FOUR CHAMBERS OF THE HEART

GRAY’S ANATOMY
RIGHT ATRIUM IVC
- is larger than superior
GENERAL AND EXTERNAL FEATURES - Drains blood from all structures below including the
diaphragm into the lowest part of the atrium near the septum
- anterior and to the right of the left atrium Eustachian valve
- extends inferior to LA - Flap like valve anterior to orifice of IVC and along its right
margin
Wall of RA - a fold of endocardium that encloses a few muscular fibres
- Anterior sternocostal surface and is of varying size
- Right pulmonary surface - When traced inferiorly, it forms the Eustachian ridge,
- A little of the right side of the anatomical base o runs into the sinus septum
SVC – dome o continuous with the valve of the coronary sinus
IVC – inferoposterior part - The lateral part
Appendage/auricle o continuous with the lower end of the terminal
- extensive muscular pouch crest.
- projects anteriorly to overlap the right side of the ascending - The Eustachian valve is large during fetal life
aorta o when it serves to direct richly oxygenated blood
- broad, triangular, pyramidal structure (from the placenta) from the RA through the
- has a wide junction with the venous component of the atrium foramen ovale into LA
sulcus terminalis - varies markedly in size in postnatal life
- marks the the junction between the venous part (sinus - sometimes cribriform or filamentous but often absent
venosus) and the atrium proper Chiari’s network
- extending - Occasionally, a reticulated network, originates from the
- between the right sides of the openings of the two venae Eustachian valve
cavae - connects to different parts of the right atrium, including the
- corresponds, internally, to the terminal crest (crista coronary sinus.
terminalis) - results from incomplete resorption of the right valve of the
crista terminalis embryonic sinus venosus
- site of origin of the extensive pectinate muscles that arise - associated with te pathogenesis of thromboembolic disease,
serially at right angles from the crest endocarditis, arrhythmias, cardiac flow obstructions, heart
anterior murmurs,
- right atrium is related to the anterior part of the mediastinal - infective endocarditis, cardiac tumours and entrapment of
surface of the right lung, catheters on percutaneous intervention
- from which it is separated by pleura and pericardium sub-Thebesian recess
posterior - prominent; located posterior to the Eustachian valve
- vertical interarterial groove descends to the crux - posteroinferior to the ostium of the coronary sinus
posterior and to the left cavotricuspid isthmus
- interatrial septum and the surrounding infolded atrial walls - area between the Eustachian and tricuspid valves
separate the atria (the mural infolding is indicated by an - inferior to the ostium of the coronary sinus
extensive interatrial groove - target of catheter-directed ablation procedures
posterior and the right o treatment of choice for atrial flutter
- right pulmonary veins coronary sinus
lateral - opens into the venous component between orifice of the
- related to the mediastinal surface of the right lung IVC, fossa ovalis and the vestibule of the atrioventricular
- anterior to hilum opening
- separated from it by the pleura, right phrenic nerve and - lies within the left atrioventricular groove
pericardiacophrenic vessels, and pericardium - the conduit for return of most of venous blood from heart,
Medially although some veins drain directly to atrial chambers
- ascending aorta - starts at the confluence of the oblique vein of LA and great
- to a limited extent, the pulmonary trunk and its bifurcation cardiac vein
- receives the middle and small cardiac veins close to its
INTERNAL FEATURES junction with the right atrium
- divided into three regions: - often guarded by a thin, semicircular Thebesian valve
o the smooth-walled venous component located o covers the lower part of the orifice
posteriorly leads anteriorly to the vestibule of the The upper limb of this valve
tricuspid valve and to the appendage - joins the Eustachian valve and its muscular extension, the
- wall of the vestibule is smooth but its junction with the Eustachian ridge
appendage is ridged around the atrioventricular junction by - also joins a tendinous structure, the tendon of Todaro,
pectinate muscles running from this commissure into the sinus septum, which is
venous sinus the septum between coronary sinus and fossa ovalis
- receives the openings of venae cavae and coronary sinus The tendon of Todaro
- originates from sinus venosus of the embryonic heart - runs forwards to insert into the central fibrous body
- SVC, IVC, coronary sinus - one of the landmarks of the triangle of Koch
o open into the venouscomponent The ostium of the coronary sinus
appendage - forms a prominent landmark in the right atrium
- trabeculated small venous ostia
- derived from atrium proper of embryonic heart - scattered around atrial walls, draining minimal atrial veins
SVC - They return a small fraction of blood from the heart,
- blood from head, neck and upper limb - most numerous on the septal aspect.
