Angiology

SHANDONG UNIVERSITY

Liu Zhiyu

Angiology

Composition Cardiovascular

system Lymphatic system

The cardiovascular systemOrganization Heart

A muscle pump to maintain the flow of blood

Consist of four chambers (right and

left atria, right and left ventricles) Artery (a.) carry blood away from the heart Veins ( v.) carry blood back to the heart Capillary microscopic vessels, the area of

exchange between blood and tissue fluid

The cardiovascular system

Blood circulation Systemic circulation

left ventricle→aorta and its branches→capillaries of body→superior and inferior vena cava→right atrium

Pulmonary circulation right ventricle→pulmonary a.→capillaries of lung → pulmonary v. →left atrium

The cardiovascular system

Vascular anastomosis

Anastomosis between a. Anastomosis between v. Arteriolovenular

anastomosis Collateral vessels Collateral circulation

The Heart

The heart

Position Lies within the pericardium in

middle mediastinum Behind the body of sternum

and coastal cartilages 2 to 6 In front of thoracic vertebrae 5

to 8 A third of it lies to the right of

median plan and 2/3 to the left

Surfaces of the heart

Surfaces of the heart Pyramidal in shape, somewhat larger

than a closed fist One apex One base Two surface Three borders Four sulcuses

Formed by left ventricle Directed downwards, forward,

and to the left Lies at the level of the fifth left

intercostal space, 1~2 cm medial to the left midclavicular line (9cm from the midline)

Cardiac apex

Cardiac base

Formed by the left atrium and to a small extent by the right atrium.

Faces backward, upward and

to the right

Sternocostal surface

Formed mainly by the right atrium and right ventricle, and a lesser portion of its left is formed by the left auricle and ventricle

Directed forwards and upwards

Diaphragmatic surface

Formed the ventricles － chiefly the left ventricle

Directed backwards and downwards, and rest upon the central tendon of the diaphragm

Borders of the heart

Right border Vertical Formed entirely by right

atrium Left border

Round Mainly formed by the left

ventricle and partly by the left auricle

Inferior border Horizontal Formed by the right ventricle

and cardiac apex

Sulcuses of the heart

Coronary sulcus (circular sulcus) which marks the division between atria and ventricles, contains the trunks of the coronary vessels and completely encircles the heart

Interatrial sulcus －separates the two atria and is hidden by pulmonary trunk and aorta in front

Sulcuses of the heart Anterior interventricular

groove Posterior interventricular

groove Mark the division between

ventricles (which separates the RV from the LV)

Cardiac apical incisure Atrioventricular crux

Chambers of the heart

Chambers of the heart

Consists of four chambers

Left and right atria Left and right auricle

Left and right ventricles

Right atrium (RA) Three inlets

Orifice of superior vena cava returns blood to the heart from the upper half of the body

Orifice of inferior vena cava returns blood to the heart from the lower half of the body

Orifice of coronary sinus returns blood to the heart from the cardiac muscle

One outlet － right atrioventricular orifice

Right atrium (RA) Crista terminalis － vertical

ridge that from superior vena cave to inferior vena cave

Sulcus terminalis － groove on exterior of heart that corresponds to crista terminalis

Two parts － separated externally by sulcus terminalis and internally by the crista terminalis Atrium proper Sinus venarum cavarum

Right atrium (RA) Atrium proper

In front of the ridge Pectinate muscles in wall

Sinus venarum cavarum Smooth walls Fossa ovalis － an oval

depression, a remnant of the fetal foramen ovale, on the lower part of interatrial septum, the most common location of atrial septal defects (ASD)

Aortic mound

Right ventricle (RV)

One inlet 　　－ right atrioventricular orifice

One outlet 　　－ orifice of pulmonary trunk

Right ventricle (RV)

Supraventricular crest (a muscular ridge between right atrioventricular orifice and orifice of pulmonary trunk )

Two parts Inflow tract Outflow tract

Right ventricle (RV)

Inflow tract Trabeculae carneae

irregularly arranged bundles of myocardium

Septomarginal trabecula － extends from interventricular septum to base of anterior papillary muscle, contains right bundle branch

Papillary muscles Conical-shaped Three: anterior, posterior

and septal

Right ventricle (RV)

Outflow tract —Conus

arteriosus 　　　　　　　　　　　 Cone-shape , smooth area

leading upward to orifice of pulmonary trunk

Pumps blood through pulmonary orifice to pulmonary trunk

Tricuspid valve Guards right atrioventricular

orifice Three triangular cusps:

anterior, posterior and septal Base of cusps are attached to

fibrous ring surrounding the atrioventricular orifice.

