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HEART

The cardiac apex almost corresponds to the apex beat, which is usually visible and always
palpable in the fifth intercostal space, slightly medial to the midclavicular line, in systole.
The sites of auscultation for the cardiac valves: the sternal end of the second left intercostal
space (pulmonary area); the sternal end of the second right intercostal space (aortic area); near the
cardiac apex (mitral area); and over the left lower sternal border, at the level of the fifth intercostal
spaces (tricuspid area).
PERICARDIUM
The pericardium contains the heart and the juxtacardiac parts of its great vessels. It consists of
two components, the fibrous and the serosal pericardium.
The fibrous pericardium is a conical sac made of tough connective tissue, completely
surrounding the heart without being attached to it. Superiorly, it is continuous exteriorly with the
adventitia of the great vessels; inferiorly it is attached to the diaphragm.
The serosal pericardium consists of two layers of serosal membrane, one inside the other: the
inner (visceral) one adheres to the heart and forms its outer covering known as the epicardium,
whereas the outer (parietal) one lines the internal surface of the fibrous pericardium. The two serosal
surfaces are opposed and separated by a film of fluid. This allows movement of the inner membrane
and the heart adhering to it, except at the arterial and venous areas of the pericardium where the two
serosal membranes merge. These last constitute two parietovisceral lines of serosal reflexion. The
separation of the two membranes of the serosal pericardium creates a narrow space, the pericardial
cavity, which provides a complete cleavage between the heart and its surroundings and so allows it
some freedom to move and change shape.
The fibrous and serosal pericardium continue with each other and form the pericardial sinuses.
The serosal pericardium surrounds the great vessels at the heart base, forming two pedicles:
an arterial pedicle (pulmonary trunk and ascending aorta) and a venous pedicle (superior vena cava,
inferior vena cava and the four pulmonary veins). Posteriorly to the arterial pedicle is situated the
transverse sinus of the pericardium. Inferiorly to the transverse sinus is situated the oblique pericardial
sinus.

GENERAL ORGANIZATION OF THE HEART


Of the four cardiac chambers, the two atria receive venous blood as weakly contractile
reservoirs for final filling of the two ventricles, which then provide the powerful expulsive contraction
that forces blood into the main arterial trunks.
The right heart starts at the right atrium, and receives the superior and inferior venae cavae
together with the main venous inflow from the heart itself via the coronary sinus. This systemic
venous blood traverses the right atrioventricular orifice, guarded by the tricuspid valve, to enter the
inlet component of the right ventricle. Contraction of the ventricle, particularly its apical trabecular
component, closes the tricuspid valve and, with increasing pressure, ejects the blood through the
muscular right ventricular outflow tract into the pulmonary trunk. The blood then flows through the
pulmonary vascular bed, which has a relatively low resistance.

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The left heart starts at the left atrium, which receives all the pulmonary inflow of oxygenated
blood and some coronary venous inflow. It contracts to fill the left ventricle through the left
atrioventricular orifice guarded by its mitral valve. The valve is the entry to the inlet of the left
ventricle. Ventricular contraction rapidly increases the pressure in the apical trabecular component,
closing the mitral valve and opening the aortic valve, enabling the ventricle to eject via the left
ventricular outflow tract into the aortic sinuses and the ascending aorta, and thence to the entire
systemic arterial tree, including the coronary arteries. This vast vascular bed presents a high
peripheral resistance that, with large metabolic demands (especially the sustained requirements of the
cerebral tissues), explains the more massive structural organization of the ‘left heart'.

