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CardiacAnatomy Scrubs James Cartlidge Intercalating Student Overview • Middle Mediastinum • Pericardium • External Heart • Orientation, Borders, Surfaces • Cardiac Chambers • RA, RV, LA, LV – with valves • Coronary Vasculature • Arteries & veins • Cardiac Conduction System • Great Vessels MiddleMediastinum • Pericardium • Heart • Origins of great vessels Gray’s Anatomy for Students, 4 Edition Pericardium • 3 Layers • Fibrous (tough CT, non-distensible) • Parietal (serous, mesothelium) • Epicardium (serous, mesothelium) • Pericardial Space • Between parietal & visceral • Serous fluid (prevents friction) • Innervation • Phrenic nerve (C3-C5) • Referred pain • Pericardial Sinuses • Transverse (separates AA+PT from SVC) First Aid for the USMLE Step 1, 2023 • ObliquePericardium th Gray’s Anatomy for Students, 4 Edition Pericardium Gray’s Anatomy for Students, 4 Edition Moore’s Clinically Oriented Anatomy, 9 Edition Pericardium • Pericarditis • Cardiac Tamponade • Inflammation of pericardium • Extensive pericardial effusion – • Idiopathic or 2 to viral infection accumulation of pericardial fluid under pressure • Pleuritic, retrosternal chest pain, • Fibrous pericardium – tough CT, pericardial friction rub, relatively non-distensible, rigid widespread saddle shaped ST elevation, PR interval depression • Heart subject to ↑ pressure, compressing chambers → compromised CO • Beck’s triad: hypotension, raised JVP, muffled heart sounds • Pulsus paradoxus, electrical alternans Zero To Finals Pericardium • Pericardiocentesis • USS guided • Drainage of fluid from pericardial cavity – relieving tamponade • Insert large-bore needle, L 5 /6th ICS near sternum (L lung cardiac notch) • Insert 14/16G needle at angle of xiphisternum & L rib border, aim for ipsilateral scapula (supero-posteriorly) Moore’s Clinically Oriented Anatomy, 9 EditionQ#1 Which nerve root(s) innervate the fibrous and parietal layers of the pericardium? A. C5-C8 B. C3-C5 C. C1-C4 D. T1-T4 E. C5-T2Q#1 Which nerve root(s) innervate the fibrous and parietal layers of the pericardium? A. C5-C8 B. C3-C5 – Phrenic nerve – referred pain C. C1-C4 D. T1-T4 E. C5-T2Q#2 Which pericardial sinus, that is utilised in cardiac surgery, separates the arterial from the venous great vessels? A. Oblique B. Coronal C. Sagittal D. Transverse E. FrontalQ#2 Which pericardial sinus, that is utilised in cardiac surgery, separates the arterial from the venous great vessels? A. Oblique B. Coronal C. Sagittal D. Transverse – separates the ascending aorta & pulmonary trunk from the superior vena cava E. Frontal ExternalHeart • Heart Surfaces • Base: L atrium, R atrium, proximal great veins • Anterior: R ventricle, R atrium, L ventricle • Diaphragmatic: L ventricle, R ventricle • L Pulmonary: L ventricle, L atrium • R Pulmonary: R atrium th Gray’s Anatomy for Students, 4 EditionExternalHeart Gray’s Anatomy for Students, 4 Edition ExternalSulci • Coronary • Separates atria from ventricles • Contains R coronary a., small cardiac v., coronary sinus, L circumflex a. • Anterior & Posterior Interventricular • Separates ventricles • Contains L anterior descending a., great cardiac v., posterior descending a., middle cardiac v. Gray’s Anatomy for Students, 4 Edition ExternalSulci • Coronary • Separates atria from ventricles • Contains R coronary a., small cardiac v., coronary sinus, L circumflex a. • Anterior & Posterior Interventricular • Separates ventricles • Contains L anterior descending a., great cardiac v., posterior descending a., middle cardiac v. Gray’s Anatomy for Students, 4 Edition HeartWall • 4 Layers • Endocardium • Innermost • Loose CT + SSE • Subendocardial • Vessels + nerves of conduction system • Purkinje Fibres • Myocardium • Involuntary, striated muscle • Epicardium • Outermost • Visceral serous pericardium First Aid for the USMLE Step 1, 2023Q#3 Which layer of the heart