SHANDONG UNIVERSITY Liu Zhiyu Angiology SHANDONG UNIVERSITY Liu Zhiyu

Angiology Composition Cardiovascular system Lymphatic system

The cardiovascular system Organization Heart A muscle pump to maintain the flow of blood Consist of four chambers (right and left atria, right and left ventricles) Artery (a.) carry blood away from the heart Veins ( v.) carry blood back to the heart Capillary microscopic vessels, the area of exchange between blood and tissue fluid

The cardiovascular system Blood circulation Systemic circulation left ventricle→aorta and its branches→capillaries of body→superior and inferior vena cava→right atrium Pulmonary circulation right ventricle→pulmonary a.→capillaries of lung → pulmonary v. →left atrium

The cardiovascular system Vascular anastomosis Anastomosis between a. Anastomosis between v. Arteriolovenular anastomosis Collateral vessels Collateral circulation

The Heart

The heart Position Lies within the pericardium in middle mediastinum Behind the body of sternum and coastal cartilages 2 to 6 In front of thoracic vertebrae 5 to 8 A third of it lies to the right of median plan and 2/3 to the left

Surfaces of the heart

Surfaces of the heart Pyramidal in shape, somewhat larger than a closed fist One apex One base Two surface Three borders Four sulcuses

Cardiac apex Formed by left ventricle Directed downwards, forward, and to the left Lies at the level of the fifth left intercostal space, 1~2 cm medial to the left midclavicular line (9cm from the midline)

Cardiac base Formed by the left atrium and to a small extent by the right atrium. Faces backward, upward and to the right

Sternocostal surface Formed mainly by the right atrium and right ventricle, and a lesser portion of its left is formed by the left auricle and ventricle Directed forwards and upwards

Diaphragmatic surface Formed the ventricles－chiefly the left ventricle Directed backwards and downwards, and rest upon the central tendon of the diaphragm

Borders of the heart Right border Left border Inferior border Vertical Formed entirely by right atrium Left border Round Mainly formed by the left ventricle and partly by the left auricle Inferior border Horizontal Formed by the right ventricle and cardiac apex

Sulcuses of the heart Coronary sulcus (circular sulcus) which marks the division between atria and ventricles, contains the trunks of the coronary vessels and completely encircles the heart Interatrial sulcus －separates the two atria and is hidden by pulmonary trunk and aorta in front

Sulcuses of the heart Anterior interventricular groove Posterior interventricular groove Mark the division between ventricles (which separates the RV from the LV) Cardiac apical incisure Atrioventricular crux

Chambers of the heart

Chambers of the heart Consists of four chambers Left and right atria Left and right auricle Left and right ventricles

Right atrium (RA) Three inlets Orifice of superior vena cava returns blood to the heart from the upper half of the body Orifice of inferior vena cava returns blood to the heart from the lower half of the body Orifice of coronary sinus returns blood to the heart from the cardiac muscle One outlet －right atrioventricular orifice

Right atrium (RA) Crista terminalis －vertical ridge that from superior vena cave to inferior vena cave Sulcus terminalis－groove on exterior of heart that corresponds to crista terminalis Two parts －separated externally by sulcus terminalis and internally by the crista terminalis Atrium proper Sinus venarum cavarum

Right atrium (RA) Atrium proper Sinus venarum cavarum In front of the ridge Pectinate muscles in wall Sinus venarum cavarum Smooth walls Fossa ovalis － an oval depression, a remnant of the fetal foramen ovale, on the lower part of interatrial septum, the most common location of atrial septal defects (ASD) Aortic mound

Right ventricle (RV) One inlet －right atrioventricular orifice One outlet 　　－orifice of pulmonary trunk

Right ventricle (RV) Supraventricular crest (a muscular ridge between right atrioventricular orifice and orifice of pulmonary trunk ) Two parts Inflow tract Outflow tract

Right ventricle (RV) Inflow tract Trabeculae carneae irregularly arranged bundles of myocardium Septomarginal trabecula －extends from interventricular septum to base of anterior papillary muscle, contains right bundle branch Papillary muscles Conical-shaped Three: anterior, posterior and septal

Right ventricle (RV) Outflow tract —Conus arteriosus Cone-shape , smooth area leading upward to orifice of pulmonary trunk Pumps blood through pulmonary orifice to pulmonary trunk

Tricuspid valve Guards right atrioventricular orifice Three triangular cusps: anterior, posterior and septal Base of cusps are attached to fibrous ring surrounding the atrioventricular orifice. To their free edges and ventricular surfaces are attached chordae tendineae , which connect the cusps to the papillary muscles.

