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AA - Cardiac surgery COPY > Cardiac Anatomy > Flashcards

Cardiac Anatomy Flashcards

1
Q

What structure occupies the central portiono fhte heat and is wedged between all 3 other valves

A

Aortic valve

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2
Q

Which AV cusp has fibrous continuity with the anterio leaflet of the mitral valve

A

Non-coronary cusp

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3
Q

Anatomic orientation of the AV groove

A

Obliquely oriented closer to vertical than horizontal

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4
Q

Two pericardial recesses

A
  1. Transverse sinus
    1. Anterior boarder: posterior surface of aorta/PA
    2. Posterior boarder: interatrial groove
  2. Oblique sinus
    1. Behind LA (between IVC and Pulmonary veins)
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5
Q

Location of phrenic nerve in mediastinum

A
  • Descends anterior to anterior scalne muscle (posterior to IMA)
  • Passes anterior to the pulmonary hilum
  • Left phrenic: attached to lateral aspect of persistent Left SVC
  • Right phrneic: attached to lateral aspect of SVC
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6
Q

Anatomy of vagus nerve in mediastinum

A
  • Courses along carotid arteries and enters thorax posterior to phrenic.
  • Descends posterior to pulmonary hilum (phrenic is anterior)
  • Left vagus: descends btw LCA and LSC (posterior to Ao Arch), left RLN hooks anterior around ligamentum arteriosum and ascends in TE groove.
  • Right vagus: right RLN hooks under RSC artery anteriorly and ascends in TE groove
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7
Q

Coronary arteries arise from what structures

A

Sinuses of Valsalva

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8
Q

Coronary artery dominance defined by what?

A

Supply of PDA

(RCA 85% of cases)

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9
Q

Anatomy of LMCA

A
  • Arises from left Sinus of Valsalva
  • Courses behind PA and anterior to LA appendage
  • Bifurcates into: LAD and LCx
    • Trifurcates: LAD, Ramus and OM
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10
Q

Anatomy of LAD

A
  • Courses along interventricular groove towards cardiac apex
  • Branches:
    • Septal perforators (dive perpendicularly into septum)
    • Diagonals (course over LV anterior wall)
    • RV branches (course to the RV anterior wall)
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11
Q

Anatomy of Circumflex Artery

A
  • Travels in left AV groove (ends near obtuse margin of LV)
  • In Left Dominant circulation, continues in AV groove to supply PDA (10-15%)
  • Branches:
    • Obtuse marginals (OM): supply lateral wall of LV and posteromedial PM
    • Sinoatrial (SA) node branch: 50% of population
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12
Q

Anatomy of RCA

A
  • Arises from right Sinus of Valsalva
  • Course: anterior to Ao and descends in right AV groove
  • Branches:
    • Conal branch: 1st branch, courses left of infundibulum
    • Acute marginals: supply anterior RV free wall
      • May continue across diaphragmatic surface to supply distal interventricular septum (10-15% pop)
    • Bifucates:
      • Posterior Descending Artery (PDA)
      • Right posterolateral artery (a.k.a. posterolateral ventricular branch [PLVB])
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13
Q

Anatomy of PDA

A
  • Courses along interventricular groove towards apex
  • Septal perforators (posteror 1/3 of septum)
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14
Q

Anatomy of PLVB

A

Provides branches to posterior wall of LV

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15
Q

Venous drainage of heart

A
  • Coronary sinus: 85% of coronary blood flow
  • Thebesian veins: 15% of coronary blood flow (directly into RA/RV)
  • Anterior interventricular vein: analog to LAD
  • Great cardiac vein: travels in AV groove and turns into coronary sinus
  • Posterior interventricular vein: analog to PDA
    • Last tributary and drains near the coronary sinus orifice
      • Explains why RV protection from retrograde cardioplegia can be marginal as cannula is usually inserted beyond entry point of vein.
  • Anterior RV veins: form small cardiac vein (right AV groove); drain into CS or RA
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16
Q

Anatomy of Persistent Left SVC

A
  • Usually drains into coronary sinus
  • Ineffective to adminster retrograde cardioplegia unless LSVC is occluded and flow diverted.
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17
Q

Anatomy of SA Node

A
  • Junction of RA and SVC (between RA appendage and SVC)
  • Horeshoe SA node: draped along SVC/RA junction (10% of patients)
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18
Q

Anatomy of fossa ovalis

A
  • True intra-atrial septum
  • Location where LA should be entered for transseptal approach
  • Location of PFO
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19
Q

Thebesian valve

A

Valve of coronary sinus

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20
Q

Eustachian valve

A

Valve of IVC

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21
Q

Tendon of Todaro

A

Continuation of Thebesian valve to the Eustacian valve

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22
Q

Important structure lying within Triangle of Koch

A

AV node

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23
Q

Boundaries of Triangle Koch

A
  1. Tendon of Todaro
  2. Orifice of Coronary Sinus
  3. Septal leaflet of TV
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24
Q

Anatomic structure located at apex of Triangle of Koch

A

Bundle of His (prior to branching on the interventricular septum)

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25
Q

Crista terminalis

A

Confluence of trabeculated RA muscle into a well defined muscle band.

