Pericardium

The Pericardium contains the heart and the roots of the great vessels, the pericardium
consists of 2 parts:
1. The fibrous: Is a sac made of tough connective tissue that surrounds the heart
2. The serosal pericardium: consists of two layers , The inner (visceral) that adheres to the
heart and forms its outer covering, the epicardium, and we have the second layer that
is The outer (parietal) that covers the surface of the fibrous pericardium. This two
serosal surfaces are separated by a film of fluid. This fluid allows the movement of the
inner membrane
The Fibrous pericardium: is compact collagenous fibrous tissue.
• In The superior part we have the adventitia of the great vessels
• In the inferior part we have the attachment to the central tendon of the diaphragm
• Anteriorly we have the attachement to the posterior of the sternum by the superior
and inferior Sternopericaridal ligaments. Also Anteriorly the fibrous pericardium is
separated from the thoracic wall by the lungs. In the anterior part we have also the
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• Laterally we have the Pleural coverings of the mediastinal surface of the lungs.
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Between the mediastinal pleural and the fibrous pericardium we have the phrenic salga
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• The aorta, superior vena cava, right and left pulmonary arteries and the four
pulmonary veins receive the extensions of the fibrous pericardium, only the inferior
vena cava hasn’t this extension.
The serosal pericardium: Enclosed within the fibrous pericardium, the serous pericardium
is itself divided into two layers: the outer (parietal) layer that lines the internal surface of
the fibrous pericardium and the internal (visceral) layer that forms the outer layer of the
heart. Between this two layers of the serous pericardium we have the pericardial cavity,
which contains pericardial fluid. It is this fluid that provides lubrication between the two
layers, and allows the heart to expand and contract.
at two places, the parietal layer of the serous pericardium reflects toward the visceral and
fuses with it, forming cul-de-sacs in order to keep the pericardial cavity closed. These two
reflections happen at the following places called Tubes :
• Superiorly, surrounding the arteries (aorta and pulmonary trunk)
• Posteriorly, surrounding the veins (superior vena cava, inferior vena
cava, pulmonary veins)
The cul-de-sac: is J-shaped and located behind the left atrium is called the oblique
pericardial sinus. The passage between the 2 pericardial tubes is the transverse
pericardial sinus, which lies superior to the left atrium.
The serous pericardium is invaginated by the heart and great vessels forming two sinuses:

oblique pericardial sinus: formed by the superior and inferior vena cavae and the four
pulmonary veins (blind-ending) and thus sits posterior to the left atrium
transverse pericardial sinus: lies between the aorta/pulmonary artery anteriorly and the
atria posteriorly, surrounding the ascending aorta; there are several pericardial recesses
there may be one or several pericardial recesses:
• aortic recesses - from the transverse sinus
o superior aortic recess : from its mouth located inferiorly, it ascends posterior to and
then to the right of the ascending aorta and ends at the level of the sternal angle
o inferior aortic recess: descending from the superiorly located mouth to run between
the lower ascending part of the aorta and the right atrium

• Pulmonary recess:
o Left pulmonary recess : with its mouth under the fold of the left vena cava, passes
to the left between the inferior and superior left pulmonary artery
o Right pulmonary: lies between the lower surface of the proximal part of the right
pulmonary artery and the upper border of the left atrium

A triangular fold of serosal pericardium is reflected from the left pulmonary artery to the
subjacent upper left pulmonary vein. It contains a fibrous ligament

Innervation
The pericardium is innervated by the Vagus with phrenic nerve and the sympathetic trunks
phrenic nerves: to fibrous and parietal serous layers
vagus nerve
sympathetic trunks: for pain, muscles and vessels of heart
 Heart
The Heart is a fibromuscular organ of a conical form, the heart is located in the chest
between the lungs behind the sternum and above the diaphragm. It is surrounded by the
pericardium

The heart has a base and apex, its surface being designated as:
• Sternocostal (atnerior)
• Diaphragmatic (inferior)
• Right and left (pulmonary)
Its borders are termed:
- upper
- inferior (acute margin or border)
- left (obtuse or border)

Apex of the heart: This is the apex of the conical left ventricle, which is directed down
forwards, and to the left. The apex is located behind the fifth left intercostal space

Anterior, ( Sternocostal ) surface of the heart: is directed forward, upward, and to the left.
Its lower part is convex. It consists of the anterior surfaces of the: right atrium: to the right
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and superior to the anterior atrioventricular groove. Also the sternocostal surface is
separated by the pericardium from
 - The body of the sternum
- The sternocostal muscles
- The third to the sixth costal cartilages

