pericardium, heart, coronary vessels ppt

Question 1

pericardium

Answer 1

-sac lies posterior to body of sternum and 2nd-6th costal cartilages at level of T5-T8
-double walled, fibroserous membrane
-encloses the heart and roots of the great vessel
-fibrous and serous pericardium
-pericardium function:
-protection from overfilling
-stability- little movement
-protects from infection

Question 2

fibrous pericardium

Answer 2

-blends with central tendon of diaphragm
-stability

Question 3

serous pericardium

Answer 3

-made up of: (outer to inner)
-1. parietal pericardium
-2. pericardial cavity- with thin layer of fluid -> lubrication
-3. visceral pericardium (epicardium)- on the heart

Question 4

pericardium position

Answer 4

-superiorly- fusion with tunica adventitia of great vessel -> connective tissue -> stability and protection
-heart lies posterior to surface of sternum by sternopericardial ligaments
-inferiorly, central tendon of diaphragm
-ascending aorta carries superiorly to sternal angle

Question 5

transverse pericardial sinus

Answer 5

-within pericardium
-posterior to the aorta and pulmonary trunk
-potential space
-space is used during bypass -> place clamp -> clamps great vessels
-can go completely through

Question 6

oblique pericardial sinus

Answer 6

-within pericardium
-blind recess posterior to the heart
-potential space
-cant completely pass through- pocket
-reflects around pulmonary veins, IVC, and esophagus

Question 7

consequence of folding of the primordial heart tube

Answer 7

-during development primordial heart tube folds
-creates spaces
-transverse pericardial sinus
-blind pouch- oblique pericardial sinus

Question 8

arterial supply pericardium

Answer 8

-pericardiacophrenic artery (branch of internal thoracic artery)
-smaller branches of:
-musculophrenic artery (terminal branch of internal thoracic artery)
-bronchial
-esophageal
-superior phrenic arteries
-coronary arteries supply the visceral layer (muscle wall, epicardium)

Question 9

venous drainage pericardium

Answer 9

-pericardiacophrenic veins (tributaries of the brachiocephlic)
-tributaries of the azygos venous system

Question 10

nerve supply pericardium

Answer 10

-sensory- phrenic nerves (C3-C5)
-pain referred to the skin of ipsilateral shoulder
-vagus nerve (CN X)c
-sympathetic trunks- vasomotor contribution

Question 11

cardiac tamponade

Answer 11

-pericardial cavity blood accumulation
-pericardial effusion large enough -> reduce ability of blood fill and leave heart -> cardiac tamponade
-life threatening
-blood drained to allow proper filling and ventricular contraction
-cardiac collapse when ventricles cant contract properly
-between fibrous pericardium and visceral layer
-BECKS TRIAD:
-1. decreased APP- hypotension
-2. venous distention- jugular neck veins
-3. muffled heart sounds

Question 12

heart and vessels

Answer 12

-double self adjusting muscular pump- can give feedback upon itself -> constriction and dilation
-right poorly oxygenated blood to lungs for oxygenation
-left well oxygenated blood from lungs to aorta

Question 13

wall layers

Answer 13

-epicardium- thin external layer (mesothelium) formed by visceral layer of serous pericardium
-myocardium- thick middle layer of cardiac muscle
-endocardium- thin internal layer (endothelium and subendothelial connective tissue) -> also covers valves
-endocardium consists of trabeculae muscle, connective tissue to papillary muscle and valve layers

Question 14

position of heart

Answer 14

-anterior to sternum, costal cartilage and the medial ends of 3rd-5th ribs on the left
-obliquely lying about 2/3 to the left and 1/3 to right on median plane
-tipped over, 3 sided pyramid with apex, base and four surfaces
-apex lies posterior to left intercostal space 9 mm from the median plane
-mitral best heard at apex
-base is posterior aspect -> mainly LA some RA
-long axis of the heart- from apex towards the right shoulder

Question 15

surfaces of the heart

Answer 15

-anterior- RV
-diaphragmatic/inferior- RV + LV, central tendon connecting to diaphragm
-left pulmonary surface- LV, cardiac impression of left lung
-right pulmonary surface- RA

Question 16

borders of the heart

Answer 16

-right border- RA, extends between SVC and IVC
-inferior border- RV and slightly LV
-left border- LV and portion of left auricle (outpouching on top of LA)
-superior border- RA, LA, both auricles, ascending aorta and pulmonary trunk emerge here, SVC enters on the right side
-posterior to aorta and pulmonary trunk and anterior to SVC -> inferior border of transverse pericardial sinus

