2 Cardiac anatomy

and physiology

The heart lies within the thorax, to the left of the midline, protected by
the rib cage and lying in close proximity to the lungs and, underneath, the
diaphragm (Fig. 2.1). The ribs and lungs can provide a challenge for the
sonographer trying to obtain clear images of the heart, as ultrasound does
not penetrate bone or aerated lung well.

Aorta

Right Left
lung lung

Heart

Fig. 2.1 The heart and its relation to the rest of the thorax

The heart consists of four main chambers (left and right atria, and left and
right ventricles) and four valves (aortic, mitral, pulmonary and tricuspid).
Venous blood returns to the right atrium (RA) via the superior and inferior
vena cavae, and leaves the right ventricle (RV) for the lungs via the
pulmonary artery. Oxygenated blood from the lungs returns to the left
atrium (LA) via the four pulmonary veins, and leaves the left ventricle (LV)
via the aorta (Fig. 2.2).

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 Cardiac anatomy and physiology
Superior vena Aorta
cava Pulmonary
artery
Right pulmonary
arteries Left pulmonary
arteries
Right pulmonary Left pulmonary
veins veins
Right atrium Left atrium
Left
Right coronary
ventricle
artery
Left anterior
Inferior vena Right descending
cava ventricle artery
Fig. 2.2 The heart and major vessels

● Cardiac chambers and valves

The aortic valve
The aortic valve lies between the left ventricular outflow tract (LVOT) and
aortic root (Fig. 2.3) and has three cusps, which open widely during systole.
In diastole, the valve closes and, in the parasternal short axis view (aortic
valve level), has a Y-shaped appearance (sometimes referred to as
resembling a ‘Mercedes-Benz badge’; Fig. 6.5).
Upstream of the aortic valve are the sinuses of Valsalva, an expanded region of
the aortic root, from which the coronary arteries originate. Each of the sinuses

Aorta Pulmonary
trunk
Pulmonary
valve Left
atrium
Tricuspid Mitral
valve valve

Aortic
Right
valve
atrium

Right Left
ventricle ventricle
Fig. 2.3 The heart valves and chambers

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 and aortic valve cusps is named according to its relationship to these coronary
PART 1: ESSENTIAL PRINCIPLES

arteries: hence the right coronary cusp lies adjacent to the sinus giving rise to
the right coronary artery (RCA), and the left coronary cusp to the sinus giving
rise to the left coronary artery (LCA). The third sinus does not have a coronary
artery, and the adjacent cusp is named the non-coronary cusp.
Where the valve cusps attach to the aortic root is often termed the aortic
valve annulus, although the annulus is not a discrete structure (unlike the
mitral valve annulus). The point where adjacent cusps meet is called the
commissure. Each cusp has a small nodule at its centre, called the nodule of
Arantius, which is more prominent in older patients. The ventricular surface
of a cusp sometimes carries small mobile filaments, called Lambl’s
excrescences, arising from the edge of the cusp. Lambl’s excrescences
are of no clinical significance, but should not be mistaken for vegetations
(Chapter 17) or papillary fibroelastoma (Chapter 21).
Below the aortic valve lies the LVOT, which includes the membranous part
of the interventricular septum (IVS) and the anterior mitral valve leaflet.
The fibrous tissue of the aortic root is continuous with the anterior mitral
valve leaflet.

The left ventricle

The normal LV is an approximately symmetrical structure, which is
cylindrical at its base (the mitral annulus) and tapers towards its apex. It
is the main pumping chamber of the heart and its wall is thicker (and
myocardial mass greater), although less trabeculated, than that of the
RV. The LV myocardium is conventionally subdivided into 16 or 17
segments, the function of each of which should be assessed individually
(Chapter 12).

The mitral valve

The mitral valve lies between the left atrium and ventricle and has two
leaflets that open during diastole and close in systole, to prevent
regurgitation of blood from the LV back into the LA. The mitral valve needs
to be thought of as more than just two leaflets, however, because the mitral
annulus, papillary muscles and chordae tendineae are all essential to the
valve’s structure and function (Fig. 2.4).
The mitral leaflets are termed anterior and posterior and attach around
their base to the fibrous mitral annulus, an elliptical ring separating the

8
 Cardiac anatomy and physiology
Left Mitral
atrium valve

Chordae
tendineae

Left Papillary
ventricle muscles

Fig. 2.4 Mitral valve anatomy

LA and LV. The anterior mitral leaflet is longer (from base to tip) than the
posterior leaflet, but the length of its attachment to the annulus is shorter
and so the surface area of both leaflets is about equal. Each leaflet is divided
into three segments, or scallops, which are named A1, A2 and A3 (anterior
leaflet) and P1, P2 and P3 (posterior leaflet), with the numbering running
from the anterolateral commissure (A1/P1) to the posteromedial
commissure (A3/P3) (Fig. 14.2).
There are two papillary muscles, named anterolateral and posteromedial
(after the location of their attachment to the LV), and which are attached to
the mitral leaflets via the chordae tendineae. Although there are two leaflets
and two papillary muscles, each papillary muscle supplies chordae to both
leaflets – it is not a 1:1 relationship. Chordae from the medial aspects of
both leaflets attach to the posteromedial papillary muscle and from the
lateral aspects to the anterolateral papillary muscle.
The chordae keep the mitral leaflets under tension during systole,
preventing prolapse of the leaflets back into the LA. They are categorized
into three groups:

