Anatomy of heart

1. ANATOMY
VALVES
CHAMBERS
CORONARY CIRCULATION

2. Pericardium
1. A superficial fibrous pericardium
2. A deep two-layer serous pericardium
a. The parietal layer lines the internal surface of the
fibrous pericardium
b. The visceral layer or epicardium lines the surface of
the heart

4. MITRAL VALVE
The normal function of the mitral valve depends on its 6
components, which are (1) the left atrial wall, (2) the annulus, (3)
the leaflets, (4) the chordae tendineae, (5) the papillary muscles,
and (6) the left ventricular wall (see the image below). [1]
• The mitral valve is also called the bicuspid valve and the left
atrioventricular valve.
• As the name bicuspid valve may suggest, the mitral valve is
considered to have two primary leaflets: the anterior and
posterior leaflets.
• The anterior leaflet has also been called the septal, medial, or
aortic leaflet, while the posterior leaflet is also referred to as
the lateral, marginal, or mural leaflet.

5. • Each leaflet is then further broken down into scallops divided by
commissures, or zones of apposition.
• Due to the high variability of leaflet and scallop anatomy, and an
alphanumeric nomenclature has been proposed by Carpentier
that breaks the leaflets into regions.
• Three regions are found on the anterior leaflet (A1-A3) with
opposing regions on the posterior leaflet (P1-P3).
• The subvalvular apparatus of the mitral valve consists of chordae
tendinae attaching to the anterior and posterior papillary muscles
of the left ventricle.

6. Left Atrial wall
The left atrial myocardium extends over the proximal portion of the
posterior leaflet. Thus, left atrial enlargement can result in mitral
regurgitation by affecting the posterior leaflet. The anterior leaflet is
not affected, because of its attachment to the root of the aorta
Mitral annulus
The mitral annulus is a fibrous ring that connects with the leaflets. It
is not a continuous ring around the mitral orifice [3] and appears to be
more D-shaped, rather than circular as prosthetic valves are

7. The straight border of the annulus is posterior to the aortic valve. The
aortic valve is located between the ventricular septum and the mitral
valve.
The annulus functions as a sphincter that contracts and reduces the
surface area of the valve during systole to ensure complete closure of
the leaflets.
Thus, annular dilatation of the mitral valve causes poor leaflet
apposition, which results in mitral regurgitation.
Mitral valve leaflets
The free edges of the leaflets have several indentations. Two of these
indentations, the anterolateral and posteromedial commissures,
divide the leaflets into anterior and posterior (see the first image
below).

8. Normally, the leaflets are thin, pliable, translucent, and soft. Each leaflet has
an atrial and a ventricular surface.
Anterior leaflet
The anterior leaflet is located posterior to the aortic root and is also
anchored to the aortic root, unlike the posterior leaflet.
Accordingly, it is also known as the aortic, septal, greater, or anteromedial
leaflet.
The anterior leaflet is large and semicircular in shape. It has a free edge with
few or no indentations.
The 2 zones on the anterior leaflet are referred to as rough and clear zones,
according to the chordae tendineae insertion.
These 2 zones are separated by a prominent ridge on the atrial surface of the
leaflet, which is the line of the leaflet closure. The prominent ridge is located
approximately 1 cm from the free edge of the anterior leaflet.

9. Posterior leaflet
The posterior leaflet is also known as the ventricular, mural, smaller, or
posterolateral leaflet.
The posterior leaflet is the section of the mitral valve that is located posterior to the
2 commissural areas.
It has a wider attachment to the annulus than the anterior leaflet. It is divided into
3 scallops by 2 indentations or clefts. The middle scallop is larger than the other 2
(the anterolateral and posteromedial commissural scallops).
The 3 zones on the posterior leaflets are referred to as rough, clear, and basal
zones, according to the chordae tendineae insertion.
The rough zone is defined in the posterior leaflet. It is distal to the ridge of the line
of the leaflet closure. It is broadest at the distal part of the scallops and tapers
toward the clefts or indentations between the scallops.

10. Chordae tendineae
The chordae tendineae are small fibrous strings that originate either
from the apical portion of the papillary muscles or directly from the
ventricular wall and insert into the valve leaflets or the muscle.
Commissural chordae
Commissural chordae are the chordae that insert into the interleaflet
or commissural areas located at the junction of the anterior and
posterior leaflets.Two types of commissural chordae exist.
Posteromedial commissural chordae insert into the posteromedial
commissural area; anterolateral commissural chordae insert into the
anterolateral commissural area.