EXTERNAL FEATURES
The heart is a hollow, fibromuscular organ of a somewhat conical or pyramidal form, with a
base, apex and a series of surfaces and ‘borders'. Enclosed in the pericardium, it occupies the middle
mediastinum between the lungs and their pleural coverings. It is placed obliquely behind the body of
the sternum and the adjoining costal cartilages and ribs.
The heart is described as having a base and apex, its surfaces being designated as
sternocostal (anterior), diaphragmatic (inferior) and right and left (pulmonary). Its borders are
termed upper, right, inferior (‘acute' margin or border) and left (‘obtuse' margin or border).
Grooves on the cardiac surface
The division of the heart into four chambers produces boundaries that are visible externally as
grooves. The interatrial groove is a shallow groove separating the two atria. The lateral limits are
defined by the borders of the atria. The atrioventricular (coronary) groove (or sulcus) separates the
atria from the ventricles. This groove, containing the main trunks of the coronary arteries, is oblique.
It descends to the right on the sternocostal surface, separating the right atrium (and its auricle or
appendage) from the oblique right margin of the right ventricle. Continuing to the left, the groove
curves around the ‘obtuse' margin and descends to the right, separating the atrial base from the
diaphragmatic surface of the ventricles. Internally, the ventricles are separated by the septum. The
mural margins of the septum correspond to the anterior and inferior (diaphragmatic) interventricular
grooves.
The base of the heart
It faces back and to the right, separated from the thoracic vertebrae by the pericardium, right
pulmonary veins, oesophagus and aorta. It is formed mainly by the left atrium, and only partly by the
posterior part of the right atrium. It extends superiorly to the bifurcation of the pulmonary trunk and
inferiorly to the posterior part of the atrioventricular groove, which contains the coronary sinus and
branches of the coronary arteries. It is limited to the right and left by the rounded surfaces of the
corresponding atria. These are separated by the interatrial groove.
The point of junction of the atrioventricular, interatrial and posterior interventricular grooves
is termed the crux of the heart.
Two pulmonary veins on each side open into the left atrial part of the base, whereas the superior and
the inferior vena cava open into the upper and lower parts of the right atrial basal region.
The apex
This is the apex of the conical left ventricle, which is directed down, forwards and to the left.
It is overlapped by the left lung and pleura. The apex is located most commonly behind the fifth left
intercostal space, near or a little medial to the midclavicular line.

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Anterior, sternocostal surface of the heart
Facing forwards and upwards, the anterior surface has an acute right and a more gradual left
convexity. It consists of an atrial area above and to the right, and a ventricular part below and to the
left of the atrioventricular groove. The right coronary groove is crossed by the right coronary artery
and the small vein of the heart. The left coronary groove is crossed by the circumflex artery (a branch
from the left coronary artery). The atrial area is occupied almost entirely by the right atrium. The left
atrium is largely hidden by the ascending aorta and pulmonary trunk. Of the ventricular region, about
one-third is made up by the left and two-thirds by the right ventricle. The site of the septum between
them is indicated by the anterior interventricular groove. The anterior interventricular groove is
crossed by anterior interventricular artery (branch from the left coronary artery) and the great vein of
the heart.
The sternocostal surface is separated by the pericardium from the body of the sternum, the
sternocostal muscles, the third to the sixth costal cartilages and the thymus. It is also covered by the
pleural membranes and by the thin anterior edges of the lungs, except for a triangular area at the
cardiac incisure of the left lung.
Inferior, diaphragmatic surface of the heart
It is formed by the ventricles and rests upon the diaphragm. It is separated from the
anatomical base by the atrioventricular groove and is traversed obliquely by the posterior
interventricular groove.
The right coronary groove, on this diaphragmatic surface, is crossed by the right coronary artery, and
the left coronary groove is crossed by the coronary venous sinus. The posterior interventricular groove
is crossed by the posterior interventricular artery ( branch from the right coronary artery) and the
small vein of the heart.
This surface of the heart is separated through diaphragm from the superior surface of the liver and the
stomach.
Left surface of the heart (pulmonary surface)
The left surface consists almost entirely of the obtuse margin of the left ventricle, but a small
part of the left atrium and its auricle contribute superiorly. It is separated by the pericardium from the
left phrenic nerve and by the left pleura from the deep concavity of the left lung.
Right surface of the heart
The right surface is rounded and formed by the right atrial wall. It is separated from the
mediastinal aspect of the right lung by the pericardium and the pleural coverings. Its convexity
merges below into the short intrathoracic part of the inferior vena cava and above into the superior
vena cava. The sulcus terminalis (terminal groove) is a prominent landmark between the true atrial
and the venous components of the right atrium.
Upper border of the heart
This is atrial (mainly the left atrium). Anterior to it are the ascending aorta and the pulmonary
trunk. At its extremity, the superior vena cava enters the right atrium.
Right border of the heart
Corresponding to the right atrium. This border extend between the orifice of inferior vena cava and
the apex of the heart.

