heart david kachlík, Štěpán jelínek. heart situation

HeartHeart

David Kachlík, Štěpán Jelínek

Heart situationHeart situation

Heart development

sinus venosus common atrium

ventricle bulbus cordis

truncus arteriosus

atrium - sinus venarum cavarum atrium (separated with crista

terminalis) ventricle (inflow part) ventriculus (outflow part separated

with crista supraventricularis)

aorta + truncus pulmonalis

Heart descriptionHeart description

basis x apex facies sternocostalis s.anterior facies diaphragmatica s. inferior /=posterior wall in clinic/ facies pulmonalis dx. + sin. margo dexter /former acutus/ margo sinister /former obtusus/ incisura apicis cordis

auricula dextra et sinistra sulcus coronarius sulcus interventricularis ant. + post.

Heart structureHeart structure

endocardium = tunica intima myocardium = tunica media

working myocardium excitomotor apparatus (EA) = conducting m. fibrous skeleton of heart

pericardium

EndocardiumEndocardium

continuous with vessels´ tunica intima

4 layers: endothelial subendothelial – collagenous fibres fibromuscular - collagenous, elastic connective tissue, smooth

muscle cells – thicker in atria subendocardial – containing conducting myocardium, loose

connective tissue

endocardium forms heart valves

Heart valves

duplication of endocardium

Internal fibrous lamina – collagenous + elastic fibres

endothelium superficially

attached to fibrous anuli without blood or lymph vessels cuspidal, semilunar, other leaflets

MyocardiumMyocardium cardiomyocytes 3 layers in ventricles

spiral (vortex), circular, longitudinal

2 in atria – internal layer = mm. pectinati 3x thicker in left ventricle than in right

one

conducting system is different in both function and structure

MyocardiumMyocardium

PericardiumPericardium

PericardiumPericardium Pericardium fibrosum – ligg. sternopericardiaca,

membrana bronchopericardiaca Pericardium serosum

lamina paretalis = pericardium lamina visceralis = epicardium = tunica serosa = mesothel tela subserosa (fat tissue, vessels)

Cavitas pericardii Sinus obliquus + transversus Liquor pericardii - 20 ml

N. phrenicus, a.+ vv. periacardiacophrenicae puncture (in case of tamponade)

below processus xiphoideus (dorsocranially) 4th / 5th intercostal space left of sternum (less frequently)

Heart cavitiesHeart cavities

atrium dextrum + sinistrum septum interatriale septum atrioventriculare ventriculus dexter + sinister septum interventriculare (pars membranacea +

muscularis)

Atrium dextrum (right atrium).Atrium dextrum (right atrium).

ostium v. cavae inferioris valvula v.c.i. Eustachii

ostium v. cavae superioris tuberculum intervenosum Loweri

ostium sinus coronarii valvula s. coronarii Thebesii

ostia vv. ventriculi dx. anteriorum foramina venarum minimarum fossa ovalis / foramen ovale cordis

limbus fossae ovalis

Atrium dextrum (right atrium)Atrium dextrum (right atrium)

auricula dextra sinus venarum cavarum crista terminalis mm. pectinati ostium atrioventriculare

dextrum trigonum nodi

atrioventricularis Kochi

Ventriculus dexter (right ventricle)Ventriculus dexter (right ventricle)

ostium atrioventriculare dextrum valva tricuspidalis

cuspis anterior, posterior, septalis

mm. papillares anterior, posterior, septalis chordae tendineae

chordae tendineae falsae s. spuriae

trabeculae carneae trabecula septomarginalis

Ventriculus dexter (right ventricle)Ventriculus dexter (right ventricle)

crista supraventricularis pars glabra = infundibulum =

conus arteriosus = outflow part ostium trunci pulmonalis

valva trunci pulmonalis valvulae semilunares dx., sin.,

ant. /semilunar cusps/ noduli Aranzii lunulae commissurae

Right-sided compartmentsRight-sided compartments

Atrium sinistrum (left atrium)Atrium sinistrum (left atrium)

auricula sinistra ostia venarum pulmonalium mm. pectinati valvula foraminis ovalis

