Translational Research in Anatomy 17 (2019) 100049

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Translational Research in Anatomy

journal homepage: www.elsevier.com/locate/tria

An anatomical review of the right ventricle T

a b c c c
Joy M.H. Wang , Rabjot Rai , Mark Carrasco , Tiwadayo Sam-Odusina , Sonja Salandy ,
Jerzy Gieleckid, Anna Zuradae, Marios Loukasc,∗
a
Department of Family Medicine, Creighton University, Nebraska, USA
b
Department of Family Medicine, Health Quest, New York, USA
c
Department of Anatomical Sciences, School of Medicine, St. George's University, West Indies, Grenada
d
Department of Anatomy, University of Warmia and Mazury, Olsztyn, Poland
e
Department of Radiology, Collegium Medicum, School of Medicine, University of Warmia and Mazury, Olsztyn, Poland

A R T I C LE I N FO A B S T R A C T

Keywords: Background: The right ventricle is the most anteriorly positioned chamber of the heart, sitting directly posterior
Heart to the sternum. The distinct anatomical features of the right ventricle create an approximately 10-fold difference
Right ventricle in vascular resistance between the right and left ventricular systems. We will first review the external and
Ventricular function general features, followed by the internal features and subsequently, the clinical relevance of this chamber of the
Tricuspid
heart.
Methods: This literature review seeks to collate and discuss peer-reviewed articles on the anatomy of the right
ventricle. It was outlined after conducting a review of the literature and standard search engines.
Results: Factors such as retrosternal location, complex geometry, and normal variants create complexities in
accurate diagnosis of right ventricle pathology.
Conclusion: Knowledge of the underlying anatomy of the right ventricle and the subsequent functional properties
are examined in this review to promote improved diagnostic protocols and clinical interventions in the future.

1. Introduction 2. Anatomical position and external morphology

Historically, the study of the right ventricle (RV) has been over- In a normal, ‘in situ’ heart, the RV is the most anteriorly positioned
shadowed by its left counterpart due to the acute nature of left ventricle chamber, sitting directly posterior to the sternum. The proximate ret-
(LV) dysfunction. The RV was viewed as a passive structure allowing rosternal location of the RV renders it a difficult structure to image on
circulation from the body to the lungs. However, as imaging modalities ultrasound and to avoid in median sternotomy. Typically, the sterno-
improve and advances are made toward understanding the pathologies costal surface is covered with epicardial fat, and less so on the dia-
of the right heart, it has become clear that the RV has been falsely phragmatic and subinfundibular surfaces [1]. The right edge of the
mistaken to be a benign structure. cardiac silhouette is formed entirely by the right atrium, while the RV
Deeper understanding of RV morphology and function are essential forms the inferior cardiac border, lying nearly horizontal to the dia-
in uncovering its pathophysiologic mechanisms. Due to the insidious phragm [2] (Fig. 1).
nature of RV dysfunction, it is often left untreated, allowing progressive Anteriorly, the RV is convex, with the pericardium separating it
deterioration and irreversible changes to occur; this can lead to cata- from the thoracic wall. The left pleura and part of the anterior margin
strophic multiorgan consequences with dim prognosis. of the left lung are interposed above and to the left. The inferior surface
Currently, there are no standardized protocols for evaluating RV of the RV is flat, with the pericardium adjoined to the central tendon
health. The detailed study of RV morpho-functional features is essential and a muscular portion of the diaphragm [3]. On the heart's surface, the
to the development of diagnostic protocols and the advancement of RV's dimensions can be approximately demarcated by the right cor-
therapeutic approaches. In this review, we aim to document the general onary sulcus and the pulmonary ventriculo-arterial junction – making
anatomical features and normal variants of the RV in order to better the RV appear as if it is winding around the LV ([1]. In contrast with the
understand its architecture. ellipsoid shape of the left ventricle (LV), the RV's shape is complex,
appearing triangular when viewed from the side and crescentic in a

∗
Corresponding author. Dean of Basic Sciences, School of Medicine, Chancellery Building, St George's University, West Indies, Grenada.
E-mail address: [email protected] (M. Loukas).

https://doi.org/10.1016/j.tria.2019.100049
Received 15 July 2019; Received in revised form 1 September 2019; Accepted 6 September 2019
Available online 24 September 2019
2214-854X/ © 2019 Published by Elsevier GmbH. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/BY-NC-ND/4.0/).
J.M.H. Wang, et al. Translational Research in Anatomy 17 (2019) 100049

Fig. 1. CT of the heart demonstrating the anatomical position of the ventricles.