Posterior aspect of the heart (The left atrium forms most of the posterior aspect of the
heart): separated from the thoracic vertebrae by the pericardium, right pulmonary veins,
esophagus and aorta, itis formed by the left atrium with a smaller contribution on the right
from the right atrium. Its boundaries are:
• superiorly: bifurcation of pulmonary trunk
• inferiorly: coronary sulcus posterior part

On its surface, the base receives:

• two pulmonary veins on each side into left atrium

• superior and inferior vena cava into right atrium

Inferior, ( Diaphragramatic ) surface of the heart

Slopes down and forwardss a little towards the apex, is formed by the ventricles, the
central tendon and a small part of the left muscular portion of the diaphragm, separated
by atrioventricular groove and is traversed obliquely by the posterior interventricular
groove.

Right surface of the heart: is rounded and formed by the Right atrial wall. Is separated
from the mediastinal aspect of the right lung by the pericardium and the pleura.
 Borders
Separating the surfaces of the heart are its borders. There are four main borders of the
heart:
• Right border – Right atrium
• Inferior border – is thin and sharp, it is formed mainly by the right ventricle
• Left border – formed by Left ventricle (and some of the left atrium) also descends
obliquely from the auricle to the cardiac apex
• Upper border – anterior: ascending aorta and the pulmonary trunk.
- Extremity: the superior vena cava entres the right atrium

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Right atrium
general and external features
The dome of the atrium is pierced by the superior vena cava, while the posteroinferior part
receives the inferior vena cava. Also we have A triangular, muscular sac known as the right
auricle, that has a junction with the true atrial component of the atrium.
Anteriorly: the right atrium is related to the anterior part of the mediastinal surface of the
right lung. The structures separating the pleura and pericardium.
Laterally: the atrium is also related to the mediastinal surface , but anterior we have its
hilium and separated from the pleura
Posteriorly: the atrial septum and the atrial walls separate the right from the left atrium
Medially: we have the ascending aorta, the root of the pulmonary trunk and its bifurcation

The right atrium, interior surface

Can be divided into 3 regions:
- A smooth walled venous component
- The vestibule of the tricuspid valve
- Auricle
Important is that the superior and inferior vena cavae open into the venous
component
The superior vena cava: returns blood from head, neck and the upper limb trough
an orifice ( anterior its orefice we have the Eustachian Valve) ( valve is a fold of
endocardium enclosing a few muscular fibres)
The inferior vena cava: returns the blood from the lower part of the body into the
lowest part of the atrium
The coronary sinus opens into the venous atrial component between the orifice of the
inferior vena cava and the vestibule of the atrioventricular opening , also the sinus
receives the middle and small cardiac veins
Anteroinferior: in the right atrium is the large and oval vestibule leading to the orifice of
the tricuspid valve.
• In the right internal ventricle: we have the inlet and outlet components of the
ventricle that supporting and surrounding the cups of the tricuspid and pulmonary
valves
Tricuspid Valve
The atrioventricular valvular complex, in both right and left ventricles consists in:
- The orifice
- The cusps imaginazione corde di supporto
- The supporting chordae tendineae
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- The papillary muscles
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Tricuspid valve Cusps: we have 3 cusps that are located
• Anterosuperiorly
• Septally
• Inferiorly
Chordae Tendinaeae: are fibrous collagenous structures that supporting the cusps
• False chordae that connect Papillary muscles to each other or to the ventricular wall
 • True chordae that arise from papillary muscles

Pulmonary Valve
The pulmonary valve is the semilunar valve that separates the right ventricle from
the pulmonary trunk, has 3 semilunar cusps and has some distance from the other
three cardiac valves. During diastole the pulmonary valve is closed and all three
cusps of the valve are opposed.

Left atrium
Smaller in volume than the right atrium, the left atrium has 3 thicker walls. We
have:
 The left part: is concealed anteriorly by the initial segments of the pulmonary trunk and
aorta.
Anteroinferiorly: it adjoins the base of the left ventricle at the orifice of the Mitral
valve.
Its Posterior aspect: forms most of the anatomical base of the heart, receving
terminations of 2 pulmonary veins from each lungs, that forms the anterior wall of
the pericardial sinus. Interiorly: the four pulmonary veins open into the upper
posterolateral surface of the left atrium

• In the Left ventricle: we have an inlet (Guarded by the mitral valve) and outlet
region (Guarded by the aortic valve)

Mitral Valve
The mitral valve is also known as the bicuspid valve. This is one of the heart’s four valves
that help prevent blood from flowing backward as it moves through the heart. We have
- The mitral orifice, that is smaller than the tricuspid orifice
- The mitral, tricuspid and aortic orifices, are connected at the central fibrous body.
And when the cusps of the mitral valv close, form a single zone called commisure.

