THE NORMAL HEART

Anatomy of the heart What’s new?

Robert H Whitaker
C The anatomy of the coronary sinus has taken on new clinical
importance as a result of the expansion of electrophysiological
investigations and interventions. There has been a drive to
Abstract avoid the ‘Valentine’ approach to cardiac description that has
Despite centuries of writings and research into cardiac anatomy and func- crept into surgical usage and an appreciation of the need to
tion, the topic is still advancing, particularly in reference to clinical appli- adhere to strict anatomical references.1
cations and embryological significance. This article presents the heart C The embryology of the heart has been revisited in an attempt
with reference to the classical anatomical position and attempts to clarify to gain more insight into congenital anomalies2 e the classical
the nomenclature that is most commonly used by anatomists. We concepts of cardiac looping and fate of the original heart tubes
encourage clinicians to use the same terminology. The references are have been questioned.3
from an excellent compilation on the heart in Clinical Anatomy.

Keywords atrium; cardiac embryology; chambers; coronary arteries;

heart; pericardium; venous drainage; ventricle chambers. The outer layer is the tough fibrous pericardium,
which blends with the adventitia of the aorta, the pulmonary
trunk, the superior vena cava and the central tendon of the
diaphragm. Within this, there are two layers of serous
The heart is a midline, valvular, muscular pump that is cone- pericardium:
shaped and the size of a fist. In adults, it weighs 300 g and lies in  a visceral layer, lining the heart
the middle mediastinum of the thorax. The inferior (diaphrag-  a parietal layer, lining the inner surface of the fibrous
matic) surface sits on the central tendon of the diaphragm, and pericardium.
the base faces posteriorly and lies immediately anterior to the These two layers of serous pericardium are continuous with each
oesophagus and descending aorta. The base comprises mainly other as they reflect off the major vessels behind and above the
the left atrium, with a small amount of right atrium. The left heart. The reflection, posteriorly, between the pulmonary veins
surface (left ventricle) and right surface (right atrium) are each is termed the ‘oblique sinus’ of the pericardium. The plane
related laterally to a phrenic nerve and a lung. The anterior between the superior vena cava and the pulmonary veins pos-
surface of the heart lies behind the sternum and the costal teriorly, and the aorta and the pulmonary trunk anteriorly, made
cartilages. The constituent parts of the anterior and inferior by the folding of the heart, is termed the ‘transverse sinus’ of the
surfaces are largely dictated by the position of the interventric- pericardium.
ular septum. Although essentially midline, one-third of the heart
lies to the right of the midline and two-thirds to the left. Features of the chambers
The interventricular septum bulges to the right because the wall
of the left ventricle is much thicker (10 mm) than that of the right Right atrium
ventricle (3e5 mm). It also lies obliquely across the heart, almost The inferior vena cava passes through the diaphragm at the level of
in the coronal plane, such that the anterior surface of the heart is T8 and immediately enters the right atrium, which lacks a true
two-thirds right ventricle and one-third left ventricle; the propor- valve. In the fetus, however, there is tissue present which directs
tions are reversed on the inferior surface. The thicker, muscular caval blood into the foramen ovale. The superior vena cava enters
part of the interventricular septum is formed from the ventricular the superior aspect of the chamber. The fossa ovalis (a remnant of
walls. The muscles of the four chambers and the four valves are the septum primum) and its overhanging limbus (a remnant of the
attached to, and supported by, a figure-of-eight-shaped fibrous septum secondum) lie on the smooth, interatrial part of the
skeleton comprising a central fibrous body and extensions (fila chamber, which developed from the sinus venosus. This smooth
coronaria) that surround the valves. This skeleton both divides area is separated from the muscular part, with its musculi pectinati,
and electrically separates the atria from the ventricles. It is the by the crista terminalis internally and the sulcus terminalis exter-
remnant of the atrioventricular (AV) cushions, and contributes to nally. The muscular part originated from the fetal atrium and is
the thinner, membranous part of the interventricular septum. represented in the mature heart as the right auricle.
Between the opening of the inferior vena cava and the AV
Pericardium orifice lies the opening of the coronary sinus, which is protected
in most hearts by a small (Thebesian) valve that prevents
The pericardium holds and protects the heart, but provides regurgitation into the coronary sinus during atrial relaxation. The
sufficient potential space for filling and emptying of the coronary sinus empties during systole. The AV node lies between
this orifice and the septal cusp of the tricuspid valve.

Robert H Whitaker MA MD MChir FRCS is an anatomy teacher at the Right ventricle

University of Cambridge, UK. He is a Fellow of Selwyn College. He Blood enters the right ventricle via the tricuspid valve, which has
qualified from the University of Cambridge and University College anterior, septal and posterior (lying inferior) cusps attached to
Hospital, London. Competing interests: none. papillary muscles by fibrous chordae tendineae. The ventricular

MEDICINE 38:7 333 Ó 2010 Elsevier Ltd. All rights reserved.

