1. Pericardium Topography and clinical anatomy of the heart
Ágnes Nemeskéri
Semmelweis University
Department of Human Morphology and Developmental Biology

2. Human heart Topograpy of heart Pericardium
Surface relation of the heart
Auscultation
Percussion
Clinical anatomy (CT, X-ray, echocardiography,
MRI) of the heart

3. 1. Topography of the heart - mediastinum
Mediastinum – central compartment of thoracic cavity
Mediastinal-pleura-Picture1.jpg
superior
mediastinum
anterior
mediastinum
middle
mediastinum
inferior
mediastinum
subdivided into 3 parts
posterior
mediastinum

4. 1. Topography of the heart – axis of the heart
- cardiac long axis lies in a line drawn from the left hypochondrium towards the right shoulder

5. 1. INTRATHORACIC TOPOGRAPHY OF THE HEARTMR

6. 1. Topography of the heart
Medio-clavicular-line
Mamillary-line

7. 2. PERICARDIUM
- fibrous pericardium is the most superficial layer of the pericardium
it is made up of dense connective tissue,
prevents the heart from overfilling with blood
continuous with the outer adventitial layer of the great blood vessels
serosal pericardium is a single layer of flat cells lying on a subserosal connective tissue
subserosal layer is closely adherent to the fibrous pericardium in the parietal membrane
visceral membrane (epicardium) fuses loosely with the myocardium (fat in the subserosal layer)
2 layers form a continuous uninterrupted membrane
between the two layers exists a small cavity called the pericardial cavity, containing a serous fluid: pericardial fluid
serosal layer faces the pericardial cavity - possibly secretes the pericardial fluid

8. 2. FIBROUS AND SEROUS PERICARDIUM
/png/close_layers_of_pericardium png
fibrous pericardium is fixed in the thoracic cavity
fibrous bag is inseparably fused to
anterior portion of the central tendon of the diaphragm
anterior surface attaches to the sternum
pretracheal fascia descends into the mediastinum from the neck
fuses with the anterior surface of the fibrous pericardium
- posteriorly it attaches to the tracheal bifurcation

9. 2. Visceral and parietal pericardium

10. 2. Development of the pericardium
Dorsal mesentery
transverse sinus

11. 2. Transverse and oblique pericardial sinus
line of reflection
between the epicardium (visceral) and parietal pericardium
transverse sinus of pericardium
oblique sinus of pericardium
„bare” area

12. 2. Oblique and transverse sinus of the pericardium

13. 2. Pericardial fluid
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Ben-Horin et al. (2005) studied the pericardial fluid in patients undergoing open heart surgery
the fluid is made up of a high concentration of lactate dehydrogenase (LDH), protein and lymphcytes
in a healthy adult there is usually ml of clear
there is little data on the normal composition of pericardial fluid to serve as a reference
in patients with ischemic heart disease there is an accumulation of angiogenic growth factors
the formation of new blood vessels and the increase in diameter of existing arterioles
it helps to prevent myocardial ischemia (lack of oxygen to the heart)

14. 3. Thoracic surface relations of heart - projections
the anterior longitudinal sulcus:
a finger’s breadth to the right of the left margin of the heart
- apex of the heart: apex beat, 9 cm to the left of the midsternal line – PALPATION!
- coronary sulcus - right end: 2 cm from sixth right sternocostal articulation:
- inlet of superior vena cava: the third right costal cartilage 1 cm from the right lateral sternal line:
- coronary sulcus - left end: the third left costal cartilage 3 cm from the left lateral sternal line:

15. 3. Thoracic surface relations of heart

16. 4. Auscultation
Heart sounds are closely associated with the closure of valves (reflect the turbulence)

17. Auscultation Auscultatory site Chest location Aortic area
Second right intercostal space close to sternum
Pulmonic area
Second left intercostal space close to sternum
Erb’s point
Second and third left intercostal space close to sternum
Tricuspid area
Fifth right and left intercostal space close to sternum
Mitral or apical area
Fifth intercostal space, left mid-clavicular line (third to fourth intercostal space and lateral to left midclavicular line in infants)
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18. Wikipedia
5. CARDIAC PERCUSSION
Leopold von Auenbrugger (1722 – 1809)
Tapping lightly on the chest, one could assess the texture of underlying tissues and organs. This technique of percussive diagnosis had its origins in testing the level of wine barrel in the cellar of his father's hotel. With this method, he was able to plot outlines of the heart.
To some the physical exam is defunct, supplanted by scans and lab. Two hundred and fifty years later, the technique of percussion is still a cornerstone of the art of the physical exam. Next time you percuss an ascitic abdomen or tap out the level of a pleural effusion, think back to Leopold Auenbrugger, his Inventum Novum (1754), and the birth of the modern physical exam. by Melinda Henry, Mayo Medical School, and Jamie Newman, MD, FACP, 2006

19. 5. PERCUSSION
/Mediastinal-pleura-Image.jpg
an area of the heart is uncovered by lung, and therefore gives a dull note on percussion:
absolute cardiac dullness (triangular)
- the remainder being overlapped by lung gives a more or less resonant note
area of relative cardiac dullness

20. 5. PERCUSSION relative dullness absolute dullness

21. 6. Clinical anatomy, conventional roentgen examination
Arcus aortae
Truncus
pulmonalis
Auricula sinistra
Ventriculus sinister
Atrium dextrum
Vena cava superior
Atrial septal defect – right atrium and ventricle increased in size (hypertrophy)

22. 6. Clinical anatomy (Rtg)
Mitral stenosis: narrowing of the orifice of the mitral valve
The constant pressure overload of the left atrium will cause the left atrium to increase in size 
Retrocardiac space – Holzknecht’s space
-left lateral view
-traversed by the esophagus
Left atrium hypertrophy
Hiatal hernia
Esophageal lesion
Left ventricular aneurysm
Pericardial cyst
Bronchogenic cyst
Aortic aneurysm
Vagal / phrenic nerve neurofibroma

23. 6. Clinical anatomy (Rtg)
Pericardiocentesis
A long cardiac needle is inserted under the xiphoid
approach on the left side of the heart
using guided imagery (echocardiography) into the chest wall
until the needle reaches the pericardial sac.

24. 6. Clinical anatomy (transthoracic echocardiography)
Echocardiogram is a sonogram of the heart
Interventricular septum defect
3D echocardiogram viewed from the apex – 4D echo

25. 6. Clinical anatomy (transesophageal echocardiography)

26. 6. Clinical anatomy (MRI, CT scan)
cardiomegaly

27. References