The right ventricle (RV) is an anteriorly positioned chamber that is directly
posterior to the sternum (Katie Yost ©2019, provided under CC-BY–NC–ND).
Fig. 2. Anatomical features of the right ventricle demonstrating the internal
cross-section [4,5]. Due to the oblique position of the heart, the RV structures discussed. (Illustration by Katie Yost ©2019, provided under CC-
BY–NC–ND).
apex is inferior to the LV apex and at times, when the RV is con-
spicuous, the heart can appear to have a bifid apex [1].
the pulmonary valve [5,10–13] (Fig. 2). According to Muresian, this
three-compartment model appears more useful and correct from an
3. Internal structure embryological point of view [1]. Each of these three parts will be dis-
cussed in the following segments.
The RV is a hollow, muscular chamber, that receives blood from the
right atrium which is then pumped through the outflow tract to the 3.1. Inflow tract
pulmonary trunk. The ventricle extends from the inferior border of the
right atrium to the cardiac apex, running nearly horizontal to make up The inflow tract shares a connection to the right atrium (RA), with
the inferior border of the heart, also referred to as the acute margin of its superior border demarcated by the annulus of the right atrioven-
the heart [3]. The RV's interior is heavily trabeculated, aside from the tricular valve (AV), the tricuspid [3,4,11]. Moving from the RA to RV,
regions directly underneath the septal leaflets of the tricuspid and there is a mild narrowing between the two cavities, then the inflow
pulmonary valves [1]. This heavy trabeculation is one of the distinct tract originates from a posteroinferior position, to project anteriorly
characteristics of the RV. and leftward as it extends from the annulus to the papillary muscles [2].
The RV wall is about 2–5 mm in thickness, 25 ± 5g/m2 in weight, As mentioned above, the inflow tract consists of the tricuspid valve
and mainly composed of deep and superficial muscle layers. The deep and its attaching structures: the chordae tendineae and papillary mus-
subendocardial fibers are arranged longitudinally from base to apex, cles. Each of these components will be discussed below.
while the superficial subepicardial fibers are generally arranged cir-
cumferentially, parallel to the AV groove [4,6]; however, these turn
obliquely as they extend toward the apex of the heart, then continue 3.1.1. Tricuspid valve
onto the LV. This continuity of fibers from RV to LV contributes to The AV valves are composed of the corresponding orifice, annulus,
ventricular interdependence [4]. leaflet, supporting chordae tendineae and papillary muscles [3]. Each of
The interventricular septum makes up the left and posterior wall of these components will be discussed in the following sections.
the RV. It is typically concave towards the LV, often resulting in the
‘crescent’ shape of the RV on axial cuts [4]. In the past, this shape led to 3.1.1.1. Tricuspid valvular orifice. The tricuspid valve orifice measures
the hypothesis that septal bulging could potentially cause RV failure, as an average of 11.4 cm and 10.8 cm in males and females, respectively. It
in the alleged “Bernheim syndrome”; however, to this date, no distinct is roughly triangular in shape, with its margins almost vertical, facing
compression of the RV due to septal bulging has ever been demon- anterolaterally to the left and somewhat inferiorly. Its margins are
strated to cause RV failure [7]. Alternatively, leftward bulging of the labeled anterosuperior, inferior, and septal, corresponding to each
septum has been shown to cause LV failure [1]. valvular leaflet. Connective tissue around the orifice of the AV valves
Traditionally, the RV was described in two parts – the sinus and the separate the atria from the ventricles, except at the location of the AV
conus [8,9]; however, this bipartite division was inadequate for de- bundle. The fila coronaria, a pair of subendocardial tendons, extend
scriptions of congenital malformation [5]. Thus, a three-part descrip- from the right fibrous trigone, partly encircling the circumference of the
tion proposed by Goor and Lillehi (1977) was adopted. They described orifice. These fibrous structures are extensions of a central fibrous
the RV as being composed of: 1) the inlet - including the tricuspid valve, skeleton that surrounds the valves and electrically separate the atria
chordae tendineae, and papillary muscles; 2) the trabeculated apical from the ventricles [14]. The fila coronaria around the tricuspid are
myocardium; 3) the outlet - including the infundibulum or conus and typically less robust than those found around the mitral valve [3].