o through an orifice that faces anteroinferiorly anterior cardiac veins and, sometimes, right marginal vein
- has no valve - may enter the atrium through larger ostia
- also receives blood from the chest wall and the oesophagus crista terminalis
o via the azygos system - smooth, C-shaped muscular ridge
 - separates right atrium and appendage from venous sinus interposed above and to the left
- originates from the upper part of the septal surface - left pleura and, to a lesser extent, the anterior margin of the
- passing anterior to the orifice of the superior vena cava left lung
- skirts its right margin to reach right side of orifice of IVC inferior surface
- marks the site of right venous valve of the embryonic heart - flat and is related mainly, with the interposition of the
- corresponding externally to the terminal groove. pericardium, to the central tendon and a small adjoining
The sinu-atrial (sinus) node muscular part of the diaphragm
- located in the superior part of the groove ventricular septum
- inferolateral to the orifice of SVC - left and posterior wall
pectinate muscles (musculi pectinati) - slightly curved and bulging into the right ventricle
- almost parallel muscular ridges o sections across the cardiac axis, the outline of the
- extend anterolaterally from the terminal crest, reaching into right ventricle is crescentic
the appendage where they form several trabeculations wall of the right ventricle
taenia sagittalis (second crest or septum spurium) - relatively thin (3–5 mm),
- The largest and most prominent pectinate muscle - ratio of the thickness of the two ventricular walls usually
- froms the bridge of the sulcus terminalis internally being 1:3
fossa ovalis
- oval depression in septal wall INTERNAL FEATURES
- superior and to the left of the orifice of the IVC supraventricular crest (crista supraventricularis)
- Its floor is the primary atrial septum (septum primum). - prominent; separates inlet and outlet components
- The rim of the fossa (limbus) is prominent - made up predominantly by the inner heart curvature
- Often said to represent the edge of septum secundum - bounded on the epicardial aspect by rightward margin of
o in reality the muscular borders of the fossa are just transverse sinus.
infoldings of the atrial walls, incorporating - thick, muscular, highly arched structure
extracardiac adipose tissue - extending obliquely anteriorly and to the right from a septal
- most distinct anterosuperiorly to the fossa usually deficient limb high on the interventricular septal wall to a mural or
inferiorly parietal limb on the anterolateral RV wall.
- Some hearts display excessive amount of extracardiac The posterolateral aspect of the crest
adipose tissue within the fold  raising a marked elevation - principal attachment for the anterosuperior leaflet of tricuspid
of the superior rim of the fossa (intervenous tubercle of valve
Lower) The septal limb of the crest
- Failure of obliteration of foramen ovale  small slit – - continuous with, or embraced by, the septal limbs of the
o sometimes found at the upper margin of the fossa septomarginal trabeculation
o ascending beneath the rim to communicate with The inlet and outlet regions
left atrium - extend apically into and from the prominent coarsely
o remains patent in up to one-third of all normal trabeculated component of the ventricle.
hearts. The inlet component
Anteroinferior in the right atrium is the - trabeculated
large, oval vestibule leading to the orifice of the tricuspid valve outlet component (infundibulum)
Triangle of Koch - predominantly smooth walls.
- defined between trabeculated appearance
o attachment of the septal leaflet of the tricuspid - caused by trabeculae carneae
valve o a myriad of endocardial, lined, irregular muscular
o anteromedial margin of ostium of coronary sinus, ridges and protrusions
o palpable round, collagenous subendocardial - These protrusions and intervening grooves impart great
tendon of Todaro variation in wall thickness
- landmark of particular surgical importance, indicating the site - protrusions vary in extent from mere ridges to trabeculations,
of the atrioventricular node and its atrial connections. fixed at both ends but otherwise free.
