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Anatomy of the

Pericardium & Heart


Karlos Noel R. Aleta, M.D.
Dept of Surgery
San Beda College of Medicine

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Outline
• Pericardium
• Heart
• Surface anatomy

• Internal anatomy

• Valves

• Chambers

• Skeleton

• Conduction pathway

• Nerve

• Blood supply

• Arterial

• Coronary artery disease

• Venous
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PERICARDIUM
• fibroserous sac w/c surrounds heart & root of great
vessels
• Invaginate the serous sac from behind during devt

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Components of the pericardium
1. FIBROUS Pericardium
• outer layer of pericardial sac
~ cone shaped bag

Boarders:
• superior: pretracheal fascia

• posterior: trachea & 1° bronchi

• anterior: sternum

• Inferior: fused w/ diaphragm

Structures w/c pass thru:


• 4 pulmonary veins

• IVC [R side]

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Components of the pericardium
2. SEROUS Pericardium
a. PARIETAL
• lines inner surface of

fibrous pericardium
b. VISCERAL
• ‘epicardium’

• lines outer surface of ♥

• completely invests heart

EXCEPT POSTERIORLY
b/w entrance of 2 vena
cavae & 4 pulmonary
veins 5
Pericardial Cavity
• space b/w parietal & visceral percardium
• (+) small amt of pericardial fluid ~ prevents
friction, “lubrication”
• normal capacity ~ 50 ml
• max capacity ~ 300 ml
• Pericardial effusion ~ accumulation of fluid w/in
sac

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Pericardial tamponade
• “cardiac tamponade”
• Limits diastole (PRELOAD)
~restricted expansion of relaxed heart
~compromise ability to fill w/ blood properly
~inadequate amount propelled to systemic circ
• 60 ~ 100 ml acute accumulation of
blood/clots/fluid can produce tamponade
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Cardiac tamponade
Clinical picture
• Beck’s triad
(hypotension,
distended neck veins,
muffled heart sounds)

• Pulsus paradoxus
(exaggerated fall in
systolic BP during
inspiration

• Drain fluid
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Constrictive Pericarditis
• Inflammation~affects both
parietal & visceral
• Thickening ~ adherence to
underlying myocardium
• May initially present w/
pericardial effusion
• Chronic constriction
• In PI, TB #1 etiology

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Pericardiectomy/pericardial
stripping
• Pericardiectomy ~
allow chamber to
expand
• Thickened
pericardium
• Anterior, posterior
• CP bypass machine

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Constrictive Pericarditis

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Constrictive Pericarditis

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Constrictive Pericardiectomy

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Sinuses

1. Transverse
• Breakdown of embryonic dorsal

mesocardium
• passage fr L --> R

• behind pulmonary trunk & ascending aorta

• sign ific anc e: ligate pulmonary trunk &

asc. aorta during cardiac transplant

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Transverse Sinus

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Sinuses
2. Oblique
• behind LV & LA

• LA & 4PV enter LA in base/posterior

• Serous p reflects onto inner surface of

fibrous p as parietal p
• Reflection of serous p forms blind ending

sac

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Oblique Sinus

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Nerve supply
• Fibrous / Parietal - Somatic N [ fr phrenic N]

• Visceral - Autonomic N [ fr coronary plexus]


• insensitive to pain

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Blood supply of Pericardium
• Fibrous & parietal → branches from:
– internal thoracic [mammary] a
– bronchial a
– pericardiacophrenic a
– aorta
– arteries to diaphragm
• Visceral → coronary a [ share w/ myocardium ]
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Pericardial pain
• felt diffusely posterior to the sternum ~
substernal pain
• May radiate to other areas

• Acute inflammation of pericardial sac ~


pericarditis
~ Pain, +/- effusion
• Auscultation ~ pericardial friction rub

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Heart
• central organ of circulatory system
• wall :
EPICARDIUM - external surface
MYOCARDIUM - middle, muscular, thickest
ENDOCARDIUM - internal surface

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Heart
• short CONE
• base: faces posteriorly
• formed b y LA &
part of RA
• apex: points downward,
to Left & forward
formed by LV
• Apex beat is Point of
Maximal Impulse
• located at 5th ICS, L
midclavicular line
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Surfaces
1. Diaphragmatic or inferior
• LV & part of RV

