 Jen : grays anatomy

 Jen : moore’s clinical

CARDIOLOGY  Jen : lily cardio
 Jen : catetan anat wa
 Jen : masih bingung
SECTION 1. Anatomy of Cardio

I. MEDIASTINUM o Anterior (smallest subdivision)

Lokasi : antar antly sternum & transversus thoracis
muscle, and postly pericardium
Definition : broad central partition that separate 2
Contain : Remnant thymus, lymph node ,fat& conn tissue
laterally placed pleural cavities (central compartment of
thoracic cavity). Is covered on each side by mediastinal
its continuous w/ sup mediastinum at sternal angle &
pleura and contain all thoracic viscera and structures
limited inferiorly by diaphragm. It also consists of
except lungs Its starts from :
sternopericardial ligaments, fibrous bands that pass from
the pericardium to the sternum, fat, lymphatic vessels, a
 Sternum & costal cartilage – bodies of thoracic vertebrae
few lymph nodes & branches of internal thoracic vessels.
 Superior thoracic aperture – diaphragm
o Middle
Contain : Lokasi di central thoracic cavity.
Pericardial sac, heart, thymus gland,
Contain : heart, origin of great vessels, pulmo trunk, arch
trachea , artery and veins
of azygos vein, SVC and main bronchi; nerves.
o Posterior
Function : Serves as passageway of esophagus, esophagus, thoracic aorta, azygos and hemi-azygos veins,
trachea, thoracic duct, nerve, artery & vein thoracic duct, vagus nerves, sympathetic trunks, and
as they make their way to abdomen splanchnic nerves.

Conn tissue di mediastinum itu loose & elastis shg bs ada

prgerakan serta volume& pressure changes in thoracic
cavity, spt pergerakan diaphragm, thoracic wall, &
tracheobronchial tree saat respi, contraction of heart &
pulsation of great arteries& passage of ingested substances
tru esophagus. Conn tissue akan makin fibrous & rigid w/
age; hence, the mediastinal structures become less mobile.

Batas :

 Anterior mediastinum
Ant. to pericardial sac & pos.t II. PERICARDIUM Commented [i-[1]: Source : lily hal 20
to body of sternum
 Posterior mediastinum Fibroserous sac surrounding heart & roots of great vessels. A (peri (myo (endo
Post to pericardial sac & conical pericardial sac lies posterior to sternum & 2nd to 6th Myocardium , thickest layer of the heart and consists of
diaphragm, ant to bodies costal cartilages (T5–T8 vertebrae). bundles of cardiac muscle cells,
vertebrae
External to the myocardium is a layer of connective tissue and
 Middle mediastinum Pericardial sac is influenced by movements of heart & great
adipose tissue through which pass the larger blood vessels and
Area in middle, include pericardial sac & vessels, sternum, & diaphragm bcs fibrous pericardium : nerves that supply the heart muscle.
its content
 Fused with the tunica adventitia of the great vessels entering Epicardium , outermost layer of the heart and is identical to
Division : and leaving the heart visceral pericardium
 Attch to post srface of sternum by sternopericardial ligamen
Yang jd patokan misahin sup and inf adlh sternal angle –  Fused with the central tendon of the diaphragm
intervertebral disc (antar T4-T5)  attached to mediastinal portions of the right & left pleurae.

 Superior mediastinum Its many connections to the surrounding structures keep the
contains SVC, brachiocephalic veins, arch of aorta, pericardial sac fi rmly anchored within the thorax and therefore
thoracic duct, trachea, esophagus, thymus, vagus help to maintain the heart in its normal position
nerves, left recurrent laryngeal nerve, & phrenic
The fibrous pericardium protects the heart against sudden overfilling
nerves. because it is unyielding and closely related to the great vessels that
 Inferior mediastinum pierce it superiorly and posteriorly. The ascending aorta carries the
is dvided by pericardial sac to: pericardium superiorly beyond the heart to the level of sternal angle.
Division :

 Fibrous pericardium

Cone-shaped, Tough conn.

tissue, trltak terluar that defines
middle mediastinum

Base : nempel di central tendon

of diaphragm
Apex : continuous w/ adventitia
of great vessels
Ant : nempel di post surface of
sternum by sternopericardial
ligament, to help retain heart position in thoracic cavity. Sac
also limit <3 distention.

