Download - Echo class 2_05262015
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External Heart: Arteries that Supplythe Heart
• Coronary circulation is the functional blood supply to the heart muscle itself (i.e. the fuel
for the heart)• Collateral routes ensure blood delivery to
heart• even if major vessels are occluded/clogged
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Different parts of the heart are supplied bydifferent coronary artery segments
Heart chambers in geometricmodels are subdivided intoperfusion zones usinganatomic knowledge in theFMA ontology
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CORONARY ARTERIES SUPPLYING THE HEART WITH OXYGEN-RICH BLOOD
Right Coronary Artery (RCA)
Left Main Coronary Artery (LMCA)
Left Anterior Descending Artery (LAD)
Posterior Descending Artery (PDA)
Left Circumflex Coronary Artery (LCx)
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Arterial Coronary Circulation
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External Heart: Arteries that Supply the Heart
• Right coronary artery (in atrioventriculargroove)– Supplies the right atrium and nearly all the
right ventricle– marginal –supply the myocardium of the– lateral right side of the heart– posterior interventricular artery – supply the– interventricular septum and adjacent portions
of the ventricular walls
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External Heart: Arteries that Supplythe Heart
• Left coronary artery:– Circumflex supplies the left atrium and theposterior wall of the left ventricle– Anterior interventricular artery supplies theanterior wall of both ventricles
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CERTAIN HEART WALL SEGMENTS ARE FED BY CERTAIN CORONARY ARTERIES AS SPECIFIED BELOW:
BASE
MID
APEX
A4C
A2C
PARASTERNALLONG-AXIS
Key:Red = LADYellow = LCxGreen = RCA
LAD = Left Anterior Descending Coronary Artery, LCx = Left Circumflex Coronary Artery, RCA = Right Coronary Artery
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DIVIDING THE LEFT VENTRICLE INTO KEY SEGMENTS
Apical Third Mid
ThirdBasal Third
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FURTHER DIVIDING THE LEFT VENTRICULAR WALLS INTO 17 SPECIFIC SEGMENTS DEFINED AS:
Anterior
Anterolateral
InferolateralInferior
Inferoseptal
AnteroseptalApex
AnteriorAnteroseptal
Inferoseptal
Anterolateral
InferolateralInferior
Anterior
SeptalLateral
Inferior
Apex
Basal
Mid-Cavity
Apical
1. Basal Anterior2. Basal Anteroseptal3. Basal Inferoseptal4. Basal Inferior5. Basal Inferolateral6. Basal Anterolateral7. Mid Anterior8. Mid Anteroseptal9. Mid Inferoseptal10. Mid Inferior11. Mid Inferolateral12. Mid Anterolateral13. Apical Anterior14. Apical Septal15. Apical Inferior16. Apical Lateral17. Apex
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PUTTING IT TOGETHER: HEART WALL SEGMENTS AND CORRESPONDING CORONARY ARTERIES
Coronary Artery: Segments:
LAD 1, 2, 7, 8, 13, 14, 17
RCA 3, 4, 9, 10, 15
LCX 5, 6, 11, 12, 16
LAD = Left Anterior Descending Artery
RCA = Right Coronary Artery
LCX = Left Circumflex Artery
Anterior
Anterolateral
InferolateralInferior
Inferoseptal
AnteroseptalApex
AnteriorAnteroseptal
Inferoseptal
Anterolateral
InferolateralInferior
Anterior
SeptalLateral
Inferior
Apex
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ANOTHER PERSPECTIVE – 17 SEGMENT MODEL OF LEFT VENTRICLE
1. Basal Anterior2. Basal Anteroseptal3. Basal Inferoseptal4. Basal Inferior5. Basal Inferolateral6. Basal Anterolateral7. Mid Anterior8. Mid Anteroseptal9. Mid Inferoseptal10. Mid Inferior11. Mid Inferolateral12. Mid Anterolateral13. Apical Anterior14. Apical Septal15. Apical Inferior16. Apical Lateral17. Apex
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SAMPLE – SEGMENTAL SCORING
Ortiz-Perez, J. T. et al. J Am Coll Cardiol Img 2008;1:282-293
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Representative Segmentation and Pattern of Contrast HE Over 17-Segments of the LAD, RCA, and LCX
Arteries
Ortiz-Perez, J. T. et al. J Am Coll Cardiol Img 2008;1:282-293
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HEART ANATOMY – COVERINGS OF THE HEART
• Coverings of the Heart: Anatomy• Pericardium – a double-walled sac around the• heart composed of:• A superficial fibrous pericardium• A deep two-layer serous pericardium• The parietal layer lines the internal surface• of the fibrous pericardium• The visceral layer or epicardium lines the• surface of the heart• They are separated by the fluid-filled• pericardial cavity• Coverings of the Heart: Physiology• The pericardium:• Protects the heart
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COVERINGS OF THE HEART: PHYSIOLOGY
• The pericardium:– Protects and anchors the heart– Prevents overfilling of the heart with blood– Allows for the heart to work in a relatively– friction-free environment
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PERICARDIUM OF THE HEART
• Pericardium (3 layers)• 1) Outer-fibrous pericardium
– Serous pericardium• 2) parietal • 3) visceral (epicardium)
• Pericardial Cavity– between layers of serous pericardium– serous fluid– lubricate heart while beating
