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Anatomy & physiology for the EP professional part I 8.4.14


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Chest, femoral and cardiac vasculature

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Anatomy & physiology for the EP professional part I 8.4.14

  1. 1. Anatomy & PhysiologyAnatomy & Physiology for the EP professionalfor the EP professional Part I
  2. 2. ObjectivesObjectives • Describe the anatomic structures of the chest • Identify the neck, chest and femoral vasculature. • Describe vascular access and complications. • Identify cardiac chambers, valves, arteries & veins • Identify blood supply to the conduction system • Describe the flow of blood through the heart
  3. 3. Thoracic CavityThoracic CavityThoracic AnatomyThoracic Anatomy
  4. 4. Thoracic AnatomyThoracic Anatomy
  5. 5. Thoracic VasculatureThoracic Vasculature
  6. 6. Thoracic VeinsThoracic Veins
  7. 7. Thoracic CageThoracic Cage • Houses the right & left Lung – Right lung has 3 lobes – Left Lung has 2 lobes • Heart • All structures are enclosed by the parietal pleura
  8. 8. Venous landmarks of upperVenous landmarks of upper chestchest
  9. 9. Chest Venous accessChest Venous access • Most often axillary access for device implants. • Internal jugular vein for T-pacer placement • Subclavian no longer the access of choice d/t pneumothorax & subclavian crush • Femoral vein for studies
  10. 10. Chest venous accessChest venous access • Axillary vein is lateral to the apex of the left lobe of the lung • Less complications of pneumothorax • Most perform a venogram prior to accessing the vein for pacemaker lead implant • Majority of cardiac devices are implanted in the left pectoral region of chest
  11. 11. Venogram using the antecubital or median basilic vein allows visualization of subclavian, axillary and innominate veins AxillaryAxillary AnatomyAnatomy
  12. 12. Complications- chestComplications- chest accessaccess • Subclavian crush – – Lead positioned via the subclavian vein. – Subclavian vein lies between the clavicle and the 1st rib. – Deterioration of the insulation material and the wires leads to failure of the pacemaker/ICD leads.
  13. 13. ComplicationsComplications • Post device implant swelling at the pectoral site may be as a result of – Generally “wet” site due to A/C status – Inadvertent arterial nick • Pressure at site may result in hemostasis – If extreme, re-open and cauterize – Often, device site pain relieved with elevation to 30 degrees and ice compress.
  14. 14. ComplicationsComplications • Pneumothorax – Because the subclavian vein is situated between the clavicle and the first rib, often times the needle must be bent to access vein. – Lung extends above the clavicle approximately 1 inch – Angle of the needle to be at least 20-30º
  15. 15. Cross section of theCross section of the Clavicle & 1Clavicle & 1stst RibRib
  16. 16. Internal JugularInternal Jugular accessaccess • Was used for the coronary sinus wire insertion • Access of choice for T -Pacers
  17. 17. IJ ComplicationsIJ Complications • Difficult puncture for many due to location of vein • Arterial puncture complication – Difficult to obtain hemostasis if A/C levels are high
  18. 18. IJ AnatomyIJ Anatomy
  19. 19. Femoral accessFemoral access • Most often used for all EP studies • As many as 4 sheaths in the veins at once (Can have 3 sheaths on one side) • Occasionally an arterial sheath is inserted during some studies • All venous lines must be connected to fluid and at KVO rate • Arterial lines must be connected to pressure during and after the case, until the line is D/C’d
  20. 20. Femoral AnatomyFemoral Anatomy
  21. 21. Femoral ArterialFemoral Arterial ComplicationsComplications • Hematoma is number one complication of arterial stick
  22. 22. Vascular ComplicationsVascular Complications • Treatment – Hematoma – Manual pressure at site • DO NOT try to “squeeze out” blood • Goal is hemostasis – Pressure dressing – Needle aspiration – Surgical evacuation • May require surgical repair of artery/vein
  23. 23. Femoral ComplicationsFemoral Complications • Arterial – Hematoma • May rapidly increase in size – Bleeding • Lack of hemostasis – Pseudoaneurysm • a.k.a. “false aneurysm” • Hematoma outside of and adjacent to artery • Communication with arterial lumen • Treat with compression or surgery
  24. 24. Femoral ComplicationsFemoral Complications • Arterial complications (cont’d) AV fistula Inadvertent cannulation of artery thru the vein May require surgical repair Retroperitoneal bleed Damage to posterior artery – Blood collects in peritoneal cavity – Flank/lower back pain – Requires surgical repair – Usually emergent repair
  25. 25. Femoral ComplicationsFemoral Complications • Venous – Hematoma • Collection of blood underneath skin • Manual compression to stop bleeding • DO NOT try to “squeeze out” • Mark the hematoma edges with sharpie pen and time the marking • Bleeding – Manual compression at site of bleeding
  26. 26. Gross Cardiac A & PGross Cardiac A & P