Phrenic nerves : origin dr C3- C5 pass thru pericardium and

innervate fibrous pericard – go to diaph to innervate it too.

Artery supply : pericardiacophrenic vessels

 Serous pericardium

Thin, continuous at root of great vessel, consist 2 parts:

o Parietal layer, lines inner surface of fibrous pericardium
o Visceral layer (epicardium), adheres to heart and great
vessels form its outer covering

Btween parietal & visceral, ada narrow space (pericardial

cavity) contains small amount of fluid , allowing uninhibited
movement & frictionless of <3
 III. THE HEART

Layers of heart (from sup to deep) :

 Epicardium, a thin external layer (mesothelium) formed

by visceral layer of serous pericardium
 Myocardium, thick middle layer trbuat dr cardiac muscle .
 Endocardium, a thin internal layer (endotel & subendo
conn tissue) /lining membrane of <3 dat also covers valves.

Cardiac orientation : Commented [i-[2]: Source : Lily hal 18

Like a pyramid that fallen over and rest on its side. Its apex two basic “rules” of normal
cardiac anatomy: (1) right-sided structures lie
project forward, downward, to left. Where the base faces in post mostly anterior to their left-sided counterparts,
direction. and (2) atrial chambers are located mostly to
the right of their corresponding ventricles
Sisi dr pyramid :

 Anterior : sternocostal
surface, arah anterior &
Vessels and nerves medial ends of 3rd - 5th
ribs on the left side.
Pericardium supplied by, branches of internal thoracic,
 Inferior : diaphragmatic
pericardiacophrenic artery which maybe parallel the phrenic
surface where it rest
nerve to the diaphragm. Smaller contributions of blood to the
 Right and left pulmo
pericardium come from musculophrenic artery, a terminal
surface
branch of the internal thoracic artery; the bronchial, esophageal,
and superior phrenic arteries from the thoracic aorta; and the
Base of heart
coronary arteries, supplying only the visceral layer of serous
pericardium Terletak di post. fixed to
pericardial wall opposite
Veins : • Pericardiacophrenic veins, tributaries of the
bodies of vertebrae T5-T8
brachiocephalic (or internal thoracic) veins
(klo lg stand dr T6-T9) &
separated from them by
• Variable tributaries of the azygos venous system
the pericardium, oblique
Nerves : pericardial sinus,
esophagus, and aorta.
- Phrenic nerves (C3–C5)—a primary source of sensory Esophagus lies post to the
fibers; pain sensations conveyed by these nerves are base.
commonly referred to the skin (C3–C5 dermatomes) of
the ipsilateral shoulder region. It contains, LA, small portion of RA, and prox part of SVC , IVC
- Vagus nerves (CN X)—function uncertain & pulmo veins
- Sympathetic trunks—vasomotor
Extends superiorly to the bifurcation of the pulmonary trunk
Pain sensation from parietal pericardium yi o/ somatic afferent and inferiorly to the coronary sulcus (groove)
in phrenic nerves. So pain related to pericardial problem may
referred to supraclavicular region of shoulder or lateral neck Receives the pulmonary veins on the right and left sides of the
area dermatomes for spinal cord segment C3-C5. (referall pain) LA & SVC IVC at the superior and inferior ends of RA.

Apex of heart

project inferiorly, anteriorly, to left, end in apex.

Formed by inferolateral part of LV and trletak in deep to left 5th

ICS, 8-9 cm from midstrenal line . Sounds of mitral valve closure
are maximal in here (apex beat)
  Left border (oblique), formed mainly by LV & slightly by
the left auricle/ atrium
 Obtuse margins : separate ant and left pulmo surface. Its
round, tumpul, extend from left auricle to cardiac apex.
Mostly by LV and LA
 Superior border : formed by RA LA and auricles in an
anterior view; ascending aorta and pulmo trunk emerge
from superior border & SVC enters its right side. Posterior
to aorta &pulmo trunk and anterior to SVC, the superior
border forms inf boundary of transverse pericardial sinus.