Anterosuperior to the insertion of the tendon of Todaro, Papillary muscles
- the septal wall is formed by the atrioventricular component of - Other conspicuous protrusions which are inserted at one end
the membranous septum, intervening between the right on to the ventricular wall and are continuous at the other end
atrium and subaortic outlet of the left ventricle with collagenous cords, the chordae tendineae (tendinous
aortic mound (torus aorticus) cords)
- bulging atrial wall anterosuperior to the membranous septum chordae tendineae (tendinous cords)
- marks the location of the non-coronary aortic sinus with its - inserted on the free edge of the atrioventricular valves.
enclosed valvular leaflet septomarginal trabeculation or septal band
- particularly prominent protrusion in the right ventricle
RIGHT VENTRICLE - reinforcing the septal surface where, at the base, it divides
- extends from the right atrioventricular (tricuspid) orifice into limbs that embrace the supraventricular crest
nearly to the cardiac apex. - Towards the apex, it supports the anterior papillary muscle
- then ascends to the left to become  infundibulum, or conus of the tricuspid valve
arteriosus o from this point, crosses to the parietal wall of the
o reaching the pulmonary orifice and supporting the ventricle as the moderator band
leaflets of the pulmonary valve moderator band
- Topographically, it possesses - the name reflects an earlier idea that septomarginal
o inlet component – supports and surrounds trabeculation prevented overdistension of the ventricle
- role as part of the conduction system of the heart involves
tricuspid valve
the right atrioventricular bundle,
o apical component – coarsely trabeculated
o as conduction cardiomyocytes move towards the
o outlet component or infundibulum – muscular;
apex of the ventricle before entering the anterior
surrounds attachments of pulmonary valve leaflets
papillary muscle.
- may be short/thick, long/thick, short/thin, long/thin: it is
EXTERNAL FEATURES occasionally absent.
convex anterosuperior surface of the right ventricle septoparietal trabeculations
- makes up a large part of the sternocostal aspect of the heart, - A further series of prominent trabeculations, extend from its
- separated from the thoracic wall only by the pericardium anterior surface and run on to the parietal ventricular wall.
Infundibulum clear zone
- smooth-walled outflow tract - smooth and translucent,
- ascends to the left, superior to septoparietal trabeculations - receives few chordae tendineae
- inferior to the arch of the supraventricular crest to the - thinner, fibrous core
pulmonary orifice basal zone,
- extending 2–3 mm from circumferential attachment leaflet
TRICUSPID VALVE - thicker from increased connective tissue,
The atrioventricular valvular complex, in both ventricles, consists of - vascularized and innervated
o orifice and its associated anulus, - contains the insertions of the atrial myocardium.
o leaflets, anterosuperior leaflet
- largest component of the tricuspid valve
o supporting chordae tendineae of various types,
- attached chiefly to the atrioventricular junction on the
o papillary muscles
posterolateral aspect of the supraventricular crest
- Harmonious interplay of all of these, together with the - extending along its septal limb to the membranous septum
myocardial mass, depends on the conduction tissues and ending at the anteroseptal commissure
mechanical cohesion provided by the cardiac skeleton. - One or more notches often indent its free margin
- All parts change substantially in position, shape, angulation Septal leaflet
and dimensions during the cardiac cycle - The attachment passes from the inferoseptal commissure on
the inferior ventricular wall across the muscular septum
TRICUSPID VALVULAR ORIFICE - then angling across the membranous septum to the
- best seen from the atrial aspect anteroseptal commissure.
- on average, 11.4 cm in circumference in males - defines one of the borders of the triangle of Koch
- 10.8 cm in females o aiding location of the AV node at the apex
- clear line of transition from the atrial wall or septum to the o ensuring avoidance during tricuspid valve surgery
lines of attachment of the valvular leaflets inferior leaflet
- margins are not precisely in a single plane - often described as being posterior, but when assessed in the
- almost vertical but at 45° to the sagittal plane attitudinally correct anatomical position, the leaflet is
- slightly inclined to the vertical, such that it ‘faces’ (on its positioned inferiorly
ventricular aspect) anterolaterally to the left and somewhat - wholly mural in attachment
inferiorly - guards the diaphragmatic surface of atrioventricular junction
- roughly triangular, its margins are described as - its limits being the inferoseptal and anteroinferior
anterosuperior, inferior and septal, corresponding to the lines commissures.