wall contains the Purkinje fibres? A. Myocardium B. Endocardium C. Sub-endocardium D. Visceral serous pericardium E. Parietal serous pericardiumQ#3 Which layer of the heart wall contains the Purkinje fibres? A. Myocardium B. Endocardium C. Sub-endocardium – contains the vessels & nerves of the conduction system – Purkinje fibres D. Visceral serous pericardium E. Parietal serous pericardium RightAtrium • Receives deoxygenated blood from: • Superior Venae Cavae • Inferior Venae Cavae • Coronary Sinus • Sinus of venae cavae • Smooth • Crista terminalis • Smooth, muscular ridge • Atriumproper • Pectinate muscles • Fossa ovalis • Foramen ovale remnant Gray’s Anatomy for Students, 4 Edition RightVentricle • Receives deoxygenated blood from RA • Conus arteriosus (infundibulum – smooth) • Trabeculae carnae muscular ridges/bridges) • Papillary muscles • Anterior, posterior, septal • Chordae tendineae • Septomarginal trabecula • Moderator band • R bundle of AV bundle to anterior wall of RV Gray’s Anatomy for Students, 4 Edition LeftAtrium • Receives oxygenated blood from pulmonary vv. • 4 x pulmonary vv. • Posterior – inflow (smooth) • Anterior – musculi pectinati • L atrial appendage • Fossa ovalis Gray’s Anatomy for Students, 4 Edition LeftVentricle • Receives oxygenated blood from LA • Thickest myocardial layer • Aortic vestibule – outflow • Trabeculae carneae • Fine & delicate • Muscular ridges/bridges • Papillary muscles • Anterior, posterior • Chordae tendineae • Interventricular septum • Muscular, membranous Gray’s Anatomy for Students, 4 EditionQ#4 Which chamber of the heart contains the crista terminalis? A. Left atrium B. Right atrium C. Left ventricle D. Right ventricleQ#4 Which chamber of the heart contains the crista terminalis? A. Left atrium B. Right atrium – separates the smooth sinus of venae cavae & pectinate muscle of atrium proper – smooth, muscular ridge C. Left ventricle D. Right ventricleQ#5 Which chamber of the heart contains the moderator band? A. Left atrium B. Right atrium C. Left ventricle D. Right ventricleQ#5 Which chamber of the heart contains the moderator band? A. Left atrium B. Right atrium C. Left ventricle D. Right ventricle – septomarginal trabecula (moderator band) – R bundle of AV bundle to anterior wall of RV AtrioventricularValves • Tricuspid • R atrioventricular orifice • RA → RV • 3 cusps: anterior, posterior, septal • Cusps continuous with each other at commissures • Free margins attached to chordae tendineae • Closes during ventricular systole (S1) • Mitral • L atrioventricular orifice • LA → LV • 2 cusps: anterior, posterior Gray’s Anatomy for Students, 4 Edition SemilunarValves • Pulmonary • At apex of infundibulum • RV → pulmonary trunk • 3 semilunar cusps: left, right, anterior • Free superior cusp edge • Middle,thickened portion: • Lateral, thin portion: lunula • Closes during ventricular diastole (S2) • Pulmonary sinuses fill • Aortic • At aortic vestibule • LV → ascending aorta • Sinuses: right, left, posterior • R & L coronary ostia th Gray’s Anatomy for Students, 4 Edition CardiacValves Valve Anatomical Projection Aortic L sternalborder (3 rib) Pulmonary L sternalborder (3 costalcartilage) Mitral(L AV) L 4/5 intercostalcartilage Tricuspid (RAV) Sternum (5 costalcartilage) Thieme Atlas of Anatomy, 4 Edition CardiacValves Valve AuscultationSite Aortic R2 intercostal space (sternal margin) Pulmonary L 2 intercostal space (sternal margin) Mitral(L AV) L 5 intercostal space (midclavicular line) Tricuspid (RAV) L 5 intercostal space (sternal margin) Thieme Atlas of Anatomy, 4 Edition CardiacValves Valvular Disease Murmur Description Aortic Stenosis • Crescendo-decrescendo,ejectionsystolic • Loudest at 2 ICS Rsternal edge • Radiatesto carotids • Accentuated sitting forward,inexpiration • Soft or absent S2 Aortic Regurgitation • Early diastolic,decrescendo,high-pitched,‘blowing’ • Loudest at 2 ICS Rsternal edge • Accentuated leaning forward,inexpiration • Soft S1 Mitral Stenosis • Delayed,mid-to-late diastolic, low-pitch,rumbling th • Loudest at 5 ICS MCL • Accentuated lying onL side, inexpiration • Loud S1 Mitral Regurgitation • Pansystolic, high-pitched,blowing • Loudest at 5 ICS MCL • Radiatesto L axilla • Accentuated lying onL side, inexpiration • Absent or quiet S1 First Aid for theUSMLEStep 1, 2023CardiacValves First Aid for theUSMLEStep 1, 2023CardiacValves First Aid for the USMLE Step 1, 2023Q#6 How many cusps does the mitral valve have? A. 1 B. 2 C. 3 D. 4 E. 5Q#6 How many cusps does the mitral valve have? A. 1 B. 2 – 2 cusps – bicuspid – anterior and posterior leaflets C. 3 D. 4 E. 5Q#7 What is the best site for auscultation of the aortic valve on the praecordium? A. Left 5 intercostal space, midclavicular line B. Left 2 intercostal space, sternal margin C. Right 2 intercostal space, sternal margin D. Left 5 intercostal space, sternal marginQ#7 What is the best site for auscultation of the aortic valve on the praecordium? A. Left 5 intercostal space, midclavicular line B. Left 2 intercostal space, sternal margin C. Right 2 intercostal space, sternal margin – aortic area D. Left 5 intercostal space, sternal marginQ#8 Upon auscultation of the praecordium, you hear a murmur. It is described as crendendo-decrescendo, ejection systolic. It is heard loudest at the 2 intercostal space, right sternal edge. It radiates to the carotids, and is accentuated when the patient is in expiration, sitting forward. What valvular disease is present? A. Mitral stenosis B. Aortic regurgitation C. Mitral regurgitation D. Aortic stenosisQ#8 described as crescendo-decrescendo, ejection systolic. It is heard loudest at the 2 intercostal space, right sternal edge. It radiates to the carotids, and is accentuated when the patient is in expiration, sitting forward. What valvular disease is present? A. Mitral stenosis B. Aortic regurgitation C. Mitral regurgitation D. Aortic stenosis – crescendo-decrescendo, ejection systolic, loudest at aortic area, radiates to carotidsQ#9 A patient presents with a murmur characteristic of mitral regurgitation. Which description would be best in keeping with what you would expect to auscultate? A. Pansystolic, high-pitched,‘blowing’ B. Early diastolic, decrescendo, high-pitched,‘blowing’ C. Delayed, mid-to-late diastolic, low-pitch, rumbling D. Crescendo-decrescendo, ejection systolicQ#9 A patient presents with a murmur characteristic of mitral regurgitation. Which description would be best in keeping with what you would expect to auscultate? A. Pansystolic, high-pitched,‘blowing’– Mitral regurgitation B. Early diastolic, decrescendo, high-pitched,‘blowing’– aortic regurgitation C. Delayed, mid-to-late diastolic, low-pitch, rumbling – mitral stenosis D. Crescendo-decrescendo, ejection systolic – aortic stenosis CoronaryArteries • R Coronary a. (R aortic sinus) • Sinoatrial nodal a. • R conus a. • R marginal a. • Posterior interventricular a. (PDA) (R dominant ~85%) • Supplies: RA, RV, SAN, AVN, IAS , part of LA, posterior 1/3 IVS, part of posterior LV • LCoronary a. (L aortic sinus) • Anterior interventricular a. (LAD) • Diagonal branches • L circumflex branch • L marginal a. • Supplies: LA, LV, anterior 2/3 IVS th Gray’s Anatomy for Students, 4 EditionCoronaryArteries First Aid for the USMLE Step 1, 2023 CoronaryArteries Order ofFrequency ofOcclusion Coronary Artery 1 Proximal L anterior descending a.(LAD) 2 Proximal Rcoronary a.(RCA) 3 Proximal L circumflexbranch(LCx) 4 Left mainstem (LMS–LCA) 5 Proximalposterior interventricular a. (PIV) 6 Rcoronary a. (diaphragmatic surface) Geeky Medics CoronaryArteries View Description ECGLeadIschaemic Changes Coronary Artery Occluded Inferior II, III,avF Rcoronary a. (RCA) Anteroapical V3,V4 Distal L anterior descending (LAD) Anteroseptal V1,V2 L anteriordescending (LAD) Anterolateral I, aVL, V5, V6 L circumflexa.