Tricuspid valve

Tricuspid complex Tricuspid ring Tricuspid valve Chordae tendineae Papillary muscles

Chordae tendineae Papillary muscles

Function of tricuspid complex Open during diastole to allow blood to enter ventricles from atria Closed during systole to prevent regurgitation of blood into atria

Valve of pulmonary trunk Guards the orifice of pulmonary trunk Has three semilunar cusps – each with free border that has central modules called nodules of semilunar valve Has three pulmonary sinuses —bulges in wall of pulmonary trunk at level of valve that correspond to cusps

Function of pulmonary valves Opening during systole, with cusps pressed toward wall of vessel as blood is forced upward Closed during diastole Ventricular pressure drops in diastole Floating together of valve cusps, with free borders meeting, thus closing the valve

Left atrium (LA) Four inlets－four orifices of pulmonary veins One outlet－left atrioventricular orifice

Left ventricle (LV) One inlet left atrioventricular orifice One outlet － aortic orifice Two parts－divided by anterior cusps of mitral valve Inflow tract－rough walls Outflow tract Aortic vestibule Smooth area leading to aortic orifice

Mitral valve Guards left atrioventricular orifice Two triangular cusps－anterior and posterior with commissural cusps between them (posteromedial and anterolateral commissures)

Mirtal complex Mitral ring Mitral valve Chordae tendineae Papillary muscles

Function of mitral complex Open during diastole to allow blood to enter ventricles from atria Closed during systole to prevent regurgitation of blood into atria

Aortic valve Guards the aortic orifice Three semilunar cusps (right, left and posterior) Each with free border that has nodules of semilunar valve Aortic sinus – bulges in aortic wall at level of valve that correspond to cusps Right－contains opening of right coronary artery Left－contains opening of left coronary artery Posterior－no opening

Function of aortic valves Opening during systole, with cusps pressed toward wall of vessel as blood is forced upward Closed during diastole Ventricular pressure drops in diastole Floating together of valve cusps, with free borders meeting, thus closing the valve

Structures of the heart

Structures of the heart Walls of heart Endocardium Inner coat of the heart wall Continuous with the valve flaps Myocardium Arranged spirally Attached to fibrous rings surrouding the four orifices of heart The walls of left ventricle are about three times thicker than that of right Epicardium Outer Visceral layer of serous pericardium

Structures of the heart Interatrial septum Located between right and left atria Contains fossa ovalis Interventricular septum Located between right and left ventricles Has upper membranous part Has thick lower muscular part Atrioventricular septum

Membranous part of interventricular septum

Ventricular Septal Defect Note the large ventricular septal defect * which may be seen in this photo. * *

Fibrous skeleton of heart Fibrous rings that surround the atrioventricular, pulmonary, and aortic orifices Left and right fibrous trigones

Conduction system of heart

Conduction system of heart Composed of specialized myocardial cells Sinuatrial node Internodal tract Atrioventricular node Atrioventricular bundle Right and left bundle branches Purkinje network

Conduction system of heart Sinuatrial node (SA node) Called the pacemaker cell (P cell) Located at the upper part of the sulcus terminalis close to the superior vena cava, under the epicardium.

Conduction system of heart Atrioventricular node (AV node) Located in the lower part of interatrial septum, near orifice of coronary sinus and base of tricuspid valve Under the endocardium Lower part related to membranous part of interventricular septum

Conduction system of heart Atrioventricular bundle (AV bundle) Passes forward through right fibrous trigon to reach inferior border of membranous part Divides into right and left bundle branches at upper border of muscular part of interventricular septum

Conduction system of heart Right and left bundle branches Right bundle branch－passes down on right side of interventricular septum to reach the septomarginal trabecular and into the base of anterior papillary muscle. Here it becomes continuous with the fibers of Purkinje fibres Left bundle branch－passes down on left side of interventricular septum beneath the endocardium. It usually divides into two branches, which eventually become continuous with the Purkinje fibers Purkinje network continuous with myocardium

