Paul Carty Soriano

U6C6: Patricia Ramos-Duncan

LO: Heart Valves Anatomy
Four valves direct forward blood flow and prevent backward blood leakage in our hearts:
Tricuspid and mitral (atrioventricular or AV) valves, which separate the atria and ventricles
Pulmonic and aortic (semilunar) valves, which separate the ventricles from the great arteries
(pulmonary artery and aorta)
Sometimes I have difficulty remembering which valves are on which side, or even if mitral valve is
another name for bicuspid valve or tricuspid valve. Here is a mnemonic to get you started:

All four valves are attached to a skeleton of dense connective tissue called the fibrous skeleton of the
heart. This skeleton is made up of four fibrous rings (or two rings and two coronets), each
surrounding a valve, a right and left fibrous trigone (formed by connections between rings), and the
membranous parts of the interatrial, interventricular, and AV septa:

This skeleton is important because it:

Keeps the valve openings open and prevents more blood pumping through them from distending
them too much
Provides attachments for the leaflets and cusps of the valves
Provides attachment for the myocardium
Forms an electrical insulator, by separating atrial and ventricular impulses so that they contract
independently and by surrounding and providing passage for the initial part of the AV bundle of
the conducting system of the heart

Tricuspid or Toilet Valve

The tricuspid valve closes the right AV opening during ventricular contraction. It is called tricuspid
because it made up of three cusps or leaflets, which are named based on their relative position in the right
ventricle: anterior, septal, and posterior cusps.

The base of each cusp is attached to the right fibrous ring, which helps maintain the shape of the opening
constant. Chordae tendineae are attached to the free edges of the cusps, just like cords attached to a
parachute:

The chordae tendineae originate from the tips of papillary muscles, which are cone-shaped projections of
muscle from the ventricular wall. The connection of the papillary muscles to the cusps via chordae
tendineae is important because without it, when the right ventricle contracts, cusps would be forced
upward with blood moving back into the right atrium. Normally, however, papillary muscles begin to
contract before the right ventricle contracts, tightening the chordae tendineae to prevent the cusps from
being inverted into the right atrium. Furthermore, because the chordae tendineae are attached to adjacent
sides of two cusps, they prevent the cusps from being separated during ventricular contraction. As a
result, proper closing of the tricuspid valve causes blood to move from the right ventricle into the
pulmonary artery. During right ventricular filling, the tricuspid valve is open, chordae tendineae are loose,
and the three cusps project into the right ventricle.
Suppose a patient has an MI which affects the walls of the inflow portion of the right ventricle. What may
we have to worry about? We may have to worry about necrosis of a papillary muscle following the MI,
which may result in prolapse of the tricuspid valve.

Pulmonic or Paper Valve

The pulmonic valve consists of three semilunar cusps: anterior, right, and left semilunar cusps. The
free edge of each cusp projects upward into the lumen of the pulmonary artery and has a nodule (middle,
thickened part) and lunula (thin, lateral part):

Compared to tricuspid and mitral valve cusps, pulmonic valve cusps are smaller in area and experience
less than half the force [1]. Also, notice that the semilunar cusps do not have chordae tendineae to support
them, but instead have pockets called pulmonary sinuses. If you guessed this means they prevent
backflow of blood using a different mechanism, youd be right. During ventricular contraction, the cusps
are pressed toward its walls as blood leaves the ventricle. After the ventricle relaxes, the elastic recoil of
the pulmonary artery wall forces blood backward toward the right ventricle, but the recoil of blood fills
the pulmonary sinuses, forcing the cusps to come together and completely closing the opening as their
edges meet. Think of this recoiling effect the next time you get your umbrella caught in the wind:

Mitral or My Valve
The mitral valve closes the left AV opening during ventricular contraction. It is made up of two cusps:
anterior and posterior cusps:

The bases of the cusps are attached to the left fibrous ring surrounding the opening and the tension
mechanism of the papillary muscles and chordae tendineae follows the same coordinated action I
described for tricuspid valve. The difference is that the left ventricle contains larger papillary muscles and
thicker chordae tendineae, but are less numerous. Also, the chordae tendineae of each papillary muscle
distribute to both cusps of the mitral valve.

Aortic or Ass Valve

Like the pulmonic valve, the aortic valve has three semilunar cusps: right, posterior, and left semilunar
cusps. The free edge of each cusp also projects upward into the lumen of the ascending aorta:

Each of these cusps also have pockets called aortic sinuses, but a major difference is that in the aortic
wall of the right and left aortic sinuses are the origins of the right and left coronary arteries, respectively.
The functioning of the aortic valve is similar to that of the pulmonic valve with one important additional
process: as blood recoils after ventricular contraction and fills the aortic sinuses, it is automatically forced
into the coronary arteries because these vessels originate from the right and left aortic sinuses:

Auscultation of the Heart Valves

So we know that closure of the semilunar and atrioventricular valves produces heart sounds, but how? The
earliest explanation was that the slapping of the valve cusps together produces the vibrations that we can
hear with our stethoscope, but that cannot be the major source of sound because blood between the cusps
cushions the slapping effect and prevents significant sound. So what is it then? The cause is actually vibration
of tense valves and adjacent walls of the heart and major vessels around the heart right after closure. This
causes vibrating turbulence in the blood which travel through the adjacent tissues to the chest wall, where we

can hear as sound by using our stethoscope. This is why the resulting sounds are therefore best heard
"downstream," at defined auscultation sites (dark circles):

So what about heart murmurs? Heart murmurs are produced by a turbulent blood flow or by a change in the
direction of blood flow. Normally, blood flows through the heart and blood vessels as laminar flow which is
streamlined and silent. However, if we develop a valvular heart disease that causes turbulent blood flow, the
turbulent flow will produce vibrations in the tissues that are heard as murmurs. Murmurs are caused in the
following conditions:

Valvular stenosis (narrowing of any heart valve)

Valvular insufficiency (regurgitation of any heart valve)
Ventricular septal defect (congenital hole in ventricular septum)
Atrial septal defect (congenital hole in atrial septum)
Coarctation of aorta (congenital narrowing of systemic aorta)
Patent ductus arteriosus (congenital disorder in which there is backward blood flow from aorta into
pulmonary artery)

References
[1] Keith L. Moore; Arthur F. Dalley; A. M. R. Agur (13 February 2013). Clinically Oriented Anatomy. Lippincott Williams & Wilkins.
[2] Richard Drake; A. Wayne Vogl; Adam W. M. Mitchell (30 January 2014). Gray's Anatomy for Students. Elsevier Health Sciences.
[3] Indu Khurana (10 February 2014). Medical Physiology for Undergraduate Students. Elsevier Health Sciences APAC. pp. 212