(LCx) Extensive anterior I, aVL, V2-V6 Proximal L coronary a.(LCA) Posterior Tall Rwave V1 Rcoronary a. (RCA) TeachMe AnatomyCoronaryArteries Geeky MedicsQ#10 A patient presents with centralised,crushing chest pain,that radiates to their neck and left arm. They are breathless and profusely sweating. You performed,and ischaemic changes,in the formof ST elevation,areECG is noted in leads II,III & aVF.Which coronary artery is occluded to produce these ischaemic changes? A. Left circumflex artery B. Proximal left coronary artery C. Left anterior descending artery D. Distal left anterior descending artery E. Right coronary arteryQ#10 A patient presents with centralised,crushing chest pain,that radiates to their neck and left arm. They are breathless and profusely sweating. You performed,and ischaemic changes,in the formof ST elevation,areECG is noted in leads II,III & aVF.Which coronary artery is occluded to produce these ischaemic changes? A. Left circumflex artery – I,aVL,V5,V6 B. Proximal left coronary artery– I,aVL,V2-V6 C. Left anterior descending artery – V1,V2 D. Distal left anterior descending artery – V3,V4 E. Right coronary artery – II, III,aVF CardiacVeins • Coronary sinus receives 4 major tributaries: • Great cardiac v. (anterior IV sulcus) • Middle cardiacv. (posterior IV sulcus) • Small cardiac v. • Posterior cardiac v. • Anterior cardiac v. (RV drains into RA) • Venae cordis minimae (drain directly into chambers – RA, RV) Gray’s Anatomy for Students, 4 EditionCardiacVeins Gray’s Anatomy for Students, 4 EditionQ#11 Into which structure do the great, middle, small and posterior cardiac veins drain into? A. Oblique sinus B. Coronary sinus C. Right atrial appendage D. Right ventricle E. Ductus arteriosusQ#11 Into which structure do the great, middle, small and posterior cardiac veins drain into? A. Oblique sinus B. Coronary sinus – receives venous drainage from 4 major tributaries (cardiac veins), draining into the right atrium C. Right atrial appendage D. Right ventricle E. Ductus arteriosus CardiacConductionSystem • Nodes & specialised conduction cells • Initiates& coordinates contraction • SAN→ Bachmann’s bundle → bundle (of His) → R & L bundleV branches (RV – septomarginal trabecula) → Purkinje fibres (subendocardial plexus) → Ventricles • Influenced by cardiac plexus • Sympathetic (T1-T4) • Parasympathetic (vagus) th Thieme Atlas of Anatomy, 4 EditionCardiacConductionSystem First Aid for the USMLE Step 1, 2023 CardiacConductionSystem ECGWave / Feature Description P wave Atrial depolarisation PRinterval Start ofatrialdepolarisation→start ofventricular depolarisation(120-200ms) QRS complex Ventricular depolarisation(<100ms) QT interval Ventricular depolarisation, mechanicalventricular contraction, ventricular repolarisation T wave Ventricular repolarisation J point Junctionbetweenend ofQRScomplex & start ofST segment ST segment Isoelectric, ventricles repolarised U wave Prominent inhypokalaemia, bradycardia First Aid for the USMLE Step 1, 2023Q#12 Which structure in the cardiac conduction system delays the electrical action potential by ~120 ms, when passing through the pathway? A. Bachmann’s bundle B. Atrioventricular node C. Bundle of His D. Septomarginal trabecula E. Sinoatrial nodeQ#12 electrical action potential by ~120 ms, when passing through the pathway? A. Bachmann’s bundle B. Atrioventricular node – delays the impulse by ~120ms, to allow the atria to fully empty their contents into the ventricles, before ventricular systole occurs C. Bundle of His D. Septomarginal trabecula E. Sinoatrial node GreatVessels • Aorta (LV→ systemic & coronary aa.) • Ascending aorta • Aortic arch • Brachiocephalic trunk: R subclavian a., R common carotid a. • L common carotid a. • L subclavian a. • Pulmonary vv. (x4 – Lungs → LA) • Venae Cavae (Systemic vv.