Heart

Summary

Gross anatomy

Overview

Characteristics

Two ventricles and two atria, which connect the pulmonary circulation with the systemic circulation

Four valves, which ensure that blood flow occurs in only one direction

Roughly the size of a fist

Weighs approx. 300–500 g

Surrounded by pericardium (a fibroserous, fluid-filled sac)

Location: in the middle mediastinum between the lungs

Anterior to the heart: sternum and rib cartilage

Posterior to the heart

Vertebral column (T5–T8)

Esophagus

Carina and primary bronchi

The upper part of the heart is at the level of the third costal cartilage.

The site of attachment for the venae cavae, aorta, and pulmonary trunk

The lower part of the heart (cardiac apex) lies left of the sternum at the level between the fourth and
fifth ribs.

Function

Pumps blood through the body via the circulatory system

ANP synthesis

The left atrium is the posteriormost part of the heart, located directly in front of the esophagus. It can
be visualized using TEE. The right ventricle is the anteriormost part of the heart and is at greatest risk of
injury following chest trauma.

The cardiac apex beat can typically be palpated to the left of the sternum, medial to the midclavicular
line at the 4th–5th intercostal space. In patients with dextrocardia, the orientation of the heart is inverse
so the apex is located to the right of the mediastinum rather than the left.
Heart and adjacent large vesselsAnatomy of the heart and adjacent large vesselsAnatomy of the heart,
aorta, trachea, and esophagus

Heart chambers

Two atria

Separated by the interatrial septum (The fossa ovalis is visible on the septum as a small oval-shaped
depression in the interatrial septum.)

Right atrium

Receives deoxygenated blood via the superior vena cava (SVC), inferior vena cava (IVC), and the
coronary veins

Pumps deoxygenated blood into the right ventricle

Right auricle (right atrial appendage)

Muscular pouch that acts to increase the capacity of the atrium

Located close to the ascending aorta

Separated from the atrium by the terminal sulcus (sulcus terminalis) and terminal crest (crista
terminalis).

Common site for the development of thrombi in patients with atrial fibrillation

Left atrium

Receives oxygenated blood from the four pulmonary veins

Pumps oxygenated blood into the left ventricle to enter the systemic circulation

Left auricle (left atrial appendage)

Muscular pouch that acts to increase the capacity of the atrium

Extends from superior aspect of the chamber in close proximity to the root of the pulmonary trunk

Common site for the development of thrombi in patients with atrial fibrillation

Two ventricles of the heart

Right ventricle

Receives deoxygenated blood from the right atrium

Pumps deoxygenated blood into the pulmonary trunk as part of the pulmonary circulation
Left ventricle

Receives oxygenated blood from the left atrium

Pumps oxygenated blood into the aorta as part of the systemic circulation

Anatomy of the heart and adjacent large vesselsBlood flow through the heart

Cardiac borders

Frontal view

Right border is formed by the right atrium

Left border is formed by the left ventricle and left atrial appendage

Inferior border is formed by the right ventricle

Superior border is formed by the atria and great vessels

Lateral view

Anterior border is formed by the right ventricle

Posterior border is formed by the left atrium and left ventricle

The cardiac borders form the cardiac silhouette on chest x-ray!

Normal chest x-ray

Heart valves

Two types of cardiac valves that differ in location and morphology

Cardiac skeleton

Consists of four fibrous rings (annuli fibrosi cordis) that surround the atrioventricular and arterial
orifices

Function

Separates atria and ventricles

Provides anchor and structural support for the valves

Provides electrical insulation layer between atria and ventricles

Closure of heart valves produces heart sounds (See auscultation of the heart in cardiovascular
examination for details.)
This mnemonic provides the order in which blood flows through the heart valves: Try PULling My AORTA
(Tricuspidal, Pulmonary, Mitral, Aortic)!