Question 17

right atrium

Answer 17

-receives venous blood from SVC, IVC and coronary sinus (venous drainage of myocardium)
-right auricle- ear like conical muscular outpouch increased the capacity of the RA -> stretch
-coronary sinus lies in the posterior part of coronary sulcus and receives blood from coronary veins
-sinus venarum- smooth walled posterior wall on which SVC, IVC and CS open
-sulcus terminalis- terminal groove
-crista terminalis- terminal crest
-pectinate muscles- rough, muscular wall -> increase support

Question 18

interatrial septum

Answer 18

-separation between RA and LA
-oval fossa- thumbprint sized depression, remnant of the oval foramen and the fetal valve
-during development fossas that lie here are initially open for blood to pass when we didnt need circulation to lungs (provided from mother)

Question 19

patent foramen ovale (PFO)

Answer 19

-no full closure were the oval fossa (thumbprint impression) was
-hole in interatrial septum
-communication of blood between the atriums
-small clot formation in venous circulation -> go in to RA -> pass through PFO -> enter into LA -> clot going into systemic circulation -> stroke

Question 20

right ventricle

Answer 20

-tricuspid valve between RA and RV
-right AV (tricuspid) orifice
-trabeculae carneae- irregular muscular elevations
-papillary muscles anchor tricuspid valve -> 3 -> septal, anterior, posterior papillary muscle
-supraventricular crest- thick muscular ridge separates muscular inflow part from smooth wall of outflow
-outflow is conus arteriosus (infundibulum) -> smooth for little resistance for blood to be pumped out into pulmonary arteries
-pulmonary semilunar valves

Question 21

interventricular septum

Answer 21

-membranous and muscular
-muscular is part of the septum and used during contraction
-membranous portion is towards the outflow tract
-partition between RV and LV
-septomarginal trabecula- muscular bundle runs from inferior part of IV septum to the anterior papillary muscle (carries the right bundle branches (conduction))

Question 22

ventricular septal defect (VSD)

Answer 22

-hole or communication that occurs between RV and LV
-closer to the membranous region of septum
-concerning for venous blood entering into systemic circulation
-blood from RV can also enter into LV and reduce CO

Question 23

left atrium

Answer 23

-pulmonary veins delivery blood back to posterior wall of LA
-forms most of the base of the heart
-significantly larger than RA
-large smooth* walled thicker* than RA -> due to high pressure
-pairs of valveless right and left pulmonary veins enter the LA on the posterior wall
-left auricle (outpouch) forms superior of the left border -> lined with pectinate muscle -> allow for overfilling
-problem with left auricle -> during atrial fibrillation -> not enough flow in the outpouch -> blood clot

Question 24

arterial fibrillation

Answer 24

-atrium during atrial systole -> dissipation of electrical signal and contraction
-abnormal p wave (beat)
-chaotic electrical acitvity
-electrical chaos -> fibrillate
-quivering behavior -> increase likelihood of stroke, ischemic bowel event, ischemic limb etc -> bc blood clot can form in atrial appendage -> systemic circulation
-fluttering

Question 25

left ventricle

Answer 25

-pass through mitral valve
-performs the most work
-walls are 2-3x thicker than RV
-pressure gradient during relaxation and filling vs contraction of LV -> BP
-arterial pressure is much higher in the systemic circulation than RV
-thick muscular ridges -> trabeculae carneae
-smooth walled, nonmuscular outflow tract (aortic vestibule)- no resistance

Question 26

CHF

Answer 26

-left ventricle pathology
-diastolic- relaxation and filling
-diastolic heart failure- enlarged muscular walls, hypertrophy (diameter of wall is thickened) -> Stiff and thick -> cant fill
-systolic heart failure - chambers are dilated and stretched out -> muscles walls are thin, atrophy -> heart cant pump/contract forcefully
-65% of blood should be pushed out but in systolic CHF is is not ejecting enough
-diastolic ejection fraction (how much blood going out) is either normal or more is coming out than what should be bc you dont have as much coming in