• rests on diaphragm

2. Left surface
• LV

3. Right surface
• RA

4. Sternocostal
• faces anteriorly

• RV , partly by RA & LV

• RV = m ost c ommon ly

injur ed in penetrating
trauma
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Penetrating cardiac injury
• Pathophysiology
• Injury pattern
• Right ventricle most common (>40 %)
• Left ventricle 2nd most common (40%)
• Right atrium 24%
• Left atrium 3%
• Complex 8%
• Coronary arteries 5%
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Cardiac Box
- Penetrating cardiac injury
- In stable patients
~ r/o (+/─) pericardial
effusion
~ prove if blood
- In unstable patients
~ open/surgery to locate &
repair external cardiac
injury

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Traumatic cardiac tamponade

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Traumatic Cardiac Injury

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D. Internal Anatomy
1. Chambers : R atrium R ventricle
L atrium L ventricle

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Internal Anatomy
2. Openings/ Valves
Function of valves: prevent backward flow of blood
a. Tricuspid = R atrioventricular, valve w/ 3 cusps
b. Mitral = L atrioventricular, valve w/ 2 cusps
c. Aortic = bet LV & aorta
d. Pulmonic = bet. RV & pulmonary trunk
e. Aortic sinuses - dilated pockets bet cusps &
aortic wall
- origin of coronary arteries
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Rheumatic Heart Disease
• vegetations
• calcifications
• affects mainly mitral valve
• cause stenosis or insufficiency
• severity may affect other valves

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Valvular surgery
• Closed Valve repair
• Open Valve repair
• Open Valve replacement

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PROSTHETIC VALVES
• Types of valves
• Mechanical

• Tissue

• Xenografts

• autografts/human homografts

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MECHANICAL VALVES

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TISSUE VALVES

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VALVE REPLACEMENT

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CHAMBERS of the HEART

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1. R ATRIUM

• quadrangular shaped

• receives blood fr SVC,


IVC & coronary sinus

• communicates w/ RV
thru R AV opening

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R ATRIUM
• crista terminalis =
smooth muscular ridge
w/c divides into 2 parts:
• 1. sinus venarum =
smooth,thin, posterior
part where vena cava
open, coronary sinus
• 2. musculi pectinati =
rough, thick, anterior
part

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R ATRIUM
• fossa o va lis
~ depression above
orifice of IVC

• marks location of former


foramen ovale [opening
thru w/c blood flows fr
RA → LA before birth]

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Congenital Heart Disease

Atrial septal defect


= incomplete closure of foramen
ovale (most common)
~ “patent foramen ovale” (PFO)

= blood flows fr LA → RA

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ATRIAL SEPTAL DEFECT

• Hole in interatrial septum (IAS) of variable


sizes
• Left-to-right shunting → atrial level
• Association with other cardiac anomalies 48
TYPES OF ASD
1. Sinus venosus
• 5-10%
• PAPVR
2. Ostium primum
• Partial AV canal
defects
• 10-15%
3. Ostium secundum
• 80%
• Patent foramen
ovale (PFO) 49
ASD REPAIR

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2. R VENTRICLE
• C -shaped cavity
~ capacity of 85 ml

• leads to Pulmonary trunk

• trabeculae carnae = fleshy


ridges on ventricular wall

• interventricular septum =
partition b/w RV & LV
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R VENTRICLE
• 2 parts:
1] membranous = thin
2] muscular = thick

Ventricular septal defect =


affects membranous part

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R VENTRICLE
• se ptoma rgin al tra becu la
= elevated band w/c bridges interventricular septum &
anterior wall near apex
= transmits right branch of conducting system

• papilla ry mu scl es = column-like projections fr


trabeculae
3 sets: anterior - most constant & largest
posterior
septal

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R VENTRICLE
• chordae tendinae = fibrous cords attached to
apices of papillary muscles fr cusps of valves

• function of papillary muscle & chordae:


* prevent eversion of cusps of valves into
atrium

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VENTRICULAR SEPTAL
DEFECT

• Congenital or acquired
• Hole/s in interventricular septum (IVS)
• May be part of other major cardiac anomalies

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VENTRICULAR SEPTAL
DEFECT

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VSD PATCH CLOSURE

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3. L ATRIUM
• sm al ler but t hicke r
wall (v s. R A)

• base of heart

• mo st co mm on si te
of b enign ca rdiac
tumo rs ca lled
my xo ma

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L ATRIUM
2 par ts :
1. Princ ip al c avity

= contains openings of 4
pulmonary veins

=AV opening [mitral


valve] is smaller than
R
= smooth surface

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L ATRIUM
2. A ur icle

= longer & narrower


(vs RA)

= interior marked by
ridges of musculi
pectinati

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4. L VENTRICLE

• more wor k than RV


~pump into systemic
circulation
• long er , m ore
conical, thic ker
walls than RV

