PK-Cardiovascular II MD6 2+3 Oct 2024 PDF

2 + 3 October 2024 Professor Dr Panagiotis Karanis Professor and Director of Anatomy Institute Coordinator Unit of Anatomy and Morphology Coordinator of the Unit of Infectious Diseases and One Health, UNic Medical School 1. Come on...

2 + 3 October 2024 Professor Dr Panagiotis Karanis Professor and Director of Anatomy Institute Coordinator Unit of Anatomy and Morphology Coordinator of the Unit of Infectious Diseases and One Health, UNic Medical School 1. Come on time to the practical sessions into the DR and for lectures too! 2. Keep the safety rules. 3. Take a drink before you come the practical sessions. 4. No phones, ipads, notebooks, other supportive material. 5. Put your gloves and start inspection of the structures in the cadaver. 6. Please, come always prepared for the practical sessions. 13 Describe the coronary circulation & venous drainage of the heart 14 Describe the relationship of the ligamentum arteriosum to the left vagus nerve. 15 Describe the location of the oesophageal and pulmonary plexuses and superficial and deep cardiac plexuses. 16 Identify the remnants of foetal structures present in the adult heart and great vessels (foramen ovale, fossa ovalis, ligamentum arteriosum). 17 Describe and identify the origin, branches and distribution of the anterior descending/ interventricular and circumflex branches of the left coronary artery. 18 Describe and identify the right coronary artery, the origin of its marginal and posterior interventricular branches and the regions of the heart they supply. 19 Outline how the blood supply to the heart varies between people. 20 Describe some common variations in supply and their clinical significance. 21 Describe the conduction system of the heart 22 Examine the structure of the pericardium 1. aorta ascendens; 2. aortic arch (arcus aortae); 3. right upper limp-head artery (brachiocephalic trunk); 4. left head artery; 5. left subclavian artery; 6. Conus arteriosus; 7. left lung artery; 8. branches of the right lung artery; 9. left lung veins; 10. right lung arteries; 11. vena cava superior; 12. vena cava inferior; 13. right coronary artery; 14. ramus interventricularis anterior (branch of the left CA); 15. auricula dextra; 16. auricula sinistra; 17. atrium dextrum; 18.atrium sinistrum. 19.ventriculus dexter; 20. ventriculus sinister; 21.apex cordis. Moore, K. L., Dalley, A. F., & Agur, A. M. (2013). Clinically oriented anatomy. Lippincott Williams & Wilkins. Schematic illustration of the muscle fibres in the area of the left ventricle Moore, K. L., Dalley, A. F., & Agur, A. M. (2013). Clinically oriented anatomy. Lippincott Williams & Wilkins. The arterial supply to the heart is provided by the right and left coronary arteries, which arise from the ascending aorta just above the aortic valve. They supply the myocardium, including the papillary muscles and conducting tissue. The principal venous return is via the coronary sinus and the cardiac veins.  *Coronary blood flow at rest is ~ 225 ml/minute ~ 5% of cardiac output (adult: 5 L blood pump through heart/minute). Moore, K. L., Dalley, A. F., & Agur, A. M. (2013). Clinically oriented anatomy. Lippincott Williams & Wilkins. Stages of cardiac cycle. The cardiac cycle describes the complete movement of the heart or heartbeat and includes the period from the beginning of one heartbeat to the beginning of the next one. The cycle consists of diastole ( = ventricular relaxation and filling) and systole ( = ventricular contraction and emptying).  Aortic Aortic valve Systole – LV contracts valve closes opens Compression of sub-endocardial coronary vessels (intramuscular) epicardial coronary vessels stay open (run along the outer surface) Diastole – LV relaxes blood flows through the subendocardial coronary vessels to the capillaries (w/out obstruction) myocardial perfusion occurs during heart relaxation End Early Diastole Systole Diastole Diastole Note The RV contraction force is less than LV. - RV pressure is less than the diastolic blood pressure At rest, the heart extracts 60- 70% O2 from each unit of blood delivered to heart. - other tissues extract only ~ 25% of O2 Heart muscle has more mitochondria – needs O2. Heart in Ventricular Diastole Viewed from Above with Atrial Chambers Removed Netter, F. H. (2011). Atlas of Human Anatomy, 5th ed., Elsevier Health Sciences. Moore, K. L., Dalley, A. F., & Agur, A. M. (2013). Clinically oriented anatomy. Lippincott Williams & Wilkins. Netter, F. H. (2011). Atlas of Human Anatomy, 5th ed., Elsevier Health Sciences. Netter, F. H. (2011). Atlas of Human Anatomy, 5th ed., Elsevier Health Sciences. Moore, K. L., Dalley, A. F., & Agur, A. M. (2018). Clinically Oriented Anatomy. Wollters Kluwer Moore, K. L., Dalley, A. F., & Agur, A. M. (2018). Clinically Oriented Anatomy. Wllters Kluwer Hansen, J. T. (2011). Netter's Clinical Anatomy. Elsevier Health Sciences.  