(= former falx septi Parchappei)

Ventriculus sinister (left ventricle)Ventriculus sinister (left ventricle)

ostium atrioventriculare sinistrum valva mitralis s. bicuspidalis

cuspis anterior, posterior (cc. commissurales)

mm. papillares anterior, posterior chordae tendinaeae

trabeculae carneae vestibulum aortae ostium aortae

valva aortae valvulae semilunares dx., sin., post. /semilunar cusps/

noduli Aranzii, lunulae, commissurae sinus aortae Valsalvae (correspond to valvulae)

Left-sided compartmentsLeft-sided compartments

ECHO

Fibrous skeleton of heartFibrous skeleton of heart anulus fibrosus dexter + sinister trigonum fibrosum dextrum /= central fibrous body/ +

sinistrum anulus aorticus + a. trunci pulmonalis tendo infundibuli tendo valvulae venae c. inf. Todaroi pars membranacea septi interventricularis

fibrous connective tissue valve support myocardium insertion electric isolation of atrial and ventricular myocardium

Heart supplyHeart supply

arteries – 2 coronary arteries (ACS, ACD) vinculum, ponticulus

veins – 3 systems, without valves

lymph drainage – 3 plexuses, 2 truncs (right one to ductus thoracicus, left one to ductus lymphaticus dexter !)

nerves – automatical impulses autonomic system (sympathetic, parasympathetic) viscerosensory fibers

Coronary arteriesCoronary arteries

Arteria coronaria dextra (ACD)Arteria coronaria dextra (ACD)

sinus aortae (Valsalvae) dexter → ACD r. coni arteriosi → Vieussens´ circle r. nodi sinuatrialis (65%) rr. atriales r. marginalis dexter (RMD) r. interventricularis posterior (RIP) r. nodi atrioventricularis (80%) r. posterolateralis dexter (RPLD)

Arteria coronaria sinistra (ACS)Arteria coronaria sinistra (ACS)

sinus aortae (Valsalvae) sinister → short (2-3cm) → ACS

r. interventricularis ant. (RIA) – clinically „left anterior descending“ (LAD) r. coni arteriosi → Vieussens´ circle r. diagonalis (RD)

r. circumflexus (RC) rr. atriales r. marginalis sinister (RMS) r. posterolateralis sinister (RPLS)

r. intermedius (RIM) – 25%, from ACS bifuraction

Coronary arteriesCoronary arteries

Arteria coronaria sinistra

ACS in posteroanterior projectionACS in lateral projection (right to left)

ACS in lateral projection (left to right)

PonticulusPonticulus

Stenosis in ACSStenosis in ACS

Arteria coronaria dextraArteria coronaria dextra

ACS in posteroanterior projection

ACS in lateral projection (right to left)

ACS in lateral projection (left to right)

Collateral vesselsCollateral vessels

Heart veinsHeart veins

Sinus coronarius → atrium dextrum ← v. cardiaca (cordis) magna

← v. interventricularis anterior ← v. maginalis sinistra

name change when crossing left border (Vieussens´valve !)

← v. ventriculi sinistri posterior ← v. obliqua atrii sinistri Marshalli ← v. cardiaca (cordis) media (= v.

interventricularis post.) ← v. cardiaca (cordis) parva

← v. marginalis dextra

Heart veinsHeart veins

Vv. ventriculi dextri anteriores = vv. cardiace (cordis) anteriores → atrium dextrum

Vv. cadiace (cordis) minimae Thebesii → all cavities

without any major clinical importance

Nerves – autonomic systemNerves – autonomic system

Sympathetic – nn. cardiaci cervicales sup.+ medii + inf., thoracici positive dromotropic, bathmotropic, inotropic,

chronotropic effect β1 receptors

Parasympathetic – n. X → rr. cardiaci cervicales sup.+inf., thoracici negative effect

Viscerosensory fibres (T1-T4) Head´s zone behind sternum and in ulnar edge

of left upper limb

Conducting system of heartConducting system of heartComplexus stimulans cordisComplexus stimulans cordisSystema conducens cordisSystema conducens cordis