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J.M.H. Wang, et al. Translational Research in Anatomy 17 (2019) 100049

3.1.1.2. Tricuspid valve leaflets. As described in its name, the tricuspid

has three valve leaflets, each named accordingly for their corresponding
positions: anterosuperior, inferior or mural, and septal. In turn, the
commissures are named anteroseptal, anteroinferior, and inferior [2].
The anterosuperior leaflet is the largest. It attaches on the posterolateral
aspect of the supraventricular crest, and extends from the septal limb to
the membranous septum, forming part of the anteroseptal commissure.
The inferior leaflet is completely attached to the mural surface,
guarding the diaphragmatic surface of the AV junction. It can have
multiple scallops and its limits are the inferoseptal and anteroinferior
commissures. The septal leaflet is one of the borders of the Triangle of
Koch, an anatomical area within the right atrium, with it location
demarcated by the coronary sinus orifice, the tendon of Todaro, and the
AV node at the apex. Thus, the septal leaflet is a clinical landmark to aid
in the localization of this conductive tissue during surgery of the right
atrioventricular valve [3].
In describing the valve surfaces, moving from the free to inserted
margin, the leaflets have three prominent zones: rough, clear, and
basal. The rough zone is relatively thick, opaque, and uneven on the
ventricular aspect where the chordae tendineae attach. The atrial aspect
of the rough zone is where adjacent leaflets touch when the valve is
closed. The clear zone is smooth, translucent, with a thin fibrous core
and few chordae tendineae attachments. The basal zone is about
2–3 mm in length, vascularized and innervated. It is thicker and con-
tains the insertions of the atrial myocardium [3].
One defining characteristic of the RV is the direct attachment of
chordae tendineae from the septal leaflet to the ventricular septum and
Fig. 3. Connections of true chordae tendineae (TChT) and false chordae ten-
medial papillary muscle [2,3]. The annular portion of this leaflet
dineae (FChT) in the right ventricle. Illustrated is Type I and II FChT which
crosses the membranous septum, bisecting it into supratricuspid AV establishes connections between the ventricular septum and the anterior pa-
(between RA and LV) and infratricuspid interventricular portions. At pillary muscle and inferior (posterior) papillary muscle. (Illustration by Katie
times, there is a gap at this membranous area, giving the false im- Yost ©2019, provided under CC-BY–NC–ND).
pression of a commissure [2].
single, thread-like structures running from a papillary muscle to a
3.1.1.3. Tricuspid movement. Contrary to its nomenclature, the
marginal attachment site near the midpoint of a leaflet, or one of its
tricuspid valve behaves like a bicuspid valve, in that the septal leaflet
scallops. Deep chordae are long, passing beyond the margins, to reach
remains fixed between the right and left fibrous trigones and the atrial
the peripheral rough zone or the clear zone. Basal chordae can be either
and ventricular septa, while the anterior and posterior leaflets fan into
short and round or long, flat, slender ribbons. These arise from the
the RV during diastole, and fan back to seal the valve during systole.
smooth or trabeculated ventricular wall, attaching to the base of a
The annulus helps in this by dilating and constricting during diastole
leaflet [3].
and systole, respectively [3].

