Heart & Great vessels

R.Arulmoli
Learning outcomes

Describe the layers and nerve supply of the pericardium.

Describe the gross anatomy of the heart and the different
chambers.
Explain the gross anatomy of right and left coronary
arteries.
Describe the major veins of heart - coronary
sinus,anterior cardiac veins and venae cordis minimae.
Describe the anatomy of the great vessels of the heart,
namely aorta, superior vena cava and pulmonary artery.
Pericardium

Pericardium is a protective covering for heart made

up of fibrous tissue.
Pericardium has 3 layers -
1) Outer-fibrous pericardium.
2) Inner serous pericardium-
a) Parietal layer
b) Visceral layer(epicardium).
Pericardial cavity:
Between layers of serous pericardium.
Serous fluid lubricates heart while beating.
Pericardium
Pericardium Nerve supply

Fibrous & parietal layer of serous

pericardium are supplied by:
Phrenic nerve
Intercostal nerves
It is pain sensitive.
Visceral layer of pericardium is
supplied by sympathetic and
parasympathetic, insensitive to
pain.
Heart
Heart-Introduction

Greek word Cardia means heart

(Cardiac).
Latin word Cor means heart
(Coronary).
Situated in the middle
mediastinum.
Situated obliquely behind the body
of sternum & costal cartilages.
1/3 of heart lies to the right & 2/3
to the left of median plane.
Size is equal to that of ones own
clenched fist.
Weighs about 300gm in male &
250gm in female.
Heart in mediastinum
Wall of the heart

Consists of three layers:

1.Endocardium - thin internal layer,lining membrane of
the heart that also covers the valves.
2.Myocardium - thick middle layer composed of
cardiac muscle.
3.Epicardium - thin external layer formed by the
visceral layer of the serous pericardium.
Heart - External features

Has 4 chambers - right &

left atria and ventricles.
Atria lies above and behind
the ventricles.
Upper part of each atrium
has an appendage called
auricle.
Has an apex and base.
4 borders -
superior,right,inferior& left.
3 surfaces - anterior,inferior
& left.
Heart - External features
Grooves or sulci

Atrioventricular or coronary
sulcus separates the atria from
the ventricles.
Interatrial groove separates
both atria.
Interventricular sulcus
separates the two ventricles.
- Anterior interventricular
groove.
- Posterior interventricular
groove.
Grooves or sulci
Apex of heart

Formed by left ventricle.

Situated in the left 5th
intercostal space 9 cm
lateral to the midsternal
line or just medial to the
mid clavicular line.
Important in
auscultation.
Base of heart

Base forms the posterior

surface.
Base is formed mainly by
left atrium and a small
part of right atrium.
Related to the T5 -T8
vertebrae.
Borders of Heart

Upper border formed by

two atria mainly left atrium.
Right border formed by
right atrium.
Inferior border formed
mainly by right ventricle.
Left border formed mainly
by left ventricle.
Sternocostal surface of heart

Formed mainly by right

atrium & ventricle partly
by left ventricle & left
auricle.
Origin of aorta &
pulmonary trunk.
Anterior part of coronary
sulcus & anterior
interventricular groove.
Mostly covered by lungs.
Diaphramatic surface of heart

Rests on the central

tendon of diaphragm.
Formed in its left 2/3 by
left ventricle & right 1/3 by
right ventricle.
Traversed by posterior
interventricular groove.
Left surface of heart

Formed mainly by left

ventricle & left auricle.
Dextrocardia

Apex of the heart rotated towards the right side.