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L VENTRICLE
• trabeculae carnae are
more nume rou s &
dense ly packe d
• papillary mu scl es
are l arg er
• Interventricular septum
• > oblique position

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SKELETON OF THE HEART
• formed by merging of fibrous
rings
• attachment for myocardium
• attachment for cusps of
valves
• keep valves patent & from
overdistension

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SKELETON OF THE HEART
• “Wringing” of blood in
• Allows myocardium to contract against a rigid
base
• Provides connective tissue skeleton for
controlled contraction of the heart

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SKELETON OF THE HEART
co mp onents :
1. 4 fib ro us rings =
each encircles a valve
2. 2 f ibrous trigones =
bet aortic ring and AV
ring
3. te ndon of co nus

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CONDUCTING SYSTEM
• modified cardiac muscles w/ power of
spontaneous rhythmicity & conduction
• more highly developed than rest of the heart

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CONDUCTING SYSTEM
Parts:
1. SINO ATRIAL (S A) No de
- in crista terminalis at junction of SVC-RA
- not visible grossly
- initiates contraction of heart
internal PA CEM AKER
2. Atriov entricular (A V) node
- near orifice of coronary sinus in septal wall
of RA
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CONDUCTING SYSTEM
3. Atri ov en tricu lar bundle (B undle of H is)
• begins at AV node & follows along membranous

septum towards the L AV opening for a distance


of 1-2 cm
a. Right branch → RV
b. Left branch → LV
4. Purki nje f ibers
• terminal conducting fibers

• ramify on individual fibers throughout ventricle

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Conduction pathway:
• SA node ---> AV node ---> AV bundle ----> bundle
branch ----> Purkinje fibers

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Cardiac Plexus
• Controls impulse conduction for the ♥
• Enables ♥ to respond to Δ-ing physiological
needs
• located at base of ♥
• extends fr trachea to aortic arch, pulmonary
trunk & ligamentum arteriosum

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Cardiac Plexus
1. Parasympathetic – fr Vagus n
- ↓ in heart rate

- ↓ force of heartbeat

- constricts CAs

2. Sympathetic - fr cervical & thoracic ganglia


- ↑ in heart rate
- ↑ force of heartbeat

- dilates CAs
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Sy mpa the tic
Subdivisions:
1. Superficial cardiac plexus
-lies in arch of aorta
2. Deep cardiac plexus
-deep to arch of aorta

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Angina Pectoris & Myocardial
Infarction
• Cardiac referred pain
• Commonly present as:
• Substernal

• L pectoral

• L arm medial

• Less common → R shoulder & arm


• w/ or w/o concommitant L side pain

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Cardiac referred pain
• Heart insensitive to touch, cutting, cold &
heat
• Ischemia + accumulated metabolic products
~ stimulate pain endings in myocardium
• Sympathetic trunk

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Blood Supply
Coronary arteries
- fr aortic sinus of
ascending aorta
1) Right
2) Left

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Right coronary artery (RCA)
branches:
1. posterior interventricular
branch = supplies
diaphragmatic surface of
both ventricles, lo ng est
2. marginal
3. br to SA node
4. br to AV node
5. br to conus

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Left coronary artery (LCA)
• bifurcates into:
1. anterior interventricular
= both ventricles,
interventricular septum,
conus
2. circumflex
Branches :
-Posterior L ventricular art
-Marginal
-Intermediate
-branch to SA node & AV
node 78
Coronary Angiogram

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Coronary Angiogram

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Coronary Angiogram

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Venous system
1. coronary sinus
~ main venous drainage (except 2.)
~ opens into RA

2. small veins ~ drain directly into chambers


- venae cordis minimae
- anterior cardiac v

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Venous Drainage
Coronary sinus tributaries:
1. Great cardiac
2. Middle cardiac
3. Small cardiac
4. Left posterior
ventricular
5. Left oblique atrial

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Myocardial ischemia
- insufficient blood supply to heart
- necrosis of an area of myocardium
- Myocardial Infarct or MI

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Common sites of coronary occlusion:
“ Triple vessel disease”
1. Anterior interventricular branch of Left coronary
art (LCA)

2. Circumflex branch of LCA

3. Posterior interventricular branch of RCA

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Most common cause of
coronary occlusion :
Atherosclerosis

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Heart-Lung Bypass Machine

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Heart-Lung Bypass Machine

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Heart-Lung Bypass Machine

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Internal Mammary Artery Grafts

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CORONARY ARTERY BYPASS
GRAFTING (CABG)

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THANK YOU

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