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right, All right. So I thought to begin with, we'll do sort of Ah, sweet on a prior knowledge check to see how people are doing. I know you guys a third years mostly, um, so you should have a pretty good basic knowledge, but let's let's have a look. Um, so I hope you won't miss hot on if we start from the blood supply coming into the heart. So we've got be superior vena cava and the inferior vena cava coming in to the right atrium, slowing through the tricuspid valve into the rock ventricle. Then the right ventricle contracts and the blood travels up through pulmonary valve into the pulmonary veins. Know, I found this a bit confusing when I was a med student because you normally think veins travel towards the heart, but in this case, pulmonary veins or traveling out of the heart towards the lungs and then the blood gets oxygenated. So oxygenated blood comes back from the lungs into the heart through those pulmonary arteries that are unlabeled that you can see on the back into the left atrium passed through the mitral valve. The probably the most important. Now it's saying into the left ventricle where it's then pumped up back through the aortic valve's on into the aorta to spread around the body. Now, pretty sure you all know the basics of that help blood flows through our But, um, a few more questions about the basic structure. Well, three layers of art we get any answers on the chop. Come on, little, let's give it a go. Yeah, all right. Okay. And since you don't worry, we have the pericardium myocardium and the endocardium on that, starting from out inwards. So if you look at this picture, the pericardium is that lining a white lining. It's usually quite five breast quite sick and is protecting the hot. Um, Then you've got the Meyer body. Um, which is that muscular Leah on the endocardium, which is lining the inside chambers pericardium, myocardium and endocardium. Next question is a little bit more clinical. Where would you oscal Tate to listen to the aortic valve and the mitral valve? These are probably in clinical practice, the valves that you can hear the easiest on I usually indicative of the most common pathologies. Many ounces. No. Oh, Sophia. So aortic valve. Second intercostal space on the right. That's very good on Dabdoub. Uh, is saying my troubles. Yeah. Where would you listen to the mitral valve? It's only when I picked for you. Aortic valve, as Sofia said, is the second intercostal space, right? Sternal edge. And then sgpt ulcer said mitral valve is the fifth intercostal space midterm taking align exactly on that 50 intercostal space. Midclavicular line is where you would feel for the apex beach when you're doing the cardiac examination. So remember that second intercostal? Oh, sorry. Fifth intercostal space midclavicular line. That's a typo. There should be fifth, not second is where you feel for the apex. Be on. Listen to the mitral valve. Okay. Which vessel carries deoxygenated blood to the lungs? A picture. In essence, that's not very hot. It's your pulmonary veins. It's carrying deoxygenated to flood to the lungs where it gets oxygenated and comes back. All right, so now let's talk about the anatomy of are valves. We've got this view which is looking from above the heart, looking down onto each of the chambers, Andre, the associative bells. The first one that I'd like to speak about is the mitral valve. And as we said earlier that can next the left atrium on the left ventricle. Um, and I'd say the left side of the heart carrying oxygenated blood is probably more important. Controversial opinion, arguable. But, um, the mitral valve carrying that, um, blood passing through it. It's quite important you get a lot of pathology of the mitral valve affecting a lot of the elder elderly population. But we'll get into that in a bit, and it's bicuspid Importantly, it's the only valves of the heart that is bicuspid. The rest of them, as you can see, a try custody. Then we've got B aortic valve, also in the left, on the left side, right side of the hot that's carrying or blood passes through it from the left ventricle into the aorta, and it's tricusp it. Then we've got the tricuspid valve between the right atrium and the ventricle. Also, try custody, as the name would suggest, um, and the pulmonary valve between the right pickle and pulmonary trunk, which is strike custody. And now, as a medical student, I remember finding valvular pathology really difficult to remember, especially the different types of murmurs you'll hear. But I think one tip I can give you guys is really focused mostly on your mitral valve and your aortic felt. So the left sided belts because they're the ones you're gonna say you're gonna hear them better be exam questions, mostly focused on them and see they usually have war of an effect on your patients than the other two. Because if you think about it, it's you're oxygenated blood. That's really important to get out and around the body. So if these valves are affected, you're gonna have worse outcomes. So really, focus on your mitral and your aortic bells when it comes to revising. Yeah, and we will go into the pathologies and look well. Don't worry, I thought. First, let's briefly go through the flow of blood on you, the difference between