Cardiovascular System III PDF

Cardiovascular System III October 8-9-10th, 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...

Cardiovascular System III October 8-9-10th, 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 What is a dermatome ? The area of skin subserved by afferent fibres of one dorsal root is called a dermatome. Netter, F. H. (2014). Atlas of Human Anatomy, Professional Edition E-Book: including NetterReference. com Access with Full Downloadable Image Bank. Elsevier Health Sciences. In today’s session we’ll go over… The gross anatomy and surface anatomy of the heart Identify the valves and their auscultation points Describe the anatomy of the valves and related anatomical structures Describe the sequence of opening and closing of the valves during the cardiac circle Examine the flow of blood through the heart Point out the differences in fetal circulation Cardiac shadow in chest x-ray Greater in AP projection, that is why PA is the method of choice. P A A P In 1895, Wilhelm Conrad Röntgen (Remscheid, Würzburg, Germany) used X-rays generated from a cathode ray tube to make the first radiographic image. He was ultimately awarded the first Nobel Prize in Physics in 1901. As the X-rays (electromagnetic radiation) pass through the body, they lose energy to the tissues. Only the photons with sufficient power to make it through are then exposed to a sheet of photographic film. It is now collected mainly as digital information rather than as a photographic image on film. X-ray (Röntgen): Albert Kölliker's hand (with ring), taken by Conrad Röntgen on January 23, 1896 Relating the anatomy to the x-ray image Occasionally, the cardiac position is abnormal due to dextroposition, dextroversion, dextrocardia, or other changes in intrathoracic structures. Image left: The mirror image of all breast and abdominal organs (Situs inversus totalis = Total inverted position) is an example of an extreme variety. With the heart on the right and the liver on the left, one lives just as well as in the correct position. It can be dangerous if it falls into the hands of a doctor who does not think about the varieties of nature and then misbehaves during an examination or operation. Remember these? Heart valves www.cts.usc. edu  Basis for Naming Cusps and Sinuses of Aortic and Pulmonary Valves The following account explains the The heart embryological basis undergoes partial for naming the rotation so that its pulmonary and apex becomes aortic valves. directed to the left, resulting in The truncus the arrangement arteriosus, the of cusps as shown common arterial in Figure B4.26C. trunk from both ventricles of the Consequently, the embryonic heart, has cusps are named four cusps (Fig. according to their B4.26A). The development of embryological the heart has four main phases: heart origin, not their The truncus tube, heart fold postnatal arteriosus divides (loop), and chamber system. 4- anatomical into two vessels, position. Cardiac cycle Systole 0.3 sec, Diastole 0.5 sec 2 step pumping mechanism  Lt & Rt atria contract and shortly after Lt & Rt ventricles contract. When atria and ventricles relax  venous return fills atria  pressure builds up  av valves open and blood enters the ventricles. Ventricles already 80% full by the time the atria contracts to get the remaining 20% of blood in the  The cardiac cycle 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). Two heart sounds are heard with a stethoscope: a lub (1st) sound as the blood is transferred from the atria into the ventricles and a dub (2nd) sound as the ventricles expel blood from the heart. The heart sounds are produced by the snapping shut of the one-way valves that usually keep blood from flowing backwards during contractions of the heart. Correlation of normal electrocardiogram (ECG) and ventricular pressure, and heart sounds 1. Heart sound: dull and long. It corresponds to the closure of the ‘sail flaps’; 2. Heart sound: short and bright. It corresponds to the closure of the ‘pocket flaps’. THE CARDIAC EXAMINATION  INSPECTION  PALPATION  PERCUSSION  AUSCULTATION  PERCUSSION By the Viennese doctor Leopold Auenbrugger(1722-1809) is said that he observed his father, who was a Graz innkeeper, tapped wine barrels to fill themcheck. This is said to have given him the idea of ​tapping the human body (to percutate, Latin percutere = violentbeat) to distinguish air-filled and liquid-filled sections. Published in 1761the results of his systematic studies, "To recognize the signs of internal chest diseases by tapping the chest". Even if the father's wine barrels are not the starting point of the percussion - before Auenbrugger, doctors had already patted the abdomen to diagnose flatulence- the