● first order or marginal chordae, which attach to the free edges of the
mitral leaflets
● second order or strut chordae, which attach to the ventricular surface
of the leaflets (away from the free edges)
● third order or basal chordae, which run directly from the ventricular
wall (rather than the papillary muscles) to the ventricular surface of the
posterior leaflet, usually near the annulus.

The mitral leaflets are normally thin and open widely during diastole, with
the anterior leaflet almost touching the IVS. As the leaflets close (coapt)

9
 they overlap at their tips by several millimetres (apposition). A reduced
PART 1: ESSENTIAL PRINCIPLES

degree of apposition results in poor coaptation and can cause mitral

regurgitation.

The left atrium

The LA is situated at the back of the heart, in front of the oesophagus (and it is
therefore the chamber immediately adjacent to the probe in the mid-
oesophageal transoesophageal echo view). The LA is a relatively smooth-walled
structure, but does have an appendage which can act as a focus for thrombus
formation. It is entered by four pulmonary veins carrying oxygenated blood
from the lungs – two from the right lung and two from the left.

The LA is not just a passive conduit between the pulmonary veins and the
LV, but contracts during atrial systole (immediately after the onset of the
P wave) to provide additional diastolic filling of the LV (the ‘atrial kick’). This
is particularly important when diastolic filling is impaired, in the presence of
elevated LV filling pressures.

The LA is separated from the RA by the interatrial septum, but there can be
a communication between the two in the form of a patent foramen ovale or
atrial septal defect (ASD) (Chapter 22).

The pulmonary valve

The pulmonary valve lies between the right ventricular outflow tract
(RVOT) and pulmonary artery, opening during systole to allow blood to pass
from the ventricle into the pulmonary circulation, and closing in diastole to
prevent regurgitation (a small amount of ‘physiological’ pulmonary
regurgitation is normal). The valve itself is structurally similar to the aortic
valve, having three cusps (called anterior, left and right).

The right ventricle

The RV is more complex to assess by echo than the left, forming a crescent-
shaped structure around the LV. It is more heavily trabeculated, but
thinner-walled than the LV, and contains a moderator band that stretches
between the free wall and the septum. The RVOT is not trabeculated and
leads to the pulmonary valve. The RV acts as the pumping chamber for
deoxygenated blood returning from the body en route to the lungs.

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The tricuspid valve

Cardiac anatomy and physiology

The tricuspid valve lies between the RA and RV, opening during diastole to
allow blood to pass from the atrium to the ventricle, and closing in systole
to prevent regurgitation (although a small amount of ‘physiological’
tricuspid regurgitation is commonly seen in normal individuals).

As its name suggests, the tricuspid valve has three cusps – in order of
decreasing size, these are called the anterior, posterior and septal cusps.
There are also three papillary muscles, which, in a similar way to the mitral
valve, are attached to the cusps via chordae tendineae. The orifice area of
the tricuspid valve is greater than that of the mitral valve, normally
7.0 cm2.

The right atrium

The RA receives blood returning to the heart via the superior and inferior
vena cavae. It also receives blood draining from the myocardium via the
coronary sinus, which enters the RA posteriorly, just superior to the
tricuspid valve. The coronary sinus is often visible on echo, particularly
when it is dilated (Fig. 21.4).

The Eustachian valve, an embryological remnant, may be seen in the RA

near the junction with the inferior vena cava.

● The coronary arteries

The coronary circulation normally arises as two separate vessels from the
sinuses of Valsalva – the LCA from the left coronary sinus, and the RCA
from the right coronary sinus (Fig. 2.5).

The initial portion of the LCA is the left main stem, which soon divides into
the left anterior descending (LAD) and circumflex (Cx) arteries. The LAD
artery runs down the anterior interventricular groove giving rise to diagonal
branches, which course towards the lateral wall of the LV, and septal
perforators that supply the IVS. The Cx artery runs in the left
atrioventricular groove, giving rise to obtuse marginal branches which
extend across the lateral surface of the LV.