diastole and systole. So blood first comes into the atrium by a passive feeling. So your vows here are closed. The valves that between your atria and you, eventually ventricles are closed on BP is allowing those atrium to fill, and then those a V valves open and the blood's still throwing through your ventricles into the heart. And this is diastole. So when your heart is essentially stealing up with blood. There's no there's a slight atrial contraction, but there's no fully forced that trick you a contraction. So it's passive. It's diastole filling up of the heart. Then we have see closure of the AB valves, which is what your first heart sound is. A lens. You've got the ventricular contraction, which is probably the most, um, important part of the heart function. So those semilunar valves, which your aortic and pulmonary mouths open up nicely. Your ventricles contract and your blood comes out that system e. And when you're aortic and pulmonary valves chose is when you have your second heart sound. So the first heart sounded you mitral valve and you'll try custody, allowing blood to come to stay in the ventricles. And then the second heart sound is when be able. So sorry about that, and you're taking pulmonary valves close. So the closer, uh, of which valves produces the second heart sound just spoken. Amount it great. So a very good Any other answer is day and see exactly. Unjury. Very good. A and C are creating the second heart sounds. So we've got a nice diagram here showing the s one is the closure of your mitral and tricuspid valves. And then sisterly occurs, which is when the ventricles contract and get the blood out of the aorta and the pulmonary arteries. Then we have feel that's when you can feel a pulse. That's when your pulse is palpable. And then s two is the closure. And that's when the hot refills again pops. If we were diastole. All right, So now, as promised, don't get too excited. We're gonna talk about valvular pathology Onda, as mentioned earlier, the two most important I Oh, aortic and mitral valve. So those are the ones like, um, let's talk specifically about, firstly, aortic stenosis. I'd say this is the most common valvular pathology You will see Onda. Quite a few of our elderly patients have aortic stenosis. Murmur is that you can hear. Um, So what you guys that come in that one? This is actually quite a common presentation. What causes aortic stenosis is old age. Essentially, when you're valve becomes calcified and undergoes general degeneration, you can have a want excuses which is so so no system. Sure, you all know it's just sort of narrowing of the valve it becomes really tight and doesn't allow blood to flow through it as nice thing. And as a consequence, you get a tryout of symptoms. So if your blood isn't able to come out of the ventricle into the aorta, you can get chest pain. You can get dyspneic, which is breathlessness Onda syncope. So you, if you're not getting enough blood to the body in specific up to the brain syncope can occur. So I have had patients who come in and say, Oh, I was just walking, had a bit of chest pain And then I fainted, and I'm not sure what happened. The otherwise medically fit, um, and you'd initially think, Oh, is it a blood pressure problem will actually listen to their heart and you can hear a bit of a murmur. Um, and you got your answer. So what sort of murmur would you hear with aortic stenosis? Does anybody know injections? A systolic Really good on? Gee, well done. So an ejection systolic moment, which is unfortunately, I don't have recordings, but it's basically a washing sounds, and it sounds a bit like a train when you listen to it. And so it's like who's stupid? That was like a um yeah. Imitation. So a wish a washing found sort of like a train of I said, um, secondly, we've got mitral regard, which is the second most common valvular pathology on its. Whereas the diagram shows it's where the blood coming from the left ventricle going up in today into the aorta is instead regarded taking up into the left atrium. So your blood is meant to be going up this way, but instead a little bit of it is back flowing into the left atrium. Yeah, that's not great again to your blood circulation around the body, because a lot of it is actually not getting out through the water on back, slowing up. So the cause is of mitral. Regurg most commonly is post, Am I. So if there's an infarct somewhere along this side of the heart, you can affect the valves, especially if your capillary muscle are affected. Um, rheumatic fever is another very common cause of several valvular apologies, usually in younger patients. So if you've got sort of like a 40 year old woman, women are exceptionally or more prone to getting rheumatic fever and valve. You pathologies and men are think mitral regard. Endocarditis is also a cause of mitral regurgitation. Also because of the others is Well, um, so if anybody asks the cause of a mitral stenosis all regards, I'd say my top differentials. They're always rheumatic fever under carditis on what sounds. But you hear, it's a soft s one on a pound systolic murmur of blowing. And if you think about it, logically, actually can sort of answer these questions yourself because the closure of the mitral valve is what causes s one. So if your mitral valve is skirt