Partition of heart

External sulci separate heart into 4 chambers and prod external

grooves which is sulci

 Coronary sulcus
Circles heart, sparate atria from ventricles. Contains right
coronary artery, small cardiac vein, coronary sinus &
circumflex branch of left coronary artery

 Ant & post interventricular sulci

Separate 2 ventricle. In ant surface contain ant
interventricular artery and great cardiac vein. In
post/diaphragmatic surface contain post interventricular
artery and middle cardiac vein

Cardiac chamber

 2 atrium : thin walled, receive blood coming to heart

 2 ventricle : thick walled, pump blood out of heart. LV
walled is much more thick than RV bcs it pump blood to
rest of body, whereas RV only pump to lungs
 Right pump : receive de-o2-genated from body thru SVC
Surface of heart IVC and send it to lungs thru pulmo trunk
 Left pump : receive 02-genated blood from lungs thru
 Ant /sternocostal surface : mostly RV, some of RA and LV
pulmo veins and send it to body thru aorta
on left.
 Cardiac chamber is separated by septa interatrial,
 Inf / Diaphragmatic surface : mostly LV and sdikit RV
interventricular and atrioventricular
sparated by post interventricular groove. This surface face
inferiorly and rest on diaphragm. Separated from base of
heart by coronary sinus.
 Left pulmo surface : face left lung, ada LV & sdikit LA
 Right pulmo surface : face right lung, ada RA Commented [i-[3]: source lily hal 19

Margin and borders

 Right margins : (slightly convex), formed by RA extending

between SVC & IVC
 Inf margins /acute : sharp edge antar ant & diaphragmatic
surfaces of heart. Formed by RV and sdikit LV deket apex
 Right atrium Right ventricle

There are 3 vein that returning the de-o2-gentated blood : Form most ant surface of <3 & small portion of diaphragmatic
(jadi RA ada 3 lubang okk + 1 orifice) surface. and almost the entire inferior border of the heart
 SVC & IVC returns blood from body
Dinding RV which leads to pulmo trunk adlh conus arteriosus /
 Coronary sinus return blood from walls of heart
infundibulum. Dindingnya smooth, derived from bulbus cordis.
Sdkngkan portion of dinding RV hv muscular, irregular
-Blood then pass from RA  RV thru right atrioventricular
structure yi trabeculae carneae  papillary muscles (attach in
orifice, discharges the poorly oxygenated blood into the right
their end spt bridge). Mostly attached to ventricular wall, but
ventricle during ventricular relaxation (diastole) and its closed
sbagian ada yg attached to tendon like fibrous cords (chordae
during ventricular contraction by triscuspid valve.
tendineae), connect to free edges of cusps of tricuspid valve. A
-Inf part of RA is divided into 2 continous space, (externally thick muscular ridge, the supraventricular crest, separates the
dtandai dgn adanya sulcus terminalis cordis which extend from ridged muscular wall of the chamber from the smooth wall of
right side opening of SVC to IVC, internally marked by crista the conus arteriosus or outflow part of RV.
terminalis which is smooth muscular ridge begin in the roof of
The inflow part of RV receives blood from RA thru right AV
atrium infront of SVC down d lateral wall of anterior lip of IVC )
(tricuspid) orifice located post of sternum (ICS 4th & 5th)
Space opposite to crista is sinus of vena cava (derived from right
3 papillary muscle (chordae tendinae yg nonjol kyk jari) in RV : Commented [i-[4]: Source : lily hal 20
horn of sinus venosus). It has a smooth, thin walls and both
vena cava and coronary sinus empty into dis space.
 Ant papillary muscle : largest and most constant, arises Contraction of papillary muscles tightens the chordae
tendineae, helping to align and restrain the leafl ets of the
from ant wall of ventricle
Space ant to crista yi right auricle/atrium proper. The walls is tricuspid valve as they are forced closed.
 Post papillary muscle : consist 1-3 structures (from v wall)
covered w/musculi pectinati./pectinate muscle
 Septal papillary musle: most inconsistent, small/absent
-opening of coronary sinus dat receives blood from cardiac veins
Chordae tendinae melekat pd ujung dr papillary muscle
located medially to IVC. They hv valve of coronary sinus (IVC jg
ada valvenya) both derived from sinus venosus. Saat dev, valve
Specialized trabeculum, septomarginal trabecular/moderator
di IVC bantu direct incoming oxygenated blood tru foramen
band (cm di kanan aj) forms bridge antar lower portion of
ovale and into left atrium
interventricular septum and base of ant papillary muscle. This
trabecular carry portion of (RBB) to ant papillary muscle in RV.