To their free edges and ventricular surfaces are attached chordae tendineae , which connect the cusps to the papillary muscles.

Tricuspid valve

Tricuspid complex

Tricuspid ring Tricuspid valve Chordae tendineae Papillary muscles

Chordae tendineae

Papillary muscles

Function of tricuspid complex Open during diastole to allow blood to enter ventricles from atria

Closed during systole to prevent regurgitation of blood into atria

Valve of pulmonary trunk

Guards the orifice of pulmonary trunk

Has three semilunar cusps – each with free border that has central modules called nodules of semilunar valve

Has three pulmonary sinuses —bulges in wall of pulmonary trunk at level of valve that correspond to cusps

Function of pulmonary valves

Opening during systole, with cusps pressed toward wall of vessel as blood is forced upward

Closed during diastole Ventricular pressure drops in diastole Floating together of valve cusps, with

free borders meeting, thus closing the valve

Left atrium (LA) Four inlets － four orifices of pulmonary veins One outlet － left atrioventricular orifice

Left ventricle (LV)

One inlet left atrioventricular orifice

One outlet － aortic orifice Two parts － divided by anterior cusps of

mitral valve Inflow tract － rough walls Outflow tract

Aortic vestibule Smooth area leading to aortic orifice

Mitral valve

Guards left atrioventricular orifice Two triangular cusps － anterior and

posterior with commissural cusps between them (posteromedial and anterolateral commissures)

Mirtal complex

Mitral ring Mitral valve Chordae tendineae Papillary muscles

Function of mitral complex Open during diastole to allow blood to enter ventricles from atria

Closed during systole to prevent regurgitation of blood into atria

Aortic valve

Guards the aortic orifice Three semilunar cusps (right, left and

posterior) Each with free border that has

nodules of semilunar valve Aortic sinus – bulges in aortic wall

at level of valve that correspond to cusps Right － contains opening of right

coronary artery Left － contains opening of left

coronary artery Posterior － no opening

Function of aortic valves

Opening during systole, with cusps pressed toward wall of vessel as blood is forced upward

Closed during diastole Ventricular pressure drops in diastole Floating together of valve cusps, with

free borders meeting, thus closing the valve

Structures of the heart

Structures of the heart

Walls of heart Endocardium

Inner coat of the heart wall Continuous with the valve flaps

Myocardium Arranged spirally Attached to fibrous rings surrouding

the four orifices of heart The walls of left ventricle are about

three times thicker than that of right Epicardium

Outer Visceral layer of serous pericardium

Structures of the heart Interatrial septum

Located between right and left atria

Contains fossa ovalis Interventricular septum

Located between right and left ventricles

Has upper membranous part Has thick lower muscular part

Atrioventricular septum

Membranous part of interventricular septum

Ventricular Septal Defect

Fibrous skeleton of heart

Fibrous rings that surround the atrioventricular, pulmonary, and aortic orifices

Left and right fibrous trigones

Conduction system of heart

Conduction system of heart Composed of specialized myocardial

cells

Sinuatrial node Internodal tract Atrioventricular node Atrioventricular bundle Right and left bundle branches Purkinje network

Conduction system of heart

Sinuatrial node (SA node)

Called the pacemaker cell

(P cell)

Located at the upper part of

the sulcus terminalis close

to the superior vena cava,

under the epicardium.

Conduction system of heart

Atrioventricular node (AV node)

Located in the lower part of interatrial septum, near orifice of coronary sinus and base of tricuspid valve

Under the endocardium Lower part related to

membranous part of interventricular septum

Conduction system of heart Atrioventricular bundle

(AV bundle) Passes forward through

right fibrous trigon to reach inferior border of membranous part

Divides into right and left bundle branches at upper border of muscular part of interventricular septum

Conduction system of heart Right and left bundle branches

Right bundle branch － passes down on right side of interventricular septum to reach the septomarginal trabecular and into the base of anterior papillary muscle. Here it becomes continuous with the fibers of Purkinje fibres

Left bundle branch － passes down on left side of interventricular septum beneath the endocardium. It usually divides into two branches, which eventually become continuous with the Purkinje fibers