year 1761 is still the birth of modern active medical diagnostics. Q: Who invented the stethoscope ? In 1816, French physician Rene Rene Theophile Hyacinthe Laënnec (1781–1826) invented the first stethoscope using a long, rolled paper tube to funnel the sound from the patient's chest to his ear. The Parisian doctor Rene Theophile Hyacinthe Laennec (1781-1826) is told he was too shy to lay his ear on a woman's breast and hear the heartbeat. He, therefore, has a leaf paper rolled up, and this roll is held between her chest wall and his ear. He became the inventor of the stethoscope (Greek: stethos = chest, skopein = to look at). The borders of the heart  All the valves lie behind the sternum; if they do not seal adequately, they ‘leak’, causing ‘murmurs’. Their positions and the points at which they can be heard (auscultated) are shown. Note: The aorta comes from the left heart (LV) but is auscultated on the right! The pulmonic artery comes from the right heart (RV) but is auscultated on the left. This is related to the twist of the outflow tract during the development of the heart.  Tricuspid valve: It is, in a sense, the ''problem child'' among the four heart valves. Corresponding to the projection of the heart's right chamber, the sound remains under the lower end of the sternum body and something to the left of it. Since there is no clear auscultation point, different medical schools also make various recommendations. In German books, the area of ​the insertion of the 6. rib is often on the right side of the sternum; English books recommend it left on the sternum. Some authors also suggest the middle of the sternum at the level of the 6th ribs. Auscultation of the valves You can hear at the 4 listening points mentioned by no means isolate one of the valves. It deals the total noise in each case which, however, is particularly the valve in question is strongly represented. Valves Cusp = flap Pulmonary and Aortic all have 3 cusps, Tricuspid, therefore they are all “tricuspid” valves. Aortic and Pulmonary “Tricuspid” valve also called “semilunar” valves. RA to RV Mitral valve has 2 cusps so it’s a “bicuspid” valve Pulmonary or pulmonic valve RV to pulmonary trunk (branches R and L) Mitral valve (the bicuspid one) LA to LV Aortic valve LV to aorta Mitral valve named after the Pope’s mitre  There are 2 types of heart valves Atrioventricular valves have flat Arterial Valves have 3 cup-shaped “semi- leaflets and a tension apparatus. lunar” cusps. Diastole Systole Atrioventricular valves  Chordae tendinae “Heart strings” Cord like tendons that connect papillary muscles to the tricuspid & mitral valves During atrial systole, chordae tendineae are relaxed because the atrioventricular valves are forced open. When the ventricles contract in ventricular systole, the increased blood pressures in both chambers push the AV valves to close simultaneously, preventing backflow of blood into the atria. Since the blood pressure in atria is much lower than that in the ventricles, the flaps attempt to evert to the low pressure regions. The chordae tendinae prevent the eversion (prolapse) by becoming tense thus pulling the flaps, holding them in closed position Semilunar valves (aortic, pulmonic)  Nodule When the opening is closed by the valve flaps, the nodules of the semilunar valve come together and reinforce to obstruct a potential triangular opening. 2 6  View of the internal surface of the right atrium: CSO, coronary sinus ostium EuchV, Eustachian valve, IVC, inferior vena cava The Eustachian valve (EV) of the inferior vena cava and the Thebesian valve (TV) of the coronary sinus is incompletely regressed structures of Eustachian valve embryonic sinus venosus. In most cases, the EV and TV disappear completely after birth or are represented only by a thin crescentic fold. On echocardiography, these vestiges may mimic Thebesi abnormal structures. an Valve In an original report, a case with giant EV and TV initially misinterpreted as rims of an atrial septal defect (ASD) led to the false diagnosis of ostium Coronary Sinus The coronary sinus serves as the primary collector of cardiac venous blood and is located in the atrioventricular groove on the diaphragmatic surface of the heart. The coronary sinus is the most prominent cardiac vein in terms of diameter. Various landmarks have been described as the location of the coronary sinus origin, including where the oblique vein of the left atrium meets the great cardiac vein and at the valve of Vieussens. The coronary sinus empties directly into the right atrium near the conjunction of the interventricular and coronary grooves (also known as the crux cordis area), located on the inferior region of the right atrial septum between