11. Leaflet chordae
The leaflet chordae are the chordae that insert into the anterior or
posterior leaflets.
Two types of chordae tendineae are connected to the anterior leaflet.
The first is rough zone chordae, which insert into the distal portion of
the anterior leaflet known as the rough zone.
The second is strut chordae, which are the chordae that branch before
inserting into the anterior leaflet.

12. The posterior leaflet has 3 types of chordae tendineae. T
he first is rough zone chordae, which are the same as the rough zone chordae of
the anterior leaflet.
The second is basal chordae, a type unique to the posterior leaflet; these insert
into the basal zone of the posterior leaflet, which is located between the clear
zone and the mitral valve annulus.
Unlike the anterior leaflet, the posterior leaflet does not have strut chordae.
The third type of chordae on the posterior leaflet is cleft chordae; these insert
into the clefts or indentations of the posterior leaflet, which divide the posterior
leaflet into 3 scallops.

13. Papillary muscles and left ventricular wall
These 2 structures represent the muscular components of the mitral
apparatus.
The papillary muscles normally arise from the apex and middle third of the
left ventricular wall.
The anterolateral papillary muscle is normally larger than the
posteromedial papillary muscle and is supplied by the left anterior
descending artery or the left circumflex artery.
The posteromedial papillary muscle is supplied by the right coronary artery.
Extreme fusion of papillary muscle can result into mitral stenosis.
On the other hand, rupture of a papillary muscle, usually the complication
of acute myocardial infarction, will result in acute mitral regurgitation.

17. AORTIC VALVE

18. Aortic root
The aortic root is the direct continuation of the left ventricular outflow
tract.
It is located to the right and posterior, relative to the subpulmonary
infundibulum, with its posterior margin wedged between the orifice of the
mitral valve and the muscular ventricular septum extending from the basal
attachment of the aortic valvar leaflets within the left ventricle to their
peripheral attachment at the level of the sinotubular junction.
Approximately two thirds of the circumference of the lower part of the
aortic root is connected to the muscular ventricular septum, with the
remaining one third in fibrous continuity with the aortic leaflet of the mitral
valve.
Its components include the sinuses of Valsalva, the fibrous interleaflet
triangles, and the valvar leaflets themselves.

19. • Annulus
When defined literally, an “annulus” is no more than a little ring.
• The aortic valve annulus is a collagenous structure lying at the level of the junction of
the aortic valve and the ventricular septum, usually a semilunar crownlike structure
demarcated by the hinges of the leaflets.
• This serves to provide structural support to the aortic valve complex as it attaches to
the aortic media distally and the membranous and muscular ventricular septum
proximally and anteriorly.
• The valvar leaflets are attached throughout the length of the root. Seen in 3
dimensions, therefore, the leaflets take the form of a 3-pronged coronet, with the
hinges from the supporting ventricular structures forming the crownlike ring.
• The base of the crown is a virtual ring, formed by joining the basal attachment points of
the leaflets within the left ventricle. This plane represents the inlet from the left
ventricular outflow tract into the aortic root.
• The top of the crown is a true ring, the sinotubular junction, demarcated by the sinus
ridge and the related sites of attachment of the peripheral zones of apposition between
the aortic valve leaflets. It forms the outlet of the aortic root into the ascending aorta.

20. • Fibrous trigones
The larger part of the noncoronary leaflet of the valve, along with part of the
left coronary leaflet, is in fibrous continuity with the aortic or anterior leaflet
of the mitral valve, with the ends of this area of fibrous continuity being
thickened to form the so-called fibrous trigones.
These trigones anchor the aortic-mitral valvar unit to the roof of the left
ventricle.
The interleaflet triangle located between the right coronary and noncoronary
aortic leaflets is confluent with the membranous septum.
Together, the membranous septum and the right fibrous trigone form the
central fibrous body of the heart. This is the area within the heart where the
membranous septum, the atrioventricular valves, and the aortic valve join in
fibrous continuity.
The hinge of the septal leaflet of the tricuspid valve separates the
membranous septum into its atrioventricular and interventricular components
(see the image below).

