CARDIAC SKELETON

The four cardiac valves are anchored to their annuli, or valve rings. These
fibrous rings, at the base of the heart, join to form the fibrous skeleton
of the heart20 (Fig. 421). The centrally located aortic valve forms the
cornerstone of the cardiac skeleton, and its fibrous extensions abut
each of the other three valves. The cardiac skeleton contains not only
the four valve annuli but also the membranous septum and the aortic
intervalvular, right, and left fibrous trigones. The fibrous trigones form
the anatomic substrate for direct mitral-aortic continuity20 (Fig. 422; see
also Fig. 421). The intervalvular fibrosa also forms part of the floor of
the transverse sinus (see Fig. 422). In patients with infective endocarditis
of the mitral or aortic valves, infection can burrow through the intervalvular
fibrosa and produce characteristic fistulas between the left ventricle and the
adjacent left atrium, ascending aorta, or transverse sinus (see Chap. 86).21
The right fibrous trigone (see Fig. 421), also known as the central fibrous
body, welds together the aortic, mitral, and tricuspid valves and forms
the largest and strongest component of the cardiac skeleton. It is through
the right fibrous trigone that the atrioventricular (His) bundle passes.
Otherwise, the fibrous cardiac skeleton serves to electrically isolate the
atria from the ventricles. Diseases or surgical alterations of one valve can
affect the shape or angulation of adjacent valves (eg, aortic valve replacement
causing severe mitral regurgitation) and can affect the nearby coronary
arteries or conduction tissue.21
TRICUSPID VALVE
The tricuspid valve is comprised of five components (ie, annulus,
leaflets, commissures, chordae tendineae, and papillary muscles). The
anterior tricuspid leaflet is the largest and most mobile and forms an
intracavitary curtain that partially separates the inflow and outflow
tracts of the right ventricle (Fig. 423). The posterior leaflet is usually
the smallest. The septal leaflet is the least mobile because of its many
direct chordal attachments to the ventricular septum. A distensible
fibroadipose annulus is unique to the tricuspid valve.21 Consequently,
dilatation of the right ventricle commonly produces circumferential
tricuspid annular dilatation that results in variable degrees of tricuspid
valve regurgitation