Chambers of heart
Right atrium External features

Receives superior vena cava

at the upper end & inferior
vena cava at the lower end.
Upper end prolonged to form
the auricle.
Sulcus terminalis - groove
passes from superior vena
cava to the inferior vena cava.
Produced by an internal
muscular ridge called the
crista terminalis.
Upper part of sulcus
terminalis contains sino atrial
node (SA node)-pacemaker of
heart.
Right atrium Internal features

Interior shows 2 parts:

1.Smooth posterior part-
Most of the tributaries
except anterior cardiac
veins open into this part.
Opening of inferior vena
cava guarded by a
rudimentary
valve(Eustachian valve).
Opening of coronary sinus
guarded by a valve
(Thebesian valve).
Right atrium Internal features

2.Rough anterior part

Presents many
transverse muscular
ridges called musculi
pectinati.
Musculi pectinati arise
from crista terminalis and
run towards the atrio
ventricular orifice.
Right atrium Internal features

Septal wall:
Presents a depression
called fossa ovalis.
Limbus fossa ovalis seen
in the margin of fossa
ovalis.
Right ventricle
Receives blood from right
atrium.
Interior has 2 parts-
1.Inflowing part is rough due
to the presence of muscular
ridges called trabeculae
carneae.
2.Outflowing part
(Infundibulum) is smooth
forms upper conical part giving
rise to pulmonary trunk.
Interior shows 2 orifices
Right atrio ventricular orifice
guarded by tricuspid valve,
pulmonary orifice guarded by
pulmonary valve.
Right ventricle
Papillary muscles:
The interior of right ventricle
shows papillary muscles.
One end is attached to the
ventricular wall and the
other end is connected to
the cusps of the tricuspid
valve by chordae tendinae.
3 papillary muscles -
Anterior, posterior & septal
(anterior is the largest).
Function- contraction brings
about tightening of chordae,
preventing regurgitation
(backflow of blood).
Left ventricle

Interior has two parts-

1.Lower rough part shows
trabeculae carneae.
2.Upper smooth part
(Aortic vestibule) gives
origin to ascending aorta.
Two orifices - Left
atrioventricular
orifice(bicuspid) guarded
by bicuspid or mitral valve
and aortic orifice guarded
by aortic valve.
Left ventricle

Papillary Muscles:
Two papillary muscles
anterior & posterior.
Chordae tendinae
attached to the cusps of
mitral valve.
Cavity of left ventricle is
circular in outline
The wall of left ventricle is
3 times thicker than those
of right ventricle (Why?)
Left Atrium

Forms the base of the

heart.
Receives 4 pulmonary
veins.
Musculi pectinati is
present only in the
auricle.
Valves of the heart
Valves of the heart
Maintain unidirectional flow
of blood and prevent its
regurgitation in the opposite
direction.
2 pairs of valves:
- a pair of atrioventricular
valves.
- a pair of semilunar valves.
Right atrioventricular valve
or tricuspid having 3 cusps.
Left atrioventricular valve or
bicuspid or mitral having 2
cusps.
Aortic & pulmonary semi
lunar valves have 3 semi
lunar cusps.
Valves of Heart

Pulmonary valve

Aortic valve

Bicuspid valve

Tricuspid valve
Aortic valve
Conducting system of heart
Made up of specialised cardiac
muscle, for initiation and conduction
of the cardiac impulse.
Sinuatrial node(SA node) -pace
maker, generates impulse, situated in
the upper part of sulcus terminalis.
Atrioventricular node (AV node) -also
generates impulse, situated just
above the opening of the coronary
sinus.
Atrioventricular bundle(AV bundle) or
bundle of His-starts from the AV node
and divides into right & left branches.
Right branch reaches the right
ventricle, divides into Purkinje fibres.
Left branch reaches the left ventricle,
divides into Purkinje fibres.
Damage to the conducting system
results in cardiac arrhythmias.
Conducting system of heart
Summary

Heart has an apex, base, 4 borders and 3 surfaces.

Right atrium shows crista terminalis, musculi
pectinati, fossa ovalis & limbus fossa ovalis.
Right ventricle shows trabeculae carneae, papillary
muscles, chordae tendinae.
Left ventricle shows trabeculae carneae, papillary
muscles, chordae tendinae.
Left atrium shows opening of 4 pulmonary veins.
Blood supply of heart
Arterial supply of the heart

The arterial supply of the heart is

provided by the right and left
coronary arteries, which arise from
the ascending aorta immediately
above the aortic valve.
The coronary arteries and their major
branches are distributed over the
surface of the heart, lying within
subepicardial connective tissue.
Arterial supply of the heart
Heart (Sternocostal surface):
Ascending aorta