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Pericardial Layers of the Heart
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Heart Wall – Layers of the Heart
• Epicardium – visceral layer of the serous• pericardium• Myocardium – cardiac muscle layer forming• the bulk of the heart• Fibrous skeleton of the heart – crisscrossing,• interlacing layer of connective tissue• Endocardium – endothelial layer of the inner• myocardial surface• Cardiac Muscle Bundles• External
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Cardiac Muscle 1000X
intercalated disc
striations nucleus
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Purkinje fibers 40X
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EXTERNAL FEATURES OF THE HEART
• Interventricular sulcus• Coronal/Coronary sulcus• Auricles of atria• Apex• Base• Coronary vessels• Ligamentum Arteriosum
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External Heart: Major Vessels ofthe Heart (Anterior View)
• External Heart: Major Vessels ofthe Heart (Anterior View)• Vessels returning blood to the heart include:– Superior and inferior vena cava– Right and left pulmonary veins
• Vessels conveying blood away from the heart:– Pulmonary trunk, which splits into right and– left pulmonary arteries– Ascending aorta (three branches) –– brachiocephalic, left common carotid, and– subclavian arteries
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External Heart: Veins that Drain theHeart
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External Heart: Major Vessels ofthe Heart (Posterior View)
Vessels returning blood to the heart include: •Right and left pulmonary veins• Superior and inferior vena cava• Vessels conveying blood away from the heartinclude:• Aorta• Right and left pulmonary arteries
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FLOW OF BLOOD• O2-poor blood (S+I VC, Coronary Sinus) enters Rt Atrium• Travels through Tricuspid Valve into Rt Ventricle• Pumped out through Pulmonary Semilunar Valve into Pulmonary trunk (branches into Pulmonary Arteries) and to lungs•After circulating through lungs, O2-rich blood returns to the heart through 4 Pulmonary veins• The O2-rich blood enters the Left Atrium• Travels through Bicuspid/Mitral Valve into Left Ventricle• Pumped out through Aortic Semilunar Valve into Aorta to be distributed to rest of body by descending aorta and branches of aortic arch
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Pathway of Blood Through theHeart and Lungs
Right atrium > tricuspid valve > right ventricle >pulmonary semilunar valve > pulmonary arteries > Lungs > pulmonary veins > left atrium >Mitral valve > left ventricle > Left ventricle > aortic semilunar valve > aorta > systemic circulation
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THE PATHWAY OF THE HEART
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Cardiovascular Flow of Blood
• HeartArteries(conducting-distributing) ArteriolesCapillaries of tissues• At Capillaries O2 is delivered and CO2 picked up•CapillariesVenulesVeinsHeart
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DETAILED IMAGES OF THE HEART’S ANATOMY – CHORDAE TENDONAE
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THE CARDIAC CYCLE
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Semilunar Valve Function
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Cardiac Intrinsic Conduction
IMPORTANT - Various nodes and intrinsic Heart Rate Generated:
• SA Node – 60 – 100 Beats/min
• AV Node – 40 – 60 Beats/min
• Bundle of His – 40 – 60 Beats/min
•Purkinje Fibers – Last resort – 20 – 40 Beats/min
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Heart Excitation Related to ECG
atrial excitation beginsImpulse delayedat AV nodeImpulse passes toheart apex; ventricularexcitation beginsVentricular excitationcompleteSA node AV node PurkinjefibersBundlebranches
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Electrocardiography
Electrical activity is recorded byelectrocardiogram (ECG)• P wave corresponds to depolarization of SA•node•QRS complex corresponds to ventricular•depolarization•T wave corresponds to ventricular repolarization•Atrial repolarization record is masked by the•larger QRS complex
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Electrocardiography
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Electrocardiography
PR interval•Atrial depolarization and contraction•QT interval•Ventricular depolarization, contraction andrepolarization•PR segment•Atrial contraction•ST segment•Ventricular contraction•ECG Tracings•Heart
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ECG TracingsHeart
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Cardiac Cycle
Cardiac cycle refers to all events associatedwith blood flow through the heart•Systole – contraction of heart muscle•Diastole – relaxation of heart muscle
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Phases of the Cardiac CyclePhases of the Cardiac Cycle• Isovolumetric relaxation – early diastole• Ventricles relax• Backflow of blood in aorta and pulmonary trunk closes semilunar valves• Dicrotic notch – brief rise in aortic pressure caused by backflow of blood. This
