The segmental approach for analysis of heart , as suggested by dr robert anderson

1. Segmental Anatomy of Heart

3. Segmental Analysis
• Richard Van Praagh Dr Robert Anderson

5. Anderson’s Philosophy
• Based on recognisable anatomical facts
• Three facets of the cardiac components
( Atria, ventricle and great vessels)
• Morphological description
• Joined/Not joined to each other
• Relationship between them
• Clarity is more important than brevity -
words replace symbols

6. Sequential Segmental Analysis
• Three Cardiac Components
• Atria
• Ventricle
• Great Vessels
• Two Junction
• Atrioventricular
• Ventriculoarterial

7. Principles
• Cardiac Components
• Identify each with its constant characteristic feature
• Determine its location/arrangement
• Junction
• Identify presence/absence of communication between different
components
• Describe the valvular morphology/connection

8. • Structures should be recognised in terms of their own intrinsic
morphology.
• NOT on that one part of the heart which is itself variable.

9. Cardiac Orientation
• Levocardia
• Mesocardia
• Dextrocardia

11. Atria - Identification

12. Morphologically Right
• Triangular appendage with broad base
• Pectinate muscle extending upto vestibule of right AV
valve
• Has crista terminalis and tinea sagittalis
• Septal surface: superior and inferior limbic bands of
fossa ovale

13. • Tubular appendage with narrow base
• Pectinate muscle limited to the appendage
Septal surface has septum primum (FO valve)
Morphologically Left Atrium

14. Atria - Arrangement
Arrangement Right Side Left Side Van Praag
Usual Morphological Right Morphological Left Situs Solitus (S)
Mirror Image Morphological Left Morphological Right Situs Inversus (I)
Right Isomerism Morphological Right Morphological Right Ambiguous (A)
Left Isomerism Morphological Left Morphological Left Ambiguous (A)

20. Common Associations with Atrial Arrangment
Arrangement Usual Mirror Image Right Isomerism Left Isomerism
Spleen Left Side Right Side Absent Multiple
Stomach Left Side Right Side Malrotation Malrotation
Liver Right Side Left Side Midline Midline
Right
Lung/Bronchus
3 Lobes 2 Lobes 3 Lobes 2 Lobes
Left
Lung/Bronchus
2 Lobes 3 Lobes 3 Lobes 2 Lobes
IVC Right Side Left Side Anterior Posterior
Aorta Left Side Right Side Posterior Anterior

25. RIGHT ISOMERISM
LEFT
ISOMERISM

27. LEFT ISOMERISM
RIGHT ISOMERISM

28. LEFT ISOMERISM

29. RIGHT
ISOMERISM

30. Systemic and Pulmonary Veins
• Systemic veins - SVC and IVC drain into the morphological right atrium
• Pulmonary veins - Four in number, drain into the morphological left atrium

31. Ventricle - Identification
• Morphologically Right Ventricle
• Coarse trabeculations
• Complete, muscular infundibulum
• Morphologically Left Ventricle
• Fine trabeculation
• Partially effaced, fibromuscular infundibulum

32. RIGHT VENTRICLE
• MORPHOLOGICAL FEATURES OF THE NORMAL RIGHT VENTRICLE
• TRAPEZOID SHAPE
• COARSE TRABECULATIONS
• A BODY OR SINUS PORTION AND AN OUTFLOW OR INFUNDIBULUM
DEMARCATED BY A MUSCULAR CREST COMPOSED OF THE PARIETAL
BAND ,SEPTAL BAND ,MODERATOR BAND.
• A TRICUSPID VALVE WITH CHORDAL INSERTIONS ON THE VENTRICULAR
SEPTUM
• TRICUSPID VALVE – PULMONARY VALVE DISCONTINUITY OWING TO
INTERVENING INFUNDIBULAR MUSCLE

33. TRAPEZOID SHAPE

35. INLET

36. OUTLET

38. LEFT VENTRICLE
• ELLIPSOIDAL OR BULLET SHAPE
• FINE TRABECULATIONS ON THE FREE WALL AND APICAL
SEPTUM,WITH A SMOOTH MID AND BASAL SEPTUM
• ADJACENT INFLOW AND OUTFLOW TRACTS
• TWO WELL DEFINED PAPILLARY MUSCLE GROUPS ORIGINATING
FROM THE FREE WALL
• ABSENCE OF SEPTAL INSERTION OF THE MITRAL VALVE
• FIBROUS CONTINUITY BETWEEN THE MITRAL AND AORTIC VALVES

