Professional Documents
Culture Documents
of the Heart
Fourth edition
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:08:17 WEST 2013.
http://ebooks.cambridge.org/ebook.jsf?bid=CBO9781139028561
Cambridge Books Online Cambridge University Press, 2013
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:08:17 WEST 2013.
http://ebooks.cambridge.org/ebook.jsf?bid=CBO9781139028561
Cambridge Books Online Cambridge University Press, 2013
Anthony M. Hlavacek, MD
Associate Professor, Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
Carl L. Backer, MD
A. C. Buehler Professor of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie
Childrens Hospital of Chicago, Chicago, IL, USA
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:08:17 WEST 2013.
http://ebooks.cambridge.org/ebook.jsf?bid=CBO9781139028561
Cambridge Books Online Cambridge University Press, 2013
Every effort has been made in preparing this book to provide accurate and
up-to-date information which is in accord with accepted standards and practice
at the time of publication. Although case histories are drawn from actual cases,
every effort has been made to disguise the identities of the individuals involved.
Nevertheless, the authors, editors and publishers can make no warranties that the
information contained herein is totally free from error, not least because clinical
standards are constantly changing through research and regulation. The authors,
editors and publishers therefore disclaim all liability for direct or consequential
damages resulting from the use of material contained in this book. Readers
are strongly advised to pay careful attention to information provided by the
manufacturer of any drugs or equipment that they plan to use.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:08:17 WEST 2013.
http://ebooks.cambridge.org/ebook.jsf?bid=CBO9781139028561
Cambridge Books Online Cambridge University Press, 2013
Contents
Preface
page vii
Acknowledgements
viii
13
51
90
111
128
150
244
321
363
Index
377
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:08:38 WEST 2013.
http://ebooks.cambridge.org/ebook.jsf?bid=CBO9781139028561
Cambridge Books Online Cambridge University Press, 2013
Preface
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:08:45 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.001
Cambridge Books Online Cambridge University Press, 2013
Acknowledgements
A good deal of the material displayed in
these pages, and the concepts espoused, are
due in no small part to the help of our
friends and collaborators. As indicated in
our preface, the major change since we
produced the third edition has been the sad
passing of our founding surgical editor,
Benson R. Wilcox. We have renamed this
fourth edition Wilcoxs Surgical Anatomy
of the Heart. We dedicate this edition to
his eternal memory. A further change has
been the retirement of Robert H. Anderson
from the Institute of Child Health at
Great Ormond Street Childrens Hospital,
London. Retirement, however, has
permitted him to establish new
connections, not least with the newest
additions to our team of authors. This has
permitted many new hearts to be
specically photographed for this new
edition, not only of autopsy specimens, but
also in the operating room. In addition, it
has created the collaboration that permits
the inclusion of wonderful images
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:09:22 WEST 2013.
http://ebooks.cambridge.org/ebook.jsf?bid=CBO9781139028561
Cambridge Books Online Cambridge University Press, 2013
Surgical approaches
to the heart
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:09:30 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.002
Cambridge Books Online Cambridge University Press, 2013
Acute margin
Apex
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:09:30 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.002
Cambridge Books Online Cambridge University Press, 2013
Thymic veins
Sup.
Brachiocephalic vein
Left
Right
Right phrenic
nerve
Inf.
Superior
caval vein
Left phrenic
nerve
Pulmonary
trunk
Aorta
Left atrial
appendage
Right atrium
Left ventricle
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:09:30 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.002
Cambridge Books Online Cambridge University Press, 2013
Sup.
Right
Left
Inf.
Thymus
Pericardial sac
Diaphragm
Left
Left lobe
of thymus
Sup.
Inf.
Right
Pericardial
sac
Right lobe
of thymus
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:09:30 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.002
Cambridge Books Online Cambridge University Press, 2013
Left
Sup.
Inf.
Right
Brachiocephalic vein
Thymic
veins
Aorta in
pericardium
Right lobe of
thymus
Left pericardiophrenic
artery and vein
Left phrenic nerve
Right pericardiophrenic
artery and vein
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:09:30 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.002
Cambridge Books Online Cambridge University Press, 2013
Ant.
Inf.
Sup.
Post.
Left
Right atrial
appendage
Sup.
Inf.
Right
Superior caval
vein
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:09:30 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.002
Cambridge Books Online Cambridge University Press, 2013
Cut edge of
pericardium
Left
Right phrenic
nerve
Sup.
Inf.
Right
Right internal
thoracic artery
Right phrenic nerve
Superior
caval vein
Ant.
Inf.
Sup.
Azygos vein
Post.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:09:31 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.002
Cambridge Books Online Cambridge University Press, 2013
Arch of aorta
Ant.
Persistent left
superior caval vein
Inf.
Sup.
Fig. 1.11 This operative view, taken through a left thoracotomy, shows the
relationship of the left phrenic nerve to a persistent left superior caval vein.
Note also the course of the superior intercostal vein.
Post.
Teres major
Latissimus dorsi
Trapezius
Bloodless triangle
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:09:31 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.002
Cambridge Books Online Cambridge University Press, 2013
Ant.
Left vagus nerve
Inf.
Sup.
Post.
Patent arterial
duct
Left recurrent
laryngeal nerve
Fig. 1.13 This operative view, taken through a left lateral thoracotomy in an
adult, shows the left recurrent laryngeal nerve passing around the arterial duct.
Brachiocephalic vein
Superior
intercostal
vein
Superior
caval vein
Sup.
Ant.
Arterial duct
Post.
Inf.
Fig. 1.14 The anatomical image shows the course of the left superior
intercostal vein.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:09:31 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.002
Cambridge Books Online Cambridge University Press, 2013
10
Left superior
intercostal vein
Aorta
Left subclavian
artery
Ant.
Inf.
Sup.
Fig. 1.15 This operative view, taken through a left lateral thoracotomy,
Post.
Aortic isthmus
shows the course of the left superior intercostal vein. (Compare with
Figure 1.14.)
Ant.
Thoracic
duct
Inf.
Sup.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:09:31 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.002
Cambridge Books Online Cambridge University Press, 2013
Left
Superior
caval vein
Sup.
Left brachiocephalic
vein
Inf.
Right
Azygos vein
Right common
carotid artery
Intercostal veins
Brachiocephalic artery
Brachiocephalic vein
Right recurrent
laryngeal nerve
Left
Sup.
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:09:31 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.002
Cambridge Books Online Cambridge University Press, 2013
11
12
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:09:31 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.002
Cambridge Books Online Cambridge University Press, 2013
Anatomy of the
cardiac chambers
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:12:20 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.003
Cambridge Books Online Cambridge University Press, 2013
14
Aorta
Transverse sinus
Right pulmonary
artery
Pericardial cavity
Left atrium
Oblique sinus
Ant.
Base
Apex
Post.
Visceral
Parietal
Fibrous
pericardium
Serous pericardium
Left
Left appendage
Inf.
Sup.
Right
*
*
*
*
*
Pulmonary
trunk
Right ventricle
Aorta
*
*
Right
appendage
Fibrous
pericardium
*
*
Pericardial cavity
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:12:20 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.003
Cambridge Books Online Cambridge University Press, 2013
15
Left
Sup.
Pulmonary trunk
Inf.
Right
Aorta
Right
appendage
Clamp in transverse
sinus
Left
Clamp tenting pericardial fold
Inf.
Sup.
Right
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:12:20 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.003
Cambridge Books Online Cambridge University Press, 2013
16
Oblique ligament
Pulmonary trunk
Left atrial
appendage
Sup.
Right
Left
Inf.
pericardial cavity, which lies behind the left atrium. Note the
oblique ligament, which occupies the site during development of
the left superior caval vein.
Sup.
Coronary sinus
Right atrium
Right
Left
Inf.
Oblique sinus
Fig. 2.6 The heart has been reected superiorly from its
pericardial cradle to show the location of the oblique sinus.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:12:20 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.003
Cambridge Books Online Cambridge University Press, 2013
Left
Sup.
Inf.
Right
Right ventricle
Aorta
Right atrial
appendage
Left
Sup.
17
Inf.
Right
Pulmonary trunk
Subpulmonary infundibulum
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:12:20 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.003
Cambridge Books Online Cambridge University Press, 2013
18
Pulmonary trunk
Left
Sup.
Inf.
Right
Left atrial
appendage
Sup.
Post.
Fig. 2.10 The base of the heart has been dissected by removing
Ant.
Inf.
Coronary sinus
the atrial walls. The dissection shows the course of a persistent left
superior caval vein as it passes through the left atrioventricular
groove (red dotted lines), emptying into the right atrium through
the enlarged orice of the coronary sinus.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:12:20 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.003
Cambridge Books Online Cambridge University Press, 2013
Sup.
19
Obtuse margin
Post
Ant
Inf.
Sternocostal
Pulmonary
Diaphragmatic
Acute margin
Fig. 2.11 The heart has been removed from the chest and is
viewed from its apex, showing the surfaces of the ventricular cone.
MORPHOLOGICALLY RIGHT
ATRIUM
The right atrium has three basic parts, the
appendage, the venous component
receiving the systemic venous return, and
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:12:21 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.003
Cambridge Books Online Cambridge University Press, 2013
20
Sup.
Right
Left
Inf.
Right atrial
appendage
Right
pulmonary
veins
Waterstons
groove
Fig. 2.12 The heart is photographed from the right side to show
Inferior caval vein
Crest of appendage
the location of the terminal groove (black dotted line) between the
appendage and the systemic venous sinus.
Left
Sup.
Inf.
Right
Appendage
ICV
SCV
Sinus node
Terminal groove
Fig. 2.13 The cartoon shows the usual site of the sinus node within
the terminal groove (upper panel). The lower panel shows the
horseshoe arrangement found in about one-tenth of cases. SCV,
superior caval vein; ICV, inferior caval vein.
Horseshoe node
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:12:21 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.003
Cambridge Books Online Cambridge University Press, 2013
21
Crest of appendage
Aorta
Left
Right
demonstrating the usual site of the sinus node. The node can often
be seen as a pale cigar-shaped area located anterolaterally in the
terminal groove. This anticipated site is highlighted in the
photograph by the white cross-hatched area.
Left
Sup.
Inf.
Inf.
Right
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:12:22 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.003
Cambridge Books Online Cambridge University Press, 2013
22
Waterstons groove
Left
Sup.
Right
Pulmonary veins
Terminal crest
Inf.
Left
Inf.
Right
Pectinate muscles
opened the right atrium. The terminal crest is seen giving rise to the
pectinate muscles of the right atrial appendage. Note that, in this
patient, the oor of the oval fossa is decient, producing an atrial
septal defect.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:12:22 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.003
Cambridge Books Online Cambridge University Press, 2013
23
Anterocaval course
Retrocaval course
Arterial circle
Distal origin from right coronary artery
Aorta
Left
Sup.
Artery to sinus node
Inf.
Right
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:12:22 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.003
Cambridge Books Online Cambridge University Press, 2013
24
Aorta
Left
Inf.
Sup.
Right
Crest of appendage
Left
Sup.
Inf.
Right
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:12:23 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.003
Cambridge Books Online Cambridge University Press, 2013
25
Superior caval
vein
Artery to
sinus node
Sup.
Left
Right
Retrocaval course
Inf.
Crest of appendage
Left
Sup.
Inf.
a retrocaval course of the artery to the sinus node, the site of the
node itself being emphasised by the white cross-hatched area.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:12:23 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.003
Cambridge Books Online Cambridge University Press, 2013
26
Retrocaval branch
Left
Sup.
Anterocaval branch
Inf.
the artery to the sinus node dividing to form an arterial circle
around the cavoatrial junction.
Right
Sup.
Post.
Ant.
Fig. 2.25 The heart is shown from the right side. The terminal
Waterstons groove
Terminal groove
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:12:23 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.003
Cambridge Books Online Cambridge University Press, 2013
27
Sup.
Oval fossa
Post.
Ant.
Inf.
Coronary sinus
Sup.
Post.
Fig. 2.27 The same specimen as seen in Figure 2.26 has been
Ant.
Inf.
transected through the oval fossa. The section shows that the rims
of the oval fossa are infoldings of the atrial walls. Note the
relationship of the anterior fold to the aortic root, the right
coronary artery, and the artery to the sinus node.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:12:23 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.003
Cambridge Books Online Cambridge University Press, 2013
28
Flap valve
Left atrium
Aortic root
Post.
Apex
Ant.
Anteroinferior rim
plane, showing that the superior rim of the oval fossa is a deep
infolding producing the interatrial groove between the systemic
venous sinus of the right atrium and the entry of the pulmonary
veins into the left atrium.
Superior infolding
Sup.
Ant.
Post.
Inf.
Left atrium
Fig. 2.29 The heart shown in Figures 2.26 and 2.27 has been
sectioned in the long axis of the venous sinus, again showing that
the superior rim of the oval fossa is an infolding of the interatrial
groove. The heart is viewed in anatomical orientation from the
back.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:12:24 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.003
Cambridge Books Online Cambridge University Press, 2013
Septal leaflet
29
Coronary sinus
Left
Sup.
Inf.
Right
Eustachian ridge
Fig. 2.30 The heart has been opened through an atriotomy, and
the interior surface of the right atrium is shown in surgical
orientation. Note the Eustachian ridge separating the mouth of the
coronary sinus from the orice of the inferior caval vein. The oor
of the oval fossa is decient, producing an atrial septal defect.
Sup.
Right
Left
Inf.
Coronary sinus
Fig. 2.31 This operative view through a right atriotomy shows the
location of the triangle of Koch.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:12:24 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.003
Cambridge Books Online Cambridge University Press, 2013
30
Membranous septum
Tendon of Todaro
Hinge of
tricuspid valve
Oval fossa
Eustachian valve
Sup.
Right
Left
Inf.
Sub-Thebesian pouch
Thebesian valve
Sup.
Right
Fig. 2.32 The endocardium has been removed from this heart,
Left
Inf.
Adipose tissue
Fig. 2.33 The heart has been sectioned in the four-chamber plane
Tricuspid valvar attachment
Ventricular septum
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:12:24 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.003
Cambridge Books Online Cambridge University Press, 2013
31
Artery to AV node
Membranous septum
Right atrium
Left atrium
Oval fossa
Sup.
Ant.
Post.
Inferior caval vein
Coronary sinus
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:12:24 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.003
Cambridge Books Online Cambridge University Press, 2013
32
Left
Sup.
Inf.
Right
Tendon of Todaro
Post.
Right
Left
Ant.
Left ventricular
outflow tract
Oval fossa
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:12:25 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.003
Cambridge Books Online Cambridge University Press, 2013
Membranous septum
33
Aortic-mitral continuity
Sup.
Post.
opened to show the origin of the aorta from the left ventricle, with
the membranous septum in brous continuity with the leaets of
the aortic and mitral valves. Note the site of the left bundle branch,
marked by the white dots.
Ant.
Inf.
Interleaflet triangle
Aortic-mitral continuity
Membranous septum
Right fibrous trigone
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:12:25 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.003
Cambridge Books Online Cambridge University Press, 2013
34
Anterosuperior leaflet
Inferior leaflet
Left
Sup.
Inf.
Septal leaflet
MORPHOLOGICALLY LEFT
ATRIUM
As with the right atrium, the left atrium
possesses an appendage, an extensive
venous component, and a vestibule. Unlike
the situation with the right atrium, it is also
surgical orientation, shows the vestibule of the right atrium and the
three leaets of the tricuspid valve.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:12:26 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.003
Cambridge Books Online Cambridge University Press, 2013
Appendage
35
Venous component
Body
Ant.
Sup.
Inf.
Vestibule
Septum
Post.
Left
Interatrial groove
Inf.
Sup.
Right
MORPHOLOGICALLY RIGHT
VENTRICLE
The musculature of the right ventricle
extends from the atrioventricular to the
ventriculoarterial junctions.
Understanding of ventricular morphology
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:12:27 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.003
Cambridge Books Online Cambridge University Press, 2013
36
Aorta
Right atrial
appendage
Left
Sup.
Inf.
Right
shows how retraction of the aorta to the left reveals the deep
trough inferior to the right pulmonary artery and between the
atrial appendages. Note that, in this heart, the artery to the sinus
node courses through this trough.
Right pulmonary
artery
Mouth of appendage
Pulmonary
venous component
Body of atrium
Sup.
Left
Vestibular myocardium
Fenestrated
oval fossa
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:12:27 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.003
Cambridge Books Online Cambridge University Press, 2013
37
Ant.
Aortic leaflet
Sup.
Inf.
Post.
Mural leaflet
Vestibule
Body of atrium
Atrial septum
Sup.
Left pulmonary veins
Post.
Ant.
Inf.
Fig. 2.46 The left atrium is windowed from the left and posterior
aspect, showing its component parts. Note the probe in the patent
foramen.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:12:28 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.003
Cambridge Books Online Cambridge University Press, 2013
38
Supraventricular crest
Septomarginal
trabeculation
Outlet
Inlet
Apical
trabecular
component
Base
Right
Left
Apex
Sup.
Left
Right
Inf.
Anterosuperior
leaflet
Septal leaflet
Tricuspid
valve
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:12:28 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.003
Cambridge Books Online Cambridge University Press, 2013
Anterosuperior leaflet
39
Left
Sup.
Inf.
Right
Septal leaflet
Sup.
Right
Left
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:12:29 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.003
Cambridge Books Online Cambridge University Press, 2013
40
Septoparietal
trabeculations
Supraventricular crest
Sup.
Left
Right
Inf.
Septomarginal trabeculation
Sup.
Septomarginal
trabeculation
Left
Right
Inf.
Pulmonary valve
Right
coronary
artery
Ventriculoinfundibular fold
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:12:30 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.003
Cambridge Books Online Cambridge University Press, 2013
41
Free-standing infundibulum
Pulmonary valve
Aortic root
Sup.
Left
Right
Inf.
Septomarginal
trabeculation
Left
Ant.
Post.
Right
Infundibular sleeve
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:12:31 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.003
Cambridge Books Online Cambridge University Press, 2013
42
Aortic valve
Left
Sup.
Inf.
Right ventricular
infundibular sleeve
Right
Fig. 2.55 In the heart shown in Figure 2.54, again viewed from
above and from the right, the pulmonary infundibulum has been
removed from the base of the heart, revealing the free-standing
myocardial sleeve that lifts the valvar leaets away from the left
ventricle. Note the site of the rst septal perforating artery.
Ventriculoinfundibular fold
Septomarginal
trabeculation
Sup.
Left
Right
Fig. 2.56 The right ventricle has been opened from the front,
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:12:31 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.003
Cambridge Books Online Cambridge University Press, 2013
43
Ant.
Left
Post.
Coarse right
ventricular
trabeculations
Right
Fig. 2.57 The apical component of the ventricular mass has been
Fine left ventricular trabeculations
Sup.
Post.
Ant.
Inf.
Outlet
Inlet
MORPHOLOGICALLY LEFT
VENTRICLE
As with the right ventricle, the musculature
of the left ventricle extends from the
atrioventricular to the ventriculoarterial
junctions. It is again conveniently
considered in terms of inlet, apical
trabecular, and outlet components
(Figure 2.58). In the left ventricle, there is
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:12:31 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.003
Cambridge Books Online Cambridge University Press, 2013
44
Base
Right
Left
Apex
Aortic leaflet
Mural leaflet
Papillary muscles
Sup.
