Medical Pharmacology Chapter 43:  Adult Cardiac Procedures

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Cardiac Anatomy

 

  • Right Ventricle overview

    • Wraps around one-third of the left ventricle (LV)

    • Muscle fibers continues with those of the LV

    • Components

      •  Inferoposterior inflow (sinus)

      •  Anterosuperior outflow (infundibular)

      •  Inflow and outflow components divided by the crista supraventricularis (definition: a ridge on the inner wall of the right ventricle, marking off the conus arteriosus: supraventricularis also called supraventricular crest)

        •  Crista supraventricularis:  joins interventricular septum and LV to the right ventricular free wall (may assist left and right ventricular function integration)

      • Inflow component:

        •  Prominent muscle bands:

          • Moderator

          • Septal

          • Parietal

        •  Muscle bundle

          • Trabeculae carneae

  • Pulmonary Artery and Peripheral Pulmonary Circulation

    • Pulmonic valve (a trileaflet valve) separates:

      •  Right ventricular infundibulum from the main pulmonary artery (PA).

      •  Trileaflet (right, anterior, left cusps)-- 4 cm2 in area.

      •  Origination -- superior portion of the right ventricle

        • 11: anterior semilunar cusp (pulmonic valve)

        • 12: left semilunar cusp (pulmonic valve)

        • 13: right semilunar cusp (pulmonic valve)

        • Reference: Rohen, J.W. and Yokochi, C.,Color Atlas of Anatomy:  Photographic Study of the Human Body, third edition, Ikaku-Shoin, New York, Tokyo, p. 240, 1993.

      •  Path:

        1. Under the aorta

        2. Bifurcation into the right and left pulmonary artery (upper part of bifurcation is attached to the inferior aortic surface by the ligimentum arteriosum - a remnant of the ductus arteriosus)

      •  Pulmonary arteries →  pulmonary arterioles →  pulmonary capillaries that spread over alveolar surfaces between two alveolar endothelial layers.

      •  Pulmonary vessels size:

        •  Left-to-right shunt: prominent main pulmonary artery and hillar vessels: prominent.

        •  Pulmonary hypertension: main pulmonary artery dilation, followed by tapering of peripheral pulmonary vessels.

  •  Left Atrium

    • Larger than right atrium

    • Receives one or two pulmonary veins on left side

    • Receives two or three pulmonary veins  on right side

    • Blood flow path:

      • Left atrium left ventricle through the mitral valve

      • Mitral valve composition:  (area = 6-8 cm2)

        • Two major anteromedial and posterolateral leaflets

        • Papillary muscles

        • Chordae tendineae

      • Mitral chordae tendineae and papillary muscle: sensitive to reduced blood supply  

  • Left Ventricle (LV)

    • Thicker (8-15 mm) > right ventricle

    • Internal dimension (4.5 cm) > right ventricle (3.5 cm)

    • Division of right ventricle from left ventricle:

      • Interventricular septum

    • Ventricular layered structures (common to both left and right ventricles)

      •  Inner layer-endocardium covered with endothelium

      • Muscle layer (myocardium)

      • Outer layer (epicardium)

  • Aortic valves

    • Adjacent to mitral valves within the left ventricle

    • Cusps-unequal sizes; area = 3-4 cm2.

      •  Right and left (coronary) cusps

      •  Posterior (non-coronary) cusp

      •  At the level of the valve, the aorta dilates to form the sinuses of Valsalva (location of the coronary ostia)

      • Reference: Rohen, J.W. and Yokochi, C.,Color Atlas of Anatomy:  Photographic Study of the Human Body, third edition, Ikaku-Shoin, New York, Tokyo, p. 240, 1993.

      • Left image

        • 1: superior vena cava

        • 9: chordae tendineae

        • 10: anterior papillary muscle

        • 11: myocardium

        • 12: pulmonary trunk

        • 13: ascending aorta

        • 19: left atrium

        • 20: aortic valve

        • 21: left ventricle

        • 22: pulmonary veins

        • 23: fossa ovalis

        • 24: left atrium

        • 25: left atrioventricular left and bicuspid or mitral) valve

        • 26: coronary sinus

        • 27: left coronary

        • 28: posterior papillary muscle

        Right Image

        • 1: superior vena cava

        • 9: chordae tendineae

        • 10: anterior papillary muscle

        • 11: myocardium

        • 13: ascending aorta

        • 18: heart apex

        • 20: aortic valve

        • 21: left ventricle

        • 22: pulmonary veins

        • 23: fossa ovalis

        • 24: left atrium

        • 25: left atrioventricular left and bicuspid or mitral) valve

        • 26: coronary sinus

        • 29: left subclavian artery

        • 30: descending aorta

        • 31: left pulmonary artery

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  • Primary Reference: Lake, C.L. Cardiovascular Anatomy and Physiology, Third edition  (Barash, PG, Cullen, BF, Stoelting, R.K, eds), Lippincott-Raven Publishers, Philadelphia, pp. 805-835, 1997

  • Primary Reference:  Ross, AF, Gomez, MN. and Tinker, JH Anesthesia for Adult Cardiac Procedures in  Principles and Practice of Anesthesiology (Longnecker, D.E., Tinker, J.H. Morgan, Jr., G. E., eds)  Mosby, St. Louis, Mo., pp. 1659-1698, 1998.

  • Primary Reference: Shanewise, JS and Hug, Jr., CC, Anesthesia for Adult Cardiac Surgery, in Anesthesia, 5th edition,vol 2, (Miller, R.D, editor; consulting editors, Cucchiara, RF, Miller, Jr.,ED, Reves, JG, Roizen, MF and Savarese, JJ) Churchill Livingston, a Division of Harcourt Brace and Company, Philadelphia, pp. 1753-1799, 2000.

  • Primary Reference: Wray Roth, DL, Rothstein, P and Thomas, SJ Anesthesia for Cardiac Surgery, in Clinical Anesthesia, third edition  (Barash, PG, Cullen, BF, Stoelting, R.K, eds), Lippincott-Raven Publishers, Philadelphia, pp. 835-865, 1997

 

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