Tricuspid valve

 Terletak di right atrioventricular orifice

 Closed saat RV contraction , terbuka
saat filling of RV.
-Numoerous of small openings of  Ada 3 cusps or leaflets (ant, post and
smalles cardiac veins (foramina septal cusps). Free margin of cusps are
of vena cordis minimiae) attach to chordae tendinea (parasut)
scattered di walls of RA.  Fs spy cegah saat kontraksi ventrikel
darah x balik ke atrium krn scara
-Separating RA & LA is langsung si cusps akan trtutup.
interatrial septum. Ada  Necrosis of papillary muscle due to MI/heart attack can
depression in septum above result in prolapse of dis valve
orifice of IVC yi fossa ovalis and
its margin yi limbus/border of Pulmonary valve
fossa ovalis. a remnant of the
oval foramen and its valve in the  Trletak di pulmo trunk, the outflow
fetus. track of RV, at apex of infundibulum
/ conus arteriosus (3rdcostal cartilage)
Fossa ovalis dulunya adalah
 Ada 3 semilunar cusps projecting
foramen ovale for fetal circ, spy
upward into lumen. Bntuknya spt
darah dr IVC bisa langsung
pocket like sinus. Trdiri dr nodule and lunula. There are
mengalir dr RA  LA bypass
left, right and ant semilunar cusps.
lungs krn blm berfungsi. Commented [i-[5]: The blood in the pulmonary sinuses
 Sltha kontraksi, the recoil blood fills pulmo sinuses and prevents the cusps from sticking to the wall of the pulmonary
force the cusps to close so prevent blood come back to RV. trunk and
failing to close
 A double-leaflet mitral valve at the left AV orifice

Trabeculae carneae are finer, more numerous and delicate

dbanding RV. Disini ada 2 papillary muscle (ant & post),
ukurannnya lbh bsr disbanding RV. their chordae tendineae are
thicker but less numerous.

Interventricular septum trdri dr 2 yi : Commented [i-[6]: source lily hal 22

 Muscular part  major part and thick, bulges into the

cavity of the right ventricle because of higher BP in LV
 Membranous part  upper and thin, continuous with the
fibrous skeleton of theheart.

Mitral valve/ bicuspid valve

Trletak di left atrioventricular orifice. The mitral valve is located

post to sternum at the level of the 4th costal cartilage. Its closed
during ventricular contraction.

Ada 2 cusps (ant & post). The

tendinous cords become taut, just
before and during systole, preventing
Left atrium the cusps from being forced into LA

Form most of base / post Aortic valve

surface of heart. The post
part, receive 4 pulmo An aortic orifice that lies in its right
posterosuperior part and is
veins (valveless).
surrounded by a fibrous ring to which
the right, posterior, and left cusps of
The left auricle form sup part of left border of <3 & overlap
the aortic valve are attached. It is
pulmo trunk. located posterior to the left side of the sternum ( 3rd ICS )