Posterosuperior muscle
Base
Apex
Inf.
Fig. 2.60 This specimen, viewed from behind after the parietal
Anteroinferior muscle
wall of the left ventricle has been removed, is dissected to show the
adjacency of the anteroinferior and posterosuperior papillary
muscles of the mitral valve.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:12:31 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.003
Cambridge Books Online Cambridge University Press, 2013
Sup.
Post.
45
Aorta
Ant.
Inf.
Mitral valve
Right atrium
Inferior extension
Fig. 2.61 This heart, seen from above and from the right in
anatomical orientation, has been prepared by removing the atrial
musculature and the non-coronary sinus of the aortic valve to
illustrate the inferior extension of the subaortic outow tract
separating the mitral valve from the septum.
THE AORTA
The ascending aorta begins at the distal
extremity of the three aortic sinuses, the
sinutubular junction, which lies at the line
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:12:32 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.003
Cambridge Books Online Cambridge University Press, 2013
46
Sup.
Non-coronary leaflet
Right
Left
Inf.
Mitral valve
Interleaflet triangle
Membranous septum
Ant.
Base
Apex
Post.
Haemodynamic ventriculoarterial junction
valve (see Figure 2.50), the attachments of the leaets of the aortic
valve (black dotted line) cross the anatomical ventriculoarterial
junction (black dashed line), incorporating crescents of ventricular
tissue into the arterial valvar sinuses, and triangles of arterial tissue
into the ventricular base.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:12:34 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.003
Cambridge Books Online Cambridge University Press, 2013
Sinutubular junction
Ascending aorta
Aortic sinus
Transverse sinus
Left atrium
Left ventricle
Ant.
Base
Apex
Post.
Left
Inf.
Sup.
Right
Pulmonary trunk
Ascending aorta
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:12:34 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.003
Cambridge Books Online Cambridge University Press, 2013
47
48
Brachiocephalic arteries
Ant.
Left
Right
Post.
Pulmonary trunk
Aorta
Fig. 2.66 The arterial trunks have been removed from the base of
the heart, and photographed from the apical aspect, showing their
patterns of branching.
Arterial ligament
Bronchial artery
Aortic arch
Trachea
Left
Inf.
Sup.
Fig. 2.67 This dissection, viewed from the right side in surgical
orientation, shows a bronchial artery arising from the aorta in the
midline and dividing to supply both bronchuses. Pulm., pulmonary.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:12:35 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.003
Cambridge Books Online Cambridge University Press, 2013
Pulmonary trunk
49
Infundibulum
Left
Inf.
Sup.
Right
Pulmonary trunk
Pericardial reflection
Ligament of Marshall
Sup.
Ant.
Post.
Fig. 2.69 The anatomical specimen is shown from the left side,
Infundibulum
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:12:35 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.003
Cambridge Books Online Cambridge University Press, 2013
50
Right pulmonary
artery
Superior
caval vein
Left pulmonary
artery
Aorta
Post.
Right
Left
Fig. 2.70 The heart has been sectioned in the short axis and
Ant.
Pulmonary trunk
Pulmonary valve
15.
16.
17.
18.
19.
20.
21.
22.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:12:35 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.003
Cambridge Books Online Cambridge University Press, 2013
Surgical anatomy
of the valves of
the heart
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:17:04 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.004
Cambridge Books Online Cambridge University Press, 2013
52
Sup.
Arterial valve
Apex
Base
Inf.
Left ventricle
Aorta
Left atrium
Atrioventricular valve
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:17:04 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.004
Cambridge Books Online Cambridge University Press, 2013
53
Sup.
Apex
Base
Valvar
leaflets
Inf.
Tendinous
cords
Papillary
muscles
Attachments
at annulus
Ventricular musculature
Valvar
sinuses
Sinutubular junction
Arterial
root
Valvar
leaflets
Sup.
Base
Apex
Inf.
Fig. 3.3 A comparable close-up of the aortic valve from Figure 3.1
shows the components of the arterial valvar complex, which
extends from the virtual plane at the nadir of the attachments of
the leaets (white dashed line) to the sinutubular junction.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:17:04 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.004
Cambridge Books Online Cambridge University Press, 2013
54
Semilunar hinges
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:17:04 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.004
Cambridge Books Online Cambridge University Press, 2013
55
Fig. 3.6 The aortic valve has been photographed from above,
with the leaets in their closed positions. As can be seen, the zones
of apposition between the leaets (red double-headed arrows)
extend from the peripheral sinutubular junction to the valvar
centroid (white circle). In anatomical terms, these zones are the
commissures between the leaets. Conventionally, however, it is
the peripheral attachments (stars) that are usually dened as the
commissures.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:17:05 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.004
Cambridge Books Online Cambridge University Press, 2013
56
Aortic leaflet
Mural leaflet
Pulmonary valve
Aortic valve
Mitral valve
Sup.
Post.
Ant.
Inf.
Tricuspid valve
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:17:05 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.004
Cambridge Books Online Cambridge University Press, 2013
57
Infundibulum
Pulmonary trunk
Aorta
Fig. 3.9 The cut across the heart to replicate the oblique
subcostal echocardiographic section shows the muscular
infundibular sleeve of the right ventricle supporting the leaets
and sinuses of the pulmonary valve. (See also Figure 3.3.)
Base
Right
Sinutubular junction
Left fibrous trigone
Left
Apex
Interleaflet triangle
Fibrous continuity
Membranous septum
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:17:05 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.004
Cambridge Books Online Cambridge University Press, 2013
58
Fibrous
continuity
Pulmonary
trunk
Infundibulum
Base
Post.
Ant.
Apex
Fig. 3.11 To produce this picture, the heart has been dissected to
parallel the parasternal long axis echocardiographic plane
(compare with Figure 3.1). The arterial roots, however, have been
left intact in this specimen, as has the mitral valve, albeit with the
arterial roots cleaned to show the free-standing sleeve of
subpulmonary infundibular musculature that lifts the leaets of
the pulmonary valve away from the base of the ventricular mass.
Note the area of brous continuity between the leaets of the
aortic and mitral valves forming part of the roof of the left
ventricle. The ends are thickened to form the right and left brous
trigones.
Removed triangle
**
*
*
*
Right atrium
Base
Post.
Ant.
Apex
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:17:06 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.004
Cambridge Books Online Cambridge University Press, 2013
59
Transverse sinus
Apex of interleaflet triangle
Non-coronary leaflet
Sup.
Apex
Base
Mitral valve
Inf.
Fig. 3.13 This heart has been sectioned through the interleaet
triangle between the non-coronary and left coronary aortic
leaets, showing how the brous wall interposes between the left
ventricular outow tract and the transverse sinus (white dotted
line).
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:17:06 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.004
Cambridge Books Online Cambridge University Press, 2013
60
Non-coronary sinus
Left
Post.
Ant.
Right
Fig. 3.14 In this heart, the tip of the brous triangle between the
left coronary and non-coronary aortic valvar leaets has been
removed, and the heart photographed from the transverse sinus to
show the location of the apex of the triangle.
Base
Left
Right
Apex
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:17:06 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.004
Cambridge Books Online Cambridge University Press, 2013
61
Fig. 3.16 This heart has been dissected by removing the entirety
Sup.
Membranous septum
Right
Left
Inf.
Aorticmitral continuity
Aortic root
Mural leaflet
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:17:07 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.004
Cambridge Books Online Cambridge University Press, 2013
62
Atrial myocardium
Fibrous annulus
Ventricular myocardium
Atrial myocardium
Fibroadipose tissue
Ventricular myocardium
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:17:07 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.004
Cambridge Books Online Cambridge University Press, 2013
63
Tendon of Todaro
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:17:07 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.004
Cambridge Books Online Cambridge University Press, 2013
64
Ant.
Sup.
Inf.
Fan-shaped
cord
Aortic leaflet of
mitral valve
Post.
Mural leaflet of
mitral valve
Sup.
Left
Right
Inf.
Aortic leaflet of
mitral valve
Fig. 3.22 This anatomical specimen, viewed from the inlet aspect,
shows the aortic leaet of the mitral valve, with tendinous cords
supporting the entirety of the free edge of the valve.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:17:08 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.004
Cambridge Books Online Cambridge University Press, 2013
Base
Right
65
Aortic leaflet
of mitral valve
Left
Apex
Strut
cords
Fig. 3.24 The mural leaet of the mitral valve has been
reected upwards, showing the basal cords (arrow), each with
their own muscular belly.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:17:08 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.004
Cambridge Books Online Cambridge University Press, 2013
66
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:17:08 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.004
Cambridge Books Online Cambridge University Press, 2013
67
Superoposterior
papillary muscle
Subaortic
outflow tract
Inferoanterior
papillary muscle
Base
Left
Aortic leaflet
Right
Apex
Mural leaflet
Fig. 3.27 Opening the mitral valve through the end of the zone
of apposition between the leaets closest to the septum, and
spreading the valve, illustrates the widely dissimilar lengths of the
two leaets at their hingepoints from the atrioventricular junction.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:17:09 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.004
Cambridge Books Online Cambridge University Press, 2013
68
A1
A2
A3
P1
P2
P3
1
2
A1
A2
A3
P1
3
P2
P3
5
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:17:09 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.004
Cambridge Books Online Cambridge University Press, 2013
Posterosuperior muscle
69
Sup.
Base
Apex
Inf.
Anteroinferior muscle
Mitral
valve
Tricuspid
valve
Ant.
Left
Right
Post.
Fig. 3.31 The atrial chambers have been removed, along with the
non-adjacent sinus and leaet of the aortic valve, revealing the
deep posteroinferior diverticulum of the left ventricular outow
tract. Note the position of the atrioventricular (AV) node (red circle)
relative to the mitral valve.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:17:10 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.004
Cambridge Books Online Cambridge University Press, 2013
70
Fig. 3.32 The cartoon shows the components of the mitral valve
Dominant right
coronary artery
Circumflex artery
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:17:10 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.004
Cambridge Books Online Cambridge University Press, 2013
71
Ant.
Right
Left
Post.
Artery to AV node
Circumflex artery
Anterosuperior leaflet
Inferior
leaflet
Ant.
Inf.
Sup.
Septal leaflet
Post.
Fig. 3.34 This picture, taken in the operating room, shows the
arrangement of the three leaets of the tricuspid valve, which are
positioned septally, anterosuperiorly, and inferiorly or murally. The
latter leaet is usually described, incorrectly, as being positioned
posteriorly.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:17:11 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.004
Cambridge Books Online Cambridge University Press, 2013
72
Anterosuperior
leaflet
Inferior
leaflet
Septal
leaflet
Base
Triangle
of Koch
Apex
Inf.
Anterosuperior
leaflet
Septal
leaflet
Inferior
leaflet
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:17:11 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.004
Cambridge Books Online Cambridge University Press, 2013
Sup.
73
Right
Inf.
Antero-superior
leaflet
Inferior leaflet
Septal leaflet
Septomarginal
trabeculation
Aortic root
Mitral
valve
Tricuspid
valve
Sup.
Right
Left
Inf.
Fig. 3.38 The base of the heart is shown from the atrial aspect,
the atrial myocardium and the non-coronary sinus of the aortic
valve having been removed. The attachment of the septal leaet of
the tricuspid valve (arrow) divides the membranous septum into its
atrioventricular and interventricular components.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:17:12 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.004
Cambridge Books Online Cambridge University Press, 2013
74
Septal leaflet
Ant.
Oval fossa
defect
Inf.
Sup.
Post.
Fig. 3.39 This operative view through a right atriotomy shows the
cordal attachments (arrows) to the septum of the septal leaet of
the tricuspid valve. The patient also has a defect in the oval fossa.
Sup.
Left
Right
Inf.
Fig. 3.40 The inferior leaet of the tricuspid valve has been
reected away from the ventricular wall to show the basal cords
(arrows).
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:17:13 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.004
Cambridge Books Online Cambridge University Press, 2013
Ant.
75
Right
Left
Post.
Sup.
Left
Right
Inf.
Fig. 3.42 This image of the closed aortic valve from above shows
the three valvar leaets (1, 2, 3) coapting snugly, held together by
the diastolic pressure of the column of blood they support. The stars
mark the commissures, which are the peripheral attachments of the
zones of apposition to the sinutubular junction.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:17:14 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.004
Cambridge Books Online Cambridge University Press, 2013
76
Leaflet
Wall of aorta
Ventriculoarterial
junction
Fig. 3.43 The histological section shows the brous core of one leaet
of the aortic valves, with its endothelial linings on the arterial and
ventricular aspects. Note that the valvar hinge is well below the
anatomical ventriculoarterial junction.
Valvar hinge
Ventricular myocardium
Sup.
Crown-like configuration
Right
Left
Inf.
Fig. 3.44 The aortic root in this specimen has been dissected by
Mitral valvar orifice
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:17:14 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.004
Cambridge Books Online Cambridge University Press, 2013
77
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:17:14 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.004
Cambridge Books Online Cambridge University Press, 2013
78
Sup.
Right
Left
Inf.
Fig. 3.47 The aortic root has been displayed by removing the
leaets of the aortic valve, the outow tract between the left
coronary and the non-adjacent aortic leaets having been opened.
The two sinuses giving rise to the coronary arteries have septal
musculature at their bases (inner red arrows), while part of the left
coronary sinus, along with the non-coronary sinus, is supported by
a brous continuity with the aortic leaet of the mitral valve (outer
red arrows).
Left ventricle
Right coronary
aortic sinus
Left coronary
aortic sinus
Fig. 3.48 The heart has been photographed from above, the
Sup.
Right
Left
Non-adjacent
sinus
Right coronary artery
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:17:15 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.004
Cambridge Books Online Cambridge University Press, 2013
79
However, because the so-called noncoronary sinus can rarely give rise to one of
the coronary arteries, it can more accurately
be described as the non-adjacent sinus. It is
the right and left coronary aortic leaets
that have a predominantly muscular origin
from the left ventricular wall, the base of
the myocardium being incorporated within
the supporting aortic sinus (Figure 3.49).
These are the leaets that are adjacent to
the pulmonary trunk. Their more distal
adjacent parts take origin from the free
aortic wall, with the small interleaet
brous triangle between them separating
the cavity of the outow tract from the
tissue plane between the aortic root and the
subpulmonary infundibulum
(Figures 3.15, 3.50).
As the attachment of the right coronary
leaet is traced from its zone of apposition
with the left coronary leaet, it drops
towards the crest of the muscular part of
the septum in the area of the membranous
septum. It then rises again to the apex of
the zone of apposition with the nonadjacent leaet (Figure 3.51). The
attachment of this posterior part of the
right coronary leaet is an integral part of
the brous skeleton. All of the nonadjacent leaet has a brous origin, and is
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:17:16 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.004
Cambridge Books Online Cambridge University Press, 2013
80
Pulmonary trunk
Infundibulum
Fig. 3.50 The aortic root in this heart has been dissected from the
Base
Left
Right
Left coronary aortic leaflet
Apex
Non-coronary
aortic sinus
Right coronary
aortic sinus
Fig. 3.51 The aortic root shown in Figure 3.50 has been enlarged
to show the triangle between the right coronary aortic leaet and
the non-adjacent leaet. The base of the triangle is made up of the
membranous septum (dashed white oval), while the apex of the
triangle rises to the sinutubular junction (red triangle). The white
arrow shows the continuity with the aortic leaet of the mitral
valve, and the black asterisk indicates the right brous trigone.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:17:17 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.004
Cambridge Books Online Cambridge University Press, 2013
81
Non-coronary leaflet
Base
Right
Left
Apex
Tricuspid valve
Fig. 3.52 The dissection through the brous triangle between the
right and non-adjacent leaets of the aortic valve shows the
relations of the aortic outow tract to the right atrium (black brace)
and right ventricle. The black dotted line shows the apex of the
triangle, which separates the left ventricular outow tract from the
transverse sinus (white asterisk). The white triangle is between the
non-adjacent and left coronary aortic sinuses.
Transverse sinus
Left ventricle
Sup.
Base
Apex
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:17:17 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.004
Cambridge Books Online Cambridge University Press, 2013
82
Aortic root
Tricuspid valve
Fig. 3.54 The heart has been prepared by removing the right
Right coronary
aortic sinus
Left coronary
aortic sinus
Non-coronary aortic sinus
Atrioventricular node
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:17:18 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.004
Cambridge Books Online Cambridge University Press, 2013
83
Aorta
Pulmonary valve
Muscular infundibulum
Left
Sup.
Inf.
Right
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:17:18 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.004
Cambridge Books Online Cambridge University Press, 2013
84
Non-adjacent
component
Rightward adjacent
component
Leftward adjacent
component
Developing aortic valve
Right coronary
component
Sup.
Left
Right
Non-adjacent
component
Left coronary
component
Inf.
Aortic valve
Left
Post.
Ant.
Right
Infundibular sleeve
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:17:18 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.004
Cambridge Books Online Cambridge University Press, 2013
85
Left
Sup.
Inf.
Right
completely from the heart shown in Figure 3.59, revealing how this
can be achieved without transgressing on the left ventricle. Note
again the location of the rst septal perforating artery.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:17:19 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.004
Cambridge Books Online Cambridge University Press, 2013
86
Sup.
Excised
membranous
septum
Right
Left
Aorta
Inf.
Ant.
Sup.
Inf.
Post.
Aorta
Triangle of Koch
walls of the right atrium and ventricle having been removed. The
red line shows the course of the atrioventricular conduction axis as
it penetrates from the atrioventricular node (star) to reach the left
ventricular outow tract. The right bundle branch re-emerges on
the right side beneath the medial papillary muscle.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:17:20 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.004
Cambridge Books Online Cambridge University Press, 2013
87
Base
Ant.
Post.
Apex
Left atrium
Left
ventricle
Fig. 3.63 This cast shows the location of the great cardiac vein in
Oblique vein
Oblique vein
the left atrioventricular groove (white dotted line). The vein does
not become the coronary sinus until it receives the oblique vein of
the left atrium.
Coronary
sinus
Left
Base
Apex
Right
Middle cardiac vein
Fig. 3.64 The heart has been removed from the body, and the
diaphragmatic surface is photographed to show the course of the
coronary sinus within the inferior left atrioventricular groove. The
great cardiac vein becomes the coronary sinus at the point where it
receives the oblique vein of the left atrium.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:17:20 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.004
Cambridge Books Online Cambridge University Press, 2013
88
Coronary
sinus
Diaphragmatic
surface
of left ventricle
Left
Inf.
Sup.
Right
Mitral valvar
orifice
Ant.
L
Post.
Fig. 3.66 The heart in this image, also shown in Figure 3.41, has a
dominant right coronary artery, which gives rise to the inferior
interventricular artery, and the artery to the atrioventricular node.