rude up and not closing properly, you're gonna get a soft s one. Are you on? That's what causes the riesgos. Just when your flower valve isn't pros, probably. So it's not shutting. It's not causing that loud s one. Instead, it's soft, and then you get a pansystolic moment. That's because when the ventricles contract, so when sisterly occurs, that blood is sort of just bubbling up. So it's pants is throughout the whole system, So it's probable bubble bubble whilst the ventricles are contracting. Yeah. Then we've got mitral stenosis, which, as I said earlier, dramatic you were Matic fever rheumatic fever. Um, mitral stenosis. The cause if you've got other options ruling out it's Matic fever for the cases, um, med school exams. And I see kids. What would you here with my trust nurses Anybody know? So again, we can sort of conclude from the pathology. If you've got a really hard tight valve when it closes, it's gonna make a loud sound because it's it's sort of hot and cracky and narrow, so you're going to actually get allowed hard s one. So when system he happens, it it creates this hard s one sound on a mid diastolic murmur. Again, we can sort of conclude that by going over how blood flows so when diastole occurs is when blood is flowing through the mitral valve. All right. And we've got a your take regard, which is, um, well, I'd say probably as common as mitral stenosis in clinical presentations. So your ticks nose is most common mitral regard on ben mitral stenosis and aortic. What the cause is so romantic fever is one of them, but also connective tissue diseases. Um, such as mom found can cause your valves to be a bit funny because aortic regard as well as my chest in their assist. But you know that's coming. Endocarditis as well, has mentioned earlier where bacteria can sit on the valves and cause them to not functioning properly. What would you here in an age, Don't take me? Gosh, any thoughts, any on suits? So in early diastolic mama, so sort of given this away a little bit earlier. But 77 year old man is admitted to Anne after he fell down in the park. He reports he was taking his dog for a walk this morning and felt a crushing pain in the center of his chest. When walking up a hill, he recounted feeling breathless, dizzy and then lost consciousness. His PCG shirt ischemic changes on examination allowed ejection. Systolic. Sorry. His STD showed no ischemic changes on examination. A loud ejection systolic murmur was hurt. Given the patient's history. Which valve in the pathology Do you think he has D aortic stenosis are correct. I gave this away a little. Yeah, but well done. Um, this is a very common question, Onda. Very common clinical scenario. So I would definitely memorize your text in OSIs is a loud ejection. Systolic murmur and the triad of symptoms are angina display here and syncope. Okay, we've got another question. So a 39 year old woman recently from returning from Chad is admitted to an E with high grade pyrexia. She reports a week long history of joint pain and has been feeling more and more breathless since our flights. On examination, she looks a bit overloaded and you can't hear the fast heart sound. A pound systolic moment is heard which radiates to the exit given patient history. Which valve in the pathology do you think she has be? Safia says, Be okay. Any of them Any of this for any of it? Very good. So, Sofia Exactly. I think in this case, there's a lot. I was hoping that be a little bit of confusion on. I'd hoped I trick you out on it. But actually, you got it right. That's healthier. Well done to you. I did think some people might question whether it's mitral stenosis because, uh, as I said earlier, rheumatic fever that causes mitral stenosis. But then a pansystolic moment with a soft test one would actually be mitral regard. Well done. Okay, so now moving on to blood supply of the heart again. I got a couple questions here. Try and try and answer them if you can. And if not, we've got the labels. Which of the two main vessels supplying the heart? Any answer? Guy? Two main blood vessels. Really good. Yeah, Right. And left. Coronary arteries. Exactly. So you got your left on this side Coming straight off the ascending in your toes on the right, on the other side. And then what are the two main branches of the left coronary artery? And what parts do they supply? Jones. Fact The events ringl the questions. Come on, Guy left, anterior descending and left. Circumflex Really, really good. Yeah. So circumplex comes around the back and goes more lateral of a tip towards the other side of the heart. On the left, anterior descending comes down nicely. Yeah, toe supply. The not only the left atrium, but also the left ventricle. And then a bit of the apex is well, brain get. Now, what are the two branches of the right coronary artery? And what parts today supply? This's a bit more of a difficult question because I feel like these are trees are really spoken of a lot. The right coronary artery right branches into the right marginal, which comes down and supplies the right ventricle. But also we have the posterior descending artery, and now, if you can see around the back, it it comes and supplies the posterior aspects. That was the right side of the heart on then, as self is very correctly said, the right