3.1.2. Chordae tendineae

3.1.2.1. False tendons/chordae tendineae. As mentioned above, FChT,
The chordae tendineae are fibrous collagenous structures that tether
also known as False Tendons (FT), are thin, fibrous, or fibromuscular
various ventricular structures to each other. They are labeled “True” or
structures that traverse the RV cavity, without connections to
“False” based on their connections. True chordae tendineae (TChT)
atrioventricular valve leaflets [3,15,16]. In a study by Loukas et al.
arise from the apical third of papillary muscles and connect to the free
(2009) 35 out of 100 cadaveric heart specimens demonstrated FT's in
margins of the AV leaflets; TChT function to prevent eversion of the
the RV; the majority seen were single bands, though samples with two
valve leaflets. Alternatively, false chordae tendineae (FChT) do not
to five bands were also seen [16]. The FT's of the RV were classified into
have connections to valve leaflets, but may connect various ventricular
five types (Type I − V) depending on their connections. Types I and II
structures to each other, such as papillary muscles to papillary muscle;
established connections between the ventricular septum and the
papillary muscle to ventricular wall; and ventricular wall to ventricular
anterior papillary muscle and posterior papillary muscle respectively
wall [3,15,16].
(Fig. 3). The other classifications: types III, IV, V; established
Initially, depending on the distance of the attachment to the margin
connections between the right ventricular free wall and the anterior
of the leaflets, the chordae tendineae can be classified into first, second
leaflet of the tricuspid, posterior papillary muscle or the anterior
or third order; however, this classification is considered to have little
papillary muscle respectively. Type I was observed to occur more
functional application. As a result, in 1971, Silver and colleagues de-
frequently than any other classification; the numerical system of type
vised a new classification based on their morphology and attachment
I − V represents the frequently each type was seen from most common
sites. This classification system divided the chordae tendineae into five
to least common. The mean length of RFT's was 18 ± 7 mm with a
types: fan-shaped, rough zone, basal, free edge, and deep chordae [17].
mean diameter of 1.4 ± 0.5 mm. Conduction tissue and muscular
Fan-shaped chordae have a short stem and branches radiate to attach to
fibers was found within Type I, III, and IV, while Type II and V were
the zones of apposition between leaflets and ends of adjacent leaflets
more fibrous. Alternatively, in Kosinski et al.‘s study (2012) of 100
[3]. They function to ensure the alignment of the valve during its
cadaveric hearts, they identified six types of false tendons classified by
functional cycle of closing and opening [17]. Rough zone chordae arise
their locations and interconnections [15]. The difference in
as a single stem, splitting into three component then each attaching to
classifications demonstrate the amount of normal variability present
the free margin, the ventricular side of the rough zone, and an inter-
within these structures.
mediate point of the leaflet, respectively. Free-edge chordae are long,

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J.M.H. Wang, et al. Translational Research in Anatomy 17 (2019) 100049