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26
Q

Anatomy of Tricuspid Valve

A
  • Leaflets:
    • Anterior
    • Septal
    • Inferior
  • Continutiy with fibrous skelaton of heart
  • Does not have true fibrous annulus circumferentially
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27
Q

Important anatomic relationships with Tricuspid Valve

A
  • AV node located at base of septal leaflet
  • Aortic valve near junction of septal and anterior leaflets
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28
Q

Surgical access to Left Atrium

A
  • Anterior to right pulmonary veins (Sondargaard’s groove)
  • Incision in LA dome
  • Transseptal approach via RA (fossa ovalis)
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29
Q

Anatomy of Mitral Valve

A
  • Leaflets:
    • Anterior (A1, A2, A3)
      • Fibrous continuity with non-coronary cusp of AV
      • Anterior in surgeons view
      • Covers 1/2 of annular circumference
      • Longer leaflet
    • Posterior (P1, P2, P3)
      • Covers 2/3 of annulus but is short with respect to dept of orifice coverage
    • Carpentier segments:
      • A1 and P1 most medial (to left in surgeons view)
30
Q

Important anatomic relationships to the mitral annulus/valve

A
  • Left side of posterior annulus (P1): circumflex artery
  • Right side of posterior annulus (P2/P3): coronary sinus
  • A3 segment: AV node
31
Q

Anatomy of right and left fibrous trigones

A
  • Dense collagenous tissue
  • Locations: 10 o-clock and 2 o-clock positions on the annulus
    • Anteror to the valve commisures
32
Q

Anatomy of RVOT

A
  • Infundibulum
  • Pulmonic valve (tricuspid)
    • No fibrous annulus (suspended in muscle)
    • Only valve not connected to fibrous skelaton of heart
33
Q

RV papillary muscle anatomy

A
  • Anteror PPM
  • Medial PPM
  • Suspend the Tricuspid Valve
34
Q

Anatomy of LV

A
  • Inflow: Mitral valve and subvalvular apparatus
  • LVOT:
    • Mitral-Aortic curtain:
      • fibrous sheet extending from the anterior leaflet of MV to mitral-aortic continutiy supporting the left and non-coronary leaflets of the AV
  • Left bundle branch:
    • enters LVOT posterior to membranous septum (between right and non-coronary AV cusps)
35
Q

Anatomy of Aortic Valve

A
  • Sinuses of Valsalva/AV Leaflets:
    • Right
    • Left
    • Non-coronary
  • Nodule of Arantius: thickened nodule, centrally located on each leaflet at point of coaptation.
36
Q

Definition of Aortic Root

A
  • Aortic annulus
  • AV leaflets
  • Sinus of Valsalva
  • Sinotubular junction
    • Junction at top of commissures
    • Point where the sinuses neck down to form the tubular Asc Ao.
37
Q

Posteromedial papillary muscle blood supply

A

RCA (90%)

38
Q

Anterolateral papillary muscle blood supply

A

LAD and Cx

39
Q

Average distance from the tips of each papillary muscle to the nearest trigone

A

~ 23 mm

40
Q
A
41
Q

What are the vessels that arise from the Right coronary artery

A

Acute marginal branches AV nodal artery Posterior interventricular artery (PIV) = posterior descending artery (PDA)

42
Q

What are the vessels that arise from the Left coronary artery

A

Left anterior descending artery Left circumflex artery

43
Q

Right dominant circulation and the percentage of people that have this

A

PIV and at least one posterolateral branch arise from RCA (80%)

44
Q

Left dominant circulation and the percentage of people that have this

A

PIV and at least one posterolateral branch arise from LCx (15%)

45
Q

Balanced cardiac circulation and the percentage of people that have this

A

dual supply of posteroinferior LV from RCA and LCx (5%)

46
Q

SA node blood supply

A

SA nodal artery, which may arise from the RCA (60%) or LCA (40%)

47
Q

Where does venous blood enter the heart?