As can be seen, the circumex artery is only marginally related to
the mural leaet of the mitral valve in this setting.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:17:20 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.004
Cambridge Books Online Cambridge University Press, 2013
89
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:17:21 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.004
Cambridge Books Online Cambridge University Press, 2013
Surgical anatomy
of the coronary
circulation
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:22:10 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.005
Cambridge Books Online Cambridge University Press, 2013
Base
Left
Right
Apex
Aorta
Removed infundibulum
91
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:22:10 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.005
Cambridge Books Online Cambridge University Press, 2013
92
Ant.
Base
Apex
Post.
Non-coronary sinus
Left
Post.
Ant.
Right
Non-adjacent sinus
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:22:10 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.005
Cambridge Books Online Cambridge University Press, 2013
93
Left hand
No.2
Right hand
No.1
Tubular aorta
Sup.
Right coronary aortic sinus
Ant.
Post.
Inf.
Fig. 4.5 The computed tomogram shows the right and left aortic
sinuses as viewed from behind. It shows the usual situation in
which the coronary arteries arise within the sinuses, proximal to the
sinutubular junction (red dashed line).
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:22:10 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.005
Cambridge Books Online Cambridge University Press, 2013
94
Sup.
Right coronary artery
Right
Left
Inf.
Fig. 4.6 In this heart, the aortic valve has been opened and the
aortic root photographed from behind to show the right and left
aortic sinuses. The right coronary artery arises well above the
sinutubular junction.(Reproduced by kind permission of Professor
Anton Becker, University of Amsterdam.)
Intramural course of
right coronary artery
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:22:10 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.005
Cambridge Books Online Cambridge University Press, 2013
Fig. 4.8 The tubular aorta has been removed at the level of the
Sup.
Left
Right
Right aortic sinus
Inf.
Sup.
Ant.
95
Post.
Fig. 4.9 In this heart, the right coronary artery has a separate
Left aortic sinus
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:22:11 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.005
Cambridge Books Online Cambridge University Press, 2013
96
Sup.
Ant.
Post.
Inf.
Left
Sup.
Inf.
Right
Pulmonary trunk
Aorta
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:22:11 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.005
Cambridge Books Online Cambridge University Press, 2013
97
Sup.
Left
Right
Inf.
Circumflex artery
Infundibulum
Aortic root
Sup.
Ant.
Post.
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:22:11 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.005
Cambridge Books Online Cambridge University Press, 2013
98
Sup.
Left
Right
Right coronary artery
Inf.
Fig. 4.14 The computed tomogram shows the main stem of the
left coronary artery arising from a solitary coronary artery, which
itself arises from the right coronary aortic sinus. The left coronary
artery extends deeply within the crest of the ventricular septum
(black double-headed arrow) before dividing into its anterior
interventricular and circumex branches.
Sup.
Left
Right
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:22:11 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.005
Cambridge Books Online Cambridge University Press, 2013
99
Sup.
Ant.
Post.
Inf.
Aortic root
Infundibulum
Left
Apex
Infundibulum
Base
Right
Aorta
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:22:11 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.005
Cambridge Books Online Cambridge University Press, 2013
100
Aorta
Sup.
Right
Left
Inf.
Right
Post.
Ant.
Left
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:22:12 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.005
Cambridge Books Online Cambridge University Press, 2013
Sup.
101
Left
Inf.
Aorta
Superior
caval vein
Left
Sup.
Inf.
Right
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:22:12 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.005
Cambridge Books Online Cambridge University Press, 2013
102
Surgical incision
Ant.
Apex
Base
Post.
Sup.
Main stem of left coronary artery
Ant.
Post.
Inf.
Aorta
Circumflex artery
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:22:12 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.005
Cambridge Books Online Cambridge University Press, 2013
103
Circumflex artery
Sup.
Ant.
Inf.
Intermediate artery
Base
Ant.
Post.
Apex
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:22:13 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.005
Cambridge Books Online Cambridge University Press, 2013
104
Sup.
Base
Apex
Inf.
Aorta
Left ventricle
Sup.
Ant.
Post.
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:22:13 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.005
Cambridge Books Online Cambridge University Press, 2013
105
Ant.
Left
Right
Post.
Base
Right
Left
Apex
Circumflex artery
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:22:13 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.005
Cambridge Books Online Cambridge University Press, 2013
106
Sup.
Right
Left
Inf.
Anterior
interventricular
artery
Anterocaval course
Origin from
circumflex artery
the variations in the origin of the artery to the sinus node, and the
variability relative to the cavoatrial junction. The left-hand panels
show the usual arrangement with the origin from the right
coronary artery, found in 55% of the population, with the rare
variant of a distal origin with coursing across the appendage (lower
left-hand panel). The right-hand panels show a proximal origin
from the circumex artery, found in around 45% of the population,
with the rare variant of a distal origin with coursing across the
dome of the left atrium. The middle panels show the variation
relative to the superior cavoatrial junction. The sinus node is shown
in green.
Retrocaval course
Arterial circle
Distal origin from right
coronary artery
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:22:14 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.005
Cambridge Books Online Cambridge University Press, 2013
107
Sup.
Left
Oblique
vein
Right
Inf.
Great
vein
Small vein
Middle vein
Coronary sinus
Coronary
sinus
Diaphragmatic surface
of left ventricle
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:22:14 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.005
Cambridge Books Online Cambridge University Press, 2013
108
Sup.
Ant.
Post.
Inf.
Mitral valve
Fig. 4.34 In this heart, the musculature of the atrial walls has
Coronary sinus
been removed to show the course of the coronary sinus within the
left atrioventricular groove. It opens into the right atrium at the
base of the triangle of Koch (black double-headed arrow).
Thebesian valve
Left
Sup.
Inf.
Right
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:22:14 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.005
Cambridge Books Online Cambridge University Press, 2013
109
Oblique vein
Coronary sinus
Sup.
Apex
Fig. 4.36 This preparation was made by casting the coronary sinus
with silastic, the heart then being photographed from behind in
anatomical orientation. The great cardiac vein is seen entering
the coronary sinus. The location of the site of drainage of the
oblique vein marks the point at which the great vein becomes the
coronary sinus.
Base
Inf.
Aorta
Sup.
Ant.
Post.
Thoracic duct
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:22:14 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.005
Cambridge Books Online Cambridge University Press, 2013
110
References cited
1. Gittenberger-de Groot AC, Sauer U,
Oppenheimer-Dekker A, Quaegebeur J.
Coronary arterial anatomy in transposition of
the great arteries: a morphologic study.
Pediatr Cardiol 1983; 4(Suppl 1): 1524.
2. Neufeld HN, Schneeweiss A. Coronary
Artery Disease in Infants and Children.
Philadelphia, PA: Lea & Febiger 1983; pp
7375.
3. Bader G. Beitrag zur Systematic und
Haugkeit der Anomalien der
Coronararterien des Menschen.Virch Arch
Path Anat 1963; 337: 8896.
4. Kaushal S, Backer CL, Popescu AR, et al.
Intramural coronary length correlates with
symptoms in patients with anomalous aortic
6.
7.
8.
9.
10.
11.
12.
13.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:22:14 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.005
Cambridge Books Online Cambridge University Press, 2013
Surgical anatomy
of the conduction
system
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:26:04 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.006
Cambridge Books Online Cambridge University Press, 2013
112
LANDMARKS TO THE
ATRIOVENTRICULAR
CONDUCTION AXIS
In patients with intractable tachycardia, it
may be necessary to ablate the
Left
Sup.
Inf.
Right
Tendon of Todaro
Coronary sinus
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:26:04 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.006
Cambridge Books Online Cambridge University Press, 2013
113
Septal leaflet
Left
Inf.
Sup.
Tendon of Todaro
Right
Atrial
septum
Mitral
valve
Ventricular
septum
Bundle of His
Tricuspid
valve
VENTRICULAR PRE-EXCITATION
Ventricular pre-excitation is a frequent
problem of cardiac rhythm that necessitates
knowledge of the pertinent anatomy for its
optimal treatment. The arrhythmia occurs
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:26:04 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.006
Cambridge Books Online Cambridge University Press, 2013
114
Atrial myocardium
Base
Apex
Ventricular myocardium
Left
Base
Apex
Right
Ventricular septum
Septal leaflet of
tricuspid valve
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:26:04 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.006
Cambridge Books Online Cambridge University Press, 2013
115
Membranous septum
Ant.
Sup.
Inf.
Post.
Aorta
Fig. 5.7 The dissection was made by removing the parietal walls
Triangle of Koch
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:26:04 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.006
Cambridge Books Online Cambridge University Press, 2013
116
Atrial wall
Ventricular wall
Base
Right
Left
Apex
Annulus
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:26:04 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.006
Cambridge Books Online Cambridge University Press, 2013
117
Atrium
Node
Ventricle
Valve
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:26:05 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.006
Cambridge Books Online Cambridge University Press, 2013
118
Left
Ant.
Post.
Right
Aorta
Tricuspid
valvar
orifice
Left
Apex
Base
Ventricular septum
Right
Atrial myocardium
Accessory AV connection
Lumen
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:26:05 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.006
Cambridge Books Online Cambridge University Press, 2013
119
Artery to AV node
Membranous septum
Right atrium
Left atrium
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:26:05 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.006
Cambridge Books Online Cambridge University Press, 2013
120
Triangle of Koch
Oval fossa
Sup.
Fig. 5.14 The photograph shows the site of ablation at the base of
Post.
Ant.
Site of ablation
Inf.
Sup.
Left
Right
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:26:05 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.006
Cambridge Books Online Cambridge University Press, 2013
Accessory AV connection
Node of Kent
Left
Apex
Base
121
Ventricular myocardium
Right
Terminal crest
Fig. 5.16 The section is taken across the right atrioventricular (AV)
junction, and comes from the heart of a patient who had ventricular
pre-excitation. The tricuspid valve was deformed by Ebsteins
malformation. An accessory muscular connection was identied
taking origin from a nodal remnant as identied by Kent, and
crossing the insulating plane to run within the muscularised leaet
of the tricuspid valve.(Section reproduced by kind permission of
Professor Anton Becker, University of Amsterdam.)
Sup.
Left
Right
Inf.
Septal isthmus
Cavotricuspid isthmus
Fig. 5.17 The right atrium has been opened and photographed in
anatomical orientation to show the circuit (arrows) known to be
responsible for the common variant of atrial utter. The utter
wave descends the terminal crest, crosses through the inferior
cavotricuspid isthmus, and then ascends through the septal isthmus
to reach the superior aspect of the terminal crest before
recommencing the circuit.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:26:05 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.006
Cambridge Books Online Cambridge University Press, 2013
122
Coronary sinus
Sup.
Ant.
Post.
Inf.
Oval fossa
Tricuspid valve
Posterior
Fig. 5.18 The right atrium has been opened through the parietal
wall, and photographed in anatomical orientation to show the
structure of the inferior cavotricuspid isthmus. It has posterior,
middle, and anterior components (black braces).
Anterior
Middle
Posterior-Fibrous
Anterior-Smooth
Middle-Pectinated
Tricuspid valve
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:26:05 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.006
Cambridge Books Online Cambridge University Press, 2013
123
Fig. 5.20 The dissection, made by Professor Damien SanchezQuintana, shows the dome of the left atrium, the epicardium
having been removed to illustrate the organisation of the
myocardial bres. Sleeves of myocardium (arrows) can be seen to
extend onto the pulmonary veins for varying distances. These
sleeves are now known to be the sources of focal activity in some
variants of atrial brillation.
Fig. 5.21 The pulmonary root has been opened, and the valvar
Semilunar hinges of
pulmonary valvar
leaflets
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:26:05 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.006
Cambridge Books Online Cambridge University Press, 2013
124
Fig. 5.22 The aortic root has been opened, and the valvar leaets
removed. There is muscle at the base of the two aortic valvar sinuses
giving rise to the coronary arteries (stars), but not in the nonadjacent sinus.
Amputated
right appendage
Tricuspid valve
Coronary sinus
Oval fossa
Fig. 5.23 The cartoon shows the lesions made within the right
Superior caval vein
ARRHYTHMIA SURGERY IN
PATIENTS WITH CONGENITAL
HEART DISEASE
As patients get older, subsequent to surgical
correction of congenital cardiac lesions,
increasing numbers present with arrhythmic
problems33. The enhanced understanding of
the macro-re-entrant circuits responsible for
the abnormal rhythms has led to
modications of surgical techniques.
Advances in the design of pacemakers and
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:26:06 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.006
Cambridge Books Online Cambridge University Press, 2013
125
Right
Sup.
Inf.
Left
Cryothermy lesion
Aorta
Tricuspid atresia
Coronary sinus
Cryocath probe
Pulmonary trunk
Fig. 5.25 The cartoon shows the lesions producing the right
Cannula in superior
caval vein
Cannula in inferior
caval vein
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:26:06 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.006
Cambridge Books Online Cambridge University Press, 2013
126
Aorta
Amputated left
appendage
Tricuspid valve
Mitral valve
Pulmonary trunk
Fig. 5.26 The cartoon shows the lesions produced in the third
Cannula in superior
caval vein
Cannula in inferior
caval vein
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:26:06 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.006
Cambridge Books Online Cambridge University Press, 2013
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:26:06 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.006
Cambridge Books Online Cambridge University Press, 2013
127
Analytical description
of congenitally
malformed hearts
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:33:07 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.007
Cambridge Books Online Cambridge University Press, 2013
icu
lar
Arterial
trunks
ria
rte
loa
icu
iov
Atr
ntr
tr
en
ATRIAL ARRANGEMENT
Ve
Atriums
129
Fig. 6.1 The cartoon shows the three segments of the heart. These
Ventricles
are the atriums, the ventricular mass, and the arterial trunks. The
segments are joined together at the atrioventricular and
ventriculoarterial junctions.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:33:07 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.007
Cambridge Books Online Cambridge University Press, 2013
130
Triangular appendage
Sup.
Right
Left
Inf.
Sup.
Post.
Ant.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:33:07 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.007
Cambridge Books Online Cambridge University Press, 2013
131
Left
Sup.
Inf.
Right
Septum spurium
Sup.
Ant.
Post.
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:33:07 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.007
Cambridge Books Online Cambridge University Press, 2013
132
Pulmonary veins
Sup.
Post.
Ant.
Inf.
Mirror-imaged
Usual
Isomeric right
Isomeric left
Fig. 6.7 The cartoon shows the four possible arrangements of the
atrial appendages, which cannot always be distinguished on the
basis of their shape. The best means of distinguishing between
them is to establish the extent of the pectinate muscles. These
muscles extend all the way to the crux in the morphologically right
atrial appendage, but are conned around the mouth of the
appendage in the morphologically left atrial appendage, leaving a
smooth posterior vestibule. Using this criterion, all congenitally
malformed hearts have appendages tting within one of the four
groups shown in the cartoon.
THE ATRIOVENTRICULAR
JUNCTIONS
Having established the arrangement of the
atrial appendages, the next step in
sequential analysis is to determine the
morphology of the atrioventricular
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:33:07 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.007
Cambridge Books Online Cambridge University Press, 2013
133
Left
Inf.
Sup.
Right
Left
Sup.
Inf.
Right
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:33:07 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.007
Cambridge Books Online Cambridge University Press, 2013
134
Left
Post.
Coarse right
ventricular
trabeculations
Ant.
Right
Fig. 6.10 The apical part of the normal ventricular mass has been
amputated, and is viewed from above. It shows the marked
difference between the ne apical trabeculations of the
morphologically left ventricle when compared to the coarse right
ventricular apical trabeculations.
Right-hand topology
Left-hand topology
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:33:08 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.007
Cambridge Books Online Cambridge University Press, 2013
Usual arrangement
Mirror-imaged pattern
Concordant
Concordant
135
Fig. 6.12 The cartoon shows how the atrial chambers can be
Discordant
Discordant
Right isomerism
Left isomerism
Right-hand topology
Right-hand topology
Left-hand topology
Left-hand topology
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:33:08 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.007
Cambridge Books Online Cambridge University Press, 2013
136
Left atrium
Right atrium
Sup.
Right
Left
Fig. 6.14 When both atriums are connected to only one ventricle,
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:33:08 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.007
Cambridge Books Online Cambridge University Press, 2013
137
Sup.
Right
Left atrium
Left
Inf.
Right AV groove
Left atrium
Right atrium
Sup.
Left
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:33:08 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.007
Cambridge Books Online Cambridge University Press, 2013
138
LA
RA
RV
LV
Absent AV connection
Usual
Mirror-imaged
Right isomerism
Left isomerism
Solitary and
indeterminate
ventricle
Dominant right
with incomplete LV
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:33:08 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.007
Cambridge Books Online Cambridge University Press, 2013
139
Sup.
Aorta
Left
Right
Inf.
VSD
Sup.
Right
Left
Aorta
Inf.
VSD
univentricular atrioventricular
connection, in which the only septal
structure in the ventricle is that
separating the outow tracts.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:33:08 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.007
Cambridge Books Online Cambridge University Press, 2013
140
Left
atrium
Right
atrium
Sup.
Left
Right
Inf.
To pulmonary trunk
Coarse apical
trabeculations
Left AV
valve
To aorta
Sup.
Right AV
valve
Right
Inf.
VALVAR MORPHOLOGY
The atrioventricular valvar morphology is
independent of the way in which the atrial
chambers connect with the ventricles. Valvar
morphology, therefore, constitutes a separate
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:33:08 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.007
Cambridge Books Online Cambridge University Press, 2013
141
Base
Left
Right
Apex
Left
atrium
Right
atrium
Left
ventricle
Right
ventricle
Sup.
Left
Right
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:33:08 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.007
Cambridge Books Online Cambridge University Press, 2013
142
Sup.
Left
Right
Inf.
Left
atrium
Left atrium
Right atrium
Base
Left
Right
Apex
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:33:08 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.007
Cambridge Books Online Cambridge University Press, 2013
143
LA
RA
LA
RV
RV
LV
LV
Straddling tricuspid
valve with doubleinlet left ventricle
Straddling
tricuspid valve
concordant AV
connections
VENTRICULAR MORPHOLOGY
AND TOPOLOGY
The nature of the atrioventricular
connections is inextricably linked with the
architectural arrangement of the
ventricular mass. Biventricular
atrioventricular connections, for example,
cannot be diagnosed without knowledge of
ventricular morphology. Double-inlet and
absent connections can all be identied
without mention of ventricular
morphology, although in this setting it is
always necessary to give more information
concerning the arrangement of the
ventricular mass. In the case of mixed and
biventricular atrioventricular connections,
it is important to describe the pattern in
which the morphologically right ventricle
is structured relative to the
morphologically left ventricle. This feature
can take only one of two topological
arrangements. This is because, when the
connections are mixed, the right-sided
atrium, with either a morphologically right
VENTRICULAR RELATIONSHIPS
Ventricular relationships, as opposed to
ventricular topology, generally should be
described as a separate feature of the heart.
Where each atrium is connected to its own
ventricle, the relationships are almost
always in harmony with both the
connection and topology present. When
the atrial chambers are in their usual
position with concordant atrioventricular
connections, the relationships described in
the setting of the heart within the chest are
almost always for the morphologically right
ventricle to be right-sided, anterior, and
inferior to the morphologically left
ventricle. In mirror-imaged atrial
arrangement, with concordant
atrioventricular connections, the
morphologically right ventricle is almost
invariably left-sided and relatively anterior,
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:33:09 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.007
Cambridge Books Online Cambridge University Press, 2013
144
Sup.
