps deoxygenated blood to lungs Left Atrium (LA) – Receives oxygenated blood from pulmonary vein – Pumps blood to LV Left Ventricle (LV) – Receives oxygenated blood from LA – Pumps oxygenated through aorta to body ARMED FORCES ACADEMY OF MEDICAL SCIENCES

7. Gross Anatomy ARMED FORCES ACADEMY OF MEDICAL SCIENCES

8. Cardiac Anatomy: Valves Classification – A-V valves Tricuspid – Separates RA and RV Mitral – Separates LA and LV – Systemic Valves Aortic – Separates LV and Aorta Pulmonic – Separates RV and Pulmonary artery ARMED FORCES ACADEMY OF MEDICAL SCIENCES Aortic Valve Mitral Valve

9. Cardiac Anatomy: Outflow Pulmonary Artery – Arising from Right Ventricle (RV) – Blood from RV to lungs Aortic Arch – Arising from Left Ventricle (LV) – Blood from LV to body ARMED FORCES ACADEMY OF MEDICAL SCIENCES

10. Normal Regional Circulation ARMED FORCES ACADEMY OF MEDICAL SCIENCES

11. Cardiac Anatomy: Coronary Arteries Left Main (LM) Left Anterior Descending (LAD) – Septal Perforating Branches – Diagonal Branches Left Circumflex (LCx) – Obtuse Marginals Right Coronary Artery (RCA) – Acute Marginals – Posterior Descending – Posterior Lateral Branch ARMED FORCES ACADEMY OF MEDICAL SCIENCES

12. Coronary Anatomy ARMED FORCES ACADEMY OF MEDICAL SCIENCES LAO Caudal ViewLAO Cranial View OM1 LM RCA D1 LCx LAD LM PLB PDA

13. Left Ventricular Volumes End Diastolic Volume (EDV) – Volume of blood in LV and end diastole – Directly proportional to venous return End Systolic Volume (ESV) – Volume of blood in LV at the end of systole (contraction) ARMED FORCES ACADEMY OF MEDICAL SCIENCES

14. Left Ventricular Volumes Stroke Volume (SV) – EDV - ESV Ejection Fraction (EF) – SV/EDV – Normal resting EF: 60% Best predictor of heart performance and heart disease prognosis – Normal exercising EF: 80% ARMED FORCES ACADEMY OF MEDICAL SCIENCES

15. Left Ventricular Volumes ARMED FORCES ACADEMY OF MEDICAL SCIENCES

16. Cardiology Physiology Cardiac Output (CO) – HR x SV Cardiac Index (CI) – CO / BSA Preload – Volume of blood in the left ventricle at end diastole – Dependent upon venous return and compliance of left ventricle Afterload – Amount of resistance the heart has to overcome to pump blood forward Mean Arterial Pressure ARMED FORCES ACADEMY OF MEDICAL SCIENCES

17. Cardiology Physiology Myocardial Contractility – Amount of force with which the heart contracts at a given preload – Dependent upon Sympathetic Nerve activity Catecholamines Myocardial mass Drugs ARMED FORCES ACADEMY OF MEDICAL SCIENCES

18. Contractility Increased Cardiac Contractility – Exercise: increased sympathetic tone – Catecholamines: epinephrine and norephinephrine – Excitement / Fear: Fight of flight response – Drugs: Digitalis and sympathomimetics Decreased Cardiac Contractility – Loss of Contractile Mass: Secondary to myocardial infarction – Myocardial muscle disease: Cardiomyopathy – Drugs: anesthetics and barbituates ARMED FORCES ACADEMY OF MEDICAL SCIENCES

19. Starling Curve In a normal heart – Increasing preload (EDV or EDV) increases SV – Increasing contractility increases stroke volume at a constant preload ARMED FORCES ACADEMY OF MEDICAL SCIENCES

20. Definitions Systolic Blood Pressure (SBP): blood pressure in brachial artery during systole Diastolic Blood Pressure (DBP): blood pressure in brachial artery during diastole Mean Arterial Pressure (MAP): average blood pressure against the walls of the aorta throughout a complete cardiac cycle – MAP = [(2 x DBP) + SBP] / 3 ARMED FORCES ACADEMY OF MEDICAL SCIENCES

21. Vascular Anatomy ARMED FORCES ACADEMY OF MEDICAL SCIENCES

22. Abdominal Blood Supply Importance: Surgical Procedures Renal Artery Stenosis Embolic Events to the GI tract Watershed areas Differential diagnosis of abdominal organ failure Nutritional Implications ARMED FORCES ACADEMY OF MEDICAL SCIENCES

23. Abdominal Blood Supply ARMED FORCES ACADEMY OF MEDICAL SCIENCES

24. Vascular Anatomy of the Neck Importance: Central Venous Access – Internal Jugular Vein – Subclavian Vein Stroke – Carotid artery arteriosclerosis ARMED FORCES ACADEMY OF MEDICAL SCIENCES

25. Neck Arteries ARMED FORCES ACADEMY OF MEDICAL SCIENCES

26. Veins of the Neck ARMED FORCES ACADEMY OF MEDICAL SCIENCES

27. Arteries of the Brain Importance: Localizing site of stroke Watershed areas Localizing site of aneurysm Importance of understanding cerebral perfusion ARMED FORCES ACADEMY OF MEDICAL SCIENCES

28. Arteries of the Brain ARMED FORCES ACADEMY OF MEDICAL SCIENCES

29. Arteries of the Brain ARMED FORCES ACADEMY OF MEDICAL SCIENCES 3D MRI with Gadolinium Gross Anatomy of Circle of Wilis

30. Arm Vasculature Importance: Placement of peripheral IVs Central Venous Catheters – Brachial vein Placement of radial arterial line ARMED FORCES ACADEMY OF MEDICAL SCIENCES

31. Arm Vasculature ARMED FORCES ACADEMY OF MEDICAL SCIENCES

32. Lower Extremity Vascular Anatomy Importance: Central Venous Catheter – Femoral Vein Arterial Line – Femoral Arterial Localizing Peripheral Arterial Disease ARMED FORCES ACADEMY OF MEDICAL SCIENCES

33. Lower Extremity Vascular Anatomy ARMED FORCES ACADEMY OF MEDICAL SCIENCES

34. Lower Extremity Vascular Anatomy Angiogram of Peripheral arterial Disease CFA: Common femoral artery DFA: Deep Femoral Artery SFA: Superficial Femoral Artery ARMED FORCES ACADEMY OF MEDICAL SCIENCES STENT

35. Conclusions Presentation was brief overview of the cardiovascular system Understanding vascular anatomy important for every doctor Cardiovascular Disease is leading cause of death ARMED FORCES ACADEMY OF MEDICAL SCIENCES