ACD 15: Pericardium & External Heart

Jalipa, Jomari
Japlit, Frances Joyce
Jardiolin, Justin Adrian
Jurilla, Joaquim Gerardo
Kiok, Keith Adrianne
Labrador, Czarina

1. Discuss with illustration the pericardium as to its layers, neurovascular

supply, sinuses, and attachments

The ​pericardium ​is a ​fibroserous sac that encloses the heart and the roots of the
great vessels. It lies in the ​middle mediastinum. It is bounded ​anteriorly by the
body of the sternum and ​2nd to 6th costal cartilages, ​posteriorly by the ​5th to 8th
thoracic vertebra​, ​superiorly ​by the ​great blood vessels​, and ​inferiorly by the
diaphragm​. It serves to restrict excessive
movements of the heart by serving as a
lubricated container.

Fibrous pericardium
It is the strong, outer fibrous part of the
sac which is firmly attached below to the
central tendon of the diaphragm via
pericardio-phrenic ligaments and attached
in front to the ​sternum via
sternopericardial ligaments. Its ​apex
fuses with the outer coats of the great
blood vessels (aorta, pulmonary trunk,
vena cavae, pulmonary veins) passing
through it.

Serous pericardium
It lines the fibrous pericardium and coats the heart. It is divided into ​parietal and
visceral layers. The ​parietal layer lines the fibrous pericardium and is reflected
around the roots of the great vessels to become continuous with the visceral layer at
the base of the heart. The ​visceral layer or epicardium is closely applied to the
heart.

The ​pericardial cavity ​is a slit-like space between the parietal and visceral layers
filled with ​pericardial fluid (50 ml) which acts as a lubricant to facilitate heart
movements.

Pericardial sinuses have no clinical significance but are formed as a consequence

of the way the heart bends during development. These lie on the posterior surface of
the heart. The ​oblique sinus is a recess formed due to the reflection of the serous
pericardium around ​large veins. The ​transverse sinus is a short passage between
the reflection of the serous pericardium around the ​aorta and pulmonary trunk and
also around the ​large veins.
 The ​phrenic nerve supplies the ​fibrous and serous parietal layer of the pericardium
while the ​sympathetic trunk and vagus nerve supply the ​serous visceral layer of
the pericardium.

2.) ​Illustrate the following:

A.)TOPOGRAPHY OF THE HEART (BORDERS AND SURFACES)

The right border is formed by the right atrium which runs from the third costal cartilage to
the sixth; the left border, by the left ventricle with the auricle of the left atrium. The inferior
border is formed mainly by the right ventricle but also by the right atrium and a small part
of the left ventricle. This runs from the sixth costal cartilage to the apex at the left fifth
intercostal space at approximately the mid-clavicular line. The apex is formed by the left
ventricle. These borders are important to recognize when examining a radiograph of the
heart.
The heart has three surfaces, namely the sternocostal surface (anterior), diaphragmatic
surface (inferior), and a base (posterior). It also has an apex, which is directed downward,
forward, and to the left. The sternocostal surface is formed mainly by the right atrium and
the right ventricle, which are separated from each other by the vertical atrioventricular
groove. The diaphragmatic surface of the heart is formed mainly by the right and left
ventricles separated by the posterior interventricular groove. The posterior surface is
formed mainly by the left atrium, into which open the four pulmonary veins.

Anterior Surface of the Heart Posterior Surface of the Heart

B.) ​CORONARY SULCUS AND ARTERIES

There are two coronary sulci in the heart including left and right coronary sulci.The left
coronary sulcus originates posterior to the ​pulmonary trunk​, and travels inferiorly
separating the left atrium and left ventricle. It is marked by the ​circumflex branch of left
coronary artery and ​coronary sinus​. Meanwhile, the right coronary sulcus begins anteriorly
and superiorly on the sternocostal surface of the heart. It is marked by the location of the
right coronary artery and ​small cardiac vein​. The right coronary sulcus separates the right
atrium and its ​auricle from the right ​ventricle inferiorly. The right coronary sulcus then
passes inferiorly on to the diaphragmatic surface of the heart and traverses to the left.
 C.) ANATOMICAL AND CLINICAL VALVES

The pulmonary valve lies behind the medial end of

the third left costal cartilage and the adjoining part
of the sternum. The pulmonary valve is heard with
least interference over the medial end of the
second left intercostal space. The aortic valve lies
behind the left half of the sternum opposite the 3rd
intercostal space. The aortic valve is best heard
over the medial end of the second right intercostal
space. The tricuspid valve lies behind the right half
of the sternum opposite the 4th intercostal space.
The tricuspid valve is best heard over the right half
of the lower end of the body of the sternum. The
mitral valve lies behind the left half of the sternum
opposite the 4th costal cartilage. The mitral valve is best heard over the apex beat, at the
level of the fifth left intercostal space, 3.5 in. (9 cm) from the midline.