A slightly thicker wall than RA. A large smooth-walled part & a Sm kyk pulmo valve ada 3 semilunar cusps projecting updward
small muscular part, the left auricle, that has pectinate muscles into lumen of ascending aorta.
in its walls but there’s no crista terminalis so x separation.
Diantara semilunar cusps and wall of ascending aorta ada 3
Ada valve of foramen ovale u/ cegah blood pass from LA  RA. sinus yaitu Right, left and post aortic siniuses. Sinus ini adlh
origin dr right and left coronary arteries. No artery arises from
A left AV orifice thru which LA discharges the oxygenated blood
the posterior aortic (noncoronary) sinus. Ad nodul lunula
it receives from pulmo veins into LV during ventricular diastole
As blood recoils after ventricular contraction and fills aortic
Left ventricle
sinus, its automatically forced into coronary arteries.
Trletak ant dr LA. LA LV mell left atrioventricular orifice.
A smooth-walled, nonmuscular, supero-anterior outflow part,
Disini myocardium has the thickest layer (2-3x thicker than RV)
the aortic vestibule, leading to aortic orifice and aortic valve
of myocardium, Because arterial pressure is much higher in the
systemic than in pulmo circ.

The LV forms the apex, nearly all

of its left (pulmonary) surface and
border, and most of diaphragmatic
surface

In a healthy adult heart, the wall

thickness is 9 to 11 mm,
Cardiac skeleton Artery and vein of heart

Adlh skumpulan dense, fibrous conn tissue in form of 4 rings w/ There are 2 coronary artery in heart which circle the heart in Commented [i-[7]: Alternative names of coronary artery yi
interconnecting areas in plane btween atria & ventricles. It coronary sulcus with marginal & interventricular branches, in main stem vessel. Primary branches yi ant interventricular
artery (LAD) and post interventricular artery (post desecending
surround 2 atrioventricular orifices, aortic orifice and opening of interventricular sulci , converging toward apex of heart :
artery / PDA)
pulmo trunks. They’re anulus fibrosus interconnecting include :
 Arises : from aortic sinuses in ascending aorta.
 Right fibrous trigone : antar a ortic ring and right  Return : coronary sinus in coronary sulcus on post surface
atrioventricular ring of heart btween LA and LV. Coronary sinus  RA btween Commented [i-[8]:
 Left fibrous trigone : antar aortic ring and left opening of IVC and right AV orifice
atrioventricular ring
Fungsi : supply myocardium and epicardium and course just
Fs nya : help maintin integrity of openings, surround & provide deep to the epicardium
point of attahment for cusps. Separate atrial & ventricle
structure. Also sbgai attachment for ventricle & atrial muscle Right coronary Left coronary
artery/RCA Artery/LCA

Ori Right aortic sinus Left aortic sinus

gin
Jala Passes anteriorly & Passes btween pulmo trunk Commented [i-[9]: Typically, the RCA supplies
n descend vertically in and left auricle bfore • The right atrium
• Most of the right ventricle
coronary sulcus to the entering coronary sulcus.
• Part of LV (diaphragmatic surface)
post and to d base of Emerging from behind • Part of the IV septum (usually the post third)
heart. Inf margin of <3 pulmo trunk, artery divides • The SA node (in approximately 60% of people)
into 2 terminal branches • The AV node (in approximately 80% of people)
Commented [i-[10]: the LCA supplies (MOORE)
Cab - Sinus atrial nodal - Ant interventricular • The left atrium
ang branch (SA Node) branch / left ant • Most of the left ventricle
- Right marginal deseceding artery • Part of the right ventricle
branch /LAD • Most of the IV septum (usually its anterior two-thirds),
(right border / including the AV bundle of conducting tissue, through its
inferior/acute Dr left side of pulmo perforating IV septal branches
margin of heart & to trunk  descend • The SA node (in approximately 40% of people)
apex) supply RV obliquely towards apex Commented [i-[11]: Source lily hal 24
in ant interventriuclar
In most people, sulcus. Here, it turns supplies blood to the inferior and posterior
distal RCA gives around inf border of walls of the ventricles and the posterior one third
rise to large branch heart and anastomoses of the interventricular septum
----- : posterior w/ d post IV branch of Commented [i-[13]: Source lily hal 24
descending artery the RCA. During its descent on the anterior surface, the
LAD gives off septal branches that supply the
- Post The ant IV branch anterior two thirds of the interventricular septum and the
interventricular supplies both ventricles apical portion of the anterior papillary muscle. The LAD also
gives off diagonal
branch in post and the IV septum
branches that supply the anterior surface of
interventriuclar the left ventricle.
sulcus as it cont to - Circumflex branch
the base of heart Jalan di coronary sulcus/ Commented [i-[12]:
supplying small left AV groove &passes
branch of AV node. the left border of heart
to reac post surface.
supplies both
ventricles and sends Large branch = left
perforating marginal artery (across
interventricular obtuse margin) that
septal branches supply the lateral and
to the IV septum. posterior wall of LV

