THE HEART AND PERICARDIUM

MEDIASTINUM

It is a thick but movable median septum that separates the lungs. It extends from root of the neck
to the diaphragm and from the sternum to the vertebral column. The heart and great vessels lie
in it. It transmits the esophagus, sympathetic trunk, and vagus from neck to abdomen, and
trachea to the lungs.

An imaginary plane from the sternal angle to the body of T4 divides it into superior (the part
above the line) and inferior (the part below). The inferior part is further subdivided into: anterior
(containing thymus and fat), middle (containing heart and pericardium) and posterior
mediastinum (containing main bronchi, esophagus etc.).

PERICARDIUM

(GK peri = around, kardia = the heart). It consists of an outer fibrous sac lined with an inner serous
sac. The heart and roots of great vessels lie inside the fibrous sac and invaginate the serous sac
from behind. Hence the serous pericardium has both a visceral and a parietal layer whereas
fibrous pericardium has a parietal layer only. Between the two layers, parietal and visceral is the
pericardial cavity. It is a potential space just like the pleural cavity. It contains pericardial fluid for
lubrication. Parietal and visceral layers are continuous at the root of great vessels. The visceral
layer is called EPICARDIUM.

FIBROUS PERICARDIUM

Fibrous sac enclosing the heart is conical in shape. It is fused with the roots of the great vessels
at its apex and its base blends with the central tendon of the diaphragm.

SEROUS PERICARDIUM

A layer of serosa lines the fibrous pericardium and it is reflected around the roots of the great
vessels to cover the entire surface of the heart. Between the two layers (parietal and visceral)
there are two sinuses, namely the transverse sinus and the oblique sinus of the pericardium. In
order to understand these spaces it is necessary to recall the development of the heart.

The heart first appears as a vascular tube lying free in space - the pericardial cavity within the
septum transversum. The heart tube is suspended by a dorsal mesocardium. The arterial end
divides into the aorta and pulmonary trunk. The venous end divides into the superior and inferior
vena cava and four pulmonary veins. With elongation, bending and rotation of the heart, the
arteries and veins pierce the pericardium in a way best appreciated while looking at the
specimen. The oblique sinus of the pericardium is no more than a cul de sac between the left and

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right pulmonary veins and inferior vena cava. The posterior wall of the left atrium between the
four pulmonary veins forms its anterior wall. Immediately behind it is the esophagus.

The presence of the transverse sinus is due to the fact that dorsal mesocardium breaks down,
thus producing a communication from right side to left between its arterial and venous ends. A
double fold of serous pericardium separates the two sinuses from each other. A finger placed in
the transverse sinus passes behind the aorta and the pulmonary trunk but in front of the SVC and
left atrium. It is through the transverse sinus that a temporary ligature is passed to occlude the
pulmonary trunk and aorta during pulmonary embolectomy, coronary bypass and other cardiac
operations.

NERVE SUPPLY OF THE PERICARDIUM

Fibrous – phrenic (C3, 4 and 5)

Parietal - phrenic (pericarditis pain is referred to the shoulder as supraclavicular nerves supplying
the skin are derived from C3, 4)

Visceral - autonomic (insensitive to pain, touch)

FUNCTIONS

The pericardium provides a slippery surface for the heart to beat inside and the lungs outside.
Apart from the bare areas in front and posteriorly, the whole pericardium is clothed by densely
adherent parietal pleura on which the breathing lungs glide. Fibrous pericardium is unable to
expand so any increase in fluid/pressure is passed on to the heart.

HEART

(Latin cor = the heart)

The muscular pump is somewhat larger than a closed fist. It weighs 300 gm in males and 250 gm
in females. It is a midline structure but lies a little more to the left. Clinically the heart is described
as consisting of right and left sides. The right side propels blood to the lungs, left to the systemic
circulation. Anatomically the right side lies much more in front of the left side.

Four chambers of the heart, two atria and two ventricles, are separated from each other by a
constriction that completely encircles the heart that is called the atrioventricular/coronary
sulcus.

The atria are separated from each other by the interatrial septum. The ventricles are separated
by interventricular septum, seen on the outside as anterior and posterior interventricular sulci.
The notched anterosuperior part of each atrium resembles a dog’s ear and is called the auricle

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(L. auris = an ear).

SURFACE MARKING OF THE HEART

The superior border: Is indicated by a line joining the two points A and B. A is 1.5 cm to the left
of the sternum on the lower border of the 2nd costal cartilage and B is the upper border of the
right 3rd costal cartilage close to the sternum.