Overview of the cardiac skeleton

Atrioventricular valves

Structure: leaflets supported by subvalvular apparatus

Valves

Tricuspid valve: consists of three leaflets; located between right atrium and right ventricle

Mitral valve (bicuspid valve): consists of two leaflets; located between left atrium and left ventricle

Subvalvular apparatus

Chordae tendineae: fibrous cords that support the AV valves and connect them to the papillary muscles

Papillary muscles (two in the left ventricle; three in the right ventricle)

Derive from the myocardium

Extend from the anterior and posterior ventricular walls and the septum

Have apices that are attached to the chordae tendineae

Contract during systole and thereby tighten the chordae tendineae: prevent prolapse of valve leaflets
and regurgitation into the atria when pressure rises during ventricular contraction

This mnemonic provides the rule of twos and threes for the atrioventricular valves: The tricuspid valve
has three leaflets and is located on the right side, as is the three-lobed right lung. The bicuspid (mitral)
valve has two leaflets and is located on the left side, as is the two-lobed left lung!

Semilunar valves

Structure: three crescent-shaped cusps without subvalvular apparatus

Valves

Pulmonary valve: located between right ventricle and pulmonary trunk

Aortic valve: located between left ventricle and aorta (consists of three leaflets and the aortic sinuses)

Anatomy of the heart and adjacent large vesselsLocalization of heart valvesValve plane of the heart

Coronary arteries
The left and right coronary arteries arise from the root of the aorta and supply the heart muscle with
arterial blood.

Coronary arterial dominance

Right-dominant (∼ 85% of the population): posterior descending artery (PDA) supplied by the RCA

Left-dominant (∼ 8% of the population): PDA supplied by the left circumflex artery (LCX)

Codominant (balanced; ∼ 7% of people): PDA supplied by both RCA and LCX

Coronary blood flow peaks during early diastole at a point when the pressure differential between the
aorta and the ventricle is the greatest (see left ventricular pressure-volume diagram.)

Coronary arteries

Source Important branches Territory

Left coronary artery (LCA)

Arises from left aortic sinus of ascending aorta

Left anterior descending artery (LAD, LADA): descends between right and left ventricles on anterior
surface of heart (in the anterior interventricular sulcus) towards cardiac apex → gives off several
diagonal branches on its course

 50% of left atrium and ventricle

Anterior aspect of the left ventricle

Anterior ⅔ of the interventricular septum

Anterolateral papillary muscle (also receives blood from the LCX)

Cardiac apex

Left circumflex artery (LCX): courses left around the heart in the coronary sulcus towards the posterior
aspect, ending before the posterior interventricular sulcus → gives off left marginal artery

Posterolateral left atrium and ventricle

Anterolateral papillary muscle (also receives blood from the LAD)

In 40% of the population: SA node

In left-dominant and codominant circulation (15% of the population): gives rise to the PDA to supply the
posterior

Right coronary artery (RCA)

Arises from right aortic sinus of the ascending aorta

Various branches

Majority of right atrium and ventricle

Right marginal artery: courses along the diaphragmatic border (acute margin) of the heart

Lateral right ventricle and cardiac apex

Posterior descending artery (PDA): descends between right and left ventricles on posterior surface of
heart (in the posterior interventricular sulcus) towards cardiac apex

Can also originate from the LCX OR LCX and RCA (in left-dominant and codominant circulation,
respectively)

Posterior ⅓ of the interventricular septum

Posteroinferior aspect of heart

Posteromedial papillary muscle

Atrioventricular nodal artery

AV node (in a left dominant circulation, the AV node is supplied by the LCA)

Bundle of His (minor contribution from the LAD)

Sinoatrial nodal artery

SA node

The LAD is the most commonly occluded coronary artery and is often referred to as the “widow maker”
due to the high mortality rate associated with LAD infarction.

The RCA usually supplies the heart’s conduction system (sinus and AV node) so that stenosis or occlusion
of this vessel often leads to cardiac arrhythmias!