Aorta
Post.
Ant.
Inf.
Outlet
Fig. 6.28 The left side of the heart is shown from a patient with
Inlet
Outlet
Inlet
Fig. 6.29 The computed tomogram shows the right side of the
Apical trabecular component
Sup.
Ant.
Post.
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:33:09 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.007
Cambridge Books Online Cambridge University Press, 2013
145
Aorta
Pulmonary
trunk
Common
arterial trunk
underscores the anomaly known as the crisscross heart14. With these hearts, and also
those with superoinferior ventricles,
connections and relationships must be
described separately, using as much detail as
is necessary to achieve unambiguous
categorisation. The essence of the criss-cross
heart, and those with superoinferior
ventricles, is that the ventricular
relationships are not as expected for the
atrioventricular connection present. Even
more rarely, the ventricular topology may be
disharmonious with the atrioventricular
connection15. All features must then be
described.
In hearts with a univentricular
atrioventricular connection, it is the
relationship of the incomplete ventricle to
the dominant ventricle that must be
described. When the left ventricle is
dominant, the incomplete right ventricle is
always anterosuperior, but can be right- or
left-sided. The sidedness of the ventricle
does not affect the basic disposition of the
atrioventricular conduction tissues in these
hearts. With a dominant right ventricle, the
incomplete and rudimentary left ventricle,
if present, is always posteroinferior, but
again can be right- or left-sided. In this
case, the sidedness of the incomplete
ventricle will affect the disposition of the
atrioventricular conduction tissue.
When considering the atrioventricular
junctions, therefore, there are four
different features to take into account.
These are, rstly, the way the atrial
myocardium is connected to the ventricular
mass; secondly, the morphology of the
atrioventricular valves guarding the
junctions; thirdly, the ventricular
morphology and topology; and nally, the
Solitary
arterial trunk
VENTRICULOARTERIAL
JUNCTIONS
Analysis of the ventriculoarterial
junctions proceeds as described for the
atrioventricular junctions, with the
morphology of the connections, the
valvar morphology, and the relationships
of the arterial trunks being different
facets requiring separate description in
mutually exclusive terms. It is also
necessary to take account of infundibular
morphology.
Ventriculoarterial connections
There are four discrete ways in which the
arterial trunks can take their origin from
the ventricular mass; namely, in
concordant, discordant, double-outlet, and
single-outlet fashion. Concordant
ventriculoarterial connections exist when
the arterial trunks arise from
morphologically appropriate ventricles.
Discordant connections account for the
trunks being connected with
morphologically inappropriate ventricles.
Double-outlet connections exist when both
great arteries take origin from the same
ventricle, which may be of right, left, or
indeterminate morphology. A single-outlet
arrangement is seen when only one arterial
trunk is connected to the heart. This may
be a common trunk, directly supplying the
systemic, pulmonary, and coronary
Infundibular morphology
Describing the morphology at the
ventriculoarterial junctions also involves
the arrangement of the musculature within
the ventricular outow tracts. This is
infundibular morphology. Although the
outlet regions are integral parts of the
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:33:09 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.007
Cambridge Books Online Cambridge University Press, 2013
146
Pulmonary
valve
Outlet
septum
Aortic
valve
SMT
Sup.
Left
Right
Ventriculoinfundibular fold
Inf.
Interventricular communication
Outlet septum
Pulmonary valve
Parietal
attachment
Septal
attachment
Sup.
Ant.
Post.
Ventriculoinfundibular fold
Inf.
Fig. 6.32 The image shows the outow tracts in a heart with
tetralogy of Fallot, viewed from the apex of the right ventricle,
with the aortic valve (star) overriding the crest of the muscular
ventricular septum, which is reinforced by the septomarginal
trabeculation, or septal band (white Y). The septal and parietal
attachments of the muscular outlet septum are well seen.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:33:09 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.007
Cambridge Books Online Cambridge University Press, 2013
Outlet
septum
Aortic
valve
Sup.
Post.
Ventriculoinfundibular fold
Inf.
Aortic
valve
SMT
Outlet
septum
Pulmonary
valve
Tricuspid
valve
Sup.
Post.
Ant.
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:33:10 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.007
Cambridge Books Online Cambridge University Press, 2013
147
148
Supraventricular crest
Pulmonary
valve
Tricuspid
valve
Sup.
Left
Right
Inf.
CATALOGUE OF
MALFORMATIONS
Having described the template of the heart,
and its position, nally it is necessary to
catalogue all intracardiac malformations. In
most cases, it is these lesions which will
require surgical attention. Any lesion,
nonetheless, cannot be presumed to be the
only lesion present until the rest of the
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:33:10 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.007
Cambridge Books Online Cambridge University Press, 2013
149
anterior
right
anterior
left
anterior
left
side-by-side
right
side-by-side
Pulmonary trunk
right
posterior
normal
left
posterior
posterior
6.
References cited
1. Shinebourne EA, Macartney FJ, Anderson
RH. Sequential chamber localization:
the logical approach to diagnosis in
congenital heart disease. Br Heart J 1976; 38:
327340.
2. Anderson RH, Wilcox BR. Understanding
cardiac anatomy: the prerequisite for optimal
cardiac surgery. Ann Thorac Surg 1995; 59:
13661375.
3. Van Praagh R. The segmental approach to
diagnosis in congenital heart disease. In:
Bergsma D (ed). Birth defects original article
series, Vol. VIII, No. 5. The Fourth
Conference on the Clinical Delineation of Birth
Defects. Part XV The Cardiovascular System.
The National Foundation March of Dimes.
Baltimore, MD: Williams and Wilkins, 1972;
pp 423.
4. Anderson RH, Ho SY. Continuing Medical
Education. Sequential segmental analysis
description and categorization for the
millennium. Cardiol Young 1997; 7:
98116.
5. Uemura H, Ho SY, Devine WA, Kilpatrick
LL, Anderson RH. Atrial appendages and
7.
8.
9.
10.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:33:10 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.007
Cambridge Books Online Cambridge University Press, 2013
Lesions with
normal segmental
connections
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:42:16 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
SEPTAL DEFECTS
Understanding the anatomy of septal
defects is greatly facilitated if the heart
is thought of as having three distinct
septal structures: the atrial septum,
the atrioventricular septum, and the
ventricular septum (Figure 7.1). The
normal atrial septum is relatively small. It is
made up, for the most part, by the oor
of the oval fossa. When viewed from the
right atrial aspect, the fossa has a oor,
surrounded by rims. The oor is derived
from the primary atrial septum, or septum
primum. Although often considered to
represent a secondary septum, or septum
secundum, the larger parts of the rims,
specically the superior, anterosuperior,
and posterior components, are formed by
infoldings of the adjacent right and left
atrial walls. Inferoanteriorly, in contrast,
the rim of the fossa is a true muscular
septum (Figure 7.2). This part of the rim is
contiguous with the atrioventricular
septum, which is the superior component
of the brous membranous septum. In the
normal heart, this brous septum is also
contiguous with the atrial wall of the
151
Atrial septum
Ventricular septum
Sup.
Left
Right
AV separating structures
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:42:17 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
152
Sup.
Left
Right
Inf.
Fig. 7.2 The heart has been sectioned in the four-chamber plane,
showing that the superior rim of the oval fossa is a deep
infolding (arrow) between the origin of the superior caval vein
from the right atrium (red star), and the entry of the right superior
pulmonary vein into the left atrium (white star). It is the oor of
the oval fossa, along with the anteroinferior muscular buttress,
which are the components of the atrial septum.
Tricuspid valve
Triangle of Koch
Apex
Inf.
Sup.
Base
Fig. 7.3 The surgical view, through a right atriotomy, shows the
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:42:17 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
153
Anteroinferior buttress
Sup.
Right
Left
Inf.
Adipose tissue
Base
Post.
Ant.
Outlet component
Apex
Apical trabecular
component
Inlet component
Membranous septum
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:42:18 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
154
Base
Left
Infundibular sleeve
Pulmonary trunk
Base
Post.
Ant.
Aortic root
Apex
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:42:18 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
155
Infundibular sleeve
Pulmonary valve
Aortic root
Sup.
Ant.
Post.
Inf.
Ventriculoinfundibular fold
Septomarginal trabeculation
Supraventricular crest
Septoparietal
trabeculations
Moderator band
Fig. 7.9 The septal surface of the right ventricle has been
Base
Ant.
Post.
Apex
Interatrial communications
There are several lesions that permit
interatrial shunting (Figure 7.10).
Although collectively termed atrial septal
defects, not all are within the connes of
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:42:19 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
156
Vestibular
defect
Atrioventricular
septal defect
Apex
Sup.
Inf.
Coronary
sinus defect
Base
Superior sinus
venosus defect
Inferior sinus
venosus defect
Oval fossa defect
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:42:20 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
157
Apex
Sup.
Inf.
Base
Apex
Sup.
Inf.
Base
Fig. 7.12 The surgical view through a right atriotomy shows three
perforations (arrows) in the ap valve of the oval fossa.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:42:20 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
158
Apex
Inf.
Sup.
Fig. 7.13 The surgical view through a right atriotomy shows the
Base
Sup.
Artery to sinus node
Ant.
Post.
Inf.
Aortic root
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:42:21 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
Infundibulum
Aortic root
Right atrium
Left atrium
Apex
Sup.
Inf.
Base
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:42:22 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
159
160
Sup.
Ant.
Post.
Inf.
Oval fossa
Coronary sinus
Apex
Sup.
Base
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:42:22 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
161
Sup.
Ant.
Post.
Inf.
Atrial septum
Left atrium
the mouth of the superior caval vein overrides the crest of the
atrial septum in the setting of a superior sinus venosus defect. Note
that the right pulmonary veins drain anomalously to the superior
caval vein while retaining their left atrial connection (white doubleheaded arrow).
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:42:22 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
162
Sup.
Post.
Ant.
Inf.
Oval fossa
Apex
Inf.
Sup.
Base
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:42:23 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
Sinus node
163
Apex
Inf.
Sup.
Base
Pericardium
Base
Ant.
Post.
Apex
Fig. 7.24 The heart is shown from the left side in anatomical
Unroofed coronary sinus
Mitral valve
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:42:23 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
164
Left atrial
appendage
Left atrium
Sup.
Orifice of SCV
Ant.
Post.
Oval fossa
Inf.
Fig. 7.26 The right atrium from the heart illustrated in Figure 7.24
Eustachian valve
Interatrial communication
through mouth of coronary sinus
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:42:23 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
165
Sup.
Right
Left
Inf.
Right atrium
Left atrium
Right ventricle
Left ventricle
orientation, shows a common atrioventricular junction (doubleheaded arrow) guarded by a common atrioventricular valve in a
heart with decient atrioventricular septation. The black brace
shows the atrioventricular septal defect, between the leading edge
of the atrial septum and the crest of the muscular ventricular
septum (stars).
Apex
Sup.
Inf.
Shunting through
perimembranous VSD
Base
Intact atrioventricular
membranous septum
Atrioventricular
conduction axis
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:42:24 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
166
Aortic root
Left ventricle
Right atrium
Sup.
Right
Left
Inf.
Apex
Sup.
Intact interventricular
membranous septum
Inf.
Base
Atrioventricular
conduction axis
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:42:24 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
167
Apex
Sup.
Inf.
Right atrium
Base
Tricuspid valve
Apex
Competent tricuspid valve
Inf.
Sup.
Base
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:42:25 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
168
Sup.
Right
Left
Inf.
Fig. 7.33 This normal heart has also been sectioned in fourchamber orientation. It shows the right and left atrioventricular
junctions (double-headed arrows with red borders) guarded by
separate atrioventricular valves (compare with Figure 7.27). The
white double-headed arrow shows the separating atrioventricular
structures.
Sup.
Ant.
Post.
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:42:28 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
Apex
169
Sup.
Base
Coronary sinus
Fig. 7.35 This view through a right atriotomy shows the surgeons
view of the atrial septal surface in a heart with an
atrioventricular septal defect and separate right and left
atrioventricular orices, or the ostium primum defect. Kochs
triangle is well formed (red star), but no longer contains the
atrioventricular node. The node is displaced posteroinferiorly to
the apex of a new nodal triangle (white star). The three dashed
lines show the options for placement of sutures so as to avoid
traumatising the atrioventricular conduction axis. The green line
runs directly from the inferior bridging leaet to the inferior
margin of the leading edge of the atrial septum. The yellow line
courses from the inferior bridging leaet to the right side of the
atrioventricular node and skirts the margins of the coronary sinus,
keeping the orice of the sinus to its right side. The blue line
courses to the right side of the atrioventricular node, but is placed
so as to leave the coronary sinus draining to the left atrium.
Inf.
Base
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:42:29 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
170
Branching AV bundle
Analogue of triangle of Kochdoes not contain AV node
Atrioventricular (AV) node
Coronary sinus
Atrial septum
Anterosuperior leaflet
Bridging leaflets
Apex
Inf.
Sup.
Left mural leaflet
Base
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:42:30 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
Anterosuperior leaflet
Superior bridging leaflet
171
Sup.
Right
Left
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:42:31 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
172
Zone of apposition
Apex
Inf.
Sup.
Base
Fig. 7.40 This operative view through a right atriotomy shows the
typical trifoliate formation of the left atrioventricular valve in a
heart with a decient atrioventricular septation and common
atrioventricular junction. It bears no resemblance to the formation
of the leaets as seen in the normal mitral valve. Note the extensive
zone of apposition between the two leaets that bridge the
ventricular septum (dashed white double-headed arrow).
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:42:32 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
173
Aorta
Mitral valve
Fig. 7.41 This view of the left ventricle, taken from the apex with
the ventricular mass sectioned in its short axis, shows the
interrelationship of the normal mitral valve and the outow tract
to the aorta. Note the oblique position of the papillary muscles
supporting the solitary zone of apposition between the leaets of
the mitral valve, along with the extensive space between the aortic
leaet of the mitral valve and the septal surface of the left
ventricle (star).
Sup.
Left
Right
Inf.
Sup.
Left
Right
Inf.
Fig. 7.42 This view of the left atrioventricular valve and the
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:42:32 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
174
Inferior leaflet
Anterosuperior leaflet
Fig. 7.43 The image shows the location of the line of coaptation
Sup.
Ant.
Post.
Inf.
Rastelli Type A
Medial papillary muscle
Sup.
Right
Left
Inf.
Anterior muscle
Rastelli Type B
Rastelli Type C
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:42:33 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
175
Inferior leaflet
Anterosuperior leaflet
Superior bridging leaflet
Sup.
Post.
Ant.
Inf.
Anterosuperior leaflet
Sup.
Ant.
Post.
Anomalous apical PM
Inferior leaflet
Inf.
Figures 7.43 and 7.45, but showing only the right ventricular
component of the superior bridging leaet, illustrates the Rastelli
Type C arrangement. Its line of coaptation with the anterosuperior
leaet of the right ventricle has moved even further into the right
ventricle (white arrow), with a concomitant decrease in size of the
anterosuperior leaet. The papillary muscle (PM) supporting the
line of coaptation is further towards the apex of the right ventricle.
The star shows the location of the muscular ventricular septum.(The
image is reproduced by kind permission of Mr. Bill Devine,
Childrens Hospital of Pittsburgh.)
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:42:34 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
176
Anterosuperior leaflet
Sup.
Right
Left
Inf.
Apex
Sup.
Inf.
Base
Fig. 7.48 This view, taken through a right atriotomy, shows the
trifoliate conguration of the left atrioventricular valve
subsequent to repair of the zone of apposition between the left
ventricular components of the bridging leaets (dashed black
double-headed arrow). Even after the surgical repair, the valve has
no similarity to the normal mitral valve (see Figure 7.49).
characteristics of a common
atrioventricular valve, rather than tricuspid
and mitral valves (Figures 7.517.55). The
potential also exists, nonetheless, for the
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:42:36 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
177
Aortic leaflet
Sup.
Right
Left
Mural leaflet
Inf.
Sup.
Left
Right
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:42:38 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
178
Right atrium
Left atrium
Right
Inf.
Oval
fossa
Sup.
Left
Inf.
the right side. The defect permits shunting at the ventricular level
only, because although the leaets of the atrioventricular valve
form a bridge across the crest of the ventricular septum into the left
ventricle, the atrial septum is intact (star).
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:42:39 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
179
Sup.
Left
Right
Inf.
Mural leaflet
Fig. 7.53 The image shows the left-sided aspect of another heart
with decient atrioventricular septation and a common
atrioventricular junction. This picture clearly shows the
attachments of the bridging leaets to the leading edge of the
atrial septum, conning shunting at the ventricular level. Note the
typical conguration of the left ventricular outow tract (star).
Apex
Inf.
Sup.
Base
Fig. 7.54 This picture, taken in the operating room, shows the
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:42:41 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
180
Apex
Inf.
Sup.
Base
Ventricular
septal defect
Fig. 7.55 This image shows how, when the surgeon separated
Atrial component
Sup.
Ant.
Post.
Ventricular component
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:42:41 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
181
Sup.
Post.
Ant.
Inf.
Fig. 7.57 A normal heart is shown from the left side, the parietal
wall of the left ventricle having been removed. There is equality in
the inlet (blue double-headed arrow) and outlet (red doubleheaded arrow) dimensions of the ventricular septum, along with
the midseptal dimension (yellow double-headed arrow). (Compare
with Figure 7.58.)
Sup.
Post.
Ant.
Inf.
Fig. 7.58 The valvar leaets have been removed from the
ventricular mass in this heart with decient atrioventricular
septation and a common atrioventricular junction. The heart is
viewed from the left side and shown in anatomical orientation.
Because the leaets have been removed, there is no way of
knowing whether, originally, there was a common atrioventricular
orice, or separate valvar orices for the right and left ventricles.
Note the scooping of the ventricular septum (yellow doubleheaded arrow), and the disproportion between inlet (blue doubleheaded arrow) and outlet (red double-headed arrow) dimensions
of the ventricular mass.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:42:43 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
182
Sup.
Ant.
Post.
Inf.
Atrioventricular node
Sup.
Post.
Ant.
Inf.
Fig. 7.60 The photograph shows the left ventricular aspect of the
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:42:44 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
183
Sup.
Post.
Ant.
Inf.
Bridging leaflets
Sup.
Post.
Ant.
Inf.
from the left side (compare with Figure 7.61), the outow tract
(black double-headed arrow) is much shorter in the presence of a
common atrioventricular valvar orice. The star shows the zone of
apposition between the bridging leaets.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:42:46 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
184
Sup.
Left
Right
Inf.
Sup.
Left
Right
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:42:48 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
Plane of
atrial septum
185
Sup.
Right
Left
Inf.
Left
ventricle
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:42:49 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
186
Apex
Inf.
Sup.
Base
Fig. 7.67 This view through a right atriotomy, and across the
orice of the tricuspid valve, shows a hole between the
ventricles that is enclosed by the walls of the muscular ventricular
septum (star).