Fun Supply RA and RV, SA & LA & LV , most of

gsi AV nodes , interatrial interventruclar septum , AV
septum , posteroinf 1/3 bundle and branches
of interventricular
septum, portion of LA &
portion post part of LV
Variation of distribution of coronary artery

 Right dominant coronary artery 85%

Post interventricular branch arises from right coronary
artery so it supply large portion of post wall of LV and
circuflex branch of Left coronary artery is small
 Left dominant coronary artery 8%
The post interventriuclar branch arises from enlarged
circumflex branch & supplies most post wall of LV
 In the remaining population, the heart’s posterior
blood supply is contributed to from branches of both
RCA and circumfl ex, forming a codominant circ.
 In 40% of ppl SA & AV nodes supplied by right
coronary artery. Sometimes circumflex branch of left
coronary artery supply these structures and ascends on
the post surface of the left atrium to the SA node.
 In many people, the anterior IV artery gives rise to a
lateral (diagonal) branch, which descends on the
anterior surface of the heart.

Cardiac veins

Coronary sinus receive 4 major tributaries :

 Great cardiac vein / ant IV sulcus (kiri) (MAGNA)

Begin in apex of heart ant IV sulcus  coronary sulcus 
vein turns to left  base of heart (ass 2/ circumflex branch
of left coronary artery  coronary sinus  RA
 Middle cardiac vein /post IV vein (kanan)(MEDIA)
e Begin in apex  post interventricular sulcus  coronary
sinus. Ass w/ post IV branch of R/L coronary artery.
 Small cardiac vein (kanan) (PARVA)
Begin in lower ant of coronary sulcus btween RA & RV 
base of heart  coronary sinus . dia bersama RCA along
acute margin of heart and may receive right marginal vein.
Klo marginal vein x join small cardiac vein  lngsung ke
RA directly.
 Oblique Vein / v. oblique sinistri / marshalli
 Post cardiac vein
Ada di post surface of LV, left of middle cardiac vein. Either
enters coronary sinus directly / join great cardiac vein.
 2 additional cardiac vein (lngsung ke RA)
o Ant vein of RV (ant cardiac vein)
LYMPHATIC DRAINAGE OF HEART Arise on ant surface of RV. They cross coronary sulcus
and enter ant wall of RA.
Lymphatic vessels in the myocardium and subendocardial
connective tissue pass to the subepicardial lymphatic plexus. Drain the ant portion of RV. Right marginal vein may
Vessels from this plexus pass to the coronary sulcus and follow part of dis group klo x brng small cardiac vein.
the coronary arteries. A single lymphatic vessel, formed by the
union of various vessels from the heart, ascends between the o Venae cordis minimae / vein of thebesius (smallest
pulmonary trunk and the left atrium and ends in the inferior cardiac veins)
tracheobronchial lymph nodes, usually on the right side numerous in RA & RV, ocassionally ass w/ LA.
 AV NODE

Excitation of atria stimulates AV node, located near opening of

coronary sinus, near attachment of septal cusp of tricuspid valve
and within atrioventricular septum.

It’s a beginning of AV bundle which excitatory impulse to all

ventricular musculature.

The AV bundle, passes from the AV node thru fibrous skeleton

of the heart and along the membranous part of the IV septum.
At the junction of the membranous and muscular parts of the
septum, the AV bundle divides into right and left bundle
branches.