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Inferior border of the heart
Also known as the acute margin of the heart, the inferior border is sharp, thin and nearly
horizontal. It extends from the lower limit of the right border to the apex and it is formed mainly by
the right ventricle, with a small contribution from the left ventricle near the apex.
Left border of the heart
Also known as the obtuse margin, the left border separates the sternocostal and left surfaces.
It is round and mainly formed by the left ventricle but, to a slight extent superiorly, is formed by the
auricle of the left atrium. It descends obliquely, convex to the left, from the auricle to the cardiac
apex.

RIGHT ATRIUM
General and external features
The right atrium is situated anteriorly and to the right. Its walls form the right upper
sternocostal surface, the convex right (pulmonary surface) and a little of the right side of the
anatomical base. The superior vena cava opens into its dome and the inferior vena cava into its lower
posterior part. An extensive muscular pouch, the auricle, projects anteriorly to overlap the right side
of the ascending aorta. The auricle is a broad, triangular structure and has a wide junction with the
true atrial component of the atrium. The junction between the venous part (sinus venosus) and the
atrium proper is marked externally by a shallow groove, the sulcus terminalis, extending between the
right sides of the openings of the two venae cavae. The sulcus terminalis corresponds, internally, to
the terminal crest (crista terminalis) which is the site of origin of the extensive pectinate muscles.
Anteriorly, the right atrium is related to the anterior part of the mediastinal surface of the right
lung, from which it is separated by pleura and pericardium. Posteriorly and to the right are the right
pulmonary veins. Medially are the ascending aorta and the root of the pulmonary trunk and its
bifurcation.
Interior surface
The interior surface of the right atrium can be divided into three regions: a smooth-walled
venous component posteriorly that leads, anteriorly, to the vestibule of the tricuspid valve and the
auricle. The smooth-walled part receives the opening of the venae cavae and the coronary sinus. The
wall of the vestibule has a ridged surface and that of the auricle is trabeculated. The superior and
inferior venae cavae open into the venous component. The superior vena cava returns blood from
head, neck and upper limb through an orifice that faces inferoanteriorly and has no valve, and also
receives blood from the chest wall and the oesophagus via the azygos system. The inferior vena cava
is larger than its superior counterpart: it drains blood from all structures below and including the
diaphragm into the lowest part of the atrium near the septum. Anterior to its orifice is a flap-like
valve, the Eustachian valve or valve of the inferior vena cava. The coronary sinus opens into the
venous atrial component between the orifice of the inferior vena cava, the fossa ovale and the
vestibule of the atrioventricular opening. The coronary sinus is often guarded by a thin, semicircular
valve that covers the lower part of the orifice (Thebesius' valve, also known as the Thebesian valve).
The ostium of the coronary sinus forms a prominent landmark in the right atrium. The sinus itself lies
within the left atrioventricular groove. The coronary sinus begins at the point where the oblique vein
of the left atrium joins the great cardiac vein. The sinus receives the middle and small cardiac veins
close to its junction with the right atrium.

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The atrium proper and the auricle are separated from the venous sinus by the crista terminalis, a
smooth, muscular ridge. The sinu-atrial node is located within the superior part of the groove, lateral
to and extending below the orifice of the superior vena cava.
The pectinate muscles (musculi pectinati), almost parallel muscular ridges, extend anterolaterally
from the terminal crest and reach into the auricle, where they form several trabeculations.
The septal wall presents the fossa ovale, an oval depression above and to the left of the orifice of the
inferior vena cava. . A small slit is sometimes found at the upper margin of the fossa, ascending
beneath the rim to communicate with the left atrium. This represents failure of obliteration of the fetal
foramen ovale, which remains patent in up to one-third of all normal hearts.
Anteroinferior in the right atrium is the large, oval vestibule leading to the orifice of the tricuspid
valve.