coronary artery is what supplies the ab note on the sinoatrial node. So now, logically moving onto my cannula infections, which is when you have a blockage of one of the coronary arteries on. As I'm sure you'll know, we've got two types of them. I've. So firstly, we've got and Stem E's, which I know as band because they're not fully inclusive. So, as you can see in this diagram, usually the from best of the atherosclerosis isn't entirely blocking the artery. So the heart is still getting a little bit of blood for just know as much as it needs on an end stemming which dance the non ST elevation and my has no e c g changes. Where is a stemi that sounds for ST Elevation am I does have e c G changes, and it's usually fully occlusive. So I know this diagram shows that there's still a little bit of an opening for that blood is just not enough. So a stemi for all intents and purposes, it's a full occlusion of an artery. Yeah, and the treatment of an endless tummy. But his bromance, I hope you all have heard of this pneumonic for amount stands for a beat. A blocker, Some reassurance is the on oxygen morphines aspirin, nine traits clopidogrel on an occiput. So this these are all medications that you essentially give for an instant me, and then there's not really any other intervention required. Whereas for a stemming which is almost serious, your treatments gonna be moving us. Which is morphine Oxygen Nitrates like your GTM spring on aspirin or crampy Considering where you are jewels, um, as well. Sometimes Onda PCI. So a stemi will always, always, always need to go through the cardiologists and straight to the cath lab for a PCI, right? I'm sorry I'm wheezing through that just because I'm wary of time. So next question, a 61 year old man presents to eat the with Central crushing pain. Chest pain, which radiates into the jaw and is associate it with nausea and profuse sweating. Your performance PCG, which shows ST segment elevation in leads to two full. You diagnose an anteroseptal ST elevation and my onto receptible. Which coronary best runs along the intervention? Curious, Apt, um, on the anterior surface of the hot to reach the apex. So in other words, well, which are treated you think is blocked in this scenario. See exactly something very good. Your left anterior descending artery, which is actually the most common artery that that's blocked in M i C. So if in doubt, always say your l a d Now just a little bit of, uh, discussion on the great vessels and levels of difficult in. Now this is kind of dull. I know. I apologize. And there's no real way to help you learn this. This is just you're gonna have to memorize it. Um, but first, easily, we have the brunt, which is of the arch. Which a break your cuff on IC, which then spit since your right common carotid and your rights trade be in, got your left common karate, it and your left subclavian. So your left common crossing and your left subclavian comes straight off the aorta. Where is on the right side? That come off the break your neck artery? Thank down the descending aorta. We've got celiac trunk at level T 12. So try and remember these as we go along, guys, cause I've got a couple questions t really something that if i it afterwards celiac trunk t 12. Then we've got superior musing Terek at once at this level here and that supplies the proximal bit of your gut. Then we have the renal and testicular coming off the L2. Just one level. Know, uh, then we have your inferior mesenteric coming off a L3 and that supplies the distal aspect of your gut. Then we have the bifurcate in at L4. Well, the aorta bifid gates into your common iliacs on. Then your common iliac, left and right, split into your internal and external iliac. Stay at L5. So that's a tiny little internal at L5. So take a look at these levels again, and I've got a few questions forth a gentleman presents to the emergency department symptoms of a stroke a CT angiogram is performed, which shows a narrowing of the artery supplying the right common carotid. Which on three has been effective? Yes. Yeah, exactly. It's not the it's not number. Lettis brink Your cup, Alec artery. So on the right side. And I said earlier of the right side of the aortic, aren't you? Have your break your panic, then splitting into your right common carotid in your right subclavian. Where is on the left? They come straight off the toe Now 67 year old man presents T E d with severe central abdominal pain radiating to the back. His records reveal a pasta medical history of abdominal aortic aneurysm. A focused abdominal ultrasound test reveals diffuse dilatation of the abdominal aorta. Most prominent at the site of it's by. Okay, Shin, Which one of the following vertebral levels correspond to the site of most prominent dilatation as evident by the fast. So what level do the and does the way A lot to bifurcate into your common I X. Come on. This is quite important. This is the one level you should You should should should remember. Sorry. Exactly. L4. So all fours, where your aorta by if I cates on. Actually, one thing that really surprised me was how high up four actually is. So if we go back to that diagram here L4 common, I mean by sick a shin. If you look on this side, actually, it's commonly in line with your belly button, and I know it looks it