Coronary arterial dominanceCoronary arteriesIllustration of the coronary arteriesCoronary blood supply

Venous drainage

Coronary sinus

Largest vein of the heart, into which all other coronary veins drain

Lies in the left posterior atrioventricular groove

Drains into the right atrium between the IVC orifice and the right atrioventricular orifice

Veins draining into coronary sinus (coronary veins):

Left side of the heart: great cardiac vein and posterior cardiac vein(s)

Right side of the heart: small cardiac vein and middle cardiac vein
Coronary veins

Lymphatics

The lymphatics of the heart drain into the anterior mediastinal nodes and the tracheobronchial nodes.

Innervation

Nervous systemNerves Function

Somatic nervous system

Phrenic nerve

Sensory innervation of the pericardium

Sympathetic nervous system

Cardiac plexus

↑ Heart rate (positive chronotropy)

↑ Contractility (positive inotropy)

↑ Conduction velocity (positive dromotropy)

Coronary artery dilation

Parasympathetic nervous system

Vagal nerve

↓ Heart rate (negative chronotropy)

↓ Contractility (negative inotropy)

↓ Conduction velocity (negative dromotropy)

Structures of cardiac conduction system

Definition: collection of nodes and specialized conduction cells that initiate and coordinate contraction
of the heart muscle.

Components

Sinoatrial node (SA node): in the upper wall of the right atrium (at the junction where the SVC enters)
Atrioventricular node (AV node): within the AV septum (superior and medial to the opening of the
coronary sinus in the right atrium)

Atrioventricular bundle (bundle of His): directly below the cardiac skeleton within the membranous part
of the interventricular septum

Purkinje fibers (modified myocytes): terminal conducting fibers in the subendocardium

See conducting system of the heart in cardiac physiology for more details.

Cardiac conduction pathwayCardiac action potentials

References:[ref][ref][ref][ref][ref

Layers of the heart

The heart wall itself consists of three layers (from inside to outside):

Endocardium

Myocardium

Epicardium: connective tissue layer attached to the outside of the myocardium, i.e., visceral layer of
serous pericardium

Pericardium: membrane that directly surrounds the heart

Layers of the heartMicroscopic anatomy of the heart

Endocardium

Description: innermost layer of heart tissue, consisting of the following three sublayers:

Endothelium (innermost): simple squamous epithelium

A layer of loose connective tissue

Subendocardium (outermost): loose connective tissue containing

Cardiac Purkinje cells

Specialized/modified cardiomyocytes that are part of the conducting system of the heart

Contain fewer contractile myofibrils and more mitochondria, glycogen, and gap junctions than normal
cardiomyocytes.

Veins and nerves

Endocardium and subendocardial tissue

Myocardium

Description: thick myocardial layer composed of the following:

Cardiomyocytes: striated muscle cells containing a single, centrally located nucleus

Contain many mitochondria, which produce ATP for contraction.

Myofibrils within cardiomyocytes are organized into sarcomeres (smallest functional contractile unit of
cardiac muscle).

Connected by intercalated discs to form long fibers.

Intercalated discs connect individual cardiomyocytes into a functional syncytium and force transmission
during muscle contraction.

They contain adherent junctions (transmit mechanical stimuli) and gap junctions (transmit electrical
stimuli)

They appear as slightly darker-staining lines between cardiac muscle cells under light microscopy and
electron microscopy.

See also comparison of muscle tissue types in the article on muscle tissue.

Atrial cardiomyocytes release atrial natriuretic peptide (ANP) when stretched (i.e., at higher BPs) → ↑
water and sodium excretion by the kidneys → ↓ BP

Fibroblasts (these become myofibroblasts after injury)

Extracellular matrix: collagen, elastin, and glycosaminoglycans

Myocardium and epicardiumCardiac muscleOverview of the sarcomere and myofilamentsCell junction

between two cardiomyocytesIntercalated discs of cardiac muscle

Damaged myocardial tissue is replaced by noncontractile scar tissue (fibrosis) that does not conduct
electrical impulses well and, thus, predisposes to cardiac arrhythmias.