3.) Discuss with illustration the blood supply of the heart as to its origin,
commencement/termination, course, branches, and areas supplied.
a.) Right coronary artery
Origin​: Anterior aortic sinus of the ascending aorta
Commencement​: Between pulmonary trunk and right
auricle
​Terminatio​n:Posterior Interventricular groove
Course​: Runs forward between the pulmonary trunk and right auricle, then
descends in right atrioventricular groove where it continues posteriorly to it at
the inferior border of the heart. Finally, it anastomoses with the left coronary
artery in posterior interventricular groove.
​Branches​:
a.) right conus artery - supplies the anterior
surface of the pulmonary conus (right ventricular infundibulum) and upper
part of the anterior right ventricle wall
b.) anterior ventricular branches - supplies anterior surface of right ventricle
c.) posterior ventricular branches - supplies diaphragmatic surface of right
ventricle
d.) posterior interventricular artery - supplies posterior part of ventricular
septum
e.) atrial branches - supplies anterior and lateral faces of right atrium and
posterior surfaces of both atriums
b.) Left coronary artery
-larger, supplies major part of the heart
Origin​: left posterior aortic sinus of the ascending aorta
Commencement​: Between pulmonary trunk and left
auricle
Termination​: Atrioventricular groove
Course​: Runs forward between the pulmonary trunk and left auricle, enters
atrioventricular groove, then divides into anterior interventricular branch and
circumflex branch
​ Branches​:
a.) anterior interventricular (descending) branch -
supplies right and left ventricles, and anterior part of ventricular septum
b.) circumflex artery - branches supply left atrium and left ventricle

Coronary artery anastomoses

- Collateral circulation between terminal branches of right and left
coronary arteries
- not large enough to provide adequate supply to cardiac muscle if
blocked by disease
- Sudden block leads to myocardial infarction

​Arterial supply to the conducting system

- Sinoatrial node - right coronary artery
- Atrioventricular node - right coronary artery
- LBB - right and left coronary arteries
- RBB - Left coronary artery

​Summary
 ​ Right coronary artery
- right ventricle
- Diaphragmatic surface of left ventricle
- Posteroinferior ⅓ of ventricular septum
- Right atrium
- Part of left atrium
- Sinoatrial node and atrioventricular node bundle
- Left bundle branch (LBB)

​ Left coronary artery

- Left ventricle
- Area of right ventricle
- Anterior ⅔ of ventricular septum
- Most of left atrium
- Right bundle branch (RBB)
- LBB

4. Discuss with illustration the venous drainage of the heart as to its

commencement/termination, tributaries, and areas drained.

Blood from the heart wall drains into the right

atrium through the ​coronary sinus​, which
lies in the posterior part of the
atrioventricular groove, ​originating from the
great cardiac vein​. It opens ​into the right
atrium to the left of the inferior vena cava.
Tributaries of the coronary sinus are the
small ​and ​middle cardiac veins which
receive blood from the posterior portion of
the right atrium and ventricle. Remainder of
the blood returns to the right atrium via the
anterior cardiac vein​, which is another
tributary of the coronary sinus, ​and small
veins that open directly into the heart chambers.
5.) Discuss with illustration the great vessels of the heart as to its formation,
origin, commencement/ termination, branches or tributaries

a.) Ascending aorta

Origin:​ Left ventricle
Commencement:​ Base of left ventricle
Termination:​Behind the right half of the sternum (the level of the sternal
angle)
Branches:​ Right coronary artery, Left coronary artery
Course: Begins at the left ventricle and runs upward and forward to come lie
behind the right half of the sternum at the level of the sternal angle, where it
becomes continuous with the arch of the aorta.
b.) Pulmonary trunk/ artery
Origin:​ Right ventricle
Commencement: ​Upper part of the right ventricle
Termination:​ Concavity of the aortic arch
Branches: Right pulmonary artery, Left pulmonary artery, Ligamentum
arteriosum
Course: Leaves the upper part of the right ventricle and runs upward,
backward terminates in the concavity of the aortic arch.

c.) Pulmonary vein

Origin:​ Superior - upper lobes
Inferior - lower lobes
Commencement:​ Left and Right hilum
Termination:​ Left atrium
Tributaries:​ Bronchial veins
Course: Superior - take an oblique inferomedial course, while the inferior
pulmonary veins run horizontally peripherally before taking a more vertical
course. They pass through the lung hilum, antero-inferiorly to the pulmonary
arteries, forming a short intrapericardial segment, to drain into the left atrium

d.) Superior vena cava

Origin: Union of two brachiocephalic veins, contains all venous blood from the
head and neck, and both upper limbs.
Commencement:​ 1st chondro-sternal joint
Course: Passes downward to end in the right atrium of the heart. Vena
azygos joins the posterior aspect of the superior vena cava just before it
enters the pericardium.
Tributaries:​ Left and Right brachiocephalic vein, Azygos veins
Termination:​ Right atrium at 3rd costal cartilage

e.) Inferior vena cava

Origin:​ Union of the right and left common iliac veins
Commencement:​ Level of 5th lumbar vertebra
Course: Commences at the level of the 5th lumbar vertebra through the union
of the right and left common iliac veins behind the abdomen and ascends
through the thoracic diaphragm and drains into the right atrium at the 3rd
costal cartilage.
Tributaries:​Hepatic veins, Inferior phrenic vein, Right suprarenal vein, renal
veins, Right gonadal vein, Lumbar veins, Common iliac veins
Termination:​ Right atrium at 3rd costal cartilage