looks further down, but in patients, your aorta actually bite your case quite high up four is higher than you think. All right, Now comes the tricky conduction pathways of the hot. So I thought we'd go through the conduction pathway and then on T E C. Geez, So what are the two nodes of the heart on where they situated? I think we already kind of briefly onto this. We've got the sinoatrial node, which sits in the right atrium, right by the superior vena cava opening so quite superior. And then we've got the atrioventricular node, which sits in the into atrial septum. So it's sort of divides both Atria, but also the atria and of interest, the ventricles of the right side. Particularly What does the bundle of hiss split into? So the conduction comes from the estate a node to the ab nose and then passes down into the bundle of his which splits, then into your left bundle branch. And you're right, Bundle branch. So three is your left hand for is your right And I've done it three and four because actually, it's your left side that the signal runs first room. So from the 80 new a V node coming to the bundle of hist splitting into left and right, and first it goes down the left side. That's quite important when you talk about ACG on left bundle Branch block class is right bundle branch block. So coming down the septum, it always comes from the left side first. And then what does your left bundle branch split into? Isn't the morning each question? Um on? So is your fascicle. Anybody know what the name of the fast schools are? So your anterior and posterior fascicle, uh, in the CGs in the heart block, if you've ever heard of, try to stick your block. This is what it means. So it's affecting your left bundle, which is made of your anterior posterior classical as well as your right bundle. So in total, the three bundles. Thank you. Three extensive calls. And then, as I'm sure you all know, what helps distribute the signal through the ventricles are coming down the bundle of kids on, then through the ventricles. What are they called? Something apiece isn't there? And your kindey fibers. So they're the ones that distribute a signal up through the walls of the heart. All right, now on TCG, this is what a normal VC You will look like. The way forms the first up with deflections is always a P wave. Then we've got the first downward deflection. Is your Q wave on? The reason why I'm saying it like this is because sometimes you can get a second. It will look like a second wave for actually, instead of a double p, it will be in our. So the second upward deflection is in our ways coming down the second down wood is an s. And then you have this ST segment which should always be flat coming to your third upward wave, which is a teammate. And sometimes you get a you wave over here after team, but that's not very common commonly seen because it's so small. So if we think about what's happening in the hot during these ways, A forms pee is atrial depolarizations in response to the essay know triggering so us a note triggers be atrial, the atria and they become depolarizing, which is why you get this spike in the voltage and then your Q s. Oh, sorry. So the PR here, the flat line of, uh after a P waves is because your essay node takes a little bit of time for the signal to come through to the 80. Note on that delay is what you're this PR line is. So if you've got a large delay, your PR complex is gonna be a long gated. Then we've got the QRS complex, which is the worst. Uh um sort of wrecking nice form of any CG that upward spike, which is your ventricular depolarizations. So when your ventricles get the signal, they depolarizing and contract, so that's the main pumping contraction. That spike is when your ventricles are contracting, the blood's coming out. Then we have your ST segment, which is the beginning of when the ventricles relax again. So the signals stopped your easy to be. It's flat. There's no electrical activity and then we have the TV which has been tricking repolarization. So when you ventricles have relaxed, I'm not contracting any further. And instead of you know, so pr this line over here is your PR complex. L on gated PR's are on indication of heart block because this delay from, um the eighth from the electrical conduction causing your GP are complex to be longer and longer. Then your QRS, which we may steal know about, and then ST So that S T segment should always be flat, which is really important when you look at you see a GI, because in am I in ST Elevation, am I This line here will be raised and we'll look at a few examples and then in terms of context of the cardiac cycles. So, as we said when the atria of contracting that's your P waves, the atrial depolarizations atria contracting pee way. Then we've got ventricle contracting. So ventricular system, which is your QRs and then when they're both reporter, I stand on relaxing and not contracting. You have a team, Okay, so looking at the leads of any CG helps to try and visualize it and see that which leads correspond to which area of the heart and and then consequently cars on to which arteries that are supplying it because quite commonly, past medicine, for example and med school finals will ask SCG shows as television in this this this lead what part of the heart is affected in