of attachment of the valvular leaflets zone of apposition between the inferior and the anterosuperior leaflets
The connective tissues around - supported by the septal papillary muscle of the conus
- separate the atrial and ventricular myocardial masses Opening of the tricuspid valve
completely - acts more like a bicuspid valve
o except at the point of penetration of the - smallest septal leaflet is fixed between the atrial and
atrioventricular bundle; ventricular septa.
o they vary in density and disposition around the - The remainder of the tricuspid anulus is muscular
valvular circumference During diastole,
‘prongs’ (fila coronaria) - anulus dilates with right ventricular relaxation
- Extending from the right fibrous trigone component of the - large anterior and posterior leaflets move away from the
central fibrous body plane of the anulus into the right ventricle
- a pair of curved, tapered, subendocardial tendons, During systole
- partly encircle the circumference. - anulus constricts as RV contracts
- completed by more tenuous, deformable fibroblastic sulcal - the two major leaflets move like sails about a relatively
- areolar tissue immobile septal leaflet and the septum itself
the tissue within the atrioventricular junction around the tricuspid orifice
- always less robust than similar elements at the mitral valve CHORDAE TENDINEAE (TENDINOUS CORDS)
The topographical ‘attachment’ of the free valvular leaflets - fibrous collagenous structures that support the leaflets of
- does not wholly correspond to the internal level of false chordae
attachment of the fibrous core of the valve to the junctional - Sometimes connect papillary muscles to each other or to
atrioventricular connective tissue ventricular wall or septum,
- line of attachment of leaflet is best appreciated in the heart - or pass directly between points on the wall, septum, or both
when examined grossly - numbers and dimensions vary in RV
- approximately 40% contain conduction cardiomyocytes
TRICUSPID VALVE LEAFLETS true chordae
- distinguished on the basis of the zones of apposition - arise from small projections on the tips or margins of the
between them: hence the name. apical third of papillary muscles
- located anterosuperiorly, septally and inferiorly, - although sometimes arise from papillary muscle bases
corresponding to the marginal sectors of the atrioventricular - or directly from the ventricular walls and septum
orifice named in conjunction. - They attach to various parts of the ventricular aspects or the
- Each leaflet is a reduplication of endocardium enclosing a free margins of the leaflets.
collagenous core, - Classified into first-, second- and third-order types
- continuous marginally and on its ventricular aspect with o according to distance of attachment from the
diverging fascicles of chordae tendineae margins of the leaflets
- basally confluent with the anular connective tissue Fan-shaped chordae
- In passing from the free margin to the inserted margin, all - have a short stem with branches that radiate
leaflets display rough, clear and basal zones. - attach to the margins (or the ventricular aspect) of the zones
rough zone of apposition between leaflets and to the ends of adjacent
- ventricular aspect leaflets.
o The rough zone is relatively thick, opaque, uneven Rough-zone chordae
o where most chordae tendineae are attached - arise from a single stem that usually splits into three
- atrial aspect components
o makes contact with the comparable surface of the - attach to free margin, ventricular aspect of rough zone and
adjacent leaflets during full valve closure to some intermediate point on the leaflet, respectively
Free-edge chordae - with a variably developed intervening substantial fibrous core
- single thread-like, long that traverses both the free edge and the semilunar attached
- passing from either the apex or the base of papillary muscle border
- attach into margin near the midpoint of a leaflet or one of its - Each semilunar leaflet is contained within one of the three
scallops sinuses of the pulmonary trunk
Deep chordae semilunar attached border
- pass beyond the margins - thickened at deepest central part (nadir) of base of each
- branching to various extents, leaflet
- attach to more peripheral rough zone or even clear zone - never forms a simple complete fibrous ring.
Basal chordae The free margin of each leaflet
- round or ribbonlike, long and slender, or short and muscular - contains a central localized collagenous thickening – nodule
- arise from smooth or trabeculated ventricular wall of Arantius
- attach to the basal component of a leaflet Perforations within the leaflets
- close to the free margin and near the commissures
PAPILLARY MUSCLES - frequently present and are of no functional significance.