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:42:50 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
187
Fibrous continuity
Apex
Inf.
Sup.
Coronary
sinus
Base
Limbs of septomarginal
trabeculation
Pulmonary valve
Base.
Right
Left
Apex
Aortic valve
shows a hole between the ventricles that, at its cranial border, has
brous continuity between the leaets of the aortic and pulmonary
valves (black dotted line). The defect, opening into the ventricular
outlets between the limbs of the septomarginal trabeculation, is
doubly committed and directly juxta-arterial.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:42:52 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
188
Muscular defects
Perimembranous defects
Septomarginal
trabeculation
Juxta-arterial defects
Trabecular
Outlet
Doubly committed
juxta-arterial defect
Trabecular
Inlet
Inlet
Outlet
Central
fibrous
body
Triangle of Koch
and atrioventricular
node
Sinus node
Remnant of
membranous
ventricular septum
Septal leaflet of
tricuspid valve
Apex
Inf.
Sup.
Base
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:42:53 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
189
Muscularising infundibulum
Sup.
Left
Right
Inf.
Aortic root
Left
atrium
Atrioventricular
membranous
septum
Right
atrium
Left
ventricle
Sup.
Septal leaflet
of tricuspid valve
Left
Right
Right
ventricle
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:42:54 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
190
Aortic root
Septal leaflet
of tricuspid valve
Membranous flap
Turned back
septal leaflet
Sup.
Left
Right
Membranous flap
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:42:56 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
Ant.
Inf.
Sup.
Membranous flap
191
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:42:57 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
192
Pulmonary trunk
Aorta
Sup.
Left
Right
Inf.
Sup.
Left
Right
Perimembranous defect
Inf.
Fig. 7.78 This is the heart shown in Figure 7.77 prior to making
the section to correlate with the echocardiographic plane. The
ventricular septal defect opens into the outlet of the right
ventricle, with the aortic valve overriding the crest of the
ventricular septum.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:42:59 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
193
Apex
Inf.
Sup.
Base
Tricuspid
valve
Sup.
Left
Right
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:43:01 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
194
Sup.
Base
Fig. 7.81 This surgical view shows a muscular defect opening into
the inlet of the right ventricle, viewed through the orice of the
tricuspid valve. The conduction axis (black dotted line), arising
from the apex of the triangle of Koch (cross-hatched triangle), is
seen to the left-hand side of the surgeon working through the
tricuspid valve.
Apex
Inf.
Sup.
Base
Fig. 7.82 This view of the heart shown in Figure 7.81, again seen
through a right atriotomy and the orice of the tricuspid valve,
shows the musculature of the ventricular septum interposing
between the basal margin of the defect (star) and the hinge of the
septal leaet of the tricuspid valve. The triangle of Koch (crosshatched triangle) is to the left-hand side of the surgeon relative to
the defect.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:43:03 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
195
Apex
Inf.
Sup.
Base
Fig. 7.83 This defect is seen through a right atriotomy with the
tricuspid valve retracted. It shows a muscular defect (star) opening
into the outlet of the right ventricle.
Pulmonary infundibulum
Tricuspid
valve
Sup.
Right
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:43:04 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
196
Aorta
Sup.
Post.
Ant.
Inf.
Left ventricle
Pulmonary valve
Sup.
Tricuspid valve
Left
Right
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:43:05 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
197
Pulmonary valve
Sup.
Left
Right
Inf.
Fig. 7.88 In this heart, the defect opening into the outlet of the
Sup.
Left
Right
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:43:06 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
198
Overriding of
aortic valve
Right
Inf.
Sup.
Left
Right
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:43:08 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
MALFORMATIONS OF THE
ATRIOVENTRICULAR VALVES
The pathological lesions that affect
atrioventricular valves, both acquired and
congenital, are legion. Not all are
199
Left atrium
Right atrium
Fig. 7.91 This heart has been sectioned to replicate the four-
Sup.
Left
Right
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:43:10 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
200
Right
Inf.
Tricuspid valve
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:43:11 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
201
Sup.
Left
Right
Inf.
Apex
Inf.
Sup.
Base
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:43:12 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
202
Apex
Inf.
Sup.
Base
Aorta
Mitral valve
Sup.
Post.
Ant.
Straddling tricuspid valve
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:43:12 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
203
Sup.
Post.
Ant.
Inf.
Mitral valve
overriding of the tricuspid valve, and shown here from the left
ventricle in anatomical orientation, the surgeon placed a patch to
close the malalignment of the ventricular septal defect, keeping his
sutures in the leaets of the overriding valve, and avoiding the
abnormally located atrioventricular conduction axis (white dotted
line [axis] and cross-hatched area [node] superimposed on the
photograph). (Compare with Figure 7.96.)
Sup.
Right
Left
Inf.
Fig. 7.98 The image shows the right atrial aspect of the heart
seen also in Figure 7.97. It is photographed in anatomical
orientation, demonstrating how the surgeon was able to close
the ventricular septal defect successfully, at the same time avoiding
the atrioventricular conduction axis (black dotted line). The site of
the abnormal atrioventricular node is shown by the star.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:43:14 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
204
Septal leaflet
Anterosuperior
leaflet
Atrialised
inlet
Sup.
Base
Sup.
Anterosuperior leaflet
Left
Right
Inf.
Inferior leaflet
Septal leaflet
from the right ventricle, shows the ventricular aspect of the heart
demonstrated in Figure 7.99. The anterosuperior leaet of the
abnormal tricuspid valve is tethered in focal fashion, with normal
attachments to the medial and anterior papillary muscles. The
rotational displacement has produced a bifoliate valve hinged at
the junction of the inlet and apical trabecular components of the
right ventricle.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:43:15 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
205
Anterosuperior leaflet
Sup.
Left
Right
Linear attachment
Septal leaflet
Inf.
Anterosuperior leaflet
Sup.
Ant.
Post.
Inf.
Atrialised
inlet
Inferior leaflet
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:43:18 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
206
Sup.
Left
Right
Septal leaflet
Inf.
Inferior leaflet
Sup.
Right
Left
through the dome of the left atrium, shows prolapse of the aortic
leaet.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:43:20 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
207
Sup.
Post.
Ant.
Inf.
Sup.
Right
Left
Inf.
Fig. 7.106 As shown in Fig. 7.105, when the leaets of the mitral
valve are prolapsed, the cords supporting them are usually
elongated. This view shows how the surgeon has shortened the
elongated cords by incising the papillary muscle and suturing the
cords within the muscle (arrow).
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:43:21 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
208
Sup.
Right
Left
Inf.
Sup.
Right
Left
Inf.
Fig. 7.108 This specimen, seen from the inlet aspect of the left
ventricle in anatomical orientation, has a cleft (arrow) in the
aortic leaet of an otherwise normally structured mitral valve. This
lesion should be distinguished from the space between the left
ventricular bridging leaets, or the so-called cleft, found in the
left atrioventricular valve of hearts with decient
atrioventricular septation and a common atrioventricular junction
(see Figure 7.109).
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:43:22 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
209
Sup.
Superior bridging leaflet
Post.
Ant.
Inf.
Mural leaflet
Fig. 7.110 This specimen, removed at surgery, shows the socalled parachute arrangement of the mitral valve. There is fusion
of the papillary muscles, along with thickening and fusion of the
tendinous cords.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:43:23 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
210
MALFORMATIONS OF THE
ARTERIAL VALVES AND
OUTFLOW TRACTS
In this section, we consider the surgical
aspects of subvalvar obstruction of the
ventricular outow tracts, valvar stenosis,
and atresia of the outow. In the normally
connected heart, obstruction in the left
ventricular outow tract produces
subaortic stenosis. It must be remembered
that the same anatomical lesions will
produce subpulmonary obstruction in the
patient with discordant ventriculoarterial
connections. Similarly, obstruction of the
right ventricular outow tract produces
subpulmonary obstruction in the heart
with normal segmental connections, but
subaortic stenosis when the
ventriculoarterial connections are
discordant. When both outow tracts are
connected to the same ventricle, the
anatomical problems are more discrete.
These are considered separately in
Chapter 8.
Stenosis of the aortic valve can occur at
valvar, subvalvar, and supravalvar levels.
Aortic regurgitation is ultimately a valvar
problem, and the perivalvar anatomy is
often of great importance. To understand
the substrates for stenosis and regurgitation
Muscular support
Sup.
Post.
Ant.
Inf.
Fig. 7.111 The aortic outow tract has been spread open and is
Fibrous support
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:43:24 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
211
Muscular support
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:43:26 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
212
Sup.
Right
Left
Inf.
Ant.
Mitral valve
Inf.
with the left ventricular outow tract having been opened, shows
the unicuspid and unicommissural arrangement as demonstrated
in Fig. 7.114. There is loss of the semilunar suspension of the
leaets (black dotted line), so that paradoxically they are
attached in true annular fashion. The solitary zone of apposition
(red arrow) points backwards towards the mitral valve. Note the
marked reduction in height of the remaining interleaet triangles
(white arrows).
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:43:27 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
213
Sup.
Right
Left
Inf.
Sup.
Right
Left
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:43:28 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
214
Sup.
Right
Left
Inf.
Sup.
Right
Left
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:43:29 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
215
Sup.
Right
Left
Inf.
Fig. 7.120 This view, taken in the operating room through the
aortic valve, shows a circular brous shelf producing subaortic
stenosis.
Sup.
Right
Left
Inf.
Mitral valve
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:43:30 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
216
Sup.
Right
Left
Inf.
Fig. 7.123 This view, taken in the operating room through the
aorta, shows how a segment of ventricular muscle (arrow) can
be removed safely to relieve shelf-like brous obstruction of the
left ventricular outow tract.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:43:32 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
217
Sup.
Ant.
Inf.
Sup.
Post.
Ant.
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:43:32 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
218
Mitral
valve
Sup.
Right
Left
Inf.
Left bundle
branch
Tricuspid
valve
Atrioventricular node
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:43:34 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
219
Sup.
Post.
Ant.
Inf.
Aortic root
Pulmonary trunk
Tubular aorta
Left
Inf.
Sup.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:43:35 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
220
Left
Fig. 7.129 In the patient shown in Figure 7.128, the surgeon has
Inf.
Sup.
Right
Left
Inf.
Sup.
Right
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:43:37 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
221
Left
Inf.
Sup.
Right
Sup.
Right
Left
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:43:38 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
222
Sup.
Right
Left
Inf.
Sup.
Right
Left
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:43:41 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
223
Pulmonary
trunk
Left
Inf.
Sup.
Right
Pulmonary
root
Mitral
valve
Tricuspid
valve
Sup.
Ant.
Post.
Inf.
Fig. 7.136 The short axis of the ventricular mass has been
displayed by removing the atrial musculature and the arterial
trunks, showing the keystone location of the centrally positioned
aortic valve (star).
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:43:41 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
224
Left
Inf.
Sup.
Right
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:43:42 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
225
Left
Inf.
Sup.
Right
Pulmonary root
Left
Inf.
Sup.
Right
Fig. 7.140 The view, taken in the operating room, shows the
Pulmonary trunk
TETRALOGY OF FALLOT
One form of obstruction of the right
ventricular outow tract is so clearly
demarcated that it constitutes an entity in
its own right, namely tetralogy of Fallot.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:43:43 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
226
Supraventricular crest
Sup.
Ant.
Post.
Inf.
Aorta
Tricuspid valve
Septomarginal
trabeculation
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:43:44 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
227
Pulmonary valve
Outlet septum
Ventriculoinfundibular
fold
Aortic valve
Sup.
Ant.
Post.
Inf.
Aortic valve
Septomarginal trabeculation
Fig. 7.142 This view of the outlet of the right ventricle of the
heart from a patient with tetralogy of Fallot, taken in anatomical
orientation, shows the divorce of the muscular structures that
combine to form the normal subpulmonary outow tract.
Pulmonary valve
Fibrous
continuity
Tricuspid valve
Sup.
Ant.
Post.
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:43:46 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
228
Outlet septum
Ventriculoinfundibular
fold
Sup.
Ant.
Post.
Inf.
Septomarginal trabeculation
Membranous flap
Sup.
Ant.
Post.
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:43:47 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
229
Patch
Sup.
Post.
Ant.
Inf.
the left ventricle, the defect in a patient with tetralogy of Fallot was
repaired by placing sutures directly through the crest of the
muscular ventricular septum. Note the haemorrhage produced at
the septal crest.
Haemorrhage
in AV bundle
Sup.
Left.
Right
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:43:47 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
230
Pulmonary
trunk
Aorta
Sup.
Left.
Right
Inf.
Aortic-pulmonary
continuity
Perimembranous VSD
Outlet septum
Left
Septoparietal
trabeculation
Apex
Base
Right
Infundibular orifice
Pulmonary valve
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:43:48 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
231
Septoparietal trabeculations
Left
Apex
Base
Right
Infundibular orifice
Outlet septum
Resected
septoparietal
bands
Left
Apex
Base
Resected parietal attachment
of septal insertion
Right
Fig. 7.151 In the patients shown in Figures 7.149 and 7.150, the
obstruction at the mouth of the infundibulum was
completely relieved by resecting the parietal extension of the
outlet septum.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:43:49 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
232
Sup.
Ant.
Post.
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:43:49 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
233
Pulmonary
atresia
Sup.
Ant.
Post.
Inf.
Aorta
Arterial duct
Aorta
Sup.
Left
Right
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:43:50 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
234
Sup.
Right
Left
Inf.
Sup.
Left
Right
Inf.
Aorta
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:43:52 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
235
Sup.
Aorta
Left
Right
Inf.
Collateral arteries
Sup.
Left
Right
Inf.
Fig. 7.158 In this heart from a patient with tetralogy of Fallot and
pulmonary atresia, shown in anatomical orientation, the
intrapericardial arteries extending to enter the right lung (arrow)
are supplied by a large systemic-to-pulmonary collateral
artery (star).
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:43:52 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
236
Sup.
Aorta
Left
Right
Inf.
Collateral arteries
Ant.
Right
Left
Post.
Fig. 7.160 In this heart from a patient with pulmonary atresia and
an intact ventricular septum, viewed from above, dissection of the
ventriculopulmonary junction shows an imperforate pulmonary
valvar membrane.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:43:53 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
237
Ant.
Right
Left
Post.
Sup.
Left
Right
Inf.
Inlet
Fig. 7.162 In this heart from a patient with pulmonary atresia and
an intact ventricular septum, viewed anatomically, the cavity of the
right ventricle is effectively represented by the inlet component
alone, due to gross hypertrophy of the walls of the apical trabecular
and outlet components. Note the stulous communication
extending through the wall to the anterior interventricular
coronary artery (white arrow).
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:43:53 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
238
Outlet
Obliterated apex
Inlet
Sup.
Left
Right
Inf.
Outlet
Inlet
Sup.
Left
Right
Inf.
construction of a systemic-pulmonary
shunt. Other options, such as the need for
pulmonary valvotomy, should be decided
after assessment of the precise anatomy of
the individual case.
Pulmonary valvar insufciency may be
congenital or acquired, the latter usually
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:43:54 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
239
Sup.
Left
Right
Inf.
Left
Apex
Base
Right
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:43:55 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
240
Left
Apex
Base
Right
Pulmonary trunk
Aorta
Fig. 7.167 In the patient shown in Figure 7.166, there was gross
dilation of the pulmonary trunk and the pulmonary arteries.
Sup.
Left
Right
Inf.
Fig. 7.168 This posterior view of the hilum of the left lung of the
heart from the patient seen in Fig. 7.165 shows the obstruction
produced by the gross dilation of the left pulmonary artery (star) as
it crosses the narrowed bronchus (double-headed arrow).
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:43:56 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
241
Pulmonary trunk
Aorta
Left
Base
Apex
References cited
1. Anderson RH, Brown NA. The anatomy
of the heart revisited. Anat Rec 1996;
246: 17.
2. Anderson RH, Webb S, Brown NA. Clinical
anatomy of the atrial septum with reference
to its developmental components. Clin Anat
1999; 12: 362374.
3. Sharratt GP, Webb S, Anderson RH. The
vestibular defect: an interatrial
communication due to a deciency in the
atrial septal component derived from the
vestibular spine. Cardiol Young 2003; 13:
184190.
4. Anderson RH, Ho SY, Falcao S, Daliento L,
Rigby ML. The diagnostic features of
atrioventricular septal defect with common
atrioventricular junction. Cardiol Young
1998; 8: 3349.
5. Crystal MA, Al Najashi K, Williams WG,
Redington AN, Anderson RH. Inferior sinus
venosus defect: echocardiographic diagnosis
and surgical approach. J Thorac Cardiovasc
Surg 2009; 137: 13491355.
6. Butts RJ, Crean AM, Hlavacek AM, et al.
Veno-venous bridges: the forerunners of the
sinus venosus defect. Cardiol Young 2011;
21: 623630.
7. Ettedgui JA, Siewers RD, Anderson RH,
Zuberbuhler JR. Diagnostic
echocardiographic features of the sinus
venous defect. Br Heart J 1990;
64: 329331.
Figures 7.166 and 7.167 shows the grossly enlarged left pulmonary
artery, which is as large as the aorta.
16.
17.
18.
19.
20.
21.
22.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:43:57 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
242
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:43:58 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
62.
63.
64.
65.
66.
67.
68.
69.
70.
ventricularaortic discontinuity
complicating bacterial endocarditis. Ann
Thorac Surg 1980; 29: 17.
Gilbert JW, Morrow AG, Talbert JW. The
surgical signicance of hypertrophic
infundibular obstruction accompanying
valvar pulmonary stenosis. J Thorac
Cardiovasc Surg 1963; 46: 457467.
Haworth SG, Macartney FJ. Growth and
development of pulmonary circulation in
pulmonary atresia with ventricular septal
defect and major aortopulmonary collateral
arteries. Br Heart J 1980; 44: 1424.
Anderson RH, Tynan M. Tetralogy of
Fallota centennial review. Int J Cardiol
1988; 21: 219232.
Anderson RH, Allwork SP, Ho SY, Lenox
CC, Zuberbuhler JR. Surgical anatomy of
tetralogy of Fallot. J Thorac Cardiovasc
Surg 1981; 81: 887896.
Suzuki A, Ho SY, Anderson RH, Deaneld
JE. Further morphologic studies on
tetralogy of Fallot, with particular emphasis
on the prevalence and structure of the
membranous ap. J Thorac Cardiovasc Surg
1990; 99: 528535.
Titus JL, Daugherty GW, Edwards JE.
Anatomy of the atrioventricular conduction
system in ventricular septal defect.
Circulation 1963; 28: 7281.
Anderson RH, Monro JL, Ho SY, Smith A,
Deverall PB. Les voies de conduction
auriculoventriculaires dans le tetralogie de
Fallot. Coeur 1977; 8: 793807.
Ando M. Subpulmonary ventricular septal
defect with pulmonary stenosis. Letter to
Editor. Circulation 1974; 50: 412.
Neirotti R, Galindez E, Kreutzer G, et al.
Tetralogy of Fallot with subpulmonary
71.