the inferior vena cava and tricuspid valve. The atrial orifice can be partially covered by a Thebesian valve, although the anatomy of this valve is highly Coronary Venous Anatomy (Revision) Coronary venous flow occurs during diastole and systole, and the coronary venous system drains the myocardium of oxygen-depleted blood. The coronary venous system dominates the arterial system; there are at least twice as many veins as arteries in human myocardial tissue. In general, veins are considered "low-resistance conduits" to the heart and can alter their capacity to maintain venous pressure. The coronary veins can be organized into two subgroups: the more unique and more minor cardiac venous system. The unique cardiac venous system comprises the coronary sinus and its tributaries, as well as the anterior cardiac veins, atrial veins, and the veins of the ventricular septum. The minor cardiac venous system, also known as the Thebesian vessels, are small vessels that drain directly into their respective heart chambers. This image shows the anatomy of the coronary sinus and its tributaries. Anterior Interventricular Vein and Great Cardiac Vein Lateral Veins, Inferior Veins, Middle Cardiac Vein Small Cardiac Vein, Oblique Vein of the Left Atrium http://www.vhlab.umn.edu/atlas/coronary-system-tutorial/coronary-venous-anatomy.shtml Clinical relations During auscultation, every clinician should be able to recognize pathological sounds upon the valves, called murmurs. The processes that affect the valves can be classified as stenoses or insufficiencies, and any heart valve can be affected by such pathological changes. These pathologies are collectively known as valvular heart disease. Some examples include aortic stenosis, aortic regurgitation, mitral stenosis and mitral regurgitation. Stenotic processes will cause the valve to harden and not open properly. Thus, it will obstruct the blood flow from one heart chamber to another or the great vessels. On the other hand, insufficiencies usually present with loose valves which cannot close entirely. In this case, the blood will flow retro- gradely every time during systolic increases of pressure, which is called regurgitation. Based on the affected valve and type of valvular pathology, murmurs are present either during systole or diastole. The timing and location of the murmur then lead us to the diagnosis.  Valvular Insuffi ciency and Heart Murmurs The mitral valve is the most frequently diseased of the heart valves. -Nodules form on the valve cusps causing irregular (turbulent) blood flow. -Diseased cusps undergo scarring and shortening, resulting in mitral insufficiency, defective functioning and leakage of the mitral valve. -As a result, blood regurgitates into the left atrium when the left ventricle contracts, producing a characteristic heart murmur. -Aortic insufficiency results in aortic regurgitation (back rush of blood into the left ventricle), producing a heart murmur and a collapsing pulse (a forcible pulse that rapidly diminishes). Patientsname A.P. / Photo: P. Karanis A patient is taken to the A&E with acute chest pain. Cardiac enzymes are elevated. The patient died and an autopsy is performed. The cause A. Chordae tendineae. of death is rupture of the papillary muscles. What structure is indicated by the arrow in Figure 2 of this patient’s B. Coronary artery. heart? C. Musculi pectinate. D. Papillary muscle. E. Trabeculae carneae. A. Chordae tendineae. B. Coronary artery. C. Musculi pectinate. D. Papillary muscle. Figure 2. Heart specimen. E. Trabeculae carneae. A. Chordae tendineae. B. Coronary artery. C. Musculi pectinate. Fetal Circulation  Fetal Circulation 20 Wochen & 3 Tage Fetal Circulation Sinual horn derivatives in wall of right atrium. Pressures opening oval foramen before birth (D) and closing foramen to become oval fossa after birth (E). Red = O2 rich blood To make it easier to understand, the picture was put upside down (in normal Blue = red O2 poor blood late pregnancy the head of the fetus is at the bottom). violet = mixed blood Fetal circulation 1 Canalis cervicis uteri 2 Cavitas amniota 3 Ductus arteriosus 4 Arcus aortae 5 V. cava superior 6 Truncus pulmonalis 7 Atrium dextrum 8 Ductus venosus 9 V. cava inferior 10 V. umbilicalis 11 V. portae hepatis 12 Aa. umbilicales 13 Atrium sinistrum 14 Funiculus umbilicalis Chambers with embryologic fetal in pink; changes postnatal in blue added Two atria------------divided by interatrial septum Fossa ovalis left over from fetal hole in septum, the foramen ovale Right atrium--------in fetus RA received oxygenated blood from mom through umbilical cord, so blood travels from Rt to Lt through the foramen ovale Left atrium Two ventricles-----divided by