RIGHT VENTRICLE
The right ventricle extends from the right atrioventricular (tricuspid) orifice nearly to the cardiac apex.
It then ascends to the left to become the infundibulum, or conus arteriosus, reaching the pulmonary
orifice and supporting the cusps of the pulmonary valve. Topographically, the ventricle possesses an
inlet component which supports and surrounds the tricuspid valve; a coarsely trabeculated apical
component; and a muscular outlet or infundibulum, which surrounds the attachments of the cusps of
the pulmonary valve.
External features
The convex anterosuperior surface of the right ventricle makes up a large part of the sternocostal
aspect of the heart, and is separated from the thoracic wall only by the pericardium. The left pleura
and, to a lesser extent, the anterior margin of the left lung are interposed above and to the left.
The inferior surface is flat and is related mainly, with the diaphragm. The left and posterior wall is the
ventricular septum. The wall of the right ventricle is significantly thinner than that of the left.
Internal features
The inlet and outlet components of the ventricle, supporting and surrounding the cusps of the tricuspid
and pulmonary valves respectively, are separated in the roof of the ventricle by the prominent
supraventricular crest (crista supraventricularis).
The inlet and outlet regions extend apically into and from the prominent coarsely trabeculated
component of the ventricle. The inlet component is itself also trabeculated, whereas the outlet
component (or infundibulum) has predominantly smooth walls. The trabeculated appearance is caused
by irregular muscular ridges and protrusions, which are known collectively as trabeculae carneae, and
are lined by endocardium.
Other conspicuous protrusions are the papillary muscles, which are inserted at one end onto the
ventricular wall and are continuous at the other end with collagenous cords, the chordae tendineae,
inserted on the free edge and elsewhere on the free aspect of the atrioventricular valves.
The smooth-walled outflow tract, or infundibulum (conus arteriosus), ascends to the left above the
septoparietal trabeculations and below the arch of the supraventricular crest to the pulmonary orifice.
Tricuspid valve
The atrioventricular valvular complex, in both right and left ventricles, consists of the orifice and its

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associated anulus, the cusps, the supporting chordae tendineae of various types and the papillary
muscles.
It is usually possible to distinguish three cusps in the tricuspid valve, hence the name. They are
located anterosuperiorly, septally and inferiorly, corresponding to the marginal sectors of the
atrioventricular orifice so named. Each is a reduplication of endocardium enclosing a collagenous
core, continuous marginally and on its ventricular aspect with diverging fascicles of chordae
tendineae and basally confluent with the anular connective tissue.
Pulmonary valve
The pulmonary valve, guarding the outflow from the right ventricle, surmounts the infundibulum and
is situated at some distance from the other three cardiac valves. Its general plane faces superiorly to
the left and slightly posteriorly. It has three semilunar cusps attached by convex edges partly to the
infundibular wall of the right ventricle and partly to the origin of
the pulmonary trunk. There is one anterior semilunar cusp, and right and left semilunar cusps.
Each cusp is a fold of endocardium, with an intervening, and variably developed, fibrous core. The
free margin of each cusp contains a central localized thickening of collagen, the nodule of the
semilunar ‘cusp' (nodule of Arantius). Each semilunar cusp is contained within one of the three
sinuses of the pulmonary trunk.
LEFT ATRIUM
Although smaller in volume than the right, the left atrium has thicker walls.
Its cavity and walls are formed largely by the proximal parts of the pulmonary veins. It is separated
from the right atrium by the interatrial septum. The left part is concealed anteriorly by the initial
segments of the pulmonary trunk and aorta: part of the transverse pericardial sinus lies between it and
these arterial trunks. Anteroinferiorly, and to the left, it adjoins the base of the left ventricle at the
orifice of the mitral valve. Its posterior aspect forms most of the anatomical base of the heart,
receiving the two pulmonary veins from each lung. It forms the anterior wall of the oblique pericardial
sinus. Interiorly, the four pulmonary veins open into the upper posterolateral surfaces of the left
atrium, two on each side. The left atrial auricle is constricted at its atrial junction and all the pectinate
muscles of the left atrium are contained within it. It is characteristically longer, narrower and more
hooked than the right auricle.