which artery supplies it. So this diagram here is quite helpful to see which leads are affecting which part of the heart and then correspond to teach our tea so leads to you concede to three and a via yes around this bottom correspond to the inferior aspect of the heart. Then we have your natural needs which are one A, V e l and V 56. These guys are these leads are your natural things and then your anterior leads. So this part are the anterior part of the heart. Are you be three and before so if you visualize it it it makes things easier. It makes sense now, a couple examples of ST elevation. So down here in the bottom, showing you what a normal ECD way form looks like. And then we've got one comparing test elevation, So can anyone try and see what leaves have ST Elevation in them on this CCG. Where can you see it So large Says in serially, which is correct, Yes. So if I can convince you that there's some in leads to over here on leads three over here as well as some in a B s, so are inferior leads. You get on, then over here in this PCG where's the ST Elevation? And for a septal? I mean so if I can convince you Yeah, yeah. Okay, so leaves B one b two b three. No questions as promised. A 77 year old man is admitted to the CIA You with ongoing testing radiating to his left shoulder. An easy G is performed, which shows ST Elevation in leads V five and a six. Given the finding, which vessel do you think is most likely affected? So let's break it down. Levi's five and B six. You remember the placements of your SED leads off quite lateral. Have anybody answered? Yeah, so leads V five and B six or on your lateral chest wall. And if you think about the artery supplying the lateral part of the heart on the left hand's fine. Do we remember? Does anybody remember? Yes, Pregnant? Exactly. Oh, you've got a bit of a conflicting audience here, so I can see why you'd say left anterior descending Marsh. Actually, it's your circumplex because think of let's go back to be Oh, it's been taking once a perfect size It It's the last time back to this diagram. All right, guys, much news this. So if we say this is your left coronary artery, your left anterior descending Yes, it kind of provides the the lateral aspect of the heart, but actually it's more so. Just be the anterior and the circumplex comes round and of providing provided supplying the area, which covers leads V five and B six. So good on uses, still recognizing that it's the left side. But actually it's the circumplex. Pick your arms team. You can just extra vision to you guys circumplex on treating here. We have no worries. Go Another question. A 60 year old man presents with tight central chest pain radiating to his left shoulder. This is his initial easy gene. What is your diagnosis? Bit of a tricky easy Geo give you that one, but if you just look for ST Elevations. Don't get folk down by me of weird wave wave forms and the other leads. I'm serious. Semi. Yep, exactly. I say that's half of the diagnosis. So ST Elevations in leads me to to V six. So if I tell you that, can we modify around? Yeah, exactly. So it's also in the septal leads. So it's anteroseptal Oh, anterior lateral. That's good. Me to be three before be five and b six. The diagram be too weak stream before maybe six. So the anteroseptal I usually say the to envy three on because yes, actually, it goes all the way around the 456. So Antero lateral And in that when you say Antara, usually it also means septal the anterograde slash septal plus lateral. Does that make sense? I'm sorry for the confusion that much Does that make a bit more sense to you? Cause I think I may have confused you that no to v to be three a mainly two receptor Elise and then your MRI for the five week said X come around the end on tour electro. Now for the interesting pot, the spotter exam. So I've got some anatomy picture. Sorry, cat. A very picky itches toe practice your anatomy and some radiology as well. Please try and engage with the questions that's gonna make it the most helpful and the most useful for you guys. So question one which other vessels come off from this vessel festival that's identify what it is looking at it from this view, If you imagine your blood's coming down your left atrium left ventricle coming up into this vessel, any answer is break. Your phalanx are no quite frozen. You have it Good thought. So if we look at where this is coming off of the hot isyour pulmonary trunk so it's your left and right pulmonary arteries coming out of the heart on this side. Oh, over and I conceal a so I can see why you think it might be a coronary artery. But actually that's a big, chunky one on your coronaries, as you'll see later in some of the other questions are much, much thinner, much, much smaller. So this is this First, um, label is your pulmonary trunk. Which other vessels come off? It are you is your left and right pulmonary on trees Yeah, and I just answered the second question for you. So this is your your aorta on the other side, carrying oxygenated blood. So pulmonary trunk on this side and your aorta on the other side, carrying oxygenated blood. Then we've got a CT a pa over here. From which ventricle does this vessel originate? So this is again your pulmonary trunk. Which ventricle does this vessel are? Originate from, right? Oh, hang