72.
73.
74.
75.
76.
77.
78.
79.
80.
81.
82.
83.
84.
85.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:43:59 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.008
Cambridge Books Online Cambridge University Press, 2013
243
Lesions in hearts
with abnormal
segmental
connections
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:54:20 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
DOUBLE-INLET VENTRICLE
Over the years, hearts with a double-inlet
ventricle have represented one of the
greater challenges to surgical correction.
They have also posed signicant problems
in adequate description and categorisation.
Even these days, many continue to describe
245
Left
atrium
Right
atrium
Dominant
left ventricle
Left
Apex
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:54:20 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
246
Left
atrium
Right
atrium
Dominant
right ventricle
Base
Fig. 8.2 This specimen is also prepared by making a section in the fourLeft
Right
Incomplete
left ventricle
Apex
Base
Left
atrium
Left
Right
Right
atrium
Apex
Dominant
right ventricle
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:54:21 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
Aorta
Incomplete
right ventricle
Pulm.
trunk
Dominant
left ventricle
Sup.
Left
Right
Inf.
247
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:54:22 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
248
Base
Left
Right
Pulmonary trunk
Sup.
Right
Left
VSD
Apex
Inf.
Pulmonary
valve
Infundibulum
LAVV
Right
atrium
RAVV
Dominant
left ventricle
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:54:22 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
249
VSD
Aorta
Aorta
VSD
Base
Base
Right
Left
Right
Left
Apex
Apex
Outlet septum
Apical septum
Aorta
RAVV
Dominant LV
LAVV
To pulmonary trunk
Base
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:54:23 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
250
Pulm. trunk
Long
infundibulum
Aorta
VSD
Right
Inf.
Apical RV trabeculations
Restrictive VSD
Aorta
Left
Inf.
Sup.
Incomplete right ventricle
Right
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:54:23 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
Pulm. trunk
251
Long
infundibulum
Aorta
Right atrium
Sup.
Sup.
VSD
Left
Right
Inf.
Apical RV trabeculations
Left
Sup.
Sinus node
Right
artery to the sinus node, arising from the right coronary artery, is
seen coursing through the interatrial groove to cross the cavoatrial
junction at the crest of the right atrial appendage. The sinus node is
visible as a pale area within the terminal groove.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:54:23 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
252
Apex
Sup.
Inf.
Base
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:54:24 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
LAVV
RAVV
Conduction tissue
Line of suture for complete septation
Line of suture for double-outlet left
ventricle
253
Fig. 8.15 The cartoon shows the dominant left ventricle with a
double inlet as seen through a sh-mouth incision in the apex of
the ventricle. The conduction axis is marked in green (see also
Figure 8.5). The potential line for complete septation, placing the
pulmonary trunk in communication with the systemic venous
return (blue dashed line), crosses the conduction axis. To avoid the
conduction axis (green dashed line), it is necessary to deviate the
site of septation so that both outow tracts remain in
communication with the pulmonary venous return through the left
atrioventricular valve. The star shows the location of the ventricular
septal defect. LAVV and RAVV, left and right atrioventricular
valves.
Branching bundle
Penetrating bundle
Atrioventricular ring tissue
Transitional cell zone
Pulmonary valve
the view of the dominant left ventricle in the setting of a doubleinlet left ventricle with discordant ventriculoarterial connections,
and the course of the conduction axis, in green, as it would be seen
by the surgeon working through the right atrioventricular valve.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:54:24 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
254
Subaortic outlet
Subpulmonary outlet
LAVV
RAVV
Sup.
Left
Right
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:54:25 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
Sup.
255
Ant.
Inf.
Common AVV to RV
Aorta
Incomplete
left ventricle
Sup.
Post.
Ant.
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:54:25 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
256
Sup.
Right
Pulm. trunk
Left
Inf.
Dominant
right ventricle
Common AV valve
Subpulmonary outlet
Left
AV valve
Right
Subaortic outlet
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:54:25 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
Left AV valve
Aorta
Sup.
257
Post.
Ant.
Inf.
RAVV
Left ventricular
apical trabeculations
Left-sided inlet
Left atrium
Right atrium
Dominant LV
Fig. 8.23 The heart has been sectioned to replicate the fourchamber echocardiographic view. It shows complete absence of the
right atrioventricular (AV) connection, the atrioventricular groove
being lled with adipose tissue, and containing the right coronary
artery. This is the essence of the usual variant of tricuspid atresia.
The section passes mostly through the dominant left ventricle (LV)
(compare with Figure 8.1), but the posterior part of the incomplete
right ventricle is just visible (star).
Absent AV connection
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:54:26 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
258
Absent left
AV connection
Left atrium
Slit-like
left ventricle
Right atrium
Sup.
Left
Right
Inf.
Sup.
Right
Left atrium
Left
Inf.
Right atrium
Dominant LV
Incomplete
right ventricle
Fig. 8.25 This heart, with the absence of the right atrioventricular
connection (white dotted lines), is sectioned to simulate the
echocardiographic four-chamber view. The solitary atrioventricular
junction (white double-headed arrow) is shared between the
dominant left (LV) and the incomplete right ventricles because of
straddling of the solitary atrioventricular valve (arrow head). This
arrangement produces a uniatrial but biventricular connection.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:54:27 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
Dimple
Sup.
Post.
Ant.
Inf.
Fig. 8.26 This view of the opened right atrium from a specimen
Oval fossa
Pectinate muscles
Coronary sinus
Sup.
Right
Left atrium
Left
Inf.
Right atrium
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:54:27 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
259
260
Aorta
VSD
Right
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:54:28 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
261
Sup.
Left
Inf.
Right
atrium
Right atrium
Imperforate
tricuspid valve
Apex
Inf.
Sup.
Base
TRANSPOSITION
A particularly important lesion is
represented by the combination of
concordant atrioventricular with
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:54:28 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
262
Sup.
Right
Left
Inf.
Fig. 8.31 The right atrium in this specimen is viewed from above
Imperforate tricuspid valve
Eustachian valve
Right
atrium
Sup.
Right
Left
Atrialised right
ventricular inlet
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:54:29 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
263
Ascending aorta
Pulmonary
trunk
Sup.
Fig. 8.33 This specimen, viewed from the left side in anatomical
orientation, shows the typical arrangement of the arterial trunks in
hypoplastic left heart syndrome due to combined aortic and mitral
atresia, but with the subclavian artery arising distally to the arterial
duct. Note the grossly hypoplastic transverse aortic arch.
Post.
Ant.
Inf.
Arterial duct
Pulmonary
trunk
Arterial duct
Sup.
Left pulmonary artery
Post.
Ant.
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:54:29 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
264
Sup.
Left
Right
Arterial duct
Inf.
Pulmonary
trunk
Good-sized
ascending aorta
Pulmonary
trunk
Sup.
Ant.
Post.
Inf.
Good-sized
ascending aorta
shown in Figure 8.34, viewed from the right side, shows arterial
pathways that are directly comparable to those seen in the heart
dissected to produce Figure 8.35.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:54:29 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
265
Arterial duct
Sup.
Left
Right
Inf.
Diminutive
ascending aorta
Pulmonary
trunk
Diminutive
ascending aorta
Sup.
Descending
aorta
Post.
Ant.
Inf.
Aortic isthmus
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:54:30 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
266
Sup.
Ant.
Post.
Aorta
Inf.
viewed from the left, mitral atresia is not always part of hypoplasia
of the left heart. In this example, there is absence of the left
atrioventricular connection, but the right atrium is connected to a
dominant ventricle with left ventricular trabeculations (not seen).
The incomplete right ventricle, supporting the aorta, is left-sided
and anterior. Had the left atrioventricular valve been formed, it
would almost certainly have been of tricuspid morphology.
Sup.
Post.
Ant.
Inf.
Imperforate
mitral valve
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:54:30 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
267
Imperforate LAVV
RAVV
the dominant left ventricle having been opened from the front,
there is a double inlet to the dominant ventricle, with the
incomplete right ventricle in the left-sided position, but with an
imperforate left atrioventricular valve (LAVV). The right
atrioventricular valve (RAVV) is patent.
Left
Inf.
Pulm.
trunk
Aorta
Morph.
left atrium
Pulm..
trunk
Morph.
left atrium
Aorta
Morph.
right atrium
Morph.
right atrium
Morph.
left ventricle
Morph.
right ventricle
Morph.
left ventricle
segmental combinations of
concordant atrioventricular and
discordant ventriculoarterial
connections that produce the
lesion usually described simply as
transposition. The arrangement
can exist in usual and mirrorimaged variants. Morph.,
morphologically; Pulm.,
pulmonary.
Morph.
right ventricle
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:54:30 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
268
Anterior intervent.
coronary artery
Aorta
Pulmonary
trunk
Left
Inf.
Sup.
Right coronary artery
Right
Morph. right
atrial appendage
Left-sided aorta
Sup.
Left
Right
Inf.
Morph.
right ventricle
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:54:31 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
269
Aorta
SCV
Oval fossa
Tricuspid
valve
Sup.
Ant.
Post.
Inf.
Sup.
Ant.
Post.
Inf.
Incision
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:54:31 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
270
Sup.
Ant.
Post.
SCV
Inf.
Oval fossa
Terminal crest
Eustachian valve
Coronary sinus
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:54:32 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
271
Perimembranous
Muscular
Fig. 8.48 The cartoon shows how the ventricular septal defect in
hearts with transposition, as in the normal heart, can be
perimembranous, muscular, or doubly committed and juxtaarterial. The cartoon also emphasises the potential for
malalignment of the muscular outlet septum, a particular feature
of the ventricular septal defect in the setting of transposition.
Muscular
outlet septum
Aorta
Tricuspidpulm. continuity
Tricuspid
valve
Sup.
Left
Right
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:54:32 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
272
Ventriculoinfundibular
fold
Aorta
Malaligned muscular
outlet septum
Caudal limb
of SMT
Tricuspid valve
Right
Left
Inf.
right side, has a ventricular septal defect (star) opening into the
outlet of the right ventricle as in Figure 8.49, but with a muscular
posteroinferior rim produced by continuity between the caudal
limb of the septomarginal trabeculation (SMT) and the
ventriculoinfundibular fold. Note the malalignment of the outlet
septum. The muscular rim protects the conduction axis, shown by
the red dotted line.
Aorta
Pulmonary
-mitral continuity
SMT
Sup.
Tricuspid valve
Right
Left
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:54:33 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
273
Sup.
Left
Right
Inf.
Right atrium
Sup.
Oval fossa
Right
Left
Inf.
AV node displaced
posteroinferiorly
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:54:34 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
274
Malaligned
ventricular
septum
Anomalous
AV node
Apex
Sup.
Regular AV node
(no contact)
Inf.
Base
Sup.
Aortic-pulm.
continuity
Aorta
Right
Left
Inf.
SMT
Tricuspid
valve
Tricuspid-pulmonary continuity
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:54:35 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
275
Valvar
Tissue tags
Septal bulge
Abnormal
tension apparatus
Fibrous shelf
Fig. 8.56 The cartoon shows the lesions that can produce subpulmonary
obstruction in the setting of transposition. Exactly the same lesions will
produce subaortic obstruction in hearts with concordant ventriculoarterial
connections.
Sup.
Tissue tag
Pulmonary trunk
Ant.
Post.
Inf.
Mitral valve
Fig. 8.57 This view of the left ventricle from a specimen with
transposition, seen in anatomical orientation from the left, shows a
tissue tag from the septal leaet of the tricuspid valve herniating
through a perimembranous ventricular septal defect and
producing subpulmonary obstruction.
Left ventricle
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:54:36 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
276
Sup.
Ant.
Pulmonary trunk
Post.
Inf.
Left ventricle
Mitral
valve
VSD
Deviated
outlet
septum
Left ventricle
Sup.
Ant.
Post.
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:54:37 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
277
Pulmonary
trunk
Sup.
Left
Right
Anterior
right-sided
aorta
Inf.
Anterior
spiralling
pulm. trunk
Right
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:54:37 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
278
Sup.
Left
Right
Pulmonary trunk
Inf.
Mitral
valve
Left ventricle
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:54:37 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
279
Aorta
Pulm.
trunk
Tricuspid
valve
Mitral
valve
Sup.
Right
Left
Inf.
Aortic root
Left
Sup.
Fig. 8.63 In this heart, the short axis is viewed from above in
Inf.
Right
Fig. 8.64 The picture, taken in the operating room, shows the
Pulmonary root
CONGENITALLY CORRECTED
TRANSPOSITION
We describe the combination of discordant
atrioventricular and ventriculoarterial
connections as congenitally corrected
transposition (Figure 8.71). When dened
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:54:39 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
280
Pulmonary trunk
Right-hand facing sinus
no. 1
Sup.
Ant.
Post.
Non-adjacent sinus
Inf.
Fig. 8.65 The cartoon shows how the two aortic sinuses
that face the pulmonary trunk can always be described
accurately as being to the surgeons left-hand or right-hand
side when standing in the non-adjacent sinus of the aorta
and looking towards the pulmonary trunk, irrespective of
the relationships of the arterial trunks. Conventionally, the
sinus to the right-hand side is described as being no. 1, while
that to the left-hand side is designated as being no. 2.
LCA
RCA
Fig. 8.66 In this heart from a patient with transposition, the aortic
Sup.
Left
Right
Non-adjacent sinus
Inf.
root has been opened and is viewed from the front. Both of the
coronary arteries arise from the left-hand facing sinus, or sinus no.
2. The main stem of the left coronary artery (LCA) was noted to take
an intramural course as it extended towards the left
atrioventricular and interventricular grooves. RCA, right coronary
artery.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:54:40 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
Right coronary
artery
Circumflex
artery
Aorta
Anterior
interventricular
artery
281
LCA
from the front, the right and left coronary arteries arise from a
solitary vessel, with the right coronary and circumex arteries then
passing in front of the arterial pedicle.
RCA
Sup.
Right
Non-adjacent sinus
Inf.
both coronary arteries arise within the left-hand facing sinus. In this
heart, the orice of the main stem of the left coronary artery (LCA)
is above the sinutubular junction. Having exited from the aortic
root, the artery courses between the arterial trunks in intramural
fashion (see Figure 8.69). RCA, right coronary artery.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:54:40 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
282
Sup.
Left
Right
Inf.
Pulmonary trunk
Aorta
Intramural
course
the left side, showing how the main stem of the left coronary artery
is embedded within the wall of the aorta as it runs towards the
anterior surface of the heart, where it divides into its circumex and
anterior interventricular branches.
Aorta
Pulmonary
trunk
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:54:41 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
Aorta
Aorta
Morph.
right atrium
Morph.
left atrium
Morph.
left atrium
Pulm.
trunk
283
Pulm.
trunk
Morph.
right atrium
Morph.
right ventricle
Morph.
right ventricle
Morph.
left ventricle
segmental combinations of
discordant atrioventricular and
ventriculoarterial connections
that produce the lesion best
described as congenitally
corrected transposition. As
shown, the arrangement can be
found in usual and mirror-imaged
variants. Morph.,
morphologically; Pulm.,
pulmonary.
Morph.
left ventricle
Aortic root
Right-sided
morph. LA
Morph. RCA
Sup.
Ant.
Post
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:54:42 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
284
Sup.
Right
Right-sided
morph. LA
Left
Inf.
Left-sided
morph. RA
Right-sided
morph. RV
Left-sided
morph. LV
Fig. 8.73 The image shows the four-chamber cut through the
computed tomographic angiographic dataset shown in Figure 8.72.
The narrow neck of the right-sided atrial appendage (star) shows
that it has left morphology (morph. LA), while the other
appendage has pectinate muscles extending to the crux (white
arrow) conrming the left-sided location of the morphologically
right atrium (morph. RA). The nature of the apical trabeculations
conrm that the atrial chambers are connected to inappropriate
morphological ventricles (morph. LV, morph. RV).
Aorta
Pulmonary
trunk
Ant.
Right
Left
Post.
Fig. 8.74 The short axis cut through the dataset created from the
computed tomographic angiograms shown in Figures 8.72 and 8.73
shows the right-sided and anterior location of the aorta relative to
the pulmonary trunk. This shows that d-transposition can also be
congenitally corrected. Note the normal position of the coronary
arteries because of the right-handed ventricular topology that is a
feature of this segmental combination.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:54:42 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
285
Sup.
Left
Right
Right
atrium
Inf.
Morph. left
ventricle
Plane of ventricular septum
Anterolateral node
Left
Mitral valve
Sup.
Inf.
Right
Aorta
Pulm.
trunk
Pulmonary valve
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:54:43 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
286
Left
Sup.
Inf.
Right
Aorta
Pulm.
trunk
Pulmonary valve
Sup.
Pulmonary trunk
Left
Right
Inf.
Aorta
Morphologically
right appendage
Morphologically
right ventricle
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:54:44 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
287
Valvar
continuity
Doubly committed
and juxta-arterial
Perimembranous
Pulmonary
valve
Tricuspid
valve
Pulm.
trunk
Mitral
valve
Morphologically
left ventricle
Sup.
Muscular
Ventricular
septal
defect
Right
Left
Inf.
Left
Right-sided
mitral valve
Inf.
Sup.
Right
Coronary sinus
Anomalous
anterior node
and bundle
Regular
node in triangle
of Koch
(no contact)
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:54:45 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
288
Left
Ventricular
septal defect
Inf.
Sup.
Right
Fig. 8.82 This further view of the patient shown in Figure 8.81
Needle on
left side
of septum
Coronary
sinus
Pulmonary
trunk
Sup.
Pulmonary-aortic
continuity
Left
Right
Inf.
Mitral
valve
Pulmonary-tricuspid
continuity
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:54:46 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
289
Valvar stenosis
Pulmonary
trunk
Tissue tags
Fig. 8.84 The cartoon shows the lesions that can produce
subpulmonary obstruction in the setting of congenitally corrected
transposition. Note the anterior position of the conduction axis,
shown in yellow. As with transposition, the same lesions produce
subaortic obstruction in the setting of concordant
ventriculoarterial connections.
Fibrous shelf
Sup.
Left
Right
Pulmonary
trunk
Inf.
Mitral
valve
Morphologically
left ventricle
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:54:47 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
290
Sup.
Site of anterior
node
Left
Right
Inf.
Mitral
valve
Perimembranous
ventricular septal defect
Atrialised
ventricle
Morphologically
right ventricle
Sup.
Left-sided
morphologically
tricuspid
valve
Post.
Ant.
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:54:52 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
291
Sup.
Post.
Ant.
Left atrium
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:54:55 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
292
Sup.
Ant.
Post.
Inf.
Fig. 8.89 The image shows the base of the heart. The atretic
Morph. right atrial appendage
Perimembranous VSD
Sup.
Post.
Ant.
Aorta
Inf.