The right border: Right end of superior border to right 6th costal cartilage 1-2 cm away from the
sternum.

The inferior border: Joins the lower point of the right border to a point in the 5th left intercostal
space just outside the mid clavicular line.

The left border: Joining the left two points of superior and inferior borders.

Position is affected by deep inspiration and expiration, erect and supine body, broad stocky build
and distended abdomen. Pregnancy and enlarged liver are associated with high diaphragm and
transverse heart.

Right border consists entirely of the right atrium, inferior border of right ventricle. Left border as
seen from the front is a narrow strip of left ventricle. Upper border is left atrium and SVC entering
right atrium (aorta and pulmonary trunk are anterior).

The anterior surface of the heart (sternocostal surface) consists of right atrium, atrioventricular
groove/sulcus, right ventricle, and strip of left ventricle and the tip of left auricular appendage.

The inferior or diaphragmatic surface consists of right atrium receiving IVC, 1/3 right ventricle
and 2/3 left ventricle.

The base or posterior surface consists almost entirely of left atrium receiving the four pulmonary
veins.

The apex is part of the left ventricle.

RIGHT ATRIUM

It is an elongated chamber that lies between the superior and inferior venae cavae. The upper
end is prolonged to the left as the auricular appendage, which overlies the commencement of
the aorta. From the angle between the SVC and the auricular appendage a slight groove
sometimes descends. It is called the sulcus terminalis and indicates the mergence of two parts
from which the atrium develops. (The sulcus terminalis is between the two caval openings.)

In the cavity of the atrium is a ridge of heart muscle called CRISTA-TERMINALIS. It corresponds in

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position to the sulcus. The interior is smooth to the right of crista. (It developed from sinus
venarium.) But the portion in front - between the crista and the auricle - is trabeculated. (It
developed from primitive atrium). The series of parallel horizontal ridges are the MUSCULI
PECTINATI (L. Pecten = comb)

A ridge guards the opening of the IVC. It is the remains of the valve of IVC, which is continued
upwards towards the opening of the coronary sinus. The coronary sinus opening is big enough to
admit the tip of the owner’s little finger.

In the lower part of the interatrial septum is a shallow saucer shaped depression, the FOSSA
OVALIS. This is the closed foramen ovale of the fetal heart that allowed blood from IVC to flow
directly into the left atrium. IVC is directed towards fossa ovalis, while SVC is directed towards
the AV orifice.

RIGHT VENTRICLE

The interior of the cavity, whose walls are much thicker than those of the atrium, is thrown into a
series of muscular bundles/ridges, the TRABECULAE CARNEAE (L carnea = flesh).
Some of these bundles are mere ridges, others are attached at both ends like bridges, and others
form fingerlike projections, the PAPILLARY MUSCLES. One of these ridges passes from the septum
to the anterior wall of the ventricle (the base of anterior papillary muscle) and is called the
SEPTOMARGINAL BAND or MODERATOR BAND (present in 60% cases and transmits part of the
right branch of the conducting system).

The tricuspid valve guards the right AV orifice. It has three cusps and admits the tips of three
fingers. The three cusps are named anterior, posterior and septal. The edges and ventricular
surfaces of the cusps receive the attachment of inelastic cords, the CHORDAE TENDINAE. The
chordae cross each other by diverging from small conical elevations of papillary muscle. The
chordae leave the atrial surface free and do not offer obstruction to the incoming blood. The
chordae of each papillary muscle control contiguous margins of two cusps. The edges and
surfaces of the cusps must meet when the valve is closed or it will leak. The cavity of the ventricle
continues upwards into a narrowing funnel shaped approach to the pulmonary orifice. The walls
of this part, the INFUNDIBULUM (also called CONUS ARTERIOSUS), are smooth.

PULMONARY ORIFICE

Three semilunar cusps guard the opening at the commencement of the pulmonary trunk (one
posterior and two anterior). The pulmonary orifice lies at a higher level than the aortic orifice.

PULMONARY TRUNK

It commences at the pulmonary orifice and arches backwards to the left of the ascending aorta.

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These two lie in a common sheath of serous pericardium. It bifurcates in the concavity of the arch
into the right and left pulmonary arteries, which enter the lung root. It is 5cm long. 4cm lies in
the pericardial cavity.

A bulging of the wall of the pulmonary trunk lies above each cusp of the valve and by creating
back flow eddies, helps close the cusps more quickly at ventricular diastole. This bulging is called
the pulmonary sinus.