Reference: Arterial supply to heart Moore, K. L., Dalley, A. F., & Agur, A. M. (2013). Clinically oriented anatomy. Lippincott Williams & Wilkins.  Right Coronary Artery (dominant in 67%) Walls of right atrium and inter-atrial septum Inferior wall of left atrium SA node in 60% of people AV node in 80% of people Walls of right ventricle 1 /3 of inter-ventricular septum Left Coronary Artery Posterior wall of left atrium The rest See anatomy book for further details. Hansen, J. T. (2011). Netter's Clinical Anatomy. Elsevier Health Sciences. Moore, K. L., Dalley, A. F., & Agur, A. M. (2013). Clinically oriented anatomy. Lippincott Williams & Wilkins. Moore, K. L., Dalley, A. F., & Agur, A. M. (2018). Clinically Oriented Anatomy. Wollters Kluwer Moore, K. L., Dalley, A. F., & Agur, A. M. (2013). Clinically oriented anatomy. Lippincott Williams & Wilkins. Hansen, J. T. (2011). Netter's Clinical Anatomy. Elsevier Health Sciences.  occlusion: coronary artery Most common sites of Moore, K. L., Dalley, A. F., & Agur, A. M. (2013). Clinically oriented anatomy. Lippincott Williams & Wilkins.  Precordial discomfort or pressure due to transient myocardial ischemia without infarction Angina pectoris described as: pressure, discomfort, or breathlessness left substernal region/chest radiates to the left shoulder and arm, as well as the neck, jaw and teeth, abdomen, and back - may radiate to the right arm. radiating pattern - referred pain  visceral afferents from the heart enter the upper thoracic spinal cord along with somatic afferents, both converging in the spinal cord’s dorsal horn.  The higher brain center’s interpretation of this visceral pain may initially be confused with somatic sensations from the same spinal cord levels. left anterior descending left anterior descending Hansen, J. T. (2011). Netter's Clinical Anatomy. Elsevier Health Sciences. Moore, K. L., Dalley, A. F., & Agur, A. M. (2013). Clinically oriented anatomy. Lippincott Williams & Wilkins. Hansen, J. T. (2011). Netter's Clinical Anatomy. Elsevier Health Sciences.  m Pericardiu Marieb, E.N., Wilhelm, P.B., and Mallatt, J. (2012), Human Anatomy, Media Update, 6th edition, Boston: Benjamin Cummings.  Cardiac tamponade Pericardiocentesis - made possible from cardiac notch of left lung Hansen, J. T. (2011). Netter's Clinical Anatomy. Elsevier Health Sciences. (Forms part of the right border of the heart) Hansen, J. T. (2011). Netter's Clinical Anatomy. Elsevier Health Sciences. Hansen, J. T. (2011). Netter's Clinical Anatomy. Elsevier Health Sciences.  (Forms part of the right border of the heart) Atrioventricular groove Tricuspid valve Chordae tendineae Papillary muscles Interventricular septum Trabeculae carneae Trabecula septomarginalis (moderator band) Pulmonary valve Pulmonary trunk Hansen, J. T. (2011). Netter's Clinical Anatomy. Elsevier Health Sciences.  (Forms the base of the heart) Left auricle Interatrial septum 4 pulmonary veins Hansen, J. T. (2011). Netter's Clinical Anatomy. Elsevier Health Sciences.  (Forms the posterior part of the heart, on the left) Bicuspid (mitral) valve Chordae tendineae Papillary muscles Trabeculae carneae Interventricular septum Aortic valve Aorta *Ligamentum arteriosus Hansen, J. T. (2011). Netter's Clinical Anatomy. Elsevier Health Sciences. Impulse generation and conduction: SA node initiates an impulse that is rapidly conducted to cardiac muscle fibers in the atria…(contraction). Impulse spreads by myogenic conduction, which rapidly transmits the impulse from the SA node to the AV node. The signal is distributed from the AV node through the AV bundle and its right and left bundles, which pass on each side of the IVS to supply sub-endocardial branches to the papillary muscles and walls of Ventricles.  Specialized cardiac muscle cells that carry impulses throughout the heart musculature, signaling the chambers to contract in the proper sequence Specialized cardiac muscle cells that carry impulses throughout the heart musculature, signaling the chambers to contract in the proper sequence. Moore, K. L., Dalley, A. F., & Agur, A. M. (2013). Clinically oriented anatomy. Lippincott Williams & Wilkins.  