Right auricle
Left coronary artery

Right
coronary
artery

Pulmonary trunk
Right coronary artery
Right coronary artery

Origin:
Branch of ascending aorta begins
from the anterior aortic (right
coronary) sinus.
Course:
Runs between the right auricle and
pulmonary trunk, enters the anterior
part of coronary sulcus, runs to the
right in the anterior part of coronary
sulcus winds around the right margin
of heart, then runs to the left in the
posterior part of coronary sulcus.
Termination:
Anastomoses with circumflex branch
of left coronary artery in the posterior
part of coronary sulcus.
Left coronary artery
Left coronary artery

Origin:
Arises from the ascending aorta -
left posterior aortic sinus.
Course:
Runs between the left auricle and
pulmonary trunk reaches the
anterior part of coronary sulcus and
terminates by dividing to 2
branches.
Termination:
Divides into anterior inter-ventricular
and circumflex branches.
Clinical importance of coronary arteries
Coronary artery anastomoses

Anastomoses between the terminal branches of the right

and left coronary arteries (collateral circulation) exist, but
they are usually not large enough to provide an
adequate blood supply to the cardiac muscle if one of
the large branches become blocked by disease.
A sudden block of one of the larger branches of either
coronary artery usually leads to myocardial death
(myocardial infarction), although sometimes the
collateral circulation is enough to sustain the muscle.
Coronary artery disease - Management

Coronary angioplasty,coronary artery stenting and

coronary by pass surgery are used for treating coronary
artery disease.

Coronary angioplasty :
A catheter is inserted into the
femoral artery in the thigh,
passed through external and
common iliac arteries and into
the aorta to the origins of the
coronary arteries.
A fine wire is then passed into
the coronary artery and is used
to cross the stenosis.
A balloon is then passed over
the wire and inflated at the level
of the obstruction, thus widening
it.
Coronary artery disease - Management

Coronary stent :
Coronary stent is
stainless tube with slots.
It is mounted on a balloon
catheter in a "crimped" or
collapsed state.
When the balloon is
inflated, the stent expands
or opens up and pushes
itself against the inner
wall of the coronary artery
and the blood flow is
maintained.
.
Coronary artery disease - Management

Coronary artery bypass

grafting (CABG) :
If the coronary artery disease is
too severe and not treated by
coronary angioplasty, surgical
bypass grafting is done.
The great saphenous vein in the
lower limb is harvested and used
as an autologous graft, which is
used to bypass blocked part of
the coronary arteries.
The internal thoracic or radial
arteries can also be used for this
purpose.
Venous drainage of heart
Venous drainage
Venous blood from the heart is drained by-
1. Coronary sinus and its tributaries.
2. Anterior cardiac vein.
3. Thebesian veins (venae cordis minimi).
Venous drainage

Coronary sinus:
Largest vein of heart, about 3 cm long.
Formed by the union of great cardiac vein and oblique vein of left atrium.
Situated in the posterior part of coronary sulcus between the left atrium
and left ventricle.
Terminates by opening into the smooth part of right atrium.
Opening is guarded by valve of coronary sinus (Thebasian valve).
Tributaries:
1. Great cardiac vein
2. Small cardiac vein
3. Middle cardiac vein
4. Posterior vein of left ventricle
5. Oblique vein of left atrium.
Venous drainage - coronary sinus
Heart (diaphramatic surface):
Left atrium

Oblique vein
of left atrium
Right atrium

Great cardiac vein

Coronary sinus

Small cardiac vein

Posterior vein of
left ventricle

Left ventricle Right ventricle Middle cardiac vein

Great vessels
Great vessels

Right atrium:
Superior vena cava
Inferior vena cava
Right ventricle:
Pulmonary trunk
Left atrium:
Pulmonary veins
Left ventricle:
Aorta
Superior vena cava

Drains deoxygenated blood from upper half of body to the right

atrium & has no valve.
Begins behind sternal end of 1st right costal cartilage, formed by
union of right & left brachiocephalic veins.
Descends down to enter right atrium at 3rd right costal cartilage.
Superior portion - extra pericardial.
Inferior part- intra pericardial serous pericardium.
Relations:
- Anterior - right lung and pleura.
- Right right phrenic nerve.
- Left brachiocephalic trunk, ascending aorta.
- Posterior - right vagus, root of right lung.
Superior vena cava
Inferior vena cava