LEFT ATRIUM

It is applied to the interatrial septum behind the right atrium. It has a small auricular appendage.
The four pulmonary veins enter it symmetrically one above the other on either side. They are
enclosed with SVC and IVC in common sheath of serous pericardium. The posterior surface of the
left atrium between the pulmonary veins forms the anterior wall of the oblique sinus of the
pericardium. The cavity is smooth walled except in the tiny auricular appendage.

The atrium may receive only less than four pulmonary veins if development is arrested. Three
veins are seen fairly commonly. It is rare to see only two or one vein entering the left atrium
because this is associated with other defects that are incompatible with life.

BICUSPID/MITRAL VALVE

Likened to a Bishop’s miter, it admits the tips of two fingers. The two cusps are a large anterior
(or septal) and a small posterior. The bases are attached to the margins of the AV orifice. Mitral
cusps are smaller and thicker than tricuspid, and are not ballooned back as much into the atrium
during systole. Like the tricuspid, they receive the chordae tendinae.

LEFT VENTRICLE

The walls of this cavity are three times as thick as that of the right ventricle because of the amount
of work the left ventricle has to do. Before birth both ventricles pumped blood into the aorta,
the left directly and the right through DUCTUS ARTERIOSUS, and their walls were equal in
thickness. After birth the left pumps into systemic circulation while the right pumps into
pulmonary circulation. This explains why the interventricular septum bulges into the right
ventricle. Because of the rotation of the heart, it does not lie in the median plane. The rotation
causes 1/3 of LV and 2/3 of RV to face anteriorly, while 2/3 of LV and 1/3 of RV face inferiorly.

The trabeculae carneae are well developed, but there is no moderator band. The two-papillary
muscles project into the cavity of the ventricle, sending from their apices the chordae tendineae
into mitral cusps.

Corresponding to the infundibulum of the right ventricle there is the AORTIC VESTIBULE in the

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left, which leads to the aortic orifice. It is fibrous and nondistensible, so it can neither empty by
contraction nor dilate.

The interventricular septum is fleshy, except at its upper end where an area the size of a
thumbnail is membranous. The aortic vertibule lies between it and the anterior cusp of the mitral
valve. Failure of fussion of the two parts results in VSD.

AORTIC ORIFICE

It lies at a lower level than the pulmonary. Three semilunar cusps, one anterior and two posterior,
guard it. The cusps are called right coronary, left coronary and non-coronary by clinicians.
(Coronary arteries originate from sinuses – little dilatations opposite the cusps.)

ASCENDING AORTA

Immediately above the orifice the wall bulges to form aortic sinuses, one above each cusp. From
the anterior sinus the right coronary emerges, while from the left posterior the left coronary. It
passes upwards arching a bit to the front towards the manubrium before curving backwards into
the arch. Here the pericardium blends with its wall. It is 2” long.

GREAT VESSELS
Six veins share a common sleeve of serous pericardium, the four pulmonary veins and IVC are
about 1 cm in length, while the SVC courses for over 2.5 cm through the pericardial cavity before
opening into the right atrium.

SURFACE PROJECTION OF THE VALVES

All behind the sternum, but this is not very important as sounds produced by the closure of these
valves and the opening of the mitral valve are by no means heard best directly over the valves
concerned. The sounds are heard best where the blood containing chambers lie nearest the chest
wall: Tricuspid - same as position; Mitral - at apex beat; Aortic - right sternal margin in 2nd
intercostal space; Pulmonary - left sternal margin at 3rd costal cartilage.

CORONARY ARTERIES

The two coronary arteries are the only arterial supply to the heart muscle. These emerge from
behind the pulmonary trunk, one on each side, sheltered by the corresponding auricle. These run
in the atrioventricular groove, the right in front, the left behind.

RIGHT CORONARY

It arises from the anterior aortic sinus (lies between the right atrial appendage and infundibulum

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of the right ventricle). It gives the SA NODAL branch. The next branch is the diagonal branch that
runs across the right ventricle. The MARGINAL BRANCH goes along the inferior border of the right
ventricle. The POSTERIOR INTERVENTRICULAR ARTERY is the largest branch of the right coronary.
It runs in the posterior interventricular sulcus to meet the anterior interventricular branch of the
left coronary. The part remaining is much smaller than the posterior interventricular branch and
is called the transverse branch. It continues in the coronary sulcus and meets the circumflex
branch of the left coronary.

