1. David Kachlík, Štěpán Jelínek
Heart
David Kachlík, Štěpán Jelínek

2. Heart situation

3. Heart development sinus venosus common atrium ventricle bulbus cordis
truncus arteriosus
atrium - sinus venarum cavarum
atrium (separated with crista terminalis)
ventricle (inflow part)
ventriculus (outflow part separated with crista supraventricularis)
aorta + truncus pulmonalis

4. Heart description basis x apex auricula dextra et sinistra
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.

5. Heart structure endocardium = tunica intima myocardium = tunica media
working myocardium
excitomotor apparatus (EA) = conducting m.
fibrous skeleton of heart
pericardium

6. 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

7. 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

8. 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

9. Myocardium

10. Pericardium

11. 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)

12. Heart cavities atrium dextrum + sinistrum septum interatriale
septum atrioventriculare
ventriculus dexter + sinister
septum interventriculare (pars membranacea + muscularis)

13. 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

14. Atrium dextrum (right atrium)
auricula dextra
sinus venarum cavarum
crista terminalis
mm. pectinati
ostium atrioventriculare dextrum
trigonum nodi atrioventricularis Kochi

15. 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

16. 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

18. Right-sided compartments

19. Atrium sinistrum (left atrium)
auricula sinistra
ostia venarum pulmonalium
mm. pectinati
valvula foraminis ovalis
(= former falx septi Parchappei)

20. 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)

23. Left-sided compartments

24. ECHO

25. 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

28. 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

29. Coronary arteries

30. 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)

33. 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

34. Coronary arteries

35. Arteria coronaria sinistra
ACS in posteroanterior projection
ACS in lateral projection (right to left)
ACS in lateral projection (left to right)

36. Ponticulus

37. Stenosis in ACS

38. Arteria coronaria dextra
ACS in posteroanterior projection
ACS in lateral projection (right to left)
ACS in lateral projection (left to right)

39. Collateral vessels

40. 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

43. Heart veins
Vv. ventriculi dextri anteriores = vv. cardiace (cordis) anteriores → atrium dextrum
Vv. cadiace (cordis) minimae Thebesii → all cavities
without any major clinical importance 

44. 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

46. 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

47. 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

49. 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)

51. Purkyně fibres (HE + elastin)

52. artificial pacemaker

53.  Physiology Heart cycle Pulse and volumes EKG curve
systole
diastole
Pulse and volumes
EKG curve
Arterial pulse curve with dicrotic notch
Endocrinne function - ANF

54. 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

55. Auscultation
Testut‘s points =
4 auscultation points

56. 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

57. Systolic/ diastolic pressures in the heart chambers

59. 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

60. Heart X-ray

61. Heart X-ray

62. Rheumatic vegetations

63. Endocarditis

64. Valvular insufficiency (regurgitation) and stenosis

65. Myocardial infarction

66. Cardiac aneurysm

67. Pericarditis

68. Cardiac trauma

69. Cardiac tamponade

70. The heart during CPR

71. Basic therapeutic operations
PTCA (= percutaneous transfemoral coronary angioplasty)

72. 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

74. Valvular replacement

75. Valvular replacement

76. Cardiac transplantation

77. Practical training X-ray of heart and lungs Valve auscultation
Heart specimen – whole x dissected
Histological slides of heart muscle

78. 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