The bundles proceed on each side of the muscular IV septum

deep to the endocardium and then ramify into subendocardial
branches (Purkinje fibers), which extend into the walls of the
Coronary lymphatics respective ventricles. The subendocardial branches of the right
bundle stimulate the muscle of the IV septum, the anterior
Follow coronary artery and drain into : papillary muscle (through the septomarginal trabecula), and the
wall of the right ventricle. The subendocardial branches of the
 Brachiocephalic nodes, ant to brachiocephalic veins left bundle stimulate the IV septum, the anterior and posterior
 Tracheobronchial nodes at inf end of trachea papillary muscles, and the wall of the left ventricle

The heart lymph is drained by an extensive plexus of valved AV BUNDLE of HIS

vessels located in the subendocardial connective tissue of all
four chambers. This lymph drains into an epicardial plexus Direct continuation of AV node  follow along lower border of
from which are derived several larger lymphatic vessels that membranous part of interventricular septum  then split into
follow the distribution of the coronary arteries and veins. Each RBB & LBB. Commented [i-[14]: Source lily pg 23
of these larger vessels then combines in the AV groove to form
a single lymphatic conduit, which exits the heart to reach the  RBB The right bundle branch is thick and deeply
buried in the muscle of the interventricular
mediastinal lymphatic plexus and ultimately the thoracic duct Continue to apex of RV. From septum  septomarginal
septum and continues toward the apex. Near
trabeculae  base of ant papillary muscle  the junction of the interventricular septum
------- subendocardial plexus of ventricular conduction cells / and the anterior wall of the right ventricle,
purkinje fibers. the right bundle branch becomes subendocardial
Cardiac conduction system and bifurcates. One branch travels across
the right ventricular cavity in the moderator
 LBB band, whereas the other continues toward the
Consist of :
To left side of muscular interventricular sptum  descend tip of the ventricle.

 Sinus atrial node to apex of LV  purkinje fibers

The anterior fascicle runs anteriorly toward the apex, forming a
 Atrioventricular node subendocardial plexus in the area of the anterior papillary
muscle. The posterior fascicle travels to the area of the
 Atrioventricular bundle  RBB & LBB
posterior papillary muscle; it then divides into a subendocardial
 Subendocardial plexus of conduction cells (purkinje plexus and spreads to the rest of the left ventricle.
fibers )
The subendocardial plexuses of both ventricles
Fungsi : initiates and coordinates contraction so heart can send distributing Purkinje fi bers to
the ventricular muscle.
contract spontaneously.

SA NODE
Sympathetic stimulation speeds up conduction and
Impulses begin at SA node (cardiac pacemaker). 70 beats per parasympathetic stimulation slows it down.
minute. Located at superior end of crista terminalis at junction
of SVC & RA.

The impulse spread from SA node spread across atria causing

contraction. The impulse spreads by myogenic conduction
Cardiac innervation pain sensation from heart, which detected at cellular
level as tissue damaging events. Like MI. this pain is
Autonomic division of PNS yi u/ : often reffered to cutaneous regions by same spinal cord
levels
 Heart rate
 Force of each contraction
 Cardiac output

Cardiac plexus supplied by autonomic nerve fibers (parasympha

& sympha) consist of superficial part & deep part.

These nerve networks lie anterior to the bifurcation of the

trachea and posterior to the ascending aorta.

This branches affect nodal tissue and conduction system,

coronary blood vessels and atrial& ventricular musculature.