Tricuspid valve
Left-sided morph.
right ventricle
DOUBLE-OUTLET VENTRICLE
It is a well-known fact that spectrums of
malformation exist in the settings of both
tetralogy of Fallot and transposition when
Fig. 8.90 The image shows the left-sided ventricle from the heart
illustrated in Figure 8.89. The atrioventricular connections are
discordant, and the aorta is supported by the left-sided
morphologically (morph.) right ventricle. The perimembranous
ventricular septal defect (VSD) is restrictive. The dotted red line
shows the course of the atrioventricular conduction axis, which is
carried on the right side of the ventricular septum. Its
anterocephalad location relative to the defect would make
enlargement difcult, if not impossible, to achieve without
producing atrioventricular block if the decision were made to
attempt biventricular repair by channelling the morphologically
left ventricle to the aorta, and then performing an atrial redirection
procedure.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:54:56 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
293
SCV
Oval fossa
Sup.
Right
Left
Inf.
Coronary sinus
Sub-aortic infundibulum
Left-sided morph.
right ventricle
Tricuspid valve
Fig. 8.92 The image shows the left-sided ventricle in the heart
shown in Figure 8.91. The ventricle is coarsely trabeculated, and
receives the morphologically (morph.) tricuspid valve. The heart
had pulmonary atresia with an intact ventricular septum, but in the
setting of discordant atrioventricular and ventriculoarterial
connections.
Sup.
Post.
Ant.
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:54:56 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
True override
is assessed relative
to chord of circle
Artery
Short axis section
B
o S
in rien epta
sh ta l
or tio
ta n
xis
294
True override
is independent of
septal axis
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:54:57 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
Ao
Ventricular
septal
defect
PT
Muscular
outlet septum
RV
Ao
PT
Interventricular
communication
LV
LV
RV
Crest of muscular
ventricular septum
Patch for biventricular connection
One-to-one
ventriculoarterial connections
295
Aorta
Pulm.
trunk
Morphologically
right ventricle
Sup.
Left
Right
the front, has a double outlet from the right ventricle with the
interventricular communication in subaortic position. The great
arterial trunks spiral in normal relationships as they leave the base
of the heart.
Inf.
interventricular communication.
Recognition of this fact also helps the
surgeon to determine whether a given
patient has a double-outlet ventriculoarterial
connection. Should it be considered
necessary to place a patch so as to tunnel the
communication to an arterial root, then the
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:54:59 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
296
Pulmonary
trunk
Aorta
Sup.
Left
Right
Inf.
Ao
PT
PT
Ao
PT
Ao
Spiralling great
arteries
(normally related)
Great arteries
parallel
-aorta to right
Great arteries
parallel
-aorta to left
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:54:59 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
Sup.
Pulmonary trunk
Left
Right
Aorta
297
Inf.
Muscular
outlet
septum
Ventriculoinfundibular fold
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:54:59 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
298
Sup.
Pulmonary
trunk
Left
Right
Inf.
Aorta
Ventriculoinfundibular fold
Sup.
Left
Right
Pulmonary
valve
Inf.
Aortic
valve
Morphologically
right ventricle
Tricuspid-mitral continuity
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:55:00 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
Ventriculoinfundibular fold
299
Pulmonary
trunk
Aorta
Sup.
Left
Right
Tricuspid-mitral
fibrous continuity
Inf.
Sup.
Left
Right
Inf.
Pulmonary
trunk
Aorta
Tricuspid-mitral continuity
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:55:01 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
300
Aortic-pulmonary continuity
Pulmonary
valve
Aortic
valve
SMT
Sup.
Left
Right
Ventriculoinfundibular fold
Inf.
Aorta
Outlet
septum
Pulm.
trunk
Sup.
Right
Perimembranous VSD
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:55:03 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
301
Pulmonary
trunk
Aorta
Outlet
septum
Sup.
Left
Right
Atrioventricular
septal defect
Inf.
Sup.
Pulmonary
trunk
Left
Right
Aorta
Inf.
Perimembranous defect
opening to inlet of RV
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:55:05 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
302
Aorta
Pulmonary trunk
Outlet septumsafe
Anterocephalad
limb-beware septal
perforator
Conduction axis
Posterocaudal limbbeware
conduction axis
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:55:06 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
303
Systemic arteries
Pulmonary
arteries
Coronary arteries
Sup.
Left
Right
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:55:07 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
304
Sup.
Common arterial trunk
Left
Right
Inf.
Right ventricle
Common
arterial
trunk
Aorta
Possible
origin
from heart
Possible
origin
from trunk
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:55:09 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
305
Common
truncal valve
Right
ventricle
Left
ventricle
Fig. 8.112 The heart has been sectioned along its long axis, and is
shown in anatomical orientation, demonstrating how the common
arterial trunk (black brace) overrides the crest of the muscular
ventricular septum (star), in this instance being equally committed
to both ventricles.
Sup.
Left
Right
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:55:10 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
306
Bridging leaflets
Sup.
Right ventricle
Left
Right
Inf.
Fig. 8.114 The heart, photographed from the front, the right
ventricle having been opened, has a common arterial trunk
supported exclusively by the right ventricle. The interventricular
communication, however, is an atrioventricular septal defect. The
bridging leaets of the common atrioventricular valve are seen
extending into the left ventricle. The left atrioventricular valve was
trifoliate.
Origin of
pulmonary
arteries
Sup.
Left
Right
Inf.
Common
truncal
valve
Ventriculoinfundibular fold
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:55:11 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
307
Sup.
Common
truncal
valve
Left
Right
Inf.
Ventriculoinfundibular fold
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:55:12 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
308
Sup.
Fig. 8.117 In this heart, the common arterial trunk has been
Ant.
Post.
Inf.
Left coronary
artery
Post.
Left
Right
Fig. 8.118 The common arterial trunk has been windowed from
Trifoliate truncal valve
Ant.
the front, showing its posterior wall, from which the right and left
pulmonary arteries take separate origin. The truncal valve has three
leaets. Note the high origin of the left coronary artery.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:55:14 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
309
Post.
Left
Right
Ant.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:55:16 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
310
Post.
Left
Right
Ant.
RPA
LPA
Confluent origin of
pulmonary arteries
Left coronary
artery
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:55:18 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
311
RPA
LPA
Post.
Left
Right
Ant.
Sup.
Left
Right
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:55:18 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
312
LSCA
RSCA
Arterial duct
LPA
RPA
LCCA
RCCA
Hypoplastic aortic
component
Common arterial trunk
Sup.
Right
Inf.
Hypoplastic aortic
component
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:55:19 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
313
Sup.
Right
Left
Inf.
Concordant ventriculoarterial
connections with parallel arterial
trunks
Hearts with this combination do not
necessarily have abnormal segmental
combinations, because if the
atrioventricular connections are
concordant, the segmental junctions will be
normal despite the unexpected
relationships of the arterial trunks. It is also
the case that patients with this arrangement
will be exceedingly rare, and it is possible
that the unusual position of the aorta could
go unnoticed. The same arrangement at the
ventriculoarterial junctions, nonetheless,
can be found with all the other possibilities
for atrioventricular connections; thus it is
appropriate to consider the combinations in
a separate section of this chapter, the more
so as they have been remarkably difcult to
understand. They are also currently
described with the most arcane of
terminologies by some, including such
spectacular phrases as isolated ventricular
inversion, and anatomically corrected
malposition. The essence of understanding
is to appreciate that, although the arterial
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:55:19 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
314
Sup.
Post.
Ant.
Inf.
RPA
Common
arterial
trunk
LPA
Circumflex artery
Pulmonary trunk
Aorta
Sup.
Left
Right
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:55:20 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
315
Sup.
Left
Right
Inf.
Aorta
Pulmonary trunk
Fig. 8.130 This heart is from a normal individual with mirrorimage arrangement of all the organs. The ventricular mass shows
left-hand topology, and the pulmonary trunk spirals in clockwise
fashion relative to the aortic root as it extends into the
mediastinum (black arrows).
Pulmonary trunk
Aorta
Right
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:55:21 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
316
Sup.
Aorta
Left
Right
Inf.
Fig. 8.132 The left side of the heart demonstrated in Figure 8.131
Mitral valve
is shown, opened from its left side. The morphologically left atrium
is connected to a left ventricle with right-hand ventricular
topology. The aorta arises from the left ventricle, its valve
supported by an extensive muscular infundibulum (double-headed
arrow). There is also a large perimembranous ventricular septal
defect. Because the atrioventricular connections are concordant,
the atrioventricular conduction axis is posteroinferiorly positioned
(yellow dotted line).
Pulmonary trunk
Aorta
Ventricular
septal defect
Sup.
Left
Right
Incomplete morphologically
right ventricle
Inf.
Fig. 8.133 The heart shown has a double-inlet left ventricle with
a right-sided incomplete right ventricle and concordant
ventriculoarterial connections, the lesion known as the Holmes
heart. The arterial trunks spiral in normal fashion, with the
pulmonary trunk extending in counter-clockwise fashion relative to
the aortic root (black arrows) (compare with Figure 8.129).
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:55:21 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
Sup.
317
Pulmonary trunk
Aorta
Post.
Ant.
Inf.
Ventricular
septal defect
Incomplete morphologically
right ventricle
Aorta
LAVV
RAVV
Right
Inf.
Fig. 8.135 The dominant left ventricle from the heart shown in
Figure 8.134 is opened. The aortic valve arises from the ventricle
with its leaets in brous continuity (black dotted lines) with both
of the atrioventricular valves (RAVV, LAVV). Note the ventricular
septal defect communicating with the left-sided incomplete right
ventricle (arrow).
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:55:22 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
318
Perimembranous
VSD
Sup.
Pulmonary trunk
Post.
Ant.
Inf.
Sup.
Ant.
Post.
Aorta
Inf.
Mitral valve
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:55:22 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
10.
11.
12.
13.
14.
References cited
15.
1. Anderson RH, Macartney FJ, Tynan M,
et al. Univentricular atrioventricular
connection: the single ventricle trap
unsprung. Pediatr Cardiol 1983; 4:
273280.
2. Anderson RH, Becker AE, Tynan M, et al.
The univentricular atrioventricular
connection: getting to the root of a
thorny problem. Am J Cardiol 1984; 54:
822828.
3. Anderson RH, Ho SY. What is a ventricle?
Ann Thorac Surg 1998; 66: 616620.
4. Jacobs ML, Anderson RH. Nomenclature
of the functionally univentricular heart.
Cardiol Young 2006; 16(Suppl 1): 38.
5. Kurosawa H, Imai Y, Fukuchi S, et al.
Septation and Fontan repair of
univentricular atrioventricular connection.
J Thorac Cardiovasc Surg 1990; 99:
314319.
6. Anderson RH, Baker EJ, Redington AN.
Can we describe structure as well as
function when accounting for the
arrangement of the ventricular mass?
Cardiol Young 2000; 10: 247260.
7. Franklin RCG, Spiegelhalter DJ, Anderson
RH, et al. Double-inlet ventricle presenting
in infancy. I. Survival without denitive
repair. J Thorac Cardiovasc Surg 1991; 101:
767776.
8. Gale AW, Danielson GK, McGoon DC,
Wallace RB, Mair DD. Fontan procedure
for tricuspid atresia. Circulation 1980; 62:
9196.
9. Laks H, Williams WG, Hillenbrand WE,
et al. Results of right atrial to right
ventricular and right atrial to pulmonary
16.
17.
18.
19.
20.
21.
22.
319
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:55:23 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
320
46.
47.
48.
49.
50.
51.
52.
53.
54.
55.
56.
57.
58.
59.
60.
61.
62.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 04:55:25 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.009
Cambridge Books Online Cambridge University Press, 2013
Abnormalities of the
great vessels
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 05:21:42 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.010
Cambridge Books Online Cambridge University Press, 2013
322
ANOMALOUS SYSTEMIC
VENOUS DRAINAGE
Abnormal systemic venous connections
are usually of little surgical signicance,
as their clinical consequences are limited.
The anomalies are apt to be encountered
as the surgeon pursues a more complex
associated intracardiac anomaly. They
are of most signicance in the setting of
isomeric atrial appendages, which we
discuss in Chapter 10, showing how socalled visceral heterotaxy is best
considered in terms of right versus left
isomerism. In this chapter, we consider
the features of the anomalous systemic
venous connections in their own right.
They may be grouped into the categories
of absence or abnormal drainage of the
right superior caval vein, anomalies of the
inferior caval vein, persistence or
abnormal drainage of the left superior
caval vein, and abnormal hepatic venous
connections. Abnormalities of the
coronary sinus usually fall into one of
these groups, although unroong,
which produces an interatrial
communication through the right atrial
orice of the sinus, has been discussed
in Chapter 7.
Left atrial
appendage
Pulmonary
trunk
Left
Sup.
Inf.
Right
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 05:21:42 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.010
Cambridge Books Online Cambridge University Press, 2013
323
ANOMALOUS PULMONARY
VENOUS CONNECTION
Very rarely, the pulmonary veins may be
obstructed or totally atretic at their atrial
junction9. This is unlikely to be a surgically
remedial situation. Much more commonly,
the pulmonary venous system, either
totally or in part, has an anomalous
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 05:21:42 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.010
Cambridge Books Online Cambridge University Press, 2013
324
Sup.
Left
Right bronchus
Right
Inf.
Aorta
Azygos vein
Superior caval vein
Morph. right
appendage
Sup.
Post.
Ant.
Inf.
Hepatic veins
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 05:21:42 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.010
Cambridge Books Online Cambridge University Press, 2013
Left pulmonary
veins
325
Left appendage
Post.
Inf.
Coronary sinus
SCV
Oval fossa
ICV
Sup.
Ant.
Post.
Enlarged mouth of
coronary sinus
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 05:21:43 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.010
Cambridge Books Online Cambridge University Press, 2013
326
Azygos vein
SCV
Anomalous vein
Left atrium
Morph. right
appendage
Sup.
Ant.
Post.
Pulmonary veins
Inf.
Fig. 9.7 This specimen, from a patient with hypoplasia of the left
heart, photographed in anatomical orientation, shows the course
of the so-called levoatrial cardinal vein. The pulmonary veins
connect in normal fashion to the left atrium, but the anomalous
vein drains the atrial contents to the superior caval vein (SCV). Thus,
there are normal venous connections, but anomalous drainage
(arrows).
Sup.
BCV
Left
Right
Inf.
Anomalous vein
Left atrium
Pulmonary veins
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 05:21:43 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.010
Cambridge Books Online Cambridge University Press, 2013
327
Sup.
Post.
Ant.
Inf.
Tricuspid
valve
Oval
fossa
Atretic mouth of
coronary sinus
Brachiocephalic vein
Vertical vein
Sup.
Ant.
Inf.
behind to show the vertical vein that drains the coronary veins
(arrows), themselves connected to the obstructed coronary sinus
(see Figure 9.9), to the left brachiocephalic vein, and thence to the
superior caval vein. This situation is analogous to the levoatrial
cardinal vein providing pulmonary venous egress in the setting of
an obstructed left atrium.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 05:21:43 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.010
Cambridge Books Online Cambridge University Press, 2013
328
Partially anomalous
unilateral drainage
Supracardiac connection
to superior caval vein
to azygos vein
Cardiac connection
to LSCV & coronary sinus
direct to right atrium
Infradiaphragmatic &
infracardiac connection
to portal venous system
to inferior caval vein
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 05:21:43 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.010
Cambridge Books Online Cambridge University Press, 2013
329
SCV
Ascending vein
Ventricular mass
Sup.
Brachiocephalic vein
Right
Left
Inf.
Ascending vein
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 05:21:43 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.010
Cambridge Books Online Cambridge University Press, 2013
330
Sup.
Right
Left
Inf.
Left bronchus
Sup.
Right
Left
Pulmonary venous confluence
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 05:21:44 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.010
Cambridge Books Online Cambridge University Press, 2013
Sup.
Ant.
331
Inf.
Left atrium
Fig. 9.17 This specimen, viewed from the left side in anatomical
Right pulmonary veins
Sup.
Post.
Ant.
Inf.
Fig. 9.18 In this heart, all four pulmonary veins (arrows) are
Absence of coronary sinus
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 05:21:44 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.010
Cambridge Books Online Cambridge University Press, 2013
332
Pulmonary venous
confluence
Sup.
Ant.
Post.
Inf.
Pulmonary venous
confluence
Sup.
Left
Hepatic portal
vein
Right
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 05:21:44 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.010
Cambridge Books Online Cambridge University Press, 2013
333
Pulmonary veins
Vertical vein
Sup.
Left
Right
Inf.
Sup.
Confluence
Right
Left
Inf.
Descending
vein
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 05:21:44 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.010
Cambridge Books Online Cambridge University Press, 2013
334
Brachiocephalic vein
Sup.
Left
Right
Inf.
Coronary sinus
Aortic coarctation
Coarctation is a congenitally derived
discrete shelf-like (Figure 9.24) or waistlike (Figure 9.25) lesion within the aorta,
which causes obstruction to the ow of
blood. It is most often found adjacent to the
opening of the persistently patent arterial
duct (Figure 9.26), or the arterial ligament
if the duct has closed, but can occur
proximally or more distally, and even in the
abdominal aorta. It is usually accompanied
by some degree of tubular hypoplasia of the
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 05:21:44 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.010
Cambridge Books Online Cambridge University Press, 2013
335
Isthmal hypoplasia
Arterial duct
Coarctation shelf is
ductal tissue
Sup.
Ant.
Post.
Descending aorta
the ductal tissue that forms the shelf lesion of aortic coarctation.
Note the coexisting hypoplasia of the aortic isthmus.
Left subclavian
artery
Sup.
Ant.
Descending aorta
Post.
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 05:21:45 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.010
Cambridge Books Online Cambridge University Press, 2013
336
Sup.
Ant.
Left subclavian
artery
Post.
Inf.
Aortic
isthmus
Arterial duct
Left subclavian
artery
Coarctation at isthmus
Ant.
Inf.
Enlarged intercostal arteries
Sup.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 05:21:45 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.010
Cambridge Books Online Cambridge University Press, 2013
Arterial ligament
Ant.
337
Aortic arch
Sup.
Inf.
Post.
Coarcted segment
Aorta
Ant.
Inf.
Sup.
Post.
Thoracic duct
Fig. 9.29 This view through a left lateral thoracotomy shows the
thoracic duct as it passes from the area of coarctation behind the
left subclavian artery.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 05:21:45 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.010
Cambridge Books Online Cambridge University Press, 2013
338
Aortic isthmus
Descending aorta
Ant.
Inf.
Sup.
Post.
Abbotts artery
Intercostal arteries
Atretic cord
Aorta
Sup.
Right
Left
Duct to descending
aorta
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 05:21:46 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.010
Cambridge Books Online Cambridge University Press, 2013
339
RSCA
LCCA
LSCA
RCCA
Duct
Sup.
Pulmonary
trunk
Aorta
Left
Inf.
Sup.
Ascending aorta
Pulmonary trunk
Left
Right
Inf.