21. • Commissures
• Each cusp is attached to the wall of the aorta by the outward edges of its
semicircular border.
• The level at which this attachment occurs is known as the sinotubular
junction and is the functional level of the aortic valve orifice. A line of
demarcation known as the supraaortic ridge identifies the sinotubular
junction.
• The small spaces between each cusp's attachment point are called the
aortic valve commissures.
• The 3 commissures lie at the apex of the annulus and are equally spaced
around the aortic trunk.
• The commissure between the left and posterior cusp is located at the right
posterior aspect of the aortic root, whereas the commissure between the
right and noncoronary cusp is located at the right anterior aspect of the
aortic root.

24. • The pulmonary valve can also be referred to as the pulmonic valve,
the right semilunar valve, and the right arterial valve.
• Its three leaflets, or cusps, are difficult to name because of the
oblique angle of the valve.
• Its nomenclature is therefore derived based on the nomenclature
of the aortic valve, which lies in proximity to it.
• The two leaflets attached to the septum are named the left and
right leaflets, and correspond to the right and left leaflets of the
aortic valve, which they face.
• The third leaflet is called the anterior leaflet or the non-coronary
leaflet (to maintain the nomenclature of the aortic valve).

26. • The tricuspid valve, also called the right atrioventricular valve, gets
its name because it is generally considered to have three leaflets:
the anterior, posterior and septal leaflets.
• Of these, the anterior, also called the infundibular or
anterosuperior, leaflet is typically the largest.
• The posterior leaflet is also referred to as the inferior or marginal
leaflet and the septal leaflet is also referred to as the medial leaflet.
• Terminating on the ventricular side of the tricuspid valve leaflets,
the chordae tendinae are connected to three papillary muscles in
the right ventricle.

27. Finger print
• TV anatomy including
the annulus, 3 leaflets
(cusps), chordal
apparatus, and papillary
is unique for a
particular person

28. Anatomy
• The tricuspid valve (TV)
has a saddle shape
because of anterior and
posterior high points
and mid septal and
lateral wall low points

29. Valve leaflets/cusps
• The valve is divided into what are called leaflets or
cusps by "commissures
• Three commissures
• The anteroseptal separates the anterior and septal
leaflets, the anteroposterior lies between the anterior
and posterior leaflets, and the poster septal divides the
posterior and septal leaflets
• The free edge of the commissures forms a smooth arch
although small projections, "miniscallops" or
commissural cusps, may be present and are most
frequently located between the anterior and posterior
cusps

30. Chordae & Papillary muscles
• The location of the anterior papillary muscle
(APM) plays a key role
• The angle (lateral tethering angle) between
the plane of the TV leaflets and the
chordae/APM at mid/end systole is
approximately 90º, allowing optimal
coaptation between the valve leaflets

31. Look into your own TV
• 3 leaflets/cusps
• Subdivided, accessory, and
commissural cusps have been
described and the number of
cusps found in a normal
"tricuspid" valve varies from 2 to
8
• The anterior leaflet is generally
the largest and the most mobile
• The septal leaflet is generally the
second largest and the least
mobile
• The posterior leaflet is typically
triangular and is generally the
smallest.

37. RIGHT ATRIA

41. Right atrium:
• Limbus of fossa ovalis (limb of oval fossa)
• Large pyramidal appendage (Snoopy’s nose)
• Crista terminalis (terminal crest)
• Pectinate muscles
• Receives venae cavae and coronary sinus*

42. Left atrium:
• Ostium secundum
• Small fingerlike appendage (Snoopy’s ear)
• No crista terminalis
• No pectinate muscles
• Receives pulmonary veins

43. Differentiation between the atria
• The only structures that are constant and allow
differentiation between the right and left atria
are the appendages
• The drainage of the systemic and pulmonary
veins does not permit the conclusive
identification of the atria, as drainage sites are
sometimes anomalous.
• The atrial septum cannot always be used either,
because it can have defects or be absent.