  27. 27. Location of the HeartLocation of the Heart • Lies roughly in the center of thoracic cavity • Attached to thorax via the great vessels
  28. 28. Location of the HeartLocation of the Heart • Apex (bottom) – Formed by tip of left ventricle – Points anterior and inferior • Base (top) – Approximately 2nd intercostal space – Angle of Louis • Anterior surface – Primarily right ventricle • Inferior (diaphragmatic) surface – Right and left ventricles, predominantly left
  29. 29. Size and Shape of theSize and Shape of the HeartHeart • Cone-shaped • Adult heart size: – ~5 inches (12 cm) long – ~3.5 inches (9 cm) wide – ~2.5 inches (6 cm) thick – About the size of a man’s fist
  30. 30. Size and Shape of theSize and Shape of the HeartHeart
  31. 31. Heart ChambersHeart Chambers • Four chambers • Two upper – Right atrium – Left atrium • Two lower – Right ventricle – Left ventricle
  32. 32. AtriaAtria Thin-walled Low-pressure Separated by interatrial septum “Atrial kick” Due to atrial contraction 25-30% of CO
  33. 33. VentriclesVentricles • Right ventricle – Pumps venous blood to lungs – Low pressure chamber • Left ventricle – Pumps arterial blood to body – High pressure chamber • Chambers separated by interventricular septum
  34. 34. • The Fibrous Skeleton of the heart consists of: – AV Valves (semi-lunar) • Tricuspid valve separates the right atrium from the right ventricle • Mitral valve separates the left atrium from the left ventricle • Fibrous skeleton is electrically inert ValvesValves
  35. 35. Valvular orientationValvular orientation
  36. 36. Valvular orientationValvular orientation
  37. 37. Accessory Pathway Locations based on Valve LandmarksAccessory Pathway Locations based on Valve Landmarks
  38. 38. ValvesValves • Pulmonic Valve Prevents blood from flowing backwards into the right ventricle • Aortic Valve Prevents blood from flowing backwards into the left ventricle.
  39. 39. Valves cont’dValves cont’d Normal Valve Areas Critical Aortic 2.5 – 3.5 cm2 .7cm2 Pulmonic 4-6 cm2 Mitral 2.5-3.5 cm2 <1.0 cm2 Tricuspid 8-10 cm2
  40. 40. Anatomy and PhysiologyAnatomy and Physiology • Coronary Blood Supply – RCA – Left Main • LAD • LCX
  41. 41. Coronary VasculatureCoronary Vasculature
  42. 42. Coronary Vasculature – Inferior viewCoronary Vasculature – Inferior view
  43. 43. CoronaryCoronary ArteriesArteries
  44. 44. Right Coronary ArteryRight Coronary Artery • Originates from the right coronary cusp of the aorta • Passes along the atrioventricular sulcus between the right atria and ventricle • Marginal branch of the RCA supplies the RA and RV
  45. 45. Right Coronary ArteryRight Coronary Artery • The coronary artery that gives rise to the posterior descending artery (PDA) is known as the “dominant” coronary artery and most often is the RCA • The PDA supplies blood to the posterior surface of both walls of the ventricles.
  46. 46. • PDA supplies the posterior third of the interventricular septum. • In 50-60% a branch of the RCA supplies the SA node. • In 85-90% of hearts the RCA also branches into the AV nodal artery. RCA cont’d
  47. 47. Left Coronary ArteryLeft Coronary Artery • Arises from the left coronary cusp of the aorta. • Consists of the left main coronary artery. • The left main artery bifurcates into the left circumflex artery (LCX) and the left anterior descending artery (LAD).
  48. 48. Left Coronary SystemLeft Coronary System • LAD travels along anterior interventricular sulcus and supplies blood to the anterior surface of both ventricles. • LAD branches include the diagonal and septal arteries.
  49. 49. Left Coronary SystemLeft Coronary System • LCX passes along the left atrioventricular sulcus between the left atria and ventricle. • Supplies the lateral wall of the LV • May also supply the inferior portion of the LV. • LCX artery supplies the SA node in 40- 60%. • LCX supplies the AV node in 10-15%.
  50. 50. Blood SupplyBlood Supply • The SA and AV nodes are supplied by the RCA and LCX. • The bundle branches are supplied by the LAD. – Thus an occluded RCA may cause nodal dysfunction. – An occluded LAD may cause a BBB. – The possibility of reentrant arrhythmias is present with any infarct.
  51. 51. CirculationCirculation • Blood in the atrium is ejected into the ventricles during atrial contraction. • Passive filling of the ventricles occurs. • Ventricles eject blood thru the pulmonary artery to the alveoli for oxygenation and thru the aorta for systemic oxygenation. • Coronary artery perfusion occurs during diastole.
  52. 52. ReferencesReferences • Netter, F H (1987) The CIBA collection of medical Illustrations. Volume 5 The heart. Colorpress, New York NY • Mazgalev, T.N., Tchou, P.J. (2000) Atrial AV Nodal Electrophysiology; A view from the millennium. Futura, Armonk, NY • Podrid, P.J., Kowey, P.R. (2001) Cardiac Arrhythmia, Mechanisms, Diagnosis & Management, 2nd Ed. Lippincott, Williams & Wilkins. Philadelphia PA • Anderson, R.H. (2000) Electrical Anatomy of the Atrial Chambers. Medtronic USA • Anderson R.H., Ho, S.W. ( n.d.) The Anatomy of the Atrioventricular Node. Article review by Sechler, D.A., RN