on. I'm having to think now, right? Pulmonary last ones. Yes, that's right. Exactly. All right. Those are said left. I think we've got a bit of a confusion. Hands are what? The confusion. It's No, we'll come back to this at the end. Let's continue at the moment. Just in interest in time. What time is that? Question number three. What is the outermost layer of the heart cold we have? This is a start. Pericardium. Exactly. You got your pericardium on between? Which layers can blood accumulate to cause a cardiac Tom? Been on. So within the That's a good thought. Much of the pericardium in the mind. I'm good thought, but actually, it's between your two layers, um, of the pericardial sac. So you've got a visceral layer on a parietal mayor, and blood can accumulate between them two. So it's actually separate. Separate from the myocardium. Yes, exactly. Learn in the pericardial sac. So which layer makes up the lining of the ventricles he spoke about? This is Well, can you remember? You got your pericardium than your myocardium. And then you're and they're called the, um, of course. Yes, well, in the audience now, which two parts of the heart does this valve connect? That's the first question. What do you think This is difficult because you're looking at it from an anterior perspective. So if you're confused as to which vessels which you look at the thickness, which two parts of the hot does this spelled? Connect. So before we go on to that part of the question, let's let's keep it simple. What vessel is that? The big vessel coming out of the heart. Stronger, thicker They go. What do you think it's gonna be your, uh, yeah. Exact. Well done for turning your my cough. It's the aorta. Exactly. So which two parts of the heart does this help connect Or which fun of the heart does he able to come off that fungible. Yes. So the left ventricle and the aorta is what your race 2000 lbs off. And now, unfortunately, because of the animation, I've just found that the second question for your this vessel pulmonary trunk essentially carries deoxygenated blood. So your aorta is carrying the oxygenated blood out of the heart to the rest of the body, and then your pulmonary is Kirk carrying deoxygenated blood to the lungs. Okay, now, Verne. Really, uh, you were saying the coronary arteries. But if you see here, can you see the very distinct difference in size between your pulmonaries your aorta? And then you're coronary arteries, pulmonary trunk and your aorta massive in comparison. So if we assume, will know assume. Actually, we know this is the anterior aspect. You're looking at this heart anteriorly. Which vessel is this and what Two branches come off of this country, so we know it's a coronary looking at the side of it. It's much smaller, and it's coming on the surface of the heart and take us left. Anterior descending and left. So complex. Exactly. So this is your left coronary artery. Coming down. Down, down, down. You we have the bifurcate in. So I got your left circumflex going that way and you got your left anterior descending coming down. And actually, I was pointing to this being left circumplex that that's not it. It's this coming off this way. If you seen straight off this left coronary artery coming down all the way, That is your so complex. And this is your left anterior descending. And then, secondly, and a scheme X numbers in this artery over here would cause ST Elevation in which leads. So this is your right coronary artery. Which leads? Would it cause ST Elevation? And think of the parts of the heart that it's supplies. So, looking here, you can see it comes down and it zooms, mainly supplying the inferior aspect. So which leads with that correspond to needs to three and a B s. She's on a roll leads to, and three because your right coronary artery supplies the in various office on a B f. You're right. And in terms of that, very well done much. Okay, Now a radiology question by almost done, guys. Well done for getting this far. Question one. What is the name of this valves that it's pointing to coming off into that big, chunky aorta, and is it tricuspid or is it bicuspid? So the damage actually kind of shows you quite well, whether it's dry custody blank aortic valve and it's try custody Exaction So, huh, Number three. How does this chamber different from its counterpart? So this is your left ventricle that pumps blood up into the aorta? How does it differ from the right ventricle? Well, it's thicker. Yes, exactly. So the walls of thicker the muscle is stronger, very good zar. And that's right. The muscle is stronger, the wall is thicker, and the chamber is actually bigger as well. If you look at the previous images, it's bigger than the right ventricle. Can't really see it. But can I have to just take my word for it? Valve tricusp it and your left ventricle slightly bigger with sickle walls and stronger musculature than the right. All right, name this on tree and its branches. I think we can make that logical conclusion that we previously spoke about the left coronary artery. Come on, this side splitting into your lady in the circumflex, so this would logically be your right coronary on tree. And what are Expro is one of them is already late. But let's let's see if you can remember the other one most to you're descending. Is