THE LEFT VENTRICLE


General and external features
It is a powerful pump that sustains pulsatile flow in the high-pressured systemic arteries.
Its long axis descends forwards and to the left. In transverse section, its cavity is oval, with walls
about three times thicker than those of the right ventricle.
It forms part of the sternocostal, left and inferior (diaphragmatic) cardiac surfaces. The base of the
ventricular cone is superficially separated from the left atrium and atrial auricle by part of the
atrioventricular groove; the coronary sinus runs in the posterior aspect of the groove to reach the right
atrium. The anterior and posterior interventricular grooves indicate the lines of mural attachment of
the ventricular septum and the limits of the left and right ventricular territories.
Internal features
The left ventricle has an inlet region, guarded by the mitral valve (ostium venosum), an outlet region,
guarded by the aortic valve (ostium arteriosum), and an apical trabecular component. The left

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atrioventricular orifice admits atrial blood during diastole, flow being towards the cardiac apex. After
closure of the mitral cusps, and throughout the ejection phase of systole, blood is expelled from the
apex through the aortic orifice.
The anterolateral wall is the ventricular septum.
Between the lower limits of the free margins of the cusps of the mitral valve and the apex of the
ventricle, the muscular walls are deeply trabeculated. These trabeculae carneae are finer and more
intricate than those of the right ventricle, but similar in structure
Mitral valve
The valve has an orifice with its supporting anulus, cusps and a variety of chordae tendineae and
papillary muscles.
It is named the ‘bicuspid valve’ and has an anterior cusp and a posterior cusp. The chordae from each
papillary muscle diverge and are attached to corresponding areas of closure on both valvular cusps.
Aortic valve
The smooth left ventricular outflow tract, or aortic vestibule, ends at the cusps of the aortic valve.
Although stronger in construction, the aortic valve resembles the pulmonary in possessing three
semilunar cusps, supported within the three aortic sinuses of Valsalva. Coronary arteries usually open
in the upper part of the sinus.

CONNECTIVE TISSUE AND FIBROUS SKELETON OF THE HEART


Running at the ventricular base, and intimately related to atrioventricular valves and the aortic orifice,
is a complex framework of dense collagen with membranous, tendinous and fibroareolar extensions.
The whole is sufficiently distinct to be termed the fibrous skeleton of the heart.
The fibrous skeleton has two functions. It ensures electrophysiological discontinuity between the
atrial and ventricular myocardial masses (except at the site of penetration of the conduction tissue).

CONDUCTION TISSUE
The cells of cardiac muscle differ from those of skeletal muscle in having the inherent ability to
contract and relax spontaneously. Ventricular cells contract and relax at a lower frequency than atrial
cells, but in the intact heart both are synchronized to a more rapid rhythm, generated by pacemaker
tissue and conveyed to them by a system of fibres specialized for conduction.
Of all the cells in the heart, those of the sinu-atrial node generate the most rapid rhythm, and therefore
function as the pacemaker of the heart. The impulse is transmitted over preferentially conducting
pathways to right and left atria and to the atrioventricular node. At the atrioventricular node, the
impulse is delayed by 40 ms. This delay allows the atria to eject their contents fully before contraction
of the ventricles begins.
The cells of the conduction system extend from the node into the stem and principal branches (right
and left) of the atrioventricular bundle (of His). Here, they become continuous with other cells, the
Purkinje fibres. Conduction of the impulse is rapid in the bundle and its branches.The cardiac impulse
therefore arrives at the apex of the heart before spreading through the ventricular walls, producing a
properly coordinated ventricular ejection.