Atrioventricular bundle Atrioventricular node ★ Sinuatrial node Atrioventricular bundle Right and left bundle branches Atrioventricular node Purkinje network

Arterial supply of the heart

Arterial supply of the heart Left coronary artery Course Arises from left aortic sinus Runs between pulmonary trunk and left auricle into coronary sulcus Branches Anterior interventricular branch －runs downward in anterior interventricular groove around inferior margin of heart to posterior interventricular groove Circumflex branch －travels to left in coronary sulcus to posterior aspect Distribution－supplies left atrium and ventricle, lesser portion of anterior wall of right ventricle, and anterior 2/3 of interventricular septum

Arterial supply of the heart Right coronary artery Course Arises from the right aortic sinus Runs forward between right auricle and pulmonary trunk into coronary sulcus Branches Right marginal branch travels along inferior border Posteror interventricular branch －travels downward in posterior interventricular groove, it anastomosises near the apex with the anterior interventricular branch of the left coronary artery Distribution: supplies right atrium and ventricle, posterioinferior 1/3 of interventricular septum, posterior wall of left ventricle, the sinuatrial node and atrioventricular node

Thrombus in Coronary Artery Angiogram 冠状动脉造影显示动脉血栓

Coronary artery bypass grafting (CABG) Precutaneous translaminal coronary angioplasty (PTCA) Stent in an artery

Venous drainage of the heart

Venous drainage of the heart Coronary sinus Lies in posterior part of coronary sulcus Carries most of venous blood from myocardium to right atrium Tributaries Great cardiac vein Middle cardiac vein Small cardiac vein

Pericardium 心包

Pericardium 心包 Fibrous pericardium 纤维心包 Serous pericardium 浆膜心包 Attached to central tendon of diaphragm inferiorly Blends with outer coat of great vessels superiorly Serous pericardium 浆膜心包 Visceral layer (epicardium) Parietal layer Pericardial cavity 心包腔 Potential space between visceral and parietal layes Contains film of pericardium fluid as a lubricant to facilitate cardiac movements

Pericardium 心包 Pericardium sinus Formed by reflection of serous pericardium Transverse sinus of pericardium 心包横窦 Posterior to ascending aorta and pulmonary trunk Anterior to superior vena cava and left atrium.

Pericardium sinus Oblique sinus of pericardium 心包斜窦－cul-de-sac , posterior to heart, bounded by pulmonary veins on either side Anterior inferior sinus of pericardium 心包前下窦

Venous drainage of heart Anterior cardiac veins －3~4 small vessels, drain into right atrium Smallest cardiac veins －drain into all chambers, mainly atria

Surface markings of heart

Surface markings of heart R. superior point－ lies on the upper border of right third costal cartilage ±1.2cm from the margin of sternum R. inferior point － lies on the sixth sternocostal joint L. superior point － lies on lower border of left second costal cartilage ±1.2cm from sternal margin Cardiac apex－in the fifth left intercostal space 7~9cm from the midline

Surface markings of heart Right border－corresponds to a line running from the upper border of right third costal cartilage ±1.2cm from the margin of sternum, downwards to sixth sternocostal joint Apex－in the fifth left intercostal space 7~9cm from the midline Left border－represented by a line running from apex upwards and medially to a point on lower border of left second costal cartilage ±1.2cm from sternal margin Lower border－represented by a line joint the lower end of right border to apex

★You must identify follow structures！ Vessels of heart Left coronary artery Anterior interventricular branch Right coronary artery Posteror interventricular branch coronary sinus Right atrium Orifice of superior vena cava Orifice of inferior vena cava Orifice of coronary sinus Sulcus terminalis Fossa ovalis Pectinate muscles Shape of heart Cardiac apex Cardiac base Coronary sulcus Anterior interventricular groove Posterior interventricular groove Cardiac apical incisure Atrioventricular crux Right and left auricle Pulmonary trunk

★You must identify follow structures！ Left atrium Orifices of pulmonary veins Left atrioventricular orifice Left ventricle Aortic vestibule Mitral valve Aortic vavle Aortic sinus Right ventricle Right atrioventricular orifice Tricuspid valve Chordae tendineae Papillary muscles Supraventricular crest Trabeculae carneae Septomarginal trabecula Conus arteriosus Valve of pulmonary trunk