Pericardium

Description

Fibroserous sac enclosing the heart

Defines the pericardial cavity

Pericardial layers

Serous pericardium (innermost)

Visceral layer of serous pericardium (epicardium)

Outermost layer of the heart wall

Separated from the parietal layer of the serous pericardium by the pericardial cavity.

Secretes lubricating serous fluid into the pericardial cavity

Contains blood vessels, lymphatics, and adipose tissue

Parietal layer of serous pericardium

Fibrous pericardium (outermost)

Pericardial cavity: space between the visceral and parietal layers of the serous pericardium that contains
serous, pericardial fluid

Innervated by the phrenic nerve

Pleural and pericardial layers (cross-section of the thorax)Pericardial layers and sinusesOpen
pericardium

The capacity of the pericardial cavity is limited by the stiff, fibrous pericardium. If fluid abnormally
accumulates in the pericardial space (pericardial effusion), intrapericardial pressure increases and may
impair cardiac function → pericardial tamponade.

Because of the sensory innervation of the pericardium by the phrenic nerve, pericarditis can result in
referred pain to the neck, arms, or shoulders (often the left side).

Microscopy of the heart valves

Composed of connective tissue and endocardium

Mostly vessel-free, with nutrition derived from the surrounding blood (This makes valvular involvement
in endocarditis difficult to treat because both the cells of the immune system and antibiotics typically
reach sites of infection via the circulatory system.)

Fine structure of a semilunar heart valve

References:[ref]

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Embryology

Clinical significance

Last updated 08/11/2020

Embryology

Overview

Mesodermal origin

Mesoderm → myocardium

Mesoderm → mesothelium → pericardium

Mesoderm → endothelium → endocardium, blood vessels, lymphatics

Steps of heart development

Two single endocardial tubes merge to form the heart tube.

The straight heart tube transforms into an S-shaped heart loop.

Endocardial cushions grow towards each other and fuse to separate the atria and ventricles.

Two atria and two ventricles form and one common outflow tract divides into an aortic trunk and a
pulmonary trunk.

Valves form from the endocardial cushion.

Fetal circulation is covered in the corresponding section of prenatal and postnatal physiology.

Postnatal derivatives of fetal vascular structures are covered in the section on postnatal adaptation of
the circulatory and respiratory system in the prenatal and postnatal physiology article.

Embryonic structures Details Give rise to

Endocardial cushions

Two protuberances located on the dorsal and ventral inner surfaces of the primitive heart tube

Atrial septum, interventricular septum, and heart valves

Primitive atrium

A single cavity separated from the ventricular cavity by the endocardial cushion
Trabeculated portions of the atria

Primitive ventricle

A single cavity separated from the atrial cavity by the endocardial cushion

Trabeculated portions of ventricles

Primitive pulmonary vein

Forms from a pouch in the dorsal wall of the primitive left atrium

Smooth portion of the left atrium

Sinus venosus

Cavity at the caudal end of the embryonic heart tube in which the veins from the embryonic circulatory
arcs unite

Right horn of the sinus venosus gives rise to the smooth part of the right atrium and the left horn to the
coronary sinus

Bulbus cordis

Connects the primitive ventricle to the truncus arteriosus

Left and right ventricular outflow tracts

Truncus arteriosus

A single arterial trunk that originates from both ventricles of the embryonic heart

Ascending aorta and pulmonary trunk

Posterior, subcardinal, and supracardinal veins

Veins of primitive cardiovascular system in the embryo that empty into the sinus venosus

Inferior vena cava

Right common cardinal vein and right anterior cardinal vein

Superior vena cava

Persistent truncus arteriosus is a congenital heart disease in which the truncus arteriosus fails to divide
into the aorta and pulmonary artery before birth.