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The human heart beats ceaselessly at 70 cycles every minute for many decades, maintaining perfusion
of pulmonary and systemic tissues. The rate and stroke volume fluctuate in response to prevailing
physiological demands.
The nodes and networks of the so-called specialized myocardial cells constitute the cardiac
conduction system. The components of this system are the sinu-atrial and atrioventricular nodes, the
atrioventricular bundle with its left and right bundle branches and the subendocardial plexus of
ventricular conduction cells (Purkinje fibres). Within the system, the main pacemaker rhythm of the
heart is generated (sinus), is influenced by nerves (sinus and its innervation) and is transmitted
specifically from atria to ventricles (atrioventricular node and bundle) and, within the ventricles, to all
their musculature. The spread of excitation is very rapid, but not instantaneous. Different parts of the
ventricles are excited at slightly different times, with important functional consequences. Failure of
the conduction system will not block cardiac contraction, but the system will become poorly
coordinated or uncoordinated. The rhythm will be slower because it originates from a spontaneous
(myogenic) activity in the working cardiac myocytes or in a subsidiary pacemaker in a more distal
part of the diseased or disrupted conduction system.
There are no specialized internodal and interatrial conduction pathways. The excitation emanating
from the sinoatrial node spreads to the atrial musculature and to the atrioventricular node through
ordinary atrial working myocardium. The geometric arrangement of fibres along well-organized atrial
muscle bundles, e.g. the terminal crest and the rims of the fossa ovale, ensure that conduction is
marginally more rapid than elsewhere within the atrium.
Sinoatrial node
The sinoatrial node is an elliptical structure, 10–20 mm long. It is located at the junction between
parts of the right atrium derived from the embryonic venous sinus and the atrium proper.
Atrioventricular node
The atrioventricular node is an atrial structure that lies at the root of an extensive tree of conduction
tissue reaching the apex of the ventricles, the papillary muscles and other regions of the ventricles.
The node, with its transitional zones, is located within the atrial component of the muscular
atrioventricular septum. The atrioventricular bundle is the direct continuation of the atrioventricular
node. The principal branches of the bundle are insulated from the surrounding myocardium by sheaths
of connective tissue. Functional contacts between ventricular conduction and working myocytes
become numerous only in the subendocardial terminal ramifications.
VASCULAR SUPPLYAND LYMPHATIC DRAINAGE
Coronary arterial supply
The right and left coronary arteries arise from the ascending aorta in its anterior and left posterior
sinuses. The levels of the coronary ostia (orifices) are variable. The two arteries, as indicated by their
name, form an anastomotic circle between the atrioventricular groove, marginal and interventricular
(descending) loops intersecting at the cardiac apex.
Right coronary artery
The right coronary artery arises from the anterior (‘right coronary') aortic sinus. It passes at first
anteriorly and slightly to the right between the right auricle and pulmonary trunk, where the sinus
usually bulges. It reaches the atrioventricular groove and descends in this almost vertically to the right
(acute) cardiac border, curving around it into the posterior part of the groove. Branches of the right
coronary supply the right atrium and ventricle and, variably, parts of the left chambers and
atrioventricular septum.

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Branches: atrial branches (The artery of the sinoatrial node), The right marginal artery, posterior
interventricular artery, Septal branches (supply the posterior interventricular septum).

Left coronary artery

The left coronary artery is larger in calibre than the right, and supplies a greater volume of
myocardium, including almost all the left ventricle and atrium, except in so-called ‘right dominance',
when the right coronary artery partly supplies a posterior region of the left ventricle. The left coronary
artery usually supplies most of the interventricular septum. It arises from the left posterior (left
‘coronary') aortic sinus.

Reaching the atrioventricular groove, the left coronary divides into several branches: the anterior
interventricular artery, left diagonal artery, the circumflex artery, the left marginal artery, anterior
septal branches (supplying its ventral two-thirds of the septum), posterior ventricular branches. The
anterior interventricular artery produces right and left anterior ventricular and anterior septal branches,
and a variable number of corresponding posterior branches.
Details of coronary distribution require integration into a concept of total cardiac supply. Most
commonly, the right coronary artery supplies all of the right ventricle (except a small region to the
right of the anterior interventricular groove); a variable part of the diaphragmatic aspect of the left
ventricle; the posteroinferior one-third of the intraventricular septum; the right atrium and part of the
left atrium. Left coronary distribution is reciprocal, and includes most of the left ventricle; a narrow
strip of right ventricle; the anterior two-thirds of the interventricular septum; most of the left atrium.

