Mitral & Aortic Valve Disease

• Valve disease involves incompetence (insufficiency) from poorly functioning valves and stenosis, which is a narrowing of the valve orifice.

Mitral Valve Disease

• Mitral valve disease commonly presents as a mixed pattern of stenosis and incompetence.
• Stenosis and incompetence both impair valve function, leading to heart changes such as left ventricular hypertrophy, increased pulmonary venous pressure, pulmonary edema, and enlargement/hypertrophy of the left atrium.
• Mitral valve stenosis may be congenital or acquired, with the latter often resulting from rheumatic fever, typically decades after an acute rheumatic endocarditis episode.

Aortic Valve Disease

• Aortic valve disease, including stenosis and regurgitation (backflow), can lead to significant heart failure.
• Aortic valve stenosis is frequently caused by atherosclerosis-induced calcification or postinflammatory/rheumatic conditions that could also cause aortic regurgitation like infective endocarditis, degenerative valve disease, rheumatic fever, or trauma.

Right Side Heart valve disease

• Right-sided heart valve disease (tricuspid or pulmonary) is usually caused by infection, with intravenous drug use, alcoholism, indwelling catheters, and extensive burns predisposing individuals, especially affecting the tricuspid valve.
• Dysfunction can cause abnormal pressure changes in the right atrium/ventricle and potentially induce cardiac failure.

Cardiac Skeleton

• The cardiac skeleton comprises dense, fibrous connective tissue forming four rings with interconnecting areas in a plane between atria and ventricles.
• The cardiac skeleton's four rings surround the atrioventricular orifices, the aortic orifice, and the pulmonary trunks, which forms the anulus fibrosus.
• Interconnecting areas include the right fibrous trigone and the left fibrous trigone.
• The right fibrous trigone is a thick area of connective tissue between the aortic and right atrioventricular rings.
• The left fibrous trigone is a thick area of connective tissue between the aortic and left atrioventricular rings.
• The cardiac skeleton maintains the integrity of the surrounded openings and is a point of attachment for cusps, separates atrial from ventricular musculature, with the atrial myocardium originating from the upper border of the rings and ventricular myocardium from the lower border of the rings.
• Also serves as a dense connective tissue partition to electrically isolate the atria from the ventricles.
• The atrioventricular bundle, goes through the anulus, is the sole connection between atrial and ventricular myocardium.

Coronary Vasculature

• Two coronary arteries originate from the aortic sinuses in the ascending aorta's initial part, supplying the heart's muscle and other tissues.
• The coronary arteries encircle the heart in the coronary sulcus with marginal and interventricular branches in the interventricular sulci, converging at the apex.
• Returning venous blood flows through cardiac veins, which primarily empty into the coronary sinus, which is a large venous structure in the coronary sulcus on the heart’s posterior surface between the left atrium and left ventricle.
• The coronary sinus empties into the right atrium between the inferior vena cava opening and the right atrioventricular orifice.

Coronary Arteries

• The right coronary artery originates from the ascending aorta's right aortic sinus, passing anteriorly/vertically in the coronary sulcus between the right atrium and right ventricle; upon reaching the heart's inferior margin, it turns posteriorly, continuing in the sulcus onto the diaphragmatic surface and base.
• Several branches arise from the main vessel.
• An early atrial branch is located in the groove between the right auricle/ascending aorta, giving off the sinu-atrial nodal branch, which passes posteriorly around the superior vena cava, supplying the sinu-atrial node.
• A right marginal branch is given off as the right coronary artery approaches the heart's acute margin, continuing along the border toward the apex.
• As the right coronary artery continues on the heart's base/diaphragmatic surface, it supplies a small branch to the atrioventricular node before giving off the posterior interventricular branch, which lies in the posterior interventricular sulcus.
• The right coronary artery supplies the right atrium and right ventricle, the sinu-atrial and atrioventricular nodes, the interatrial septum, part of the left atrium, the posteroinferior third of the interventricular septum, and the posterior part of the left ventricle.