44. Features of the morphologic LV:
• Smooth septal surface, fine trabeculae
• Septophobic attachments of the mitral valve
(attachments only to free wall)
• No infundibulum which results in fibrous
continuity of the mitral and semilunar valves

45. Features of the morphologic RV
• Coarse trabeculae with prominent septal
band, parietal band, and moderator band.
• Septophillic attachments of the tricuspid valve
(attachments to septum and free wall)
• Well-developed infundibulum (= conus= cone
of muscle beneath the semilunar valve) which
results in fibrous dyscontinuity between the
tricuspid and semilunar valves

46. Septal and parietal bands
Large apical trabeculations
Coarse septal surface
Crescentic in cross sections
Thin free wall (3–5 mm)

47. No septal or parietal band
Small apical trabeculations
Circular in cross section( variabl
•Thick free wall (12–15 mm)

48. Arterial supply of Heart
 Right coronary artery
 Left coronary artery

49. Right Coronary Artery
 Arises from anterior aortic sinus of the
Ascending Aorta.
 It descends in the right atrioventricular
groove.
 Near inferior border continuous
posteriorly along the atrioventricular
groove.
 Anastomose with left coronary artery in
the posterior interventricular groove.

50. Right Coronary Artery

51. Branches of Right Coronary Artery
1. Right conus artery:
Supplies infundibulum and anterior wall
(upper part) of right ventricle.
2. Anterior ventricular (2-3) branches:
Supply anterior surface of right ventricle.
Marginal branch is the largest and reaches
up to the Apex.

52. Branches of Right Coronary Artery
3. Posterior ventricular (2) branches:
Supply diaphragmatic surface of the right
ventricle.
4. Atrial branches:
Supply anterior and lateral surface of the
right atrium. One branch supply posterior
surface of both right and left atria.
Artery of Sinuatrial Node (60%)

53. Branches of Right Coronary Artery
5. Posterior interventricular (descending)
artery
 Runs towards apex in the posterior
interventricular groove.
 Supply right & left ventricles, including
its inferior wall.
 Supply posterior part of the ventricular
septum (Excluding Apex).
 Large septal branch Supply
Atrioventricular Node.

54. Right Coronary Artery

55. Right Coronary Artery

56. Left Coronary Artery
 Larger then Right coronary artery.
 Arises from posterior aortic sinus of the
Ascending Aorta.
 Passes between pulmonary trunk and left
auricle.
 It enters in the atrioventricular groove and
divides into an anterior interventricular
branch and a circumflex branch.
 Supply greater part of the left Atrium, left
ventricle and ventricular septum.

57. 1. Anterior interventricular (descending) artery:
 Runs in the anterior interventricular groove to
the Apex.
 Passes around the Apex to enter the posterior
interventricular groove & anastomoses with
the terminal branches of Right coronary
artery.
 Supply right and left ventricles & anterior
part of ventricular septum.
 Left diagonal branch and left conus artery are
its branches.
Branches of Left Coronary Artery

58. Left Coronary Artery

59. Branches of Left Coronary Artery
2. Circumflex artery:
 Winds around the left margin of the
heart in the atrioventricular groove.
 Left marginal branch: Supply left
ventricular margin up to Apex.
 Anterior and posterior ventricular
branches: Supply left ventricle.
 Atrial branches: Supply left atrium.
3. Artery of Sinuatrial Node (40%)

60. Left Coronary Artery

61. Conducting system of Heart
 S-A Node: Right coronary artery (60%)
Left coronary artery (40%)
 A-V Node and A-V Bundle: Right coronary artery
 Right Bundle branch: Left coronary artery
 Left Bundle branch: Right & Left coronary
arteries

62. Venous Drainage of Heart
1. Coronary Sinus:
 Runs in the coronary sulcus (posterior
atrioventricular groove).
 Continuation of great cardiac vein.
 Opens in the right atrium.
 Tributaries:
 Great cardiac vein
 Middle cardiac vein
 Small cardiac vein

63. Venous Drainage of Heart
2. Anterior cardiac veins:
 Opens directly in the right atrium.

64. Contents of Heart grooves
1. Right atrioventricular groove:
Right coronary artery
Small cardiac vein
2. Left anterior atrioventricular groove:
Left coronary artery
3. Left posterior atrioventricular groove:
Coronary sinus
4. Anterior interventricular groove:
Anterior interventricular artery
Great cardiac vein
5. Posterior interventricular groove:
Posterior interventricular artery
Middle cardiac vein

65. Cardiac Veins (Sternocostal Surface)
Anterior cardiac veins

66. Cardiac Veins (Diaphragmatic Surface)

67. Nerve supply of the Heart
Cardiac plexus lies below the arch of Aorta.
1. Sympathetic Supply:
Cervical and upper thoracic spinal nerves
2. Parasympathetic Supply:
Vagus nerve

68. Thank You