A

Most venous blood from the heart drains into the RA through the coronary sinus, although a small amount drains through Thebesian veins into all four chambers

48
Q

What is the physiological effect of venous blood entering 4 chambers through Thebesian veins

A

Contributes to the physiologic R-L shunt since there is resultant deoxygenated blood on the left side of the heart

49
Q

Draw a diagram demonstrating blood pressure and corresponding LV volume, heart sounds and ECG strip

A

TN C3

50
Q

What are the layers of the heart

A

endocardium, myocardium, epicardium, visceral pericardium, pericardial cavity, parietal pericardium

51
Q

What are the semilunar valves of the heart and the number of leaflets of each

A

◆ aorti valve - 3 valve leaflets ◆ pulmonic valve - 3 valve leaflets

52
Q

What are the atrioventricular valves, what are they composed of and how many leaflets do each have

A

Subvalvular apparatus present in the form of chordae tendinae and papillary muscles ◆ Tricuspid valve - 3 valve leaflets ◆ Mitral/bicuspid valve - 2 valve leaflets

53
Q

Describe the conduction system of the heart

A

■SA node governs pacemaking control ■ anterior, middle, and posterior-internal nodal tracts carry impulses in the right atrium and along Bachmann’s bundle in the left atrium from the SA node ■ atrial impulses converge at the AV node (except Bachmann’s bundle) ◆ the AV node is the only conducting tract from the atria to the ventricles because of electrical isolation by the annulus fibrosis (except when accessory pathways are present) ■ The bundle of His bifurcates into left and right bundle branches (LBB and RBB) ■ LBB further splits into anterior and posterior fascicles ■ RBB and fascicles of LBB give off Purkinje fibres which conduct impulses into the ventricular myocardium

54
Q

What are the annulus fibroses

A

The right and left fibrous rings of heart (anuli fibrosi cordis) surround the atrioventricular and arterial orifices

55
Q

Describe the cardiac innervation

A

■ Sympathetic nerves ◆ innervate the SA node, AV node, ventricular myocardium and vasculature ◆ SA node (β1) fibres increase pacemaking activity (chronotropy - HR) ◆ cardiac muscle (β1) fibres increase contractility (inotropy - SV) ◆ stimulation of β1- and β2-receptors in the skeletal and coronary circulation causes vasodilatation ■ Parasympathetic nerves ◆ innervate the SA node, AV node, atrial myocardium but few vascular beds ◆ basal vagal tone dominates the tonic sympathetic stimulation of the SA node and AV node resulting in slowing of pacemaker activity and conduction ◆ parasympathetics have very little impact on total peripheral vascular resistance

56
Q

What is reduced dromotropy

A

Decreased conduction speed in the AV node

57
Q

What is the visceral epicardium?

A

Makes contact with the heart.

58
Q

What is the acute margin in terms of cardiac border anatomy?

A

Inferior edge, creates the angle between the sternocostal surface and the diaphragmatic surface.

59
Q

What ribs cover the heart?

A

3rd, 4th, and 5th.

60
Q

Where is the phrenic nerve in the thoracic inlet?

A

Just posterior to the IMA. They run on the anterior surface of the anterior scalene muscle.

61
Q

What is the right phrenic nerve’s course after the thoracic inlet? When might it be injured in heart surgery?

A

It lies on the lateral surface of the SVC, in harm’s way during dissection for venous cannulation for CPB. Or during RIMA dissection.

62
Q

What does the right recurrent laryngeal nerve pass around?

A

R SC artery. Ascends in the TE groove.

63
Q

Excessive dissection of the SC arteries (eg during shunt procedures) can damage what? Causing what pathology?

A

The subclavian loop, which carries fibers from the stellate ganglion to the eye and head. Damage here can cause Horner’s syndrome.

64
Q

Where are the phrenic and vagus nerves in relation to the pulmonary hilum?

A

Phrenic is anterior. Vagus is posterior.

65
Q

Describe a midline sternotomy.

A

Skin incision from the jugular notch to the xiphoid. Bovie to the presternal fascia and expose the periostium. Divide the sternum midline with a saw. Hemostasis. Sternal spreader. Divide the thymic fat pad to the brachiocephalic (innominate) vein. Open the pericardium.

66
Q

How can you extend a sternotomy to expose the branches of the aortic arch?

A

Extend the incision onto the neck along the anterior border of the SCM.

67
Q

How can you extend a median sternotomy to expose the proximal descending thoracic aorta?

A

Perpendicular extension of the incision through the third intercostal space.

68
Q

What incision is used for double lung and heart-lung transplants?

A

Bilateral transverse thoracosternotomy (ie clam shell incision) through the 4th or 5th interspace.

69
Q

What non-sternotomy and non-clam shell incision can be made to access the R heart; tricuspid, and mitral valves; and R coronary?

A

R anterolateral thoracotomy. Can be used for Blalock-Hanlon atrial septectomy, or for valvular replacement after previous sternotomy.

70
Q

To access the distal aortic arch and descending aorta, what incision can be made?

A

Left posterolateral thoracotomy. CPB cannulation must be done through femoral.

AA - Cardiac surgery COPY (29 decks)

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