Download Myocardium

Heart
David Kachlík, Štěpán Jelínek
Heart situation
Heart development
 sinus venosus
 atrium - sinus venarum cavarum
 common atrium
 atrium (separated with crista
 ventricle
terminalis)
 ventricle (inflow part)
 ventriculus (outflow part separated
with crista supraventricularis)
 bulbus cordis
 truncus arteriosus
 aorta + truncus pulmonalis
Heart 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 structure
 endocardium = tunica intima
 myocardium = tunica media
working myocardium
 excitomotor apparatus (EA) = conducting m.
 fibrous skeleton of heart
 pericardium

Endocardium
 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
Myocardium
 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
Myocardium
Pericardium
Pericardium
 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 cavities
 atrium dextrum + sinistrum
 septum interatriale
 septum atrioventriculare
 ventriculus dexter + sinister
 septum interventriculare (pars membranacea +
muscularis)
Atrium dextrum (right atrium).
 foramen v. cavae inf.

valvula v.c.i. Eustachii
 foramen v. cavae sup.

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)
 auricula dextra
 sinus venarum cavarum
 crista terminalis
 mm. pectinati
 ostium atrioventriculare
dextrum
 trigonum nodi
atrioventricularis Kochi
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)
 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 compartments
Atrium sinistrum (left atrium)
 auricula sinistra
 ostia venarum pulmonalium
 mm. pectinati
 valvula foraminis ovalis
(= former falx septi Parchappei)
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 compartments
ECHO
Fibrous 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 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 arteries
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)
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 arteries
Arteria coronaria sinistra
ACS in
posteroanterior
projection
ACS in lateral
projection
(right to left)
ACS in lateral
projection
(left to right)
Ponticulus
Stenosis in ACS
Arteria coronaria dextra
ACS in
posteroanterior
projection
ACS in lateral
projection
(right to left)
ACS in lateral
projection
(left to right)
Collateral vessels
Heart 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 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 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 heart
Complexus stimulans cordis
Systema conducens cordis
„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 - parts
 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 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
pacemaker
 Physiology
 Heart cycle


systole
diastole
 Pulse and volumes
 EKG curve
 Arterial pulse curve with dicrotic notch
 Endocrinne function - ANF
Examination
 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 – Testut´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 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-ray
Heart 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
operations
 PTCA (= percutaneous
transfemoral coronary
angioplasty)
Basic 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 replacement
Valvular replacement
Cardiac
transplantation
Practical training
 X-ray of heart and lungs
 Valve auscultation
 Heart specimen – whole x dissected
 Histological slides of heart muscle
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