Question 27

tricuspid valve

Answer 27

-between RA and RV
-guards the right AV orifice
-tendinous cords (chordae tendineae) attach to free edges and the ventricular surfaces of the anterior, posterior, and septal cusps
-cords attach to adjacent cusps preventing prolapsing and regurgitation
-papillary muscle- bases attach to ventricular wall and apices attach to tendon cords -> anchor valves doors during systolic contraction
-papillary muscles begin to contract before the RV contraction
-papillary muscles contract -> pull chordae tendineae -> allow opening of orifices -> blood flows to fill RV
-papillary muscles anchor tricuspid valve -> 3 -> septal, anterior, posterior papillary muscle

Question 28

pulmonary valve

Answer 28

-apex of the conus arteriosus
-level of left 3rd costal cartilage
-semilunar cusps (anterior, right and left)
-after RV outflow tract
-3 cusps

Question 29

mitral valve

Answer 29

-double leaflet-> anterior and posterior
-left AV orifice
-posterior to sternum at level of 4th costal cartilage
-each cusps has more than 1 tendinous cord to papillary muscle -> due to strength of LV and pressure gradient -> stronger
-cord become taut just before and during systole preventing back flow to LA
-papillary muscles receive electrical signal to start contraction prior to ventricular wall -> firm anchor during systolic contraction -> no back flow
-during prolapse when one valve door closes or and the other has a later closure or is loose -> back flow

Question 30

aortic valve

Answer 30

-posterior to left side of the sternum at the level of 3rd intercostal space
-aortic sinuses- spaces at the origin of the ascending aorta between wall and cusp
-3 cusps (right, left and non-coronary posterior
-backflow of blood due to recoil of elastic aorta -> causes filling of coronary arteries
-home to the right and left coronary artery and come off the right and left aortic valve cusps
-after systole and during diastole -> blood has little bit of back flow and pools in the cusps -> supplies the right and left coronary arteries

Question 31

heart sounds

Answer 31

-mitral valve- 5th intercostal space -best heard at apex -> mitral regurgitation
-tricuspid- 4th-5th intercostal space regurgitation or VSD
-aortic- 2nd intercostal space -> on the right bc of aortic arch- aortic stenosis
-pulmonic- left 2nd intercostal space- pulmonic stenosis
-left sternal border- aortic/ pulmonic regurgitation

Question 32

coronaries

Answer 32

-coronary arteries next to aortic valve
-aortic valve closes-> backflow fills cusps -> supplies right and left coronary arteries -> supplies myocardium
-right coronary goes down to supply part of right atrium, electrical tissue that supplies RA and RV
-branches come down from RV to supply full RV
-left main coronay artery -> left anterior descending artery (LAD) -> left circumflex artery

Question 33

coronary arteries supplies

Answer 33

-in dx MI -> no oxygen to muscle wall
-right coronary artery blockage- lack of blood on EKG to RV and RA
-right marginal artery- supplies RV and apex
-left coronary- LA, LV, septum, AV bundle
-left anterior descending -> supplies for of RV and LV and septum
-left circumflex- supplies LA and LV
-left marginal artery- comes off left circumflex -> supplies LV
-posterior interventricular artery- supplies RV and LV and septum

Question 34

myocardial infarction

Answer 34

-P wave- atrial contraction
-QRS- ventricular contraction
-ST segment- baseline
-ST elevation- no blood supply to myocardium in that region
-depending which ECG lead had elevation -> corresponds to location of MI
-between QRS complex and T wave should go back to isoelectic baseline
-decreased contractility to areas being supplied less

Question 35

venous drainage

Answer 35

-coronary sinus
-one of 3 things emptying into RA
-great cardiac vein contributes
-middle cardiac vein, small cardiac vein
-place a pacemaker wire into the coronary sinus and track this out to lateral wall and leaving pacemaker wires in the coronary sinus extended out into smaller vein -> Allows for pacing of LV
-wire in RA, RV, and coronary vein -> biventricular pacing (pacing of both ventricles simultaneously)

Question 36

lymphatic drainage

Answer 36

-lymphatic vessels of myocardium and the subendocardial connective tissue pass to the subepicardial lymphatic plexus
-this plexus passes to the coronary sulcus and follow the coronary arteries
-inferior drainage from tracheobronchial lymph nodes on the right side

Question 37

conduction system

Answer 37

-sinoatrial node- takes feedback from parasympathetic and sympathetic and delivers initiation of electrical beat
-passing through fibers -> passes to LA -> LA and RA contract together -> AV node at base of RA -> signal collected in AV node -> slight pause for ventricular filling from atrial contraction -> bundle of his -> right and left bundle branch -> signal to RV and LV -> RV and LV contraction
-atrial contraction -> positive deflection of p wave
-pausing of AV node -> isoelectric baseline
-QRS- electrical signal to ventricles and contraction
-depolarization of the ventricle myocyte and electrical fibers going back to negative charge -> readys for next contraction