Left Coronary Artery

• The left coronary artery originates from ascending aorta's left aortic sinus, passing between the pulmonary trunk and left auricle before entering the coronary sulcus.
• As it emerges from behind the pulmonary trunk, the artery divides into two terminal branches, the anterior interventricular and the circumflex.
• The anterior interventricular branch (left anterior descending artery—LAD) continues around the left side of the pulmonary trunk and descends obliquely toward the apex of the heart in the anterior interventricular sulcus,. along its course, one or two large diagonal branches may arise and descend diagonally across the anterior surface of the left ventricle.
• The circumflex branch courses toward the left, in the coronary sulcus and onto the heart's base/diaphragmatic surface, ending before reaching the posterior interventricular sulcus.
• A large branch, the left marginal artery, arises from it and goes across the heart's obtuse margin.
• The left coronary artery's configuration enables it to supply most of the left atrium and left ventricle plus the interventricular septum, including the atrioventricular bundle, and its branches.
• Variations are seen in the distribution patterns of coronary arteries.
• The right and left coronary arteries commonly consists of a right dominant coronary artery.
• The posterior interventricular branch originates from the right coronary artery, which supplies a large portion of the heart's posterior wall and a relatively small circumflex branch.
• Hearts containing a left dominant coronary artery, the posterior interventricular branch begins from an enlarged circumflex branch, supplying most of the left ventricle's posterior wall.
• Sometimes the arteries supplying the sinu-atrial and atrioventricular nodes differ, but often these two structures are supplied by the right coronary artery, but either vessel of the circumflex branch of the left coronary artery can supply these.

Clinical Terminology for Coronary Arteries

• The short left coronary artery is called the left main stem vessel.
• One of its primary branches, the anterior interventricular artery, is called the left anterior descending artery (LAD).
• The terminal branch of the right coronary artery, the posterior interventricular artery, is called the posterior descending artery (PDA).

Clinical terms: Heart Attack

• A heart attack occurs when insufficient heart perfusion leads to irreversible tissue damage, due to total occlusion of a major coronary artery.

Coronary Artery Disease

• Occlusion of a major coronary artery from atherosclerosis causes inadequate myocardium oxygenation and cell death.
• The problem's is based on the size and location of the artery, the degree of the blockage, and the presence of collateral vessels.
• Depending on the severity, angina or myocardial infarction (MI) can develop.

Percutaneous Coronary Intervention

• Technique involves inserting a long, fine tube (catheter) into the femoral artery in the thigh and passing it through the iliac arteries to the abdominal aorta and coronary arteries (or via radial/brachial arteries).
• Then, a fine wire is passed into the coronary artery and across the stenosis, followed by balloon angioplasty/stent placement to widen/hold open the obstruction, and can include suction extraction of a coronary thrombus and rotary ablation of a plaque.

Coronary Artery Bypass Grafts

• In cases of extensive coronary artery disease, surgical coronary artery bypass grafting may be necessary.
• The great saphenous vein from the lower limb is removed and used to bypass blocked artery sections (alternative internal thoracic and radial arteries can also be used).

Heart Attack Symptoms

• Classic heart attack symptoms include chest heaviness/pressure (severe, lasting >20 mins) with sweating, chest pain (elephant sitting) radiating to the left arm and nausea.
• The rate of occlusion and collateral channel development influences ischemia and infarction severity.
• Women experiencing typical symptoms of severe chest pain, cold sweats, and left arm pain, women often have abdominal pain, achiness in the jaw/back, nausea, shortness of breath, or fatigue.
• Although undetermined why this differs, cardiac ischemia needs to be considered with a varying range of symptoms.

Common Congenital Heart Defects: Defects in the Atrial and Ventricular Septa

• A defect in the interatrial septum allows blood to pass from the higher pressure chamber to the lower pressure chamber and has been clinically referred to as a shunt.
• An atrial septal defect (ASD) allows oxygenated blood to flow from the left atrium (higher pressure) across into the right atrium resulting in a left to right shunt and volume overload on the right-side circulation. Many patients are often asymptomatic, but can worsen and need to be closed surgically.
• Over several years this increased blood flow into the right atrium causes right atrial/ventricular hypertrophy and enlargement of the pulmonary trunk, resulting in pulmonary arterial hypertension and has causes dyspnea (shortness of Breath) symptoms such as breathlessness, tiredness, palpitations and increased heart failure
• The left ventricle is NOT enlarged in ASD as the blood volume has not been affected.
• Ventriculoseptal defect (VSD), are the most common cases and have most frequents lesions in the membranous portion of the septum and allows blood to from from the left ventricle.
• This causes right ventricular hypertension, increased arterial pulmonary blood flow, increased pulmonary pressure, increased blood return to the left ventricle that in turn dilates.
• Pulmonary edema may also occur at increased pulmonary pressure and in severe cases surgery may be required.
• Ventriculoseptal defects can be isolated or part of a syndromic pattern such as Tetralogy of Fallot.

Tetralogy Of Fallot

• Consists of four abnormalities: pulmonary stenosis, VSD, overriding aorta (originating from the left ventricle), and right ventricular hypertrophy.
• This causes a decrease in lung blood flow, defects in the interventricular septum, and reduces oxygenated blood return. Cyanosis can occur.
• The defects produces require surgery that can be achieved by the success of Cardiopulmonary bypass.