Parasympathetic Symphathetic
 Decrease HR  Increase HR
 Reduce force of  Increase force of
contraction contraction
 Constrict coronary  (indirectly) produces
arteries , saving energy dilation of the coronary
between periods of arteries by inhibiting
increased demand. their constriction. This
supplies more oxygen &
nutrients to
myocardium during
periods of incris activity

Origin : presynaptic fibers of Origin : upper 4 / 5 segment of Cardiac cycle

the vagus nerves (CN X). thoracic spinal cord enter and
move thru symphathetic trunk
Postsynaptic parasympathetic
cell bodies (intrinsic ganglia) from presynaptic fibers with
are located near the SA and cell bodies in the
AV nodes and along the intermediolateral cell columns
coronary arteries. (lateral horns) of the superior
five or six thoracic segments of
the spinal cord and from
postsynaptic sympathetic
fibers with cell bodies in the
cervical and superior thoracic
paravertebral ganglia of the
sympathetic trunks

Visceral afferent
 Component of cardiac plexus
 Pass thru cardiac plexus and return to CNS from
symphatetic trunk and in vagal cardiac branches
 Vagal cardiac nerves return to vagus nerve X. they
sense alteration of BP and blood chemistry so they
concerned w/ cardiac reflexes.
 Afferent ass w/ cardiac nerves from symphathetic
trunks , return to either cervical or thoracic portion of
symphathetic trunk. If they’re in cervical portion of
trunk, they normally descend to thoracic region where
they reenter upper 4/5 thoracic spinal cord segments
along with afferents from thoracic region of
sympathetic trunk.

Visceral afferents ass w/ sympathetic system conduct

Surface Anatomy - Tricuspid valve (T): near left sternal border in 5th or 6 th
intercostal space
The heart and great vessels are approximately in the middle of - Mitral valve (M): apex of heart in 5th intercostal space in
the thorax, surrounded laterally and posteriorly by the lungs midclavicular line
and bounded anteriorly by the sternum and the central part of
the thoracic cage

Superior border
corresponds to a line connecting thevinferior border of the
2nd left costal cartilage to the superiorvborder of the 3rd
right costal cartilage.

Right broder
corresponds to a line drawn from the 3rd right costal
cartilage to the 6th right costal cartilage; this border is
slightly convex to the right.

Inferior border
corresponds to a line drawn from the inferior end of the right
border to a point in the 5th intercostal space close to the left
midclavicular line; the left end of this line corresponds to the
location of the apex of the heart and the apex beat.

Left border
corresponds to a line connecting the left ends of the lines
representing the superior and inferior borders.

The location of the apex beat (mitral area) varies in position; it

may be located in the 4th or 5th intercostal spaces, 6–10 cm
from the midline of the thorax

Percussion

is performed at the 3rd, 4th, and 5th intercostal spaces from the
left anterior axillary line to the right anterior axillary line.
Normally, the percussion note changes from resonance to
dullness (because of the presence of the heart) approximately 6
cm lateral to the left border of the sternum

The areas (sites) of auscultation are

- Aortic valve (A): 2nd intercostal space to right of sternal

border
- Pulmonary valve (P): 2nd intercostal space to left of
sternal border
I. MEDIASTINUM (CONTINUED)  Brachiocephalic trunk
 Left common carotid artery
Superior Mediastinum  Left subclavian artery
 Nerves
located superior to the transverse thoracic plane passing
o Vagus and phrenic nerves
through the sternal angle and the junction (IV disc) of vertebrae
o Cardiac plexus of nerves
T4 and T5.
o Left recurrent laryngeal nerve
From anterior to posterior, the main contents of the superior  Trachea
mediastinum are  Esophagus
 Thoracic duct
 Thymus
Location : ant part of sup mediastinum. Post to
manubrium of sternum &, anterior to pericardium.

After puberty, its largely replaced by fat.

Arterial supply : mainly from ant intercostal & ant

mediastinal branches of internal thoracic arteries.

The veins of the thymus end in the left brachiocephalic,

internal thoracic, and inferior thyroid veins.

The lymphatic vessels of the thymus end in parasternal,

brachiocephalic, and tracheobronchial lymph nodes

 Great vessels in mediastinum

o Brachiocephalic veins
Inf border of 1st right costal cartilage, the
brachiocephalic veins unite to form the SVC.

o Superior part of SVC

o Bifurcation of the pulmonary trunk and roots of
pulmonary arteries
o Arch of aorta and roots of its major branches
Post mediastinum

Thoracic aorta

Esophagus

Thoracic duct and lymphatics trunk

Vessels and lymph nodes

Nerves