it cost area descending? So it does start with a P, but its proximal descending well done. Burn the good job. On which nodes does this artery supply sinoatrial very good mileage. It's a bit of a trick question, actually, because it's applied boats. Uh huh. Supplies the essay nose on. Did the AB notes if cause if you think about it, both are on the right side and specifically the right atrium. So they're both on the right, and they're both supplied by the right coronary artery. So if you have a blockage in your right coronary, if you've got an M I of the right coronary arteries that can knock out both your nodes and cause you to go until the pretty nasty arrhythmia. So that right coronary, although it's not as who commonly spoken about, is quite important. Now this is the arch of the aorta here in an MRI of the heart Minutes vessels. Do you remember what this all tree is and can you name any of its branches? Well, there's only two branches, actually. The king name of it. So it's the first. That's what you call it. Break your Catholic. Exactly. Their own. And initial. Well done. And what are its branches? All right, current it and right subclavian. Exactly. So you got You're breaking of the trunks coming out to split into your right subclavian. And you're right. Common carotid on, then this artery here. What do you think this is? This is a tricky question. Don't get fooled. Don't be fooled. I guess me saying that which put you off answering women. So you're Marsh. I can see why you think it's the left common carotid it. But if you remember, the left common corrupted comes off the aorta directing. We spoke about this. So on the right hand side, they come off the brake. Okay? Folic trunk. So the break you comes up into the right subclavian and right, Common crafted. But the left common carotid it on the left subclavian comes straight off of the aorta. So this artery here is actually a different on three entirely any thoughts is that the left vertebral exactly use up over were in well done. Yes, it's your left vertebral artery, which supplies the spine and the brain to your vertebra. Um, membrane. And this can be excellent, but it's sometimes when people tilt the head back. You can include your Vectra lottery quite easily, um, and going to sing collapse. So if he's lying down in a Boston, for example, that's that's common question. That you had it in my finals that a patient was lying down in the bathtub for a long time with head back relaxing. And then they passed out on that because they were occluding a vertebral artery. So they were minimizing the supply of blood to the brain and then passed out. So left vertebral artery. Well done. Last question. Kind of tricky, actually. So we'll finish on a on a good note if if someone can get this right, I'll be really impressed. Um, it's chest rate. The a graph of is she is an AP film that you can still see that the heart's quite big. The patient have a loud s one on a mid diastolic murmur. What is your differential diagnosis imagined. Her nose is well done. Birth? Did I oversell back has a really hard question, but actually, it was really eating. So my Charleston OSIS. Exactly. And you can see that on a chest radiograph as a really big heart. So cardiomegaly. And that's because the left ventricle is having to work really hard to pump the blood out. So it's it's gonna have become bigger and bigger and bigger, and you're going to get red left ventricular hypertrophy and left sided failure. So your heart's going to be really good. But you Sorry about your hot, You know how it's gonna be really big. Um, but quite inefficient. So you might also see a patient with Dema and breathlessness because the hot isn't pumping correctly. So heart family ever since. Okay, thank you very very much for attending to night session. I know we ran a bit over, So apologies. Um other Any questions at this point on D a shameless plug here. This is a coupon code. If you could please, please, please give some seed back. It not only helps me, but it also helps FEMA, um, know what works well for you guys and what we can improve on. It's a bit of a win win? Yes, exactly. Me? Um And I think, actually, if you do do the feedback, you get a certificate to your attendants, which is good for your CV. Yeah. Um, yeah. So yes. Difficult on D. You also get to contribute towards making things better for when we do more sessions. Exactly. Coming. And that's my email. Right on the bottom. If you've got any troubles, you need any help If you want to come, um, award and see some patients or if you needed any breathing, email me and I'll be happy to help Where can be found? This is good question. Um, it's our If you email me, I can send you the slides official that also, please do so on the Beamer end. Only if you're willing to give us a slide. Sometimes what we do is we work them on to the metal. So then, if we were as well, is giving people the slides way low. Sorry, this difficult. Also, Just give them the slides as well. So it's kind of a two in one. That's sometimes that's why hopeful, But again, something it's up to you how you want to do this. If you want to email people? That stuff? I I don't mind to me, but I can I can put them up if you like. Yeah, that's fine. Yeah. Yeah. Um hum gonna turn off the recording, actually.