39. INLET

41. OUTLET

43. Ventricle - Topology
• Two basic patterns, which cannot be changed without physically taking apart the
ventricular components and reassembling them
• Described only with respect to right ventricle
• Thumb = inlet, palmar surface = septum and finger = outlet
• Right Hand Topology ( Van Praag = dextro looping or d-looping or D)
• Possible when morphological right ventricle on right heart side
• Left Hand Topology ( Van Praag = levo looping or l-looping or L)
• Possible when morphological right ventricle on left heart side

47. Ventricle - Relation
• Position of ventricle with respect to each other
• Right and Left
• Anterior and Posterior
• Superior and Inferior
• Secondary to rotation of the distal/outlet portion of the ventricle
• Dishamonious arrangements - Criss Cross Hearts
★ Irrespective of the relation of the ventricular mass in space, the topology
remains same

49. Complete/Incomplete Ventricle
• Ventricle has three components
• Inlet
• Apical Trabeculated Portion
• Outlet
• Incomplete/Hypoplastic ventricle - Only one or two of the three components
are present
• Incomplete ventricle’s position described in terms of the dominant ventricle

51. Complete/Incomplete Ventricle
★ Topology of incomplete right ventricle difficult to determine, but
however small the ventricle, the morphology (left or right) can usually
be determined
★ Virtually all human hearts have two ventricles, however one may be
very small and the heart may be functionally univentricular. The term
univentricular heart/single ventricle heart should be restricted to
heart with a true solitary ventricle

52. Atrioventricular Connection
Atria 2 2 1
Ventricle 2 1 1
Connection Biatrial Biventricular Double Inlet Ventricle Uniatrial Univentricular
Types
Concordant
Discordant Mixed
Dominant RV
Dominant LV
Solitary Ventricle
Absent Right AV
Connection
Absent Left AV
Connection
• Connection of atrial myocardium with ventricular myocardium irrespective
of valvular morphology

58. Biatrial Biventricular
Atrial Usual Mirror Image Right Isomerism Left Isomerism
Van Praag S I A A
Ventricle
Right
Handed
Topology
Left Handed
Topology
Right
Handed
Topology
Left Handed
Topology
Right
Handed
Topology
Left Handed
Topology
Right
Handed
Topology
Left Handed
Topology
Van Praag d-loop l-loop d-loop l-loop d-loop l-loop d-loop l-loop
Van Praag D L D L D L D L
Type Concorant Discordant Discordant Concorant Mixed Mixed

61. Double Inlet Ventricle
Atrial Usual/Mirror Image/Isomerism
Van Praag S/I/A
Ventricle
Dominant RV
Incomplete LV
Dominant LV
Incomplete RV
True Single Ventricle
Ventricle Topology Cannot be determined Cannot be determined -
Van Praag Ambiguous Ambiguous Ambiguous
Van Praag X X X
Type DIRV DILV DIV

63. Uniatrial Univentricular
Atrial Usual/Mirror Image/Isomerism
Van Praag S/I/A
Ventricle
Dominant LV
Incomplete/Small RV
Dominant RV
Incomplete/Small LV
Ventricle Topology Cannot be determined Right/Left
Van Praag Ambiguous Ambiguous
Van Praag X X
Type Absent Right AV connection Absent Left AV Connection

66. Atrioventricular Valvular Morphology
Atria 2 2 1
Ventricle 2 1 1
Connection Biatrial Biventricular Double Inlet Ventricle Uniatrial Univentricular
Types
Both Patent Valves
One Imperforate and the Other Patent
Common Valve
Straddling Valve
Overriding Valve
Patent and Committed
Straddling Valve
Overriding Valve
• Morphology of Valve Independent of communication at AV junction

70. OVERRIDING VALVES
• Overriding may be defined as a biventricular emptying of an
atrioventricular valve or biventricular origin of a semilunar valve
• It is a property of the valve annulus and is always associated with a
malalignment ventricular septal defect.