3.1.3. Papillary muscles infundibulum [2–5,11]. This muscular structure is actually an infolding
There are three main papillary muscles in the RV: anterior, inferior, of the ventricular roof, separating the inlet and outlet portions of the RV
and medial or septal. Each of these muscles correspond to the valvular [2,5]. It is separated from the aorta by epicardial fat and despite its
leaflets it supports in both size and location. The anterior papillary thick appearance, incisions or deep sutures through this crest can run
muscle is the largest, arising from the right anterolateral ventricular into the transverse sinus and right AV groove, having the potential to
wall, below the anteroinferior commissure of the inferior leaflet, jeopardize the right coronary artery [5,11].
blending with the right end of the septomarginal trabecula (SMT). As its The conus ligament, also known as the tendon of the infundibulum,
name implies, the SMT is the main support for the anterior papillary is suspected to connect the pulmonary muscular infundibulum poster-
muscle; often, smaller anterior papillary muscles can also be seen in the iorly to the root of the aorta [3]. However, it should be noted that the
vicinity, providing additional support [2]. The inferior papillary muscle term “tendon” given to this structure is a bit of a misnomer as Loukas
is the next largest, arising from below the inferoseptal commissure, and et al. (2008) demonstrated that in the few cases where these structures
is often bi- or trifid. The septal/medial papillary muscle is often small, were found, they were merely condensed fascial bands, rather than a
arising from the posterior septal limb of the SMT, located on the su- true tendon [18].
perior portion of the septum, beneath the attachment of the supra-
ventricular crest [2,3]. 3.2.3. Moderator band
The septal/medial papillary muscle, sometimes called the Papillary In the anatomically oriented heart, the MB is the most inferior of the
Muscle of the Conus (PMC) is present in 82% of the hearts, and in the septoparietal trabeculations [11]. This structure bridges the ventricular
rest, it is replaced by tendinous chords [16]. It appears as a single pa- cavity between the septum and parietal wall [2,19]. Conventionally, it
pilla in most, but double papilla have also been documented. The base is classified as part of the SMT as it arises from this structure at about a
of the PMC is a surgical landmark for safe access to the right bundle third to a half the distance to the apex [2,20]. It supports the anterior
branch (RBB) during ventricular septal defect repair as this is the lo- papillary muscle of the tricuspid valve and incorporates the right AV
cation at which it emerges from the septal musculature to become bundle [12,19]. In a study of 100 adult human cadavers by Loukas et al.
subendocardial [2,5,16]. (2010), the MB was identified in 92% of hearts examined, with the
All the papillary muscle support chordae tendineae attachments to majority having a “short and thick” morphology, lying roughly equi-
its corresponding leaflet. As mentioned above, FChT can also connect distant between the tricuspid valve and apex [20]. The average length
papillary muscles to each other or to the ventricular wall. At the dia- and thickness was approximately 16.23 ± 2.3 mm and 4.5 ± 1.8 mm,
phragmatic level, the papillary muscle bases of the tricuspid merge into respectively. The “artery of the moderator band,” a branch of the left
the trabecular apical section, making it difficult to distinguish between anterior descending (LAD) artery, supplies the MB; in hearts with a
the two compartments in this area; whereas the difference is better prominent MB, the artery can measure up to 1000u in diameter [5,21].
appreciated directly inferior to the tricuspid septal leaflet [1]. This artery is also the major blood supply for the anterior papillary
muscle, and has also been shown to supply the antero-lateral part of the
3.2. Apical trabecular portion RV free wall [21]. Damage to the MB and/or the artery may result in
ischemia to distal structures [19].
Moving towards the apex, the ventricular cavity is composed of
numerous intersecting muscle bundles, called trabeculations, running 3.2.3.1. Clinical relevance. As a fairly prominent trabeculation within
between the parietal and septal wall (Ho, 2017). These trabeculations the RV, the MB has been implicated in several clinical conditions and
are characteristically coarse in the RV; arising from these trabeculations procedures. It has been suggested that the MB can act as a protective
are various prominent structures, such as the parietal band (PB), mechanism to resist the overdistension of the right ventricle, and has
moderator band (MB), and the septomarginal trabeculation (SMT). The thus was named the “moderator” band by King in 1837. In cardiac
trabecular portion is typically defined as the point where the PB joins echocardiography, the MB can be useful as a landmark for the RV,
with the infundibular septum, forming the supraventricular crest (dis- particularly in a congenitally abnormal heart; however, at times, it has
cussed below) [2–5,11]. also been mistaken for an apical thrombus [22,23]. As the MB
incorporates a portion of the right AV bundle, it has been implicated
3.2.1. Septomarginal trabeculation (aka septomarginal band) in both pre-excitation conditions, as well as post-surgical heart blocks.
The septomarginal trabeculation (SMT), also known as the septo- In Mahaim tachycardias, the etiology was found to be accessory
marginal band (SMB), is a prominent Y-shaped muscular strap, ad- conduction fibers within the MB [24,25]. The MB lies directly
herent to the septal surface, that bifurcates into anterosuperior and adjacent to the site of repair of apical ventricular septal defects (VSD)
inferoposterior limbs [2,5,11]. The anterosuperior limb extends along when approached from the right atrium. In these surgeries, Kurosawa &
the infundibulum to the pulmonary valve leaflets, and the posterior Becker (1985) have reported iatrogenic heart blocks resulting from
limb runs toward the RV inlet, giving rise to the medial papillary removal of the MB. Conversely, other studies have reported successful
muscle complex. The SMT extends inferiorly to the apex of the ven- treatment of idiopathic premature ventricular contractions (PVCs) after
tricle, giving rise to the MB and anterior papillary muscle, then breaks ablation of the MB [26,27].
up into general apical [5,11]. Towards the apex, the wall is particularly
thin, making it vulnerable to perforation by cardiac catheters and pa- 3.3. Outflow tract
cemaker electrodes [11]. Occasionally, the SMT is abnormally formed
or hypertrophied, and it can divide the ventricle, forming what's called The outflow tract begins at the distal continuation of the supra-
a “Double-Chambered RV” [4]. Lying between the limbs of the SMT is ventricular crest, extending superiorly and posteriorly toward the pul-
another important structure, the Supraventricular Crest [2,11]. monary valve [2]. Within this tract, a ‘muscular sleeve’ called the in-
fundibulum or conus arteriosus, extends from the ventricular base to
3.2.2. Supraventricular crest (aka crista supraventricularis, the the valve, attaching to the leaflets in semilunar fashion [3,5,11]. This
ventriculoinfundibular fold) ‘sleeve’ does not have a septal component; instead, it stands above the
The supraventricluar crest, also known as the crista supraven- ventricular septum, lifting the pulmonary valve leaflets away from the
tricularis, or the ventricular infundibular fold, is a thick and highly LV, permitting the removal of the entire valve (without leaving a hole
arched structure extending obliquely forwards and to the right of the in the ventricular septum) in the Ross procedure [2,11,28]. The rela-
heart, attaching to the most superior portion of the ventricular septum tively small septal portion of the outflow tract lies only within the most
and merging to form the posterior wall of the subpulmonary proximal portion, where the supraventricular crest attaches to the