backflow• causes the valve to close and creates a slight pressure rebound
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Phases of the Cardiac Cycle
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THE CARDIAC CYCLE
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Cardiodynamics
Cardiac output (CO) : the amount of bloodpumped by each ventricle in one minute
•Cardiac output equals heart rate times strokevolume
Cardiac output (ml/min) =
Heart Rate (HR) (beats/min) X
Stroke Volume (SV) (ml/beat)
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Cardiodynamics
Heart rate (HR) : number of heart beats in a minute
•Stroke volume (SV) – amount of blood ejected from the ventricles with each beat
•SV = EDV - ESV
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Cardiac Output: Example
CO (ml/min) = HR (75 beats/min) x
SV (70 ml/beat)
•CO = 5250 ml/min (5.25 L/min)
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Cardiodynamics
Ventricular pressure increases forcing bloodthrough the semilunar valves: ventricularEjection
•End-systolic volume (ESV)
•Amount of blood that remains in theventricles after the contraction and closing ofthe semilunar valves
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Factors Affecting stroke volume(EDV-ESV)
EDV (end diastolic volume) is affected by
•Venous return - amount of blood returning to the heart or blood flow during filling time
•High venous return= high EDV
•Slow heartbeat and exercise increase venousreturn to the heart, increasing SV
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Factors Affecting stroke volume(EDV-ESV)
Filling time -duration of ventricular diastole
•Depends on the heart rate
•Blood loss and extremely rapid heartbeatdecrease SV
•The longer the filling time the higher theEDV will be
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Factors Affecting stroke volume(EDV-ESV)
Preload• Stretchiness of the ventricles during Diastole
• Directly proportional to the EDV
• Frank-Starling principle (“more in = more out”) or increased EDV=increased SV
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Factors Affecting stroke volume(EDV-ESV)
ESV (end systolic volume). It is influenced by: •Contractility
• Force produced during a contraction
• Positive inotropic (increase Calcium entry)
• Increased sympathetic stimuli
• Certain hormones, some drugs
• Increase SV by decreasing ESV
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Factors Affecting stroke volume(EDV-ESV)
Afterload
•The pressure that must be overcome for theventricles to eject blood (back pressureexerted by blood in the large arteries leavingthe heart)
• Increased afterload will increase ESV anddecrease SV
• Increased by factors that restricts arterial bloodflow
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PRELOAD AND AFTERLOAD DEPICTED
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STRESS PERFUSION IMAGES
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Stress-Perfusion
Rest-Perfusion
Baseline LV contrastuptake
RV contrastuptake
Myocardialcontrast uptake
Viability andcoronaryangiography
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Walls of the ventricles:Left wall is thicker!
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Find:1. Walls of the ventricles2. Auricles3. Inner walls of the atria4. Fossa ovalis5. Trabeculae carnae6. Atrioventricular valve(a) "Bicuspid valve"(b) "Tricuspid valve"7. Chordae tendonae8. Papillary muscles9. Aortic & pulmonary valves
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Coronary arteries are the FIRST branches of the aorta!
1. Coronary arteries(a) Left coronary artery(b) Right coronary artery(c) Interventricular branches(d) Right marginal branch
2. Cardiac veins
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Heart in VENTRAL view.
(You see mostly right ventricle!)
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Heart in DORSAL view.
(You see mostly left ventricle.)
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Intrinsic regulation of heart beat
1. Sinoatrial node is PACEMAKER OF HEART, and beginning of process. Geenrates periodic impulses that initiate contraction of right atrium.
2. Signal then runs to Atrioventricular node. Message is passed along a track of Purkinje fibers called the...
3. Atrioventricular bundle. Atrioventricular bundle then splits into right and left limbs/branches that pass to individual inner ventricular walls on right and left.
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Maximum Heartrate Calculation(Suggested) MAXIMUM HEARTRATE can be calculated by the formula:
208 - (0.7)(your age) = normal maximum heartrate.
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Heartrate
Resting heartrate average is variable depending on ages, sex, weight, etc.
MAXIMUM HEARTRATE used to be calculated by the formula:
220 - your age = normal maximum heartrate.(This is now known to be oversimplified and incorrect.)