Upload
kirsten-brougham
View
241
Download
4
Embed Size (px)
Citation preview
HeartHeart
David Kachlík, Štěpán Jelínek
Heart situationHeart situation
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
Heart descriptionHeart description
basis x apex 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.
Heart structureHeart structure
endocardium = tunica intima myocardium = tunica media
working myocardium excitomotor apparatus (EA) = conducting m. fibrous skeleton of heart
pericardium
EndocardiumEndocardium
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
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
MyocardiumMyocardium 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
MyocardiumMyocardium
PericardiumPericardium
PericardiumPericardium 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)
Heart cavitiesHeart cavities
atrium dextrum + sinistrum septum interatriale septum atrioventriculare ventriculus dexter + sinister septum interventriculare (pars membranacea +
muscularis)
Atrium dextrum (right atrium).Atrium dextrum (right atrium).
ostium v. cavae inferioris valvula v.c.i. Eustachii
ostium v. cavae superioris 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
Atrium dextrum (right atrium)Atrium dextrum (right atrium)
auricula dextra sinus venarum cavarum crista terminalis mm. pectinati ostium atrioventriculare
dextrum trigonum nodi
atrioventricularis Kochi
Ventriculus dexter (right ventricle)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
Ventriculus dexter (right ventricle)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
Right-sided compartmentsRight-sided compartments
Atrium sinistrum (left atrium)Atrium sinistrum (left atrium)
auricula sinistra ostia venarum pulmonalium mm. pectinati valvula foraminis ovalis
(= former falx septi Parchappei)
Ventriculus sinister (left ventricle)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)
Left-sided compartmentsLeft-sided compartments
ECHO
Fibrous skeleton of heartFibrous 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
Heart supplyHeart 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
Coronary arteriesCoronary arteries
Arteria coronaria dextra (ACD)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)
Arteria coronaria sinistra (ACS)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
Coronary arteriesCoronary arteries
Arteria coronaria sinistra
ACS in posteroanterior projectionACS in lateral projection (right to left)
ACS in lateral projection (left to right)
PonticulusPonticulus
Stenosis in ACSStenosis in ACS
Arteria coronaria dextraArteria coronaria dextra
ACS in posteroanterior projection
ACS in lateral projection (right to left)
ACS in lateral projection (left to right)
Collateral vesselsCollateral vessels
Heart veinsHeart 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
Heart veinsHeart veins
Vv. ventriculi dextri anteriores = vv. cardiace (cordis) anteriores → atrium dextrum
Vv. cadiace (cordis) minimae Thebesii → all cavities
without any major clinical importance
Nerves – autonomic systemNerves – 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
Conducting system of heartConducting system of heartComplexus stimulans cordisComplexus stimulans cordisSystema conducens cordisSystema conducens cordis
„Excitomotor apparatus“„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
Conducting system of the heart - Conducting system of the heart - partsparts
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
Conducting system of heartConducting 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)
Purkyně fibres (HE + elastin)
artificial artificial pacemakerpacemaker
PhysiologyPhysiology
Heart cycle systole diastole
Pulse and volumes EKG curve Arterial pulse curve with dicrotic notch Endocrinne function - ANF
ExaminationExamination
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
Auscultation
Testut‘s points
=
4 auscultation points
Auscultation – Auscultation – Testut´s pointsTestut´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
Systolic/ diastolic
pressures in the heart chambers
Basic clinical unitsBasic 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
Heart X-rayHeart X-ray
Heart X-rayHeart X-ray
Rheumatic vegetations
Endocarditis
Valvular insufficiency
(regurgitation) and
stenosis
Myocardial infarction
Cardiac aneurysm
Pericarditis
Cardiac trauma
Cardiac tamponade
The heart during CPR
Basic therapeutic Basic therapeutic operationsoperations
PTCA (= percutaneous transfemoral coronary angioplasty)
Basic therapeutic operationsBasic 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
Valvular replacementValvular replacement
Valvular replacement
Cardiac Cardiac transplantationtransplantation
Practical training
X-ray of heart and lungs Valve auscultation Heart specimen – whole x dissected
Histological slides of heart muscle
Thank you for attention…..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