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J.M.H. Wang, et al. Translational Research in Anatomy 17 (2019) 100049

septum. Given that the RV outflow tract passes anterior and cephalad to forms a distinct separation between the tricuspid valve and pulmonary
the LV's, any perforation within the ‘septal’ outflow tract is more likely valve pathway of the RV; in contrast, the pathway between the mitral
to run out of the heart, rather than into the LV [2]. As the infundibulum and aortic valves of the LV are in fibrous continuity [5].
reaches the pulmonary valve, its wall thickness tapers from 3 to 5 mm Most studies consider the septum to be a continuous part of the LV;
to approximately 1.5 mm [2]. The dimensions of the outflow tract can however, closer anatomical inspection reveals it is impossible to clearly
vary, being generally independent of the RV size [5]. divide the septum into left and right parts. The larger septal arteries
divide to left and right branches, but there is no demonstrable sidedness
3.3.1. Pulmonary valve within the septum nor preferential arteries for one side or the other [1].
The pulmonary valve is the most superiorly situated cardiac valve
due to the musculature of the subpulmonary infundibulum; this feature 4.1. Clinical evaluation of the RV
allows safe resection of the valve from the rest of the outflow tract
[2,11,28]. Due to the semilunar shape of its leaflets, the pulmonary Diagnostic inspection of RV is significantly more complex [1] due to
valve does not have a ring-like annulus [5]. The hinge lines of the several factors such as its complex geometry; its retrosternal position;
pulmonary leaflets cross the anatomic junction between the ventricular and the limited definition of the endocardial surface due to the heavy
musculature and arterial wall of the pulmonary trunk; the supraleaflets trabeculations [4].
incorporate ‘triangles of arterial wall within the ventricle’, while the In determining which structures to include in the RV volume ana-
base of pulmonary valvar sinus possess ‘crescents of ventricular muscle’ lysis, the trabeculation and papillary muscles are more clinically re-
[2,11]. levant compared to the septum. When the trabeculations and papillary
muscles are included, volumes are larger and ejection fractions are
3.3.2. Arterial supply lower. When these structures are excluded, there is less inter-observer
The arterial supply of the structures at the conotruncal region is variability and shorter acquisition times [1,31].
typically by branches of the right and left coronary arteries. The right Aside from RV area and volume, Muresian recommends that ultra-
side of this region is supplied by branches from the conal artery of the sound interrogations include estimation of the RV outflow tract, RV
right coronary artery or directly from the aorta. The right anterior conal wall thickness, longitudinal shortening, tricuspid annular velocity, and
branch is the most constant. It has been reported that forms an ana- functional area change. In addition, myocardial performance index,
stomotic arterial ring (Vieussens anastomosis) between the right and determination of RV strain by tissue Doppler imaging (TDI) and mea-
left conal arteries, the left being the first branch of the LAD artery. surement of pulmonary artery pressure are also essential to get an ac-
Generally, there are three collateral circulation pathways: preconal curate assessment of the right heart [1].
(precardiac), retroconal (interarterial), and retroaortic pathways. These
pathways provide circulation between right and left coronary systems 5. Conclusion
in all instances of one-sided coronary occlusion [5].
Due to the relatively recent investigations into the morpho-func-
4. Comparison to LV tional features of the RV, further analysis is essential to the develop-
ment of evidence-based diagnostic protocols and therapeutic ap-
Differences between RV and LV structure are determined by the two proaches. This review aims to document the general anatomical
distinct circulatory system: pulmonary and systemic, volume-driven features and normal variants of the RV in order to better understand its
and pressure-driven respectively [2]. There is an approximate 10-fold architecture and role in cardiac function.
difference in the vascular resistance of these two systems [1,29] and
this difference accounts for several of the distinct features of the RV, Conflicts of interest
including: 1) the ventricular shape 2) the ventricle wall thickness 3) the
trileaflet configuration of the tricuspid valve (compared to the bicuspid The authors have no conflicts of interest to disclose.
of the mitral) 4) a more apical hinge line of the septal leaflet on the
tricuspid valve (compared to the anterior leaflet on the mitral) 5) the Acknowledgements
presence of septal papillary attachments to the leaflets of tricuspid 6)
the presence of a moderator band 7) the presence of more than 3 pa- The authors wish to thank Katie Yost MS, CMI, Medical Illustrator
pillary muscles 8) the presence of coarse trabeculation and 9) the for the illustrations used in this publication.
outflow tract configuration [4,11,15]. These differences are generally
apparent in the average heart; however, they can be altered or missing References
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