Patent Ductus Arteriosus (PDA)

• The ductus arteriosus is in the left branch of the pulmonary artery and inferior aspect of the aortic arch, it can fail close at birth and causes a patent or persistent ductus arteriosus.
• In turn, this causes the oxygenated blood in the aortic arch to enter the pulmonary artery and causes pulmonary hypertension and lead to atrial/ ventricular enlargement.
• This can have success with surgical or endonascular intervention/ treatment however is necessary.

Cardiac Defects

• All of these defects cause a left-to-shunting of oxygenated blood to be mixed with deoxygenated blood.
• Rarely, a right-to-left shunt occurs that may cause death. Some of the deoxygenated blood is returned to the systemic blood stream.

Cardiac Auscultation

• Cardiac Auscultation reveals normal heart rate rhythms and auscultation also gives way to cardiac murmurs which have the sounds associated with the phases.

Cardiac Veins

• The coronary sinus receives 4 major tributaries: great, middle, small, and posterior cardiac veins.

Great Cardiac Vein

• Begins from the Apex and ascends into the AP interventricular sulcus and is linked to the anterior interventricular and turn to the left coronary artery.
• It continues to the path into the coronary sinus, enters the right atrium.

Middle Cardiac Vein (posterior interventricular vein)

• Begins near the apex and ascends in posterior interventricular veins toward coronary sinus and it connected to interventricular branch to coronary artery.

Small Cardiac Vein (posterior interventricular vein)

• The Small Cardiac Vein begins in anterior section between the right ventricle and right atrium. Also enters groove from the base to enter the coronary sinus with artery connection.

Posterior Cardiac Vein

• Lies near the surface of the left ventricle with the enters directly to the midcardiac or to cardiac veins. Additional groups:
• Anterior veins of the right ventricle (anterior cardiac veins) cross the sulcus and can drain the anterior portion.
• Smallest cardiac veins have been seen in the atrium and the ventricle that drain to these areas.

Coronary Lymphatics

• Coronary vessels follow Arteries and Lymphs. These in include the:
• Brachiocephalic
• Tracheobronchial

Cardiac Conduction System

• Cardiac muscle is spontaneously but is able to contract and the conduction system begins and coordinates this contraction. Basic components of the system include:

• sinu-atrial node, atrioventricular node, atrioventricular bundle and subendocardial. Pattern of cardiac system that creates contraction/excitation In this area that has connective stimulation and contraction of the cardiac tissues are decreased.

• A undirtectional event occurs that stems from muscles/apex and has arterial tracts.

• Cardiac Conduction System issues is caused and affected by coronary diseases that interrupt and make the heart beat irregular in chambers and orders. This leads to death/ failure.

Sinu-Atrial Node

• Impulses begin at the sinu-atrial node. These are located at the Crista Terminalis and junction where the Atrium and Superior Vena Cava meets.
• Signals are created and spread across the atria from this, causing the muscles to contract.
• Atrioventricular Node: This is created when the electrical signal connects the atria and forms into the Atrioventricular system by having excitatory impulses in ventricular muscles
• Ventricles are connected by a bundl and they follow though the septum, then break branches to each side.
• The right carries septum touches septomarginal/papilary areas and subdivides in order that the ventricle tissues can connect.
• The left passes through septum and apex with the muscles to contract and tissues do the best of their abilities to get the ventricles in working condition.

Cardiac Innervation Innervation

• Cardiac Innervation is responsible for regulations for:
• Heart rate
• Contractions and Force of Contractions

Vagal Cardiac Nerves Afferent

• Visceral fibers also go through cardiac plexus and get sent through central central system to afferent cardiac nerves.
• Vagal nerves has sensory of blood pressure and other sensors.

sympathetic vs parasympathetic Innervation

• Stimulation Parasympathetic reduces heart rate as Stimulation sympathetic increases it
• Stimulation Parasympathetic reduces contraction contractions stimulation sympathetic increases the force of contraction
• Stimulation Parasympathetic cardiac artery

Pulmonary trunk Innervation

• Fibers are contained with the pericardial sac covered visceral tissues

Ascending Aorta

• Ascending aorta is made the surface for serous pericardium at the base where aorta and left ventricle is then moves upwards to the second right and enters superior mediastinum

Superior and middle mediastinum

• Located posterior upper front the vertebra
• Its superborder is when moving from jugular notch and anterior borders are side of the plural membranes

Mediastinum major structures includes

• Thymus, which is an asymmetrical

• Brachiocephalic Veins, upper chest

• Superior intercostal vein;

• Cavus veina cava, large opening in upper chest

• Branches to aorta

• Esophagus

• Veins

• A sympathetic is also in this area. Lymph

• Right and left Veins for the brachial area that are in the thymus and neck. Veins connect in clavicle area and cross over Lump are is affected.