OPENING OF PULMONARY VALVE
- All the major papillary muscles supply chordae to adjacent During diastole,
components of the leaflets they support - All three leaflets are tightly apposed
two major papillary muscles in the right ventricle - The pulmonary valve is difficult to visualize at ECG
- located in anterior and inferior positions. - and usually only the posterior leaflet is visible when the valve
third, smaller muscle is closed
- lies medially, systole
- together with several smaller, variable muscles attached to - atrial systole
the ventricular septum. o may cause a slight posterior movement of the
The anterior papillary muscle valve leaflets
- largest, - ventricular systole
- its base arising from right anterolateral ventricular wall o pulmonary valve opens passively
- inferior to the anteroinferior commissure of inferior leaflet, - closes rapidly at the end of systole
- blending with the right end of the septomarginal trabecula
The inferior papillary muscle LEFT ATRIUM
- bifid or trifid
- arises from myocardium inferior to the inferoseptal GENERAL, EXTERNAL FEATURES
commissure - smaller in volume than the right,
The septal (medial) papillary muscle of the conus - thicker walls (3 mm on average)
- muscle of Lancisi - possesses a venous component that receives pulmonary
- almost always present veins, vestibule and an appendage
- most superior and largest of the small septal papillary - roughly cuboidal, extending posterior to the right atrium
muscles - separated from RA by the obliquely positioned septum.
- arises from posterior septal limb of the septomarginal o RA is therefore anterolateral to the right part of LA
trabeculation
- The left part is concealed anteriorly by the initial segments of
- locates the right bundle branch within the right ventricle.
the pulmonary trunk and aorta:
septal leaflet
o part of the transverse pericardial sinus lies
- tethered by individual chordae tendineae directly to the
between it and these arterial trunks
ventricular septum
Its cavity and walls
- such septal insertions are never seen in the left ventricle
- formed largely by proximal parts of the pulmonary veins that
- When closed, the three leaflets fit snugly together
are incorporated into the atrium during development
o the pattern of the zones of apposition confirming
Its extensive body
the trifoliate arrangement of the tricuspid valve.
- remnant of the initial atrial component of the primary heart
tube
PULMONARY VALVE Anteroinferiorly, and to the left
- guarding the outflow from the right ventricle - adjoins the base of the left ventricle at the orifice of the mitral
- surmounts infundibulum valve
- situated at some distance from the other 3 cardiac valves Posterior aspect
- general plane faces superiorly to left, slightly posteriorly. - forms most of the anatomical base of the heart
three semilunar leaflets - approximately quadrangular
- attached by convex edges partly to infundibular wall of RV - receiving the terminations of (usually) two pulmonary veins
- partly to the origin of the pulmonary trunk o forming the anterior wall of the oblique pericardial
line of attachments sinus
- curved, rising at the periphery of each leaflet - This surface ends at the shallow vertical interatrial groove
- near their zones of apposition (the commissures) that descends to the cardiac crux
- reaching the sinutubular ridge of the pulmonary trunk left atrial appendage
Removal of the leaflets - characteristically longer, narrower and more hooked than the
- reveals that the fibrous semilunar attachments enclose three right,
crescents of infundibular musculature within the pulmonary - finger-like extension with more deeply indented margins
sinuses - constricted at its atrial junction
three roughly triangular segments of arterial wall - its contained pectinate muscles are much smaller than their
- incorporated within ventricular outflow tract beneath the apex right counterparts.
of each commissural attachment. - lacks a crista terminalis
Thus there is no proper circular ‘anulus’ supporting the leaflets - muscle bundles are arranged in a whorl-like fashion rather
fibrous semilunar attachment than being in an array
- essential requisite for snug closure of the nodules and - tip of the appendage has a variable position lying over the
lunules of the leaflets during ventricular diastole pulmonary trunk and anterior interventricular artery, pointing
anterior, posterior and septal leaflets posteriorly towards the aorta
- based on fetal position but this changes with development - its narrow morphology renders the left atrial appendage a
- becoming anterior, right and left, respectively, in the adult potential site for deposition of thrombi
Each leaflet is an endocardial fold
The four pulmonary veins - Obese children aged 2years have a greater left ventricular
- open into the superior posterolateral surfaces, two on each mass
side part of the atrioventricular groove with the coronary sinus within in its
- This typical arrangement is present in 20–60% of the posterior aspect
population. - separates the base of the ventricular cone is superficially
- A common variation includes presence of a short or long left separated from the left atrium
common venous trunk and multiple pulmonary veins on the - Except where obscured by the aorta and pulmonary trunk
right The anterior and posterior (inferior) interventricular grooves
- The right pulmonary veins travel posterior to their respective - indicate the lines of mural attachment of the ventricular
venae cavae septum and the limits of the ventricular territories.