Purkinje network continuous with myocardium

★

Sinuatrial node

Atrioventricular node

Atrioventricular bundle

Right and left bundle branches

Purkinje network

Arterial supply of the heart

Arterial supply of the heart

Left coronary artery Course

Arises from left aortic sinus Runs between pulmonary trunk and left

auricle into coronary sulcus Branches

Anterior interventricular branch －runs downward in anterior interventricular groove around inferior margin of heart to posterior interventricular groove

Circumflex branch － travels to left in coronary sulcus to posterior aspect

Distribution － supplies left atrium and ventricle, lesser portion of anterior wall of right ventricle, and anterior 2/3 of interventricular septum

Arterial supply of the heartRight coronary artery Course

Arises from the right aortic sinus Runs forward between right auricle and

pulmonary trunk into coronary sulcus Branches

Right marginal branch travels along inferior border

Posteror interventricular branch － travels downward in posterior interventricular groove, it anastomosises near the apex with the anterior interventricular branch of the left coronary artery

Distribution: supplies right atrium and ventricle, posterioinferior 1/3 of interventricular septum, posterior wall of left ventricle, the sinuatrial node and atrioventricular node

Thrombus in Coronary Artery Angiogram冠状动脉造影显示动脉血栓

Stent in an artery

Precutaneous translaminal coronary angioplasty (PTCA)

Coronary artery bypass grafting (CABG)

Venous drainage of the heart

Venous drainage of the heart

Coronary sinus Lies in posterior part of

coronary sulcus Carries most of venous

blood from myocardium to right atrium

Tributaries Great cardiac vein Middle cardiac vein Small cardiac vein

Pericardium 心包

Pericardium 心包 Fibrous pericardium 纤维心包

Attached to central tendon of diaphragm inferiorly

Blends with outer coat of great vessels superiorly

Serous pericardium 浆膜心包 Visceral layer (epicardium) Parietal layer

Pericardial cavity 心包腔 Potential space between visceral and

parietal layes Contains film of pericardium fluid as a

lubricant to facilitate cardiac movements

Pericardium 心包

Pericardium sinus Formed by reflection of serous

pericardium Transverse sinus of pericardium 心包横窦 Posterior to ascending aorta and

pulmonary trunk Anterior to superior vena cava and

left atrium.

Pericardium sinus

Oblique sinus of pericardium 心包斜窦－ cul-de-sac , posterior to heart, bounded by pulmonary veins on either side

Anterior inferior sinus of pericardium 心包前下窦

Venous drainage of heart

Anterior cardiac veins － 3~4 small vessels, drain into right atrium

Smallest cardiac veins － drain into all chambers, mainly atria

Surface markings of heart

Surface markings of heart

R. superior point － lies on the upper border of right third costal cartilage ±1.2cm from the margin of sternum

R. inferior point － lies on the sixth sternocostal joint

L. superior point － lies on lower border of left second costal cartilage ±1.2cm from sternal margin

Cardiac apex － in the fifth left intercostal space 7~9cm from the midline

Surface markings of heart

Right border － corresponds to a line running from the upper border of right third costal cartilage ±1.2cm from the margin of sternum, downwards to sixth sternocostal joint

Apex － in the fifth left intercostal space 7~9cm from the midline

Left border － represented by a line running from apex upwards and medially to a point on lower border of left second costal cartilage ±1.2cm from sternal margin

Lower border － represented by a line joint the lower end of right border to apex

★You must identify follow structures！

Shape of heart Cardiac apex Cardiac base Coronary sulcus Anterior interventricular

groove Posterior interventricular

groove Cardiac apical incisure Atrioventricular crux Right and left auricle Pulmonary trunk

Vessels of heart Left coronary artery Anterior interventricular branch Right coronary artery Posteror interventricular branch coronary sinus Right atrium Orifice of superior vena cava Orifice of inferior vena cava Orifice of coronary sinus Sulcus terminalis Fossa ovalis Pectinate muscles

★You must identify follow structures！

Right ventricle Right atrioventricular orifice Tricuspid valve Chordae tendineae Papillary muscles Supraventricular crest Trabeculae carneae Septomarginal trabecula Conus arteriosus Valve of pulmonary trunk

Left atrium Orifices of pulmonary veins Left atrioventricular orificeLeft ventricle Aortic vestibule Mitral valve Aortic vavle Aortic sinus