Question 38

innervation

Answer 38

-sympathetic and parasympathetic
-parasympathetic- relaxation
-sympathetic- flight and fight
-heart rate
-vascular constriction

Question 39

cardiac cycle

Answer 39

-blood into RA
-beginning diastole- atria fill with blood valves closed
-ending of diastole- increased atrial pressure opens AV valves -> ventricular filling
-start of systole- atria contract and empty and ventricles are full
-middle of systole- ventricles begin to contract, pressure closes AV valves, atria relax
-end of systole- ventricle contract, increased pressure in ventricles, aortic and pulmonary valves open, blood ejected into aorta and pulmonary artery
-diastole- ventricles empty, ventricles relax, aortic and pulmonary vales close

Question 40

cardiac skeleton

Answer 40

-provides structure
-allow for structure of heart valves
-fibers support valve cusps
-AV node will pass from RA into RV -> valvular disease or surgery here (especially tricuspid) -> interrupt cardiac skeleton -> conduction system disease -> may need pacing

Question 41

widow maker

Answer 41

left anterior descending artery (LAD) is totally or almost completely blocked. The critical blockage in the artery stops, usually a blood clot, stops all the blood flow to the left side of the heart, causing the heart to stop beating normally
-LV not being supplied

Question 42

54 year old male with PMH significant for hyperlipidemia, hypertension, GERD presented with episodes of mid sternal chest pain associated with mild shortness of breathe, aggravated by cough. Pt was active and well until about 1 month prior when he had flu like illness with similar chest pain which progress to worsening fatigue, pedal edema, NYHA class 2-3 symptoms (minor activity causes SOB). Clinical exam revealed elevated jugular venous pulse to the angle of jaw and 2+ bilateral edema. Auscultation revealed normal dual heart sounds with no rub or murmurs and mild bilateral basal crackles.

Answer 42

-differentials dx- percarditis, pericardial effusion, pericardial tamponade
-PERICARDITIS- transient constrictive pericarditis (CP)
-exacerbated by cough*- pressure compresses heart
-pt treated according to institutional guideline for treatment with tapering dose of prednisone, NSAID and colchicine, along with pantoprazole

Question 43

fibrous pericardium

Answer 43

-still
-inelastic
-cant expand when overfilled

Question 44

left atrium pulmonary veins

Answer 44

-4 pulmonary veins dump into LA

Question 45

stenosis

Answer 45

-increases pressure of blood flow
-heart has to work harder to pump blood past
-think of finger over a hose

Question 46

systolic failure

Answer 46

-heart camp pump
-prior heart attacks, infections, ischemia
-cant push blood out
-ejection fraction goes down by more than half

Question 47

systolic failure

Answer 47

-heart cant relax
-heart cant fill
-hypertrophy sometimes
-backup of blood into LA -> backs up into lungs -> SOB

Question 48

murmur

Answer 48

-flow over area where there is resistance
-turbulence
-may reverberate somewhere else

Question 49

74 year old female pt admitted with progressive increase in breathlessness, orthopnea, ankle edema over the previous 3 weeks. Her general practitioner had prescribed Augmentin. She had suffered from dyspepsia (chest discomfort), increasing over recent weeks, general practitioner had noted new murmur. Tachypneic (25 beat min), with thready low volume pulse. Sitting BP was 110/70. apex beat was in the anterior axillary line (slightly off to the left!) and parasternal lift (palpable pulsation on the chest wall) was prominent. pansystolic murmur audbile, late inspiratory crackles were heard throughout both lung fields and lower extremity edema

Answer 49

-sinus tachycardia (110 beat min)
-anterolateral Q waves of previous infarction and chest x-ray confirmed cardiomegaly and interstitial edema
-showed dilated anterior and septal hypokinesis and apical dilation compatible with previous anterior infarction. Mitral regurgitation was noted but left atrial size was normal
-this is common presentation of progressive systolic dysfunction after unheralded myocardial infarction
-heart burn was actually heart pain

Question 50

heart failure symptoms

Answer 50

-enlarged heart
-swollen and cyanotic legs and feet
-bloated stomach
-fluid around the lungs- LV -> LA -> lungs (backup)
-when laying down orthopnea -> fluids pool at bottom -> even more SOB laying down