 THE NORMAL HEART

wall is normally 3e5 mm thick and raised internally by inter-

weaving strands of muscle (trabeculae carneae). Some of this Coronary arteries and branches
muscle joins the anterior papillary muscle, low on the anterior
Left atrial
septal wall, as the septomarginal trabecula (moderator band) and Left coronary
carries part of the right bundle branch of conducting tissue. Left conus
Right conus
Blood passes superiorly to leave this chamber via the smooth
conus arteriosus (infundibulum) and the pulmonary valve, Left atrial
Sinoatrial nodal
which has two anterior cusps and one posterior cusp (PAPA e Circumflex
PulmonaryeAnteriorePosterioreAnterior). Right coronary
Diagonal
Left atrium Right atrial Left
The left atrium is a box-shaped chamber that lies posteriorly at the marginal
base of the heart and receives blood from the lungs via four large,
valveless pulmonary veins into the four quadrants of the chamber.
The terminology and development of the smooth and muscular
parts of the left atrium correspond to those of the right atrium. Atrioventricular
nodal
Left ventricle
Blood enters the left ventricle via the mitral valve, which has Right marginal
larger anterior and smaller posterior cusps, each with chordae
tendineae and papillary muscle. The mitral valve is an active
Posterior (inferior)
valve and not simply a flap of tissue.4 The muscle wall is about
interventricular and
10 mm thick and roughened by trabeculae carneae. The smooth
septal branches Anterior interventricular
outflow tract is the aortic vestibule, corresponding to the
(anterior descending) and
membranous part of the interventricular septum, leading to the
septal branches
aortic valve with its two posterior cusps and one anterior cusp
(APAP e AorticePosterioreAnteriorePosterior). The relation- Figure 1
ship of these cusps to the ostia of the coronary arteries is
described below. The trabeculated pattern of the musculi pecti-
nati and the trabeculae carneae is an efficient means of gaining aortic sinus) and the left from the left posterior sinus (also known
power without excessively thickening the wall of the chamber. as Sinus 2 or left coronary aortic sinus). The coronary arteries are
A single papillary muscle has separate chordae tendineae to two shown in Figure 1 and Table 1. The third sinus is named the right
adjacent valvular cusps, which helps draw them together and posterior sinus or non-coronary sinus.6
prevents valvular eversion during systole.
Right coronary artery
Conducting system of the heart The right coronary artery passes from its origin anteriorly
Specialized cardiac muscle fibres form the: between the right atrial appendage and the pulmonary trunk to
 sinoatrial node (in the right atrial wall between the opening of enter first the right anterior AV groove and then the right
the superior vena cava and the auricle) posterior AV groove, where it anastomoses with the circumflex
 AV node (in the left wall of the right atrium, at the superior branch of the left coronary artery. In 90% of individuals, it
limit of the interventricular septum) provides a posterior (inferior) interventricular branch as it
 AV bundle (arising from the AV node and descending in the reaches the posterior interventricular groove on the inferior
interventricular septum). surface of the heart; this anastomoses with the termination of
Contractions originating from the sinoatrial node (pacemaker) the anterior interventricular artery (left coronary) in the
spread through the atrial walls to reach the AV node, and then groove.
the left and right bundles. The plexus of Purkinje fibres allows
Left coronary artery
spread of excitation to the ventricular walls so that the inferior
The left coronary artery arises from the left posterior aortic sinus
aspects of the ventricles contract first. Further autonomic
and passes anteriorly between the left atrial appendage and
nervous control is via cardiac branches from each of the cervical
pulmonary trunk, to lie in the left anterior AV groove. Here it
sympathetic ganglia and thoracic ganglia T1e5; parasympathetic
divides into the:
fibres arise from the superior and inferior cardiac branches of the
 circumflex artery; and the
vagus and from the recurrent laryngeal nerve.5 All autonomic
 anterior interventricular artery.
nerves pass via the superficial and deep cardiac plexuses on the
The circumflex artery continues first in the anterior and then in
lateral and medial aspects of the aortic arch.
the posterior AV groove, and anastomoses with the terminal
branches of the right coronary artery. The anterior interventric-
Blood supply to the heart
ular artery (often termed the ‘left anterior descending artery e
The ostia of the coronary arteries arise in the aortic sinuses above LAD’) passes down the same named groove, around the apex of
the attachment of the base of the relevant cusp e the right the heart, and anastomoses with the terminal branches of the
from the anterior sinus (also known as Sinus 1 or right coronary posterior (inferior) interventricular artery.

MEDICINE 38:7 334 Ó 2010 Elsevier Ltd. All rights reserved.

 THE NORMAL HEART

Branches of the coronary artery system Cardiac veins

Right coronary artery Left marginal vein

C Left atrial

C Right conus

C Sinoatrial nodal (60% of individuals) Oblique vein

C Right atrial left atrium
C Right marginal

C Posterior (inferior) interventricular (90%)

Ventricular branches Coronary sinus

Septal branches
C Atrioventricular nodal (90%)

C Smaller branches to the right ventricle

Anterior cardiac
veins
Left coronary artery
C Sinoatrial nodal (40%)

Circumflex artery Small cardiac

C Left marginal
vein
C Left conus

C Posterior (inferior) interventricular (10%)

Middle cardiac vein

Ventricular branches
Septal branches Great cardiac vein
C Atrioventricular nodal (10%)
Posterior ventricular vein
Anterior interventricular artery
C Left conus

C Diagonal Figure 2
C Ventricular and septal

Table 1 atrium before crossing the right coronary artery to enter the right
atrium. In addition, 20e30% of all drainage is in the venae cordis
The 10% of individuals in whom most of both ventricles and minimae (Thebesian veins) e small venous channels seen
the septum are supplied by the left coronary artery are said to throughout the myocardium which drain directly into the
have left cardiac (coronary) dominance. The presence of collat- chambers of the heart. A
eral communications between the right and left coronary systems
has been recently reviewed7 suggesting that there is more
collateral circulation than classically taught. Note that the coro-
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MEDICINE 38:7 335 Ó 2010 Elsevier Ltd. All rights reserved.