Cardiac veins
The heart is drained by the coronary sinus and its tributaries, the anterior cardiac veins and the small
cardiac veins. The large majority of cardiac veins drain into the wide coronary sinus, 2 or 3 cm long,
lying in the posterior atrioventricular groove between the left atrium and ventricle. The sinus opens
into the right atrium between the opening of the inferior vena cava and the right atrioventricular
orifice.
Innervation of the heart

Initiation of the cardiac cycle is myogenic, originating in the sinu-atrial node. All the cardiac branches
of the vagus (parasympathetic) and all the sympathetic branches (the upper four or five thoracic spinal
segments) contain both afferent and efferent fibres. Sympathetic fibres accelerate the heart and dilate
the coronary arteries when stimulated, whereas vagal fibres slow the heart and cause constriction of
the coronary arteries.

Nearing the heart, the autonomic nerves form a mixed cardiac plexus. These plexus contains ganglion
cells. Cholinergic and adrenergic fibres, arising in or passing through the cardiac plexus, are
distributed most profusely to the sinu-atrial and atrioventricular nodes.

MAJOR BLOOD VESSELS

The major blood vessels comprise the pulmonary trunk, the thoracic aorta and its branches, the
superior and inferior venae cavae and their tributaries.

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Pulmonary trunk

The pulmonary trunk, or pulmonary artery, conveys deoxygenated blood from the right ventricle to
the lungs. It is the most anterior of the cardiac vessels and arises from the base of the right ventricle.

Below the aortic arch it divides, level with the fifth thoracic vertebra and to the left of the midline,
into right and left pulmonary arteries. The pulmonary trunk bifurcation lies below, in front and to the
left of the tracheal bifurcation.

Thoracic aorta

Ascending aorta

The ascending aorta is typically 5 cm long and begins at the base of the left ventricle. It ascends
obliquely. At its origin there are three almost hemispherical outward bulges (sinuses of Valsalva), one
posterior (non-coronary), one left and one right, which correspond to the three cusps of the aortic
valve. Distally there are three aortic sinuses.

Aortic arch

The aortic arch continues from the ascending aorta. The arch first ascends diagonally back and to the
left over the anterior surface of the trachea, then back across its left side and finally descends to the
left of the fourth thoracic vertebral body, continuing as the descending thoracic aorta. It curves
around the hilum of the left lung, and extends upwards to the mid level of the manubrium of the
sternum.

Three branches arise from the convex aspect of the arch: the brachiocephalic trunk, left common
carotid and left subclavian arteries.

Descending thoracic aorta

The thoracic aorta is the segment of descending aorta confined to the posterior mediastinum. It begins
level with the lower border of the fourth thoracic vertebra, continuous with the aortic arch, and ends
anterior to the lower border of the 12th thoracic vertebra in the diaphragmatic aortic aperture. At its
origin it is left of the vertebral column, as it descends it approaches the midline, and at its termination
is directly anterior to it. The thoracic aorta provides visceral branches to the pericardium, lungs,
bronchi and oesophagus, and parietal branches to the thoracic wall.

VEINS
Superior vena cava
The superior vena cava returns blood to the heart from the tissues above the diaphragm. It is
approximately 7 cm in length, and is formed by the junction of the two brachiocephalic veins (right
and left) behind the lower border of the first right costal cartilage near the sternum. It descends
vertically behind the first and second intercostal spaces, and ends in the upper right atrium behind the
third right costal cartilage. Its inferior half is within the fibrous pericardium. The superior vena cava
has no valves.
Tributaries of the superior vena cava are the azygos vein and small veins from the pericardium and
other mediastinal structures.

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The brachiocephalic vein is formed by internal jugular vein and subclavian vein.
Inferior vena cava
The inferior vena cava returns blood to the heart from the tissues below the diaphragm (inferior limbs,
abdominal cavity and pelvis); it drains into the inferoposterior part of the right atrium.

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