- orifices are smooth and oval, the left pair frequently opening The sternocostal surface of the ventricle
via a common channel. - curves bluntly into its left surface at the obtuse margin

Interpulmonary ridges INTERNAL FEATURES

- between ipsilateral orifices - has an
- the most prominent is located between the openings of the o Ostium venosum
left atrial appendage and left superior pulmonary vein.  inlet region guarded by the mitral valve
- infoldings of the left atrial wall and contain adipose tissue, o ostium arteriosum
atrial arteries and nerve bundles.  outlet region guarded by the aortic valve
At the site of the pericardial reflection o apical trabecular component.
- atrial musculature extends into the pulmonary veins The left atrioventricular orifice
- Forming myocardial sleeves - admits atrial blood during diastole,
o thickest in the inferior wall of superior pulmonary - flow being directed towards the cardiac apex
veins and the superior walls of the inferior - After closure of the mitral leaflets and throughout the ejection
pulmonary veins. phase of systole, blood is expelled from the apex through the
o They lie external to the venous tunica media and aortic orifice
internal to the epicardium/adventitia - in close contact with fibrous continuity between the leaflets
o often the site of focal electrical activity that initiates of the aortic and mitral valves (the ‘subaortic curtain’)
atrial fibrillation o In contrast to the orifices within the right ventricle
o the inlet and outlet turn sharply round this fibrous
INTERNAL FEATURES curtain.
Atrial myocardial bridges and crossing strands muscular ventricular septum
- connecting the left superior and inferior pulmonary veins - anterolateral wall
epicardial fat pads - the convexity of which completes the circular outline of the
- on the pulmonary venous component left ventricle
- house the ganglionated cardiac intrinsic nerve plexuses - Towards the aortic orifice, the septum becomes the thin and
(typically four) collagenous interventricular component of the membranous
o superior left, posterolateral, left inferior and septum
posteromedial - deeper, finer, more intricate trabeculae carneae than of RV
Minimal cardiac veins (venae cordis minimae) o Between the inferior limits of the free margins of
- return blood directly from the myocardium to the left atrial the leaflets of the mitral valve and the ventricular
cavity apex
The left atrial aspect of the septum o characteristically more developed nearer the apex,
- characteristically rough appearance - becoming smoother as the superior septal surface is
- bounded by a crescentic, superiorly concave ridge that reached
marks the site of the foramen ovale Membranous septum
vestibule - an oval or round area below and confluent with the fibrous
- smooth circumferential area of atrial wall that surrounds the triangle separating the right and the non-coronary leaflets of
orifice of the mitral valve is the the aortic valve.
left atrial or mitral isthmus
- musculature between the ostium of the inferior pulmonary
vein and the anulus of the mitral valve HYPERTROPHIC CARDIOMYOPATHY
- area where the vestibule of the left atrium directly opposes An athlete’s heart
the wall of the great cardiac vein, coronary sinus and - physiologically hypertrophy but in a uniform fashion
circumflex coronary artery - the left ventricle cavity < 55 mm in size
- thickness decreases on deconditioning
LEFT VENTRICLE hypertophic cadiomyopathy
- characterized by myocardial wall thickening
GENERAL, EXTERNAL FEATURES - particularly a disproportionate thickening of the
- constructed in accordance with its role as a powerful pump interventricular septum in comparison with the posterior wall
for the high-pressured systemic arterial circulation - asymmetric patterns of left ventricular hypertrophy,
- described as half-ellipsoid or cone-shaped - sharp segmental transitions
- longer and narrower than the right ventricle - left atrial enlargement
- extending from its base in the plane of the atrioventricular - bizarre electrocardiographic patterns.