Cardiac morphogenesis

See acyanotic congenital heart defects and cyanotic heart defects for associated heart defects.

Cardiac looping

Week 4 of gestation: looping of the primary heart tube establishes left-right polarity

The heart begins to beat spontaneously by week 4 of gestation and is detectable via transvaginal
ultrasound by week 6 of gestation.

A defect in cardiac looping is caused by a defect in the dynein arm of microtubules and results in
Kartagener syndrome with situs inversus and dextrocardia. See primary dyskinesia for details.

Chamber septation

Atrial septation

Development of the septum primum and foramen primum

Initially, the two atria communicate via the foramen primum.

The septum primum, located cranially, grows caudally towards the dorsal endocardial cushion.

Narrowing of the foramen primum occurs as the septum primum grows towards the endocardial
cushion.

Development of the foramen secundum

Before fusion of the septum primum with the endocardial cushion is complete, an opening appears in
the cranial end of the septum primum, known as the foramen secundum, through which interatrial
communication continues.

Development of the septum secundum

A second muscular septum begins to grow in two segments:

The superior part grows caudally from the roof of the primitive right atrium.

The inferior part grows cranially from the endocardial cushion.

Development of the foramen ovale cordis

The space between the two parts of the septum secundum is known as the foramen ovale.

The superior portion of the septum primum disappears.

The inferior portion of the septum primum persists and acts as a one-way valve, allowing blood to flow
from the right atrium into the left atrium.

Formation of the atrial septum (no further interatrial communication)

The septum secundum fuses with the remnant of the septum primum to form the atrial septum.

Closure of the foramen ovale occurs shortly after birth, when the left atrial pressure increases (due to
loss of low resistance placental circulation) and the right atrial pressure decreases (due to increased
pulmonary circulation upon lung inflation).

If the septum primum and septum secundum fail to fuse after birth, a patent foramen ovale (PFO)
remains. Later in life, a PFO can result in a paradoxical embolus, in which a venous thrombus may travel
via the PFO from the venous to the arterial circulation and cause end-organ infarction (e.g., stroke).

Atrial septation

Ventricular septation

A caudally located muscular interventricular septum forms with an interventricular foramen between
the two ventricles.

The cranially developing aorticopulmonary septum rotates and caudally fuses with the muscular
interventricular septum → this fusion forms the membranous interventricular septum and closes the
interventricular foramen (heart).

Endocardial cushions grow to further separate the ventricles and the atria.

Ventricular septation
Abnormal development of the membranous interventricular septum results in a ventricular septal
defect, the most common congenital cardiac anomaly.

Development of the outflow tract

Development of the aorticopulmonary septum (AP septum)

Neural crest and endocardial cells migrate to form truncal ridges and bulbar ridges from the truncus
arteriosus and bulbus cordis, respectively.

Truncal and bulbar ridges spiral and fuse to form the AP septum.

Division of the ventricular outflow tract

The aorticopulmonary septum fuses and rotates 180°, dividing the outflow tract into the aorta (from the
left ventricle) and pulmonary trunk (from the right ventricle).

Associated conotruncal abnormalities:

- Failure to spiral: transposition of the great vessels

- Malaligned AP septum: tetralogy of Fallot

- Partial AP septum development: persistent truncus arteriosus

Valve formation

Stage Embryonic origin Structures

Development of semilunar valves

Endocardial cushions of outflow tract

Aortic valve

Pulmonary valve

Development of atrioventricular valves

Fused endocardial cushions of AV canal

Mitral valve

Tricuspid valve

Defective development of the heart valves can result in

- Stenotic valves

- Regurgitant valves

- Displaced valves (e.g., Ebstein anomaly)

- Atretic valves (e.g., Tricuspid atresia)

- Minor abnormalities (e.g., Bicuspid aortic valve)

References:[ref]

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Clinical significance

Last updated 08/11/2020