„Excitomotor apparatus“„Excitomotor apparatus“

enables generation of heart automatic impulse formed with modified cardiomyocytes:

less myofibrils placed in periphery no intercalar discs connections by desmosomes and nexuses different size glycogen gathered around the nucleus

Conducting system of the heart - Conducting system of the heart - partsparts

nodus sinuatrialis (Keith-Flack) right atrium near foramen v. cavae superioris

interatrial connections (fasciculi atriales) fasciculus interatrialis (Bachmann) další svazky sporné

anterior (James), medius (Wenckebach), posterior (Thorel)

nodus atrioventricularis (Aschoff-Tawara) right atrium in Koch‘s triangle near ostium atrioventriculare

dextrum

myocytes smaller than those of working myocardium rich blood supply

Conducting system of heartConducting system of heart fasciculus atrioventricularis (atrioventricular bundle) His-Kent-Gaskell

AV blockage of 1st-3rd grade truncus f.a. crus f.a. (Tawara)

dextrum sinistrum

limbus anterior limbus posterior

rami subendocardiales (Purkyně) larger than typical cardiomyocytes with lighter cytoplasma quick impulse conduction towards heart apex

accessory connections → preexcitation syndrom WPW (Wolf-Parkinson-White)

Purkyně fibres (HE + elastin)

artificial artificial pacemakerpacemaker

PhysiologyPhysiology

Heart cycle systole diastole

Pulse and volumes EKG curve Arterial pulse curve with dicrotic notch Endocrinne function - ANF

ExaminationExamination

physical examination (aspection, percussion, palpation, ausculatation)

EKG, Holter echocardiography, oesophageal echok. (X-ray of heart and lungs) coronarography nuclear medicine biochemistry: troponins, CK MB, myoglobin

Auscultation

Testut‘s points

=

4 auscultation points

Auscultation – Auscultation – Testut´s pointsTestut´s points

4 auscultation points Valva mitralis – 5th intercostal space left of strenum in

medioclavicular line Valva tricuspidalis – 4th intercostal space left (or right)

of strenum Valva aortae – 2th intercostal space right of sternum Valva trunci pulmonalis – 2th intercostal space left of

sternum

Erb´s point (3rd intercostal space left of sternum) - murmurs

Systolic/ diastolic

pressures in the heart chambers

Basic clinical unitsBasic clinical units

Endocardium: endocarditis, valvular defects (inborn, acquired)

Myocardium: ischmeic heart disease (AP, IM), myocarditis, cardiomyopathy

Pericardium: pericarditis, tamponade Conducting system: arrythmia Developing defects: septal defects, transposition

of large vessels, Fallot´s tri-, tetra-, pentalogy, opened Botallo´s duct, aorta coarctation

Heart X-rayHeart X-ray

Heart X-rayHeart X-ray

Rheumatic vegetations

Endocarditis

Valvular insufficiency

(regurgitation) and

stenosis

Myocardial infarction

Cardiac aneurysm

Pericarditis

Cardiac trauma

Cardiac tamponade

The heart during CPR

Basic therapeutic Basic therapeutic operationsoperations

PTCA (= percutaneous transfemoral coronary angioplasty)

Basic therapeutic operationsBasic therapeutic operations

by-passing venous grafts (v. saphena magna) arterial grafts (a. radialis) artery lifting (a. thoracica interna, a.

gastroomentalis sinistra) a.thoracica interna (clinically „a. mammaria

interna – left/right = „LIMA, RIMA“)

valve replacement (porcine, plastic) transplantation

Valvular replacementValvular replacement

Valvular replacement

Cardiac Cardiac transplantationtransplantation

Practical training

X-ray of heart and lungs Valve auscultation Heart specimen – whole x dissected

Histological slides of heart muscle

Thank you for attention…..Thank you for attention…..

... and finaly several important notes: speciality of the cnducting system the worst blood supply of subendocardial

layers - ↑ risk of hypoxia The thickest muscular wall of left ventricle - ↑

risk of hypoxia