groove to the cardiac apex - autosomal dominant inheritance pattern of abnormalities in
- long axis descends anteriorly and to the left genes coding for myocardial proteins
- In transverse section, at right angles to the axis, mutations of the β-MHC (major histocompatibility complex) gene
o its cavity is oval or nearly circular - usually develop the classic form of hypertrophy
- walls three times thicker (8–12 mm) than those of the right cardiac troponin T gene mutations
ventricle - only mild or clinically undetectable hypertrophy
- forms part of sternocostal, left and inferior (diaphragmatic) Rare forms of hypertrophy
cardiac surfaces - localized left ventricular apical hypertrophy
- The shape changes from elliptical in the neonatal period to o cardiac troponin I mutations
the round adult shape later in infancy - isolated midcavity hypertrophy
- The effect of obesity on the heart is apparent as early as the o cardiac actin and MLC (myosin light chain) gene
second year of life. mutations
Echocardiography - found between the two major leaflets and so the mitral valve
- assesses the degree of thickening should be described as a continuous veil that is attached
- effect on systolic function around the entire circumference of the orifice
o such as dynamic left ventricular outflow free edge
obstruction - bears several indentations,
o systolic anterior motion of the aortic mitral valve - two are sufficiently deep and regular to be nominated as the
leaflet ends of a solitary and oblique zone of apposition or
o mid-systolic closure of the aortic valve. commissure
o There may also be a degree of diastolic These anteromedial (inferoseptal), posterolateral
dysfunction (superoposterior) extremities
Serial short-axis gradient echo MRI - two independent commissures, each positionally named as
- accurate measurement of wall thickness indicated in brackets.
- particularly useful in assessing apically confined hypertrophy - the official names for these leaflets – anterior and posterior,
histological changes respectively – are somewhat misleading because of the
- cardiomyocytic disarray obliquity of the valve
- replacement fibrosis
- collagenous component expansion
Treatment
- usually medical
o except refractory cases and left ventricular outflow anterior leaflet (aortic, septal, ‘greater’ or anteromedial)
tract obstruction gradient > 50 mmHg. - guards 1/3 of circumference of the orifice when open
 Ventricular septal myotomy and - semicircular or triangular
myectomy - few or no marginal indentations.
- Catheter alcohol septal ablation - fibrous core (lamina fibrosa) is continuous on the outflow
o non-surgical alternative aspect, beyond the margins of the fibrous subaortic curtain,
with the right and left fibrous trigones
- a number of patients may also require implantation of
- Between the trigone
cardiac defibrillators to prevent sudden cardiac death
o continuous with the fibrous curtain
- beyond the trigones
MITRAL VALVULAR ORIFICE
o with the roots of the anular fibrous prongs
- well-defined transitional zone between the atrial wall and the - deep crescentic rough zone
leaflet bases, o that receives various chordae tendineae
- smaller than the tricuspid orifice (mean circumference is 9.0
- The ridge limiting the outer margin of the rough zone
cm in males and 7.2 cm in females)
o maximal extent of surface contact with the mural
- approximately circular orifice
leaflet in full closure.
- almost vertical and at 45° to the sagittal plane in diastole, but
- clear zone
with a slight anterior tilt.
o between rough zone and valvular anulus
ventricular aspect
- faces anterolaterally to the left and a little inferiorly towards o devoid of attachments of chordae, although its
left ventricular apex fibrous core carries extensions from chordae
- almost co-planar with tricuspid orifice but posterosuperior attached in the rough zone
- posteroinferior and slightly to the left of the aortic orifice - no basal zone and continues into the valvular curtain
The mitral, tricuspid and aortic orifices - critically placed between inlet and outlet of the ventricle
- intimately connected at their central fibrous body o hinging on its anular attachment
zone of coaptation; commissure o continuous with the subaortic curtain
- formed when mitral valve close During passive ventricular filling and atrial systole
The anulus of the valve - smooth atrial surface is important in directing a smooth flow
- not a simple fibrous ring but is made up of fibrocollagenous of blood towards the body and apex
elements of varying consistency, from which the fibrous After the onset of ventricular systole and closure of mitral valve
leaflet cores take origin; - ventricular aspect of its clear zone merges into the smooth
- the variable consistency is essential to allow the major surface of the subaortic curtain,
changes in anular shape and dimensions during the cardiac - remaining fibrous walls of the subvalvular aortic vestibule
cycle that are needed for optimal valvular efficiency forms the smooth boundaries of the ventricular outlet
- its area increases linearly with BSA in children and YA posterior leaflet (mural, ventricular, ‘smaller’ or posterolateral)
- strongest at the internal aspects of the left and right fibrous - two or more minor indentations.