71. Malalignment
• For overriding atrioventricular valves, the atrial and ventricular septa are malaligned.
• The ventricular septal defect tends to involve the basal portion of the inlet septum
• For the assessment of atrioventricular connections, an atrium is considered to join the
ventricle into which >50% of the valve orifice empties
• A common atrioventricular valve is usually associated with concordant or discordant
connections, although a common-inlet arrangement applies if >75% of the valve orifice
empties into only one of the two ventricles.
• Overriding of the semilunar valves is associated with malalignment of the outlet septum
relative to the remainder of the ventricular septum. Malalignment can be lateral, rotational, or a
combination of these .
• The ventricular septal defect is located beneath the overriding artery and is either membranous
or outlet in location, or a combination of the two. As with the atrioventricular valves, the 50%
rule also applies to the semilunar valves

72. STRADDLING
• Straddling Valves In contrast to annular overriding, straddling involves the
anomalous insertions of chordae tendineae (tendinous cords) or papillary
muscles into the contralateral ventricle .
• Thus, straddling involves only the atrioventricular valves and requires the
presence of a ventricular septal defect. Although straddling does not affect
the evaluation of atrioventricular connections.

73. • The three types of straddling are determined by the sites or cordal
insertion into the contralateral ventricle along the crest (type A) or body
(type B) of the ventricular septum, or onto the ventricular free wall (type C).

74. Ventriculoarterial Connection
• Connection of ventricular myocardium with arterial trunk irrespective of
valvular morphology

75. Ventriculo-arterial connection
• If the aorta arises from the left ventricle and the pulmonary artery
arises from the right ventricle, the relationship is concordant
• When the aorta arises from the right ventricle and the pulmonary
artery from the left ventricle, the relationship is discordant
• A great vessel should be related to a ventricle by at least 50% of its
dimension to be considered committed to it
• No particular view to determine the relationship

76. Great vessel relationship
• Aorta - gives rise to neck vessels as it
courses posteriorly, and has coronary
arteries arising from its root
• Pulmonary artery - courses posteriorly
almost immediately after it arises from
the heart and bifurcates shortly after
its origin
PSAX, Subcostal short axis

77. Ventriculoarterial Connection
Ventricle Right handed topology/Left handed topology
Van Praag D/L
Great Vessels
Two Vessels connected to
Two ventricles
Two Vessels connected to
Single Ventricle
Single Vessel Connected to
One/Both Ventricles
Type
Concordant
Discordant
Double Outlet Ventricle
DORV/DOLV
Common Trunk
Solitary Trunk
Aortic root with Pulmonary
Atresia
Pulmonary root with Arotic
Atresia

83. Ventriculoarterial Connection-Two Ventricles Two
Arteries
Ventricle Right handed topology Left handed topology Right handed topology Left handed topology
Van Praag D L D L
Pulmonary Trunk
Origin
Right Heart Ventricle Right Heart Ventricle Left Heart Ventricle Left Heart Ventricle
Aorta Origin Left Heart Ventricle Left Heart Ventricle Right Heart Ventricle Right Heart Ventricle
Type Concordant Discordant Discordant Concordant

84. Ventriculoarterial Valvular Morphology
Ventricle Right handed topology/Left handed topology
Van Praag D/L
Great Vessels
Two Vessels
connected to Two
ventricles
Two Vessels
connected to Single
Ventricle
Single Vessel
Connected to Both
Ventricles
Single Vessel
Connected to One
Ventricles
Type
Concordant
Discordant
Double Outlet Ventricle
DORV/DOLV
Common Trunk
Solitary Trunk
Aortic root with
Pulmonary Atresia
Pulmonary root with
Arotic Atresia
Valves
Both Patent
One Patent and the other imperforate
Overriding
Common Valve Single Valve

87. Relation of Arterial Trunks
• Described at the level of the ventriculoarterial valve
• Position of aorta described with respect to the pulmonary trunk as the
centre
• Normal position of aorta - Posterior and Right of Pulmonary Trunk
• Normal - Pulmonary Artery spirals around the Aorta
• Parallel ascent of great vessels also observed, usually ASSOCIATED
with DORV or discordant ventriculoarterial connection
• Right aortic arch passes right of the trachea

92. Ventricular Infundibulum
• Three parts
• Anterior/Parietal - Free ventricular wall
• Posterior - Ventriculo infundibular fold
★ Separates ventriculoarterial valve from atrioventricular valve
• Infundibular/Outlet Septum
★ Separates the ventriculoarterial valves from each other

93. Ventricular Infundibulum
• Effaced ventriculo infundibular fold > continuity between atrioventricular
valve and ventriculoarterial valve
• Normal
• Morphological Right Ventricle - Complete muscular infundibulum with
no pulmonary-tricuspid continuity
• Morphological Left Ventricle - Partially effaced infundibulum with
arotomitral continuity ( Aortomitral Curtain)