Opening of the mitral valve:

At the start of diastole, opening is passive but rapid, the cusps parting and projecting into
the ventricle when the left atrial pressure exceeds the left ventricular diastolic pressure.
The orifices and the cusps changes position, form and area. Both valve smove anteriorly
and to the left during diastole and reverse their movements

Aortic Valve
The aortic valve resembles the pulmonary (for the 3 semilunar cusps), supported within
the three aortic sinuses of Valsalva.
Aortic valve cusps: The aortic valve consists of three cusps
- Right
- Left
- Non-coronary, according to the origins of the coronary arteries.
Valvular function depends upon the semilunar attachments of the cusps.
 Impulse- Conducting Tissues Of The Heart
SINUATRIAL NODE
The SA node, is one of the major elements in the cardiac conduction system, the system
that controls the heart rate. This system generates electrical impulses and conducts them
throughout the muscle of the heart, stimulating the heart to contract and pump blood .

The SA node is the heart's natural pacemaker. The SA node consists of a cluster of cells
that are situated in the upper part of the wall of the right atrium, The electrical impulses
are generated there. The SA node is also called the sinus node

ATRIOVENTRICULAR NODE
The atrioventricular (AV) node is a small structure in the heart, located in the Koch triangle,
this node is pervaded by an irregular collagenous reticulum but is less dense than in the
sinu-atrial node.

The atrioventricular Bundle is the direct continuation of the atrioventricular node,

Traversing the fibrous body, it branches on the crest of the muscular interventricular
septum.
• The right branch of the bundle is a discrete group of fascicles that courses at first
within the myocardium and after towards the apex of the ventricle, entering the
septomarginal trabecula to reach the anterior papillary muscle
• The left branch we have numerous fine fascicles that leave the left margin through
much of its course along the crest of the muscular ventricular septum.
 • The principal branches are insulated from the surrounding myocardium by sheaths
of connective tissue

Also we know that the Purkinje network is subendocardial, so muscular excitation

proceeds from the endocardial to the epicardial aspect

Coronary Arterial supply

The two arterie sas indicated by their name, form an oblique inverted crown.
o The Right coronary artery arises from the anterior aortic sinus, and passes tot the
right auricle and pulmonary trunk, and the artery ends a little to the left.
- The right anerior and lateral branches are double and supply the right atrium
- The posterior branch Is usually single and supplies the right and left atria.
- The artery of the sinuatrial node is an atrial branch, distributed to the
myocardium of both atria, mainly the right

o The left coronary artery lies between the pulmonary trunk and the left atrial
auricle, reaching the atrioventricular groove, and the left coronary divides into two
or three branches.
It arises from the left posterior aortic sinus, is very larger than the right and supplies
a greater volume of myocardium. The left coronary usually supplies mosti f the
interventricular septum

Cardiac Veins
The heart is drained by the coronary sinus and its tributaries
- The anterior cardiac veins
- The small cardiac veins
the coronary sinus and its tributaries return blood to the right atrium from entire heart

LYMPHATIC DRAINAGE OF THE HEART

Cardiac lymphatic vessels form Subendocardial and Myocardial that draining into the
Subepicardial Plexus. Efferents from the subepicardial form the left and right cardiac
collecting trunks, two or three of this trunks receving vessels from both ventricles

INNERVATION
 The innervation of the heart refers to the network of nerves that are responsible for the
functioning of the heart. The heart is innervated by sympathetic and parasympathetic
fibres from the autonomic branch of the peripheral nervous system.
The network of nerves supplying the heart is called the cardiac plexus. It receives
contributions from the right and left vagus nerves, as well as contributions from the
sympathetic trunk. These are responsible for influencing heart rate, cardiac output, and
contraction forces of the heart.

CARDIAC PLEXUS
The cardiac plexus is a plexus of nerves situated at the base of the heart. It is formed by
cardiac branches derived from both the sympathetic and parasympathetic nervous
systems.
Also described by regional names for its Coronary, Pulmonary, Atrial and Aortic extensions.
These plexus contain Ganglion cells, snd this cells are also found in the heart along the
distribution of branches of the plexus
- Superficial part of cardiac plexus
- Deep part of the cardiac plexus
- Left coronary plexus
- Right coronary plexus
- Atrial plexues