SA node (sinoatrial) In wall of RA Sets basic rate: 70-80 Is the normal pacemaker However, note that the basic rate of SA node is about 100 Impulse from SA to atria Impulse also to AV node via internodal pathway AV node In interatrial septum – near opening of coronary sinus Moore, K. L., Dalley, A. F., & Agur, A. M. (2013). Clinically oriented anatomy. Lippincott Williams & Wilkins.  From AV node through AV bundle (bundle of His) Into interventricular septum Divides R and L bundle branches Become subendocardial branches (“Purkinje fibers”) Contraction begins at apex Moore, K. L., Dalley, A. F., & Agur, A. M. (2013). Clinically oriented anatomy. Lippincott Williams & Wilkins.  Electrical conduction system Specialized cardiac muscle cells that carry impulses throughout the heart musculature, signaling the chambers to contract in the proper sequence 1. AV node (Keith-Flack node); 2. Aschoff-Tawara node; 3. HIS bundle; 4. Purkinjie fibres; 5. SVC; 6. Entry (confluence) of SVC; 7. IVC; 8. Entry (confluence) of IVC; 9. Vv. pulmonales; 10. Fossa ovalis; 11.Valva mitralis; 12. M. papillaris.  HEART INNERVATION: Cardiac Plexus Consists of a tangle of Branches (both both sympathetic and sympathetic and parasympathetic parasympathetic) fibres emanating from - It is located below the this plexus pass arch of the aorta, above with the right the bifurcation of the pulmonary artery pulmonary trunk into to the posterior of the 2 pulmonary the atria to be arteries, anterior to the distributed with tracheal bifurcation. the coronary arteries and reach the SA and AV nodes. Hansen, J. T. (2011). Netter's Clinical Anatomy. Elsevier Health Sciences. Consists of a tangle of both sympathetic and parasympathetic fibers located below arch of the aorta, above the bifurcation of the pulmonary trunk, and anterior to the tracheal bifurcation. sympathetic and parasympathetic branches that emanate from this plexus pass with the right pulmonary artery to the posterior of the atria to be distributed with the coronary arteries and reach the SA and AV nodes. Visceral afferent (sensory) fibers chemoreceptors that detect the chemicals that form in ischemic tissue. fibers travel with the sympathetic fibers, entering the spinal cord at the levels that the preganglionic fibers emerged, notably by the T1 white rami communicantes. pathway involved in referred pain from cardiac ischemia. Note the T1 dermatome (medial cord of brachial plexus).  Dorsal motor nucleus o vagus The vagus nerve Note: Reduced (parasympathetic) decreases heart rate. Cardioacceleratory baroreceptor activity center Cardioinhibitory inhibits the center parasympathetic nerves Sympathetic trunk and excites the ganglion (T1-T4 or T5) sympathetics. Medulla oblongata Sympathetic cardiac SA node nerve increase heart rate and force of contraction. AV node Thoracic spinal cord Sympathetic trunk Parasympathetic fibers Sympathetic fibers Interneurons Marieb, E.N., Wilhelm, P.B., and Mallatt, J. (2012), Human Anatomy, Media Update, 6th edition, Boston: Benjamin  Sympathetic fibers: T1-T4 (T5) Parasympathetic fibers: Vagus Moore, K. L., Dalley, A. F., & Agur, A. M. (2013). Clinically oriented anatomy. Lippincott Williams & Wilkins. Marieb, E.N., Wilhelm, P.B., and Mallatt, J. (2012), Human Anatomy, Media Update, 6th edition, Boston: Benjamin Cummings. Hansen, J. T. (2011). Netter's Clinical Anatomy. Elsevier Health Sciences. By the end of this session you should be able to: Describe the anatomy of the coronary circulation and venous drainage of the heart Describe some common heart variations in blood supply and their clinical significance Identify the remnants of foetal structures present in the adult heart and great vessels Describe internal/external surface anatomy of the heart and innervation Pericardium Nerve plexuses: oesophageal, pulmonary, superficial and deep cardiac  Literature: - illustrations and slides for this presentation were taken from:  Hansen, J. T. (2011). Netter's Clinical Anatomy. Elsevier Health Sciences.  Marieb, E.N., Wilhelm, P.B., and Mallatt, J. (2012), Human Anatomy, Media Update, 6th edition, Boston: Benjamin Cummings.  Moore, K. L., Dalley, A. F., & Agur, A. M. (2013). Clinically oriented anatomy. Lippincott Williams & Wilkins.  Netter, F. H. (2014). Atlas of Human Anatomy, Professional Edition E-Book: including Netter Reference. com Access with Full Downloadable Image Bank. Elsevier Health Sciences.  Netter, F. H. (2011). Atlas of Human Anatomy, 5th ed., Elsevier Health Sciences.  Mark Nielsen Shawn Miller (2011). Atlas of Human Anatomy. Willey.