Drains deoxygenated blood from

the lower half of the body to the
right atrium.
Enters the thorax piercing the
central tendon of diaphragm at
T8 and immediately opens into
the right atrium at the level of 6th
right costal cartilage.
It has a valve at the opening of
right atrium.
Situated partly inside & outside
the pericardium.
Inferior vena cava
Pulmonary artery (trunk)
Conveys deoxygenated blood from the right
ventricle to the lungs. Situated in the middle
mediastinum.
5 cm in length & 3 cm in diameter.
Extent:
- Begins at 3rd left costal cartilage T5.
- Ends below the arch of aorta to divide
into right & left branches.
Relations:
- Initially in front of ascending aorta.
- Later to the left of ascending aorta.
Right pulmonary artery larger, longer than
left passes below the arch of aorta.
Left pulmonary artery anterior to left bronchus
connected to arch of aorta by ligamentum
arteriosum.
Pulmonary veins

Conveys oxygenated blood

from lungs to left atrium.
4 in number, 2 on each side
pierce the fibrous
pericardium & open
separately into the upper &
posterior part of left atrium.
No valves at the opening into
the left atrium.
Aorta

Conveys oxygenated blood to whole

body.
Passes upwards & right for about 5cm, it
arches upwards, backwards and to the
left over the left pulmonary artery.
Parts of Aorta:
In thorax :
- Ascending aorta
- Arch of aorta
- Descending aorta
In the abdomen:
- Abdominal aorta
Terminates by dividing into right and left
common iliac arteries.
Ascending aorta
5 cm long begins from the left ventricle, situated in the
middle mediastinum.
Extent:
- Begins at left sternal margin at 3rd costal cartilage.
- Ends at right sternal margin at the 2nd costal cartilage-T4.
Along with pulmonary trunk covered by serous pericardium.
Aortic sinus - 3 dilatations at the origin - left, right, posterior.
Branches Two coronary arteries-right and left.
Relations: Anterior Infundibulum of the right ventricle,
pulmonary trunk, auricle of the right atrium.
Posterior left atrium.
Right side superior vena cava, right atrium.
Left side - pulmonary trunk, left atrium.
Ascending aorta
Arch of Aorta
Origin: Continuation of ascending aorta, situated in the superior
mediastinum.
Extent :
- Begins at right border of sternum Upper margin of 2nd costal
cartilage-T4 (sternal angle).
- Ends at the lower border of body of T4(sternal angle).
Relations:
Anterior- left phrenic nerve, left superior intercostal vein, left vagal
trunk, left pleura and thymus.
Posterior - Trachea, left recurrent laryngeal nerve, oesophagus,
thoracic duct.
Superior - left brachicephalic vein, branches of the arch of aorta.
Inferior -left bronchus, bifurcation of pulmonary trunk, left recurrent
laryngeal nerve, ligamentum arteriosum.
Branches : 3 branches - Brachicephalic trunk
- Left common carotid artery
- Left subclavian artery
Arch of Aorta
Coarctation of aorta

Coarctation of aorta, a
congenital defect, occurs
when the aorta narrows.
Coarctation can occur
anywhere in the aorta, but
is most likely to happen in
the segment just after the
aortic arch.
Descending thoracic aorta
Origin - Continuation of arch of aorta.
Extent -Begins at left side of lower border of body of T4.
-Ends by opening through the aortic orifice on the
diaphragm T12 to become abdominal aorta.
Relations :
Anterior root of the left lung, pericardium, oesophagus,
vertebral part of diaphragm.
Posterior- vertebral column, accessory hemiazygos veins
Right - oesopahgus, thoracic duct, azygos vein.
Left - left pleura, lung.
Branches:
- Nine pairs of posterior intercostal arteries and one subcostal artery.
- Oesphageal and bronchial artery.
- Pericardial and mediastinal branches.
Descending thoracic aorta
Aortic aneurysm
Any questions ?
Thank you