interventricular septum Right ventricle-----in fetus the pulmonary trunk has high resistance => ductus arteriosus shunts blood to aorta In the fetus, the RA received oxygenated blood from the mother through the umbilical cord, so blood travels Rt to Lt through the foramen ovale: fossa ovalis is left after it closes. The pulmonary trunk had high resistance (because the lungs did not function yet) => ductus arteriosus shunted blood to aorta; it becomes ligamentum arteriosum after birth. Umbilical arteries > - distal parts > obliterate to Lig. umbilicale mediale The medial umbilical ligament (or cord of umbilical artery, or obliterated umbilical artery) is a paired structure found on the deep surface of the anterior abdominal wall, and is covered by the medial umbilical folds (plicae umbilicales mediales). - proximal parts > Aa. vesicales superiores Umbilical vein > Lig. teres hepatis at the lower  By far the most common site for tearing in traumatic aortic rupture is the proximal descending aorta, near where the left subclavian artery branches off from the aorta. The tethering of the aorta by the ligamentum arteriosum makes the site prone to shearing forces during sudden deceleration. Image pinterest.com  Atrial and Ventricular Septal Defects (ASD & VSD) Congenital anomalies of the interatrial septum- usually related to incomplete closure of the oval foramen- are atrial septal defects or ASDs. A probe size patency (defect) appears in the superior part of the oval fossa in 15% to 25% of people. By themselves, they are usually of no clinical significance; however, large ASDs allow oxygenated blood from the lungs to be shunted from the left atrium through the defect into the right atrium, causing enlargement of the right atrium and ventricle and dilation of the pulmonary trunk. Ventricular septal defects or VSDs are congenital and rank first on lists of cardiac defects. Isolated VSDs account for approximately 25% of all forms of congenital heart disease with defect size varying from 1 to 25 mm. A VSD causes the left-to-right shunt of blood through the defect. A large shunt increases pulmonary blood flow, which causes pulmonary disease (hypertension or increased blood pressure) and may cause cardiac failure. Patent foramen ovale Patent ductus arteriosus Q: A patient is diagnosed with deep vein thrombosis of the right inguinal vein. While in hospital, he suddenly experiences chest pain and difficulty in breathing. His blood O2 saturation drops to 89%. Which is the path followed by a blood clot travelling from the right inguinal vein to the lungs? A. Right inguinal vein to inferior vena cava to Right atrium to Right ventricle to pulmonary trunk. B. Right inguinal vein to inferior vena cava to Right atrium to Right ventricle to pulmonary vein. C. Right inguinal vein to inferior vena cava to superior vena cava to Right ventricle to pulmonary trunk. D. Right inguinal vein to superior vena cava to Right atrium to Right ventricle to pulmonary vein. E. Right inguinal vein to superior vena cava to Right atrium to right ventricle to Q: A patient is diagnosed with deep vein thrombosis of the right inguinal vein. While in hospital, he suddenly experiences chest pain and difficulty in breathing. His blood O2 saturation drops to 89%. Which is the path followed by a blood clot travelling from the right inguinal vein to the lungs? A. Right inguinal vein to inferior vena cava to Right atrium to Right ventricle to pulmonary trunk. B. Right inguinal vein to inferior vena cava to Right atrium to Right ventricle to pulmonary vein. C. Right inguinal vein to inferior vena cava to superior vena cava to Right ventricle to pulmonary trunk. D. Right inguinal vein to superior vena cava to Right atrium to Right ventricle to pulmonary vein. E. Right inguinal vein to superior vena cava to Right atrium to right ventricle to pulmonary trunk. In today’s session we have… Gone over the gross anatomy and surface anatomy of the heart. Identified the valves and their auscultation points. Described the anatomy of the valves. Described the sequence of the valves opening and closing during the cardiac circle. Examined blood flow through the heart and how that differs during fetal life.  Literature Images and videos used in this presentation come from various Atlas’ and Thank you! internet sites and are the property of their respective owners. Hansen, JT. 2010. Netter’s Clinical Anatomy 2. Saunders Elsevier Lippert H. 2000. Lehrbuch Anatomie. Urban & Fischer. Lippert, H. 1998. Anatomie am Lebenden. Springer. Moore, Dalley, Agur, Clinically Oriented Anatomy, 8th Ed. Wikipedia Hurst's the Heart. 2011. Fuster V, Walsh R, Harrington RA.13th Ed. Crawford MH, DiMarco J, Paulus W. 2009. Cardiology. 3rd ed.