→ RA) • Superior: L & R brachiocephalic vv. • L & R, internal jugular & subclavian vv. • Inferior • Pulmonary aa. (RV → lungs) • Pulmonary trunk: L & R pulmonary aa. Gray’s Anatomy for Students, 4 EditionGreatVessels th Gray’s Anatomy for Students, 4 Edition GreatVessels • Aortic Dissection • Inner wall tear → two channels for flow (false lumen – double-barrel) • Intimal tear → dissects through tunica media • Constriction of aortic lumen → ↓ systemic circulation → further weakness & dilatation of wall → aortic aneurysm • Sudden, severe chest or back pain – tearing / ripping sensation GreatVessels • Aortic Dissection • Stanford Classification • Type A – ascending aorta (2/3 cases) • Type B – descending aorta, distal to L subclavian origin (1/3 cases) • DeBakey Classification • Type I – ascending aorta, to at least aortic arch, possibly distally beyond • Type II – originates & confined to ascending aorta • Type IIIa – descending aorta, will extend distally, only section above diaphragm • Type IIIb – descending aorta, extends distally, involves aorta below diaphragmGreatVessels First Aid for the USMLE Step 1, 2023 GreatVessels • Aortic Aneurysm • Localised dilation of a. (>50% normal diameter (>1.5x)) • Commonly affected:ascending aorta • Due to underlying wall weakness or pathological process • Often asymptomatic – incidental finding • May cause space occupying symptoms – mediastinum compression • Chest/back pain • Trachea or L bronchus – cough, dyspnoea, stridor • Phrenic nerve – hiccups • Oesophagus – dysphagia • Recurrent laryngeal nerve – hoarse voice • 1 concern: rupture of aorta → death First Aid for the USMLE Step 1, 2023Q#13 Which great vessel is formed by the union of the left and right brachiocephalic veins? A. Inferior vena cava B. Pulmonary veins C. Superior vena cava D. Coronary sinus E. Azygous veinQ#13 Which great vessel is formed by the union of the left and right brachiocephalic veins? A. Inferior vena cava B. Pulmonary veins C. Superior vena cava – formed by the joining of the left and right brachiocephalic veins D. Coronary sinus E. Azygous veinQ#14 as a tearing in nature. You are concerned that they may have an it aortic dissection. A CT angiogram is performed and reports that the dissection appears to have started in the ascending aorta and is confined to there. What DeBakey classification is this presentation? A. Type I B. Type II C. Type IIIa D. Type IIIb E. Type BQ#14 A patient presents with sudden,severe back pain.They describe it as a dissection.A CT angiogramis performed and reports that the dissection appears to have started in the ascending aorta and is confined to there. What DeBakey classification is this presentation? A. Type I - ascending aorta,to at least aortic arch,possibly distally beyond B. Type II – originates & confined to ascending aorta C. Type IIIa - descending aorta,will extend distally,only section above diaphragm D. Type IIIb - descending aorta,extends distally,involves aorta below diaphragm E. Tsubclavian originClassification - descending aorta,distal to LQ#15 A patient presents with hoarseness. Imaging determines that an aortic aneurysm is present. Which structure found in the mediastinum if compressed, would result in this symptom? A. Oesophagus B. Phrenic nerve C. Trachea D. Left bronchus E. Recurrent laryngeal nerveQ#15 A patient presents with hoarseness. Imaging determines that an aortic aneurysm is present. Which structure found in the mediastinum if compressed, would result in this symptom? A. Oesophagus - dysphagia B. Phrenic nerve - hiccups C. Trachea – cough, dyspnoea, stridor D. Left bronchus – cough dyspnoea, stridor E. Recurrent laryngeal nerve - hoarseness ThankY ou AnyQuestions? References • Gray’s Anatomy for Students, 4 Edition • First Aid for the USMLE Step 1, 2023 • Moore’s Clinically Oriented Anatomy, 9 Edition • Thieme Atlas of Anatomy, 4 Edition • https://geekymedics.com • https://teachmeanatomy.info • https://almostadoctor.co.uk • https://www.passmedicine.com • https://zerotofinals.com