The RCA runs in the right atrioventricular groove, and in most people gives
rise to the posterior descending artery which runs down the posterior
interventricular groove. This defines ‘dominance’ – most people therefore

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PART 1: ESSENTIAL PRINCIPLES
Left
coronary
artery

Circumflex

Obtuse
marginal
Right
coronary
Diagonals
artery

Left
anterior
Posterior descending
descending
Fig. 2.5 The coronary circulation

have a ‘dominant’ RCA, but in some people the Cx gives rise to the posterior
descending artery and they are said to have a ‘dominant’ Cx.

● The pericardium
The pericardium is a sac-like structure that surrounds most of the heart.
There is an outer fibrous layer – the fibrous pericardium – which blends
with the diaphragm inferiorly, and an inner layer – the serous pericardium –
which itself has two layers (the parietal pericardium, continuous with the
fibrous outer layer, and the visceral pericardium, which is the epicardium of
the heart).
The pericardium contains ‘gaps’ where vessels enter and leave the heart,
and the pericardium forms a small sleeve around these vessels. As a result,
there is a small pocket of pericardium around the aorta/pulmonary
artery (transverse sinus) and between the four pulmonary veins (oblique
sinus).
The pericardial cavity is a potential space between the parietal and visceral
layers, and normally contains less than 50 mL of fluid. Inflammation of the
pericardium (pericarditis) can lead to the accumulation of a larger volume of
fluid – a pericardial effusion. If this affects the normal functioning of the
heart, cardiac tamponade can result. In the longer term, inflammation of
the pericardium can lead to thickening of pericardium and pericardial
constriction.

12
● The cardiac cycle

Cardiac anatomy and physiology

The events that occur during each heartbeat are termed the cardiac cycle,
commonly represented in diagrammatic form (Fig. 2.6). The cardiac cycle
has four phases:

1. isovolumic contraction
2. ventricular ejection
3. isovolumic relaxation
4. ventricular filling.

These phases apply to both left and right heart, but we will focus on the left
heart here for clarity. Phases 1–2 correspond with ventricular systole and
phases 3–4 with ventricular diastole.

Isovolumic
relaxation
Ventricular
ejection Ventricular
Isovolumic filling
contraction

Aortic
120 Aortic valve
valve
closes
Pressure (mmHg)

100 opens Aortic pressure

80
60
AV valve AV valve
40 closes opens
20
Atrial pressure
0
130 Ventricular pressure
Volume (mL)

Ventricular volume
90
R
50
P
T ECG
Q S

Systole Diastole

Fig. 2.6 The cardiac cycle. (AV  atrioventricular; ECG  electrocardiogram)

Isovolumic contraction begins with closure of the mitral valve, caused by

the rising LV pressure at the start of ventricular systole. After the mitral
valve has closed, pressure within the LV continues to rise but the LV volume
remains constant (hence ‘isovolumic’) until the point when the aortic valve
opens.

13
 Ventricular ejection commences when the aortic valve opens and blood is
PART 1: ESSENTIAL PRINCIPLES

ejected from the LV into the aorta. The LV volume falls during the ejection
phase, as blood is expelled from the LV, but pressure continues to rise until
it peaks and then starts to fall.
Isovolumic relaxation commences with closure of the aortic valve.
Pressure within the LV falls during this phase (but volume remains
constant), until the LV pressure falls below LA pressure. At this point, the
pressure difference between LA and LV causes the mitral valve to open and
isovolumic relaxation ends.
Ventricular filling begins as the mitral valve opens and blood flows into
the LV from the LA. This phase ends when the mitral valve closes at the
start of ventricular systole. Towards the end of the ventricular filling phase,
atrial systole (contraction) occurs, coinciding with the P wave on the ECG,
and this augments ventricular filling.
As shown in Fig. 2.6, the pressures within the cardiac chambers vary
throughout the cardiac cycle. Table 2.1 lists the typical pressures found
within each chamber. A pressure difference between two chambers causes
the valve between them to open or close. For example, when LA pressure
exceeds LV pressure the mitral valve opens, and when LV pressure exceeds
LA pressure the mitral valve closes.

Table 2.1 Normal intracardiac pressures

Pressure (mmHg)
Right atrium Mean 0–5
Right ventricle Systolic 15–25/diastolic 0–5
Pulmonary artery Systolic 15–25/diastolic 5–12
Left atrium Mean 5–12
Left ventricle Systolic 100–140/diastolic 5–12
Aorta Systolic 100–140/diastolic 60–90

Closure of the mitral and tricuspid valves can be heard with a stethoscope as
the first heart sound (S1). Closure of the aortic and pulmonary valves causes
the second heart sound (S2). During expiration S2 occurs as a single sound,
but during inspiration the return of venous blood to the right heart makes
the pulmonary valve close slightly later than the aortic valve, causing
normal physiological splitting of S2 with the pulmonary component (P2)
occurring just after the aortic component (A2). The presence of an ASD
removes this respiratory variation in S2, so that the slight gap between A2
and P2 is there all the time (‘fixed splitting’).

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