trigone - Lack of definition of the major intervalvular commissures has
anterior, posterior coronary prongs led to disagreement and confusion concerning the territorial
- Extending from internal aspects of the left and right fibrous extent of this leaflet and the possible existence of accessory
trigone of anulus scallops.
- tapering, fibrous, subendocardial tendons - Closed position
- partly encircle the orifice at the atrioventricular junction o the posterior leaflet may conveniently be regarded
- Between the prong tips, the atrial and ventricular myocardial as comprising all the valvular tissue posterior to
masses are separated by a more tenuous sheet of the anterolateral (inferoseptal) and posteromedial
deformable fibroelastic connective tissue. (superoposterior) ends of the major zone of
continuation of the fibrous subaortic curtain apposition with the aortic leaflet
- Spanning anteriorly between the trigones - Thus defined, it has a wider attachment to the anulus than
- fibrous core of central part of the aortic leaflet of mitral valve does the anterior leaflet
- descends from the adjacent halves of the left and adjacent - guarding 2/3 of the circumferential attachments.
(non-coronary) valve leaflets - Further indentations divide the mural leaflet into
o large middle scallop
MITRAL VALVE LEAFTLETS o smaller lateral septal commissural scallops
- The name ‘bicuspid valve’ is explicit but erroneous because Each scallop has a crescentic opaque rough zone
the leaflets are not cuspid, or ‘peaked’, in form - receiving on ventricular aspect the attachments of the
Small accessory leaflets chordae
o define the area of valvular apposition in full closure
Membranous clear zone
 - From the rough zone to within 2–3 mm of its anular
attachment
- devoid of chordae
The ratio of rough to clear zone
- anterior leaflet is 0.6
- middle scallop of the posterior leaflet is 1.4.
- Much more of the mural leaflet is in apposition with the aortic
leaflet during closure of the mitral valve
basal zone
- 2–3 mm is thick and vascular, and receives basal chordae.

OPENING OF THE MITRAL VALVE

At the onset of diastole
- Opening is passive but rapid
- leaflets parting and projecting into the ventricle as left atrial
pressure exceeds left ventricular diastolic pressure.
- partially occluding the ventricular inlet.
Atrial systole
- jetting blood apically and causing re-opening of the leaflets
- As maximal filling is achieved, the leaflets again float rapidly
together
- Closure is followed by ventricular systole, which starts in the
papillary muscles and continues rapidly as a general
contraction of the walls and septum
Coordinated contraction of the papillary muscles
- increases tension in the chordae
- promotes joining of the corresponding points on opposing
leaflets, preventing their eversion
mural and septal excitation and contraction
- left ventricular pressure increases rapidly
- The leaflets ‘balloon’ towards the atrial cavity,
- atrial aspects of the rough zones come into maximal contact
Precise papillary contraction, and increasing tension in the chordae
- prevent valvular eversion and maintain valvular competence
during cardiac cycle
- orifices and the leaflets of both valves undergo considerable
changes in position, form and area
- Both valves move anteriorly and to the left during systole,
and reverse their motion in diastole.
Systole
- mitral valve reduces orificial (anular) area by 40%
- shape changes from circular to crescentic at the height of
systole
- anular attachment of aortic leaflet the concavity of the
crescent
- attachment of its mural leaflet, although remaining convex,
contracts towards the anterior cardiac wall
- smooth left ventricular outflow tract (aortic vestibule)
terminates at the aortic valve leaflets
aortic valve
- resembles pulmonary valve in possessing 3 semilunar
leaflets although stronger in construction
o supported within the three aortic sinuses of
Valsalva
- often described as possessing an anulus in continuity with
the fibrous skeleton
- no complete collagenous ring that supports the attachments
of the leaflets
- As with the pulmonary valve, the anatomy of the aortic valve
is dominated by the fibrous semilunar leaflet attachment