LEFT CORONARY

It passes backwards along the ÀV groove. It gives the ANTERIOR INTERVENTRICULAR BRANCH
that goes down in the anterior interventricular groove to anastomose at the apex with a branch
of the posterior interventricular artery. The parent trunk, not much narrowed, passes in the AV
groove giving branches to the posterior wall of the left ventricle and runs to anastomose with the
terminal branch of the right coronary. (It is called the CIRCUMFLEX BRANCH of the left coronary.)

Right and left coronary arteries vary in the manner in which they distribute blood to the heart.

The right ventricle is supplied by the right coronary, except a narrow strip at the upper margin of
the anterior surface that is supplied by the left coronary. The left ventricle is supplied by the left
coronary except a strip on the diaphragmatic surface where it is supplied by the posterior
interventricular artery. The two interventricular arteries share the supply of IV septum usually
about equally.

Supply of the atria is more variable.

SA node is supplied more often by a branch from the right coronary (60%; left coronary 40%).

ÀV node and bundle of His are supplied by the posterior interventricular branch of the right
coronary artery.

CARDIAC VEINS

Most veins accompany the arteries in the sulci and tend to be superficial. Many of the veins open
into the coronary sinus (60% of blood). Some veins open directly into the right atrium. Some small
veins open into all of the four chambers of the heart.

CORONARY SINUS

Lies in the AV groove or coronary sulcus in the posterior part, and opens into the posterior wall
of the right atrium - just left of the orifice of IVC.

The great cardiac vein accompanies the anterior interventricular artery. The posterior vein of the

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left ventricle joins it to form the coronary sinus.

The middle cardiac vein accompanies the posterior interventricular artery. It opens in the CS.

The small cardiac vein goes with the marginal branch of the right coronary. It opens into the right
atrium directly.

The anterior cardiac veins are seen on the anterior surface of the heart. These veins open directly
into the right atrium.

Very small veins called venae cordes minimae open directly into all four chambers of the heart.

CONDUCTING SYSTEM OF THE HEART

It consists of:

i) SINUATRIAL NODE (SANode)

ii) ATRIOVENTRICULAR NODE (AVNode)
iii) BUNDLE OF HIS

SA NODE: It initiates the heartbeat. It is the PACEMAKER. It is about 3 cm by 2 mm and occupies

an area left of the sulcus terminalis. (It is hard to see in human hearts, especially cadavers. It is
relatively easy to see in bovine hearts.) It has a rich supply of nerve fibers (sympathetic as well as
parasympathetic). Sympathetic nerves stimulate or increase the rate, whereas vagus (mainly
right) decreases the rate. Conduction of the impulse to the AV node is carried out by the muscle
fibers of the heart.

AV NODE: It is a small nodule in the interatrial septum just near the opening of the coronary
sinus. It is supplied by the left vagus.

BUNDLE OF HIS: A peculiar bundle of muscle fibers about 2mm thick. It is the sole muscular
connection between musculature of the atria and ventricles. It extends from the AV node through
the fibrous skeleton to the interventricuar septum. It divides into right and left crus/branches at
upper part of muscular septum. These descend to bases of papillary muscle. The right branch
passes through the moderator band (if the moderator band is present). The fibers of the AV
bundle are continued into the Purkinje fibers, which lie in the endocardium.

The SA node initiates the impulse for contraction of the heart, which is rapidly conducted to the
cardiac muscle cells of the atria, causing them to contract. The impulse enters the AV node and
is transmitted through the AV bundle and its branches (crura) to the papillary muscles first and
then throughout the walls of the ventricles. The papillary muscles contract first, tightening the
chordae tendineae and drawing the cusps of the atrioventricular valves together. Next,

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contraction of the ventricular muscle occurs. The septum and apex contract slightly earlier than
the base of ventricles.

Cardiac Plexus:

 It is formed by sympathetic and parasympathetic fibers as well as some parasympathetic

ganglia.
 It contains afferent as well as efferent fibers.
 It is located on the arch of aorta and bifurcation of trachea
 Post ganglionic sympathetic fibers from cervical and thoracic ganglia accelerate the heart
and dilate the coronary arteries.
 Postganglionic parasympathetic fibers from the plexus and the atrial wall slow the heart
and constrict the coronary arteries.

To review the heart with images visit:

http://www.med.mun.ca/anatomy/imagedb/heart/index.html

Myocardial infarction and referred pain

http://www.med.mun.ca/anatomy/imagedb/MI_ChestPain/index.html

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