Arterial duct
BCA
LCCA
Descending
aorta
LSCA
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 05:21:46 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.010
Cambridge Books Online Cambridge University Press, 2013
340
RCCA
LCCA
RCCA
RCCA
LCCA
LSCA
LCCA
LSCA
LSCA
Interruption
between
carotid arteries
(Type C)
Interruption
between
LCCA and LSCA
(Type B)
Interruption
at isthmus
(Type A)
Vascular rings
Aortic rings are malformations associated
with abnormal regression of part of a
double aortic arch. Knowledge of the
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 05:21:46 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.010
Cambridge Books Online Cambridge University Press, 2013
13
13
4
6
Ao
341
Ao
PT
PT
Arterial duct
R
SCA
CCA
Fig. 9.37 This cartoon shows how the denitive system of aortic
arches is derived from the embryological primordiums depicted in
Figure 9.36. Note that the subclavian arteries (arrows), derived from
the seventh segmental arteries, have migrated proximal to the
origin of the ducts, and that the right aortic arch has atrophied
(yellow and red dotted channels). The left sixth arch persists as the
arterial duct.
L
Oesophagus
SCA
Trachea
CCA
Duct
Duct
Fig. 9.38 The cartoon shows the perfect hypothetical double arch, with right (R) and left
Ao
(L) components, and with a subclavian artery (SCA), common carotid artery (CCA), and arterial
duct arising from each arch. The descending aorta (arrow) is in the midline, or in a neutral
position. Ao, aorta; PT, pulmonary trunk.
PT
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 05:21:46 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.010
Cambridge Books Online Cambridge University Press, 2013
342
Tracheo-oesophageal
pedicle
Right-sided arch
Left-sided arch
RSCA
RCCA
LCCA
LSCA
Post.
Fig. 9.39 In this heart, there is persistence of both the right- and
Right
Left-sided
arterial
ligament
Left
Ant.
left-sided aortic arches, with the origin of the common carotid (RCCA,
LCCA) and subclavian (RSCA, LSCA) arteries in symmetrical fashion
from the superior surface of the arches. There is a ligamentous
left-sided arterial duct. The arrangement produces obvious
compression of the tracheo-oesophageal pedicle.
Tracheo-oesophageal
pedicle
RCCA
LCCA
Ant.
RSCA
Left
Right
LSCA
Post.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 05:21:47 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.010
Cambridge Books Online Cambridge University Press, 2013
343
Diverticulum
of Kommerell
RSCA
Fig. 9.41 This cartoon shows how an aberrant origin of the right
subclavian artery (RSCA) is explained on the basis of the
hypothetical double arch. The proximal portion of the right arch is
known as the diverticulum of Kommerell, and the initial segment
of the right arch is interrupted between the right common
carotid and right subclavian arteries (star). The duct, shown in the
left-sided position (black curved line), has become ligamentous in
this example.
Ant.
Left
RCCA
Right
Post.
Trachea
LCCA
LSCA
RSCA
considerable tracheo-oesophageal
compression is not obvious until the duct is
divided, and its ends are allowed to spring
apart (Figure 9.45).
A right-sided aortic arch can exist aside
from its association with vascular rings.
The arch is right-sided when it crosses over
the main stem of the right-sided bronchus.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 05:21:47 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.010
Cambridge Books Online Cambridge University Press, 2013
344
Ant.
Right
Left
Post.
Aorta
Trachea
Pulmonary
trunk
LCCA
Diverticulum
of Kommerell
Arterial duct
Aberrant LSCA
Vagus nerve
Aberrant LSCA
Ant.
Inf.
Sup.
Post.
construction of a subclavian-to-pulmonary
arterial shunt. With mirror-imaged
branching, the rst branch of the aorta
beyond the coronary arteries is the
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 05:21:47 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.010
Cambridge Books Online Cambridge University Press, 2013
345
Oesophagus
Ant.
Inf.
Sup.
Post.
PULMONARY ARTERIAL
ANOMALIES
By far the most common malformation of
the pulmonary arteries, excluding atresia or
stenosis, is for either the right or left
pulmonary artery to have an aortic origin.
Most frequently the anomalous artery arises
via the arterial duct. Although seen in the
presence of pulmonary atresia, usually
with the other lung supplied by major
systemic-to-pulmonary collateral arteries
(Figure 9.48), it can be found with the other
pulmonary artery connected to the patent
pulmonary trunk. In this arrangement, the
duct will often close with time. There will
then be apparent unilateral absence of that
pulmonary artery that was initially fed
through the duct. This is common in
tetralogy of Fallot or a double-outlet right
ventricle, but about half of the patients thus
aficted have otherwise normal hearts. In
our experience, it is rare to nd true absence
of the hilar pulmonary artery.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 05:21:48 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.010
Cambridge Books Online Cambridge University Press, 2013
346
Trachea
RSCA
Oesophagus
LSCA
Right arch
RCCA
Arterial
duct
LCCA
Sup.
Right
Left
Pulmonary trunk
Inf.
RSCA
Right pulmonary
artery
LSCA
RCCA
LCCA
Pulmonary
trunk
Right
Ascending
aorta
Inf.
between the left common carotid (LCCA) and left subclavian (LSCA)
arteries. The ascending aorta, however, gives rise to the two
common carotid arteries only, the right subclavian artery (RSCA)
being isolated, and arising from the right pulmonary artery via
the right-sided arterial duct (white star). The descending aorta
and the left subclavian artery are fed by the left-sided arterial duct
(red star).
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 05:21:48 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.010
Cambridge Books Online Cambridge University Press, 2013
347
Sup.
Arterial ligament
Left
Right
Inf.
Pulmonary trunk
Aorta
Left
Inf.
Right
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 05:21:48 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.010
Cambridge Books Online Cambridge University Press, 2013
348
Descending aorta
Trachea
Arterial duct
Right pulmonary
artery
Sup.
Right
Left
Inf.
Right pulmonary
artery
Aorta
Post.
Right
Left
Trachea
Ant.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 05:21:48 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.010
Cambridge Books Online Cambridge University Press, 2013
Right
pulmonary
artery
Oe
Left
pulmonary
artery
Sup.
Ant.
Post.
Inf.
Aorta
Pulmonary
trunk
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 05:21:48 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.010
Cambridge Books Online Cambridge University Press, 2013
349
350
Pulmonary trunk
Left
Sup.
Aorta
Inf.
Right
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 05:21:49 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.010
Cambridge Books Online Cambridge University Press, 2013
Ant.
Inf.
351
Pericardial reflection
Sup.
Post.
Vagus nerve
Aneurysmal duct
Ascending aorta
Descending aorta
Sup.
Pulmonary trunk
Right
Left
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 05:21:49 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.010
Cambridge Books Online Cambridge University Press, 2013
352
Aortopulmonary
window
Descending
aorta
Aortic
valve
Sup.
Right
Left
Inf.
Pulmonary trunk
Duct
Left
pulmonary
artery
Aorta
Sup.
Ant.
Post.
Inf.
Pulmonary valve
setting of the origin of the right pulmonary artery from the aorta
and interruption of the aortic arch. The heart is sectioned to
replicate the left anterior oblique subcostal echocardiographic
section. In this heart, the window (open double-headed arrow) has
some length. Note also the separate walls of the arterial trunks
proximal to the window (closed arrow).
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 05:21:49 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.010
Cambridge Books Online Cambridge University Press, 2013
353
Pulmonary trunk
Ant.
Sup.
Inf.
Post.
Fig. 9.59 This view through a left lateral thoracotomy shows a silk
ligature encircling a left coronary artery that is arising from the
pulmonary trunk.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 05:21:49 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.010
Cambridge Books Online Cambridge University Press, 2013
354
Sup.
Post.
Ant.
Pulmonary trunk
Inf.
Circumflex artery
orientation, the main stem of the left coronary artery takes origin
from the pulmonary trunk, arising from one of the sinuses adjacent
to the aorta. It then divides into the circumex and anterior
interventricular arteries.
Circumflex artery
Aorta
Pulmonary
trunk
Post.
Left
Right
Ant.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 05:21:50 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.010
Cambridge Books Online Cambridge University Press, 2013
355
Sup.
Ant.
Post.
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 05:21:50 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.010
Cambridge Books Online Cambridge University Press, 2013
356
Sup.
Fig. 9.63 The tubular aorta has been removed from the aortic
Left
Right
Right aortic sinus
Inf.
root, showing the origin of the right coronary artery from the left
coronary aortic sinus, with intramural coursing across the
peripheral attachment of the valvar leaets at the sinutubular
junction (arrow).
Sup.
Right coronary artery
Right
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 05:21:50 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.010
Cambridge Books Online Cambridge University Press, 2013
357
Infundibulum
Aorta
Ant.
Left
Circumflex artery
Right
Post.
Sup.
Right
Inf.
Anomalous communications
of the coronary arteries
Fistulous communications between the
coronary arteries and the ventricles are seen
most frequently when atresia of an outow
tract is seen in the setting of an intact
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 05:21:51 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.010
Cambridge Books Online Cambridge University Press, 2013
358
Retro-aortic
circumflex
artery
Aorta
Right
coronary
artery
Sup.
Post.
Artery to
sinus node
Ant.
Inf.
Myocardial
bridging
Sup.
Right
Left
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 05:21:51 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.010
Cambridge Books Online Cambridge University Press, 2013
359
Left
Sup.
Inf.
Right
Clamp on appendage
Fistula
Left
Inf.
Sup.
Right
Fig. 9.70 The broad stula shown in Figure 9.69 has been divided.
Aortoventricular tunnels
These tunnels are rare lesions. The
anatomical arrangement is difcult to
understand, as the essence of the lesions
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 05:21:51 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.010
Cambridge Books Online Cambridge University Press, 2013
360
Post.
Right coronary artery
Right
Left
Ant.
Aorta
Fistula
Termination in
left ventricle
shows a stula taking origin from the left coronary artery (arrow)
and terminating in the left ventricle.
Sup.
Right coronary leaflet
Post.
Ant.
Inf.
Aorta
Fig. 9.72 The aortic root has been opened and photographed
Left ventricle
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 05:21:52 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.010
Cambridge Books Online Cambridge University Press, 2013
361
Aortoventricular tunnel
Sup.
Right
Left
Inf.
Fig. 9.73 The aortic root has been opened and is photographed
Right aortic leaflet
References
1. Anderson RC, Heilig W, Novick R, Jarvis
C. Anomalous inferior vena cava with
azygos drainage: so-called absence of the
inferior vena cava. Am Heart J 1955; 49:
318322.
2. Moller JH, Nakib A, Anderson RC,
Edwards JE. Congenital cardiac disease
associated with polysplenia: a
developmental complex of bilateral leftsidedness. Circulation 1967; 36: 789799.
3. Venables AW. Isolated drainage of the
inferior vena cava to the left atrium. Br
Heart J 1963; 25: 545548.
4. Winter FS. Persistent left superior vena
cava: survey of world literature and report
of 30 additional cases. Angiology 1954; 5:
90132.
5. Bankl H. Congenital Malformations of the
Heart and Great Vessels. Baltimore, MD:
Urban and Schwarzenberg, 1977; p 194.
6. Agnoletti G, Annechino F, Preda L, Borghi
A. Persistence of the left superior caval
vein: can it potentiate obstructive lesions of
the left ventricle? Cardiol Young 1999; 9:
285290.
7. Edwards JE, DuShane JW. Thoracic
venous anomalies. I. Vascular connection
between the left atrium and the left
innominate vein (levoatriocardinal vein)
associated with mitral atresia and premature
closure of the foramen ovale (case 1). II.
Pulmonary veins draining wholly to the
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 05:21:52 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.010
Cambridge Books Online Cambridge University Press, 2013
362
30.
31.
32.
33.
34.
35.
36.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 05:21:52 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.010
Cambridge Books Online Cambridge University Press, 2013
10
Positional anomalies
of the heart
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 05:22:01 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.011
Cambridge Books Online Cambridge University Press, 2013
364
Morphologically
right atrial appendage
Left
Inf.
Sup.
Right
Aorta
Apex to right
Pulmonary trunk
Morphologically right ventricle
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 05:22:01 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.011
Cambridge Books Online Cambridge University Press, 2013
365
Left
Fig. 10.2 This picture, taken from the right side of the
Sup.
Inf.
Right
Pulmonary trunk
Left
Sup.
Inf.
Right
Aorta
Fig. 10.3 The skin and upper sternum have been opened in the
Morphologically right ventricle
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 05:22:01 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.011
Cambridge Books Online Cambridge University Press, 2013
366
RIGHT-SIDED HEART
CRISS-CROSS AND
SUPEROINFERIOR VENTRICLES
Right-sided
left ventricle
Left-sided
right ventricle
Anterior
right ventricle
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 05:22:01 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.011
Cambridge Books Online Cambridge University Press, 2013
367
Fontan
conduit
Morph.
left atrium
Morph. RV
Morph. LV
Post.
Right
Left
Ant.
Oversewn
pulmonary root
Aorta
Morph. RV
Morph. LV
Sup.
Post.
Ant.
Fontan conduit
Inf.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 05:22:01 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.011
Cambridge Books Online Cambridge University Press, 2013
368
Usual side-by-side
ventricles
Aorta
Sup.
Pulm.
trunk
Left
Right
Inf.
Tricuspid
valve
Fig. 10.8 In the heart shown in Figure 10.6, the right ventricle
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 05:22:01 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.011
Cambridge Books Online Cambridge University Press, 2013
369
Left
Inf.
Sup.
Right
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 05:22:02 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.011
Cambridge Books Online Cambridge University Press, 2013
370
Left
Sup.
Inf.
Morphologically
left atrial
appendage
Right
Aorta
Right
superior
caval
vein
Left
Sup.
Left superior
caval vein +
terminal groove
Right
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 05:22:02 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.011
Cambridge Books Online Cambridge University Press, 2013
371
Ant.
Post.
Inf.
Sup.
Morph. right atrial appendage
Ant.
Post.
Inf.
Aorta
Fig. 10.13 The image shows the left side of the heart in
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 05:22:02 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.011
Cambridge Books Online Cambridge University Press, 2013
372
Ant.
Left
Right
Aorta
Post.
Sup.
Left
Right
Aorta
Inf.
Common atrium
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 05:22:02 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.011
Cambridge Books Online Cambridge University Press, 2013
Sup.
Ant.
Post.
Inf.
Septal strand
Fig. 10.16 The heart has been opened through the right
Ant.
Inf.
Septal strand
Fig. 10.17 The left side of the heart shown in Figure 10.16 has
been opened through an incision close to the crux. The pectinate
muscles also encircle the left-sided vestibule, showing that there
are morphologically right atrial appendages bilaterally. The star
shows the common atrioventricular valve.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 05:22:02 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.011
Cambridge Books Online Cambridge University Press, 2013
373
374
Right
Left
Inf.
Sup.
Right
Left
Inf.
Fig. 10.19 In this heart from a patient with isomeric right atrial
appendages, the pulmonary veins drain in anatomically anomalous
fashion to the atrial roof, even though returning directly to the
heart. Note that the common atrioventricular valve is connected
exclusively to a dominant left ventricle, indicating the presence of a
double-inlet connection.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 05:22:02 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.011
Cambridge Books Online Cambridge University Press, 2013
375
Morphologically
left atrial
appendage
Sup.
Ant.
Post.
Inf.
Morphologically
left atrial
appendage
appendage
Sup.
Ant.
Post.
Inf.
Fig. 10.21 The image shows the opposite side of the heart
illustrated in Figure 10.20. The left-sided appendage is also of left
morphology.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 05:22:02 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.011
Cambridge Books Online Cambridge University Press, 2013
376
Left bundle
branch in
left-sided
ventricle
Anterior
connection
Posterior
connection
Posterior
connection
10.
11.
12.
13.
14.
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 05:22:03 WEST 2013.
http://dx.doi.org/10.1017/CBO9781139028561.011
Cambridge Books Online Cambridge University Press, 2013
Index
Numbers in italics refer only to illustrations
A
Abbotts artery 337, 338
absent pulmonary valve syndrome 239
accessory pathways 11419, 114
left-sided 116, 117
paraseptal 11719, 118
right-sided 117, 118
aneurysms
membranous septum 274
patent arterial duct 350
ansa subclavia 12
anterior septum 119
anterolateral muscle bundle hypertrophy 21617
aorta
anatomy 457
arch 456, 48
development 3401
double 3413
interrupted 3001, 33740
right-sided 3434
ascending 45, 47
coarctation 211, 3001, 3347
intercostal arteries 467, 336
common arterial trunk 3089, 312
congenitally corrected transposition 2816, 286
coronary arteries, anomalous origins 916, 313,
3545
descending 467
double-outlet ventricle 2956, 297, 3001
hypoplasia 334
parallel arterial trunks 31319
pulmonary arteries arising from 3456, 347
spiral arrangement of arterial trunks 313, 314
mirror-image 315
tetralogy of Fallot 2312
transposition 2758
vascular rings 3405
see also common arterial trunk
aortic atresia
in congenitally corrected transposition 291
with mitral atresia 260, 2636
aortic root 16, 52, 59, 91, 159
aortic sinuses 78, 914, 124, 21112
in aortic stenosis 218
Leiden nomenclature 93
in transposition 278, 280
aortic stenosis
subvalvar 210, 21318
dynamic 218
xed 21417
supravalvar 218, 21921
valvar 21013
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 05:22:16 WEST 2013.
http://ebooks.cambridge.org/ebook.jsf?bid=CBO9781139028561
Cambridge Books Online Cambridge University Press, 2013
378
Index
B
Bachmanns bundle 22
basal cords 63, 65, 68, 74
bicuspid valve see mitral valve
BlandWhiteGarland syndrome 353, 3545
C
Cantrells syndrome 3656
cardiac position/malposition see under heart
cardiac veins 1057, 161
great 86, 87, 106, 107
middle 106
small 106
see also coronary sinuses
carotid artery, left 46
Carpentiers classication of mural leaet scallops
66, 68
caval veins
inferior
abnormalities 322, 323, 324
atrial appendage isomerism 132, 374
oval fossa and 156, 159
scimitar syndrome 330
sinus venosus and 156, 160
persistent left superior 8, 17, 18, 3223, 325
unroong of the coronary sinus 15960,
1612, 164
superior
abnormalities 322
proximity of phrenic nerve 3, 7
sinus venosus and 1569, 161
in venous switch procedures 267
total cavopulmonary connection 24850, 252, 259
cavoatrial junction 159
central brous body 313, 45, 579
ventricular septal defects 186
circumex coronary artery 71, 96, 1012, 105
valves and 70, 889
coarctation of the aorta 211, 3001, 3347
intercostal arteries 467, 336
commissural cords 63, 64
commissures 55, 63
common arterial trunk 145, 148, 30313
arterial anatomy 30713
denition 303, 304
interventricular communications 3067
surgical repair 3045
truncal valve 303, 307, 3089
conduction axis see atrioventricular conduction axis
congenital malformations
cataloguing 1489
morphological analysis 129
atrial arrangement 12932
atrioventricular connections 1329
cardiac position 148
valves 1403, 145, 148
ventricular relationships 1435
ventricular topology 1323, 134, 143
ventriculoarterial junctions 1458
D
d-transposition 263, 276
DamusKayeStansel procedure 247
dead-end tract 112
dextrocardia 364
see also right-sided heart
diverticulum of Kommerell 343, 344
double aortic arch 3413
double-inlet ventricle 136, 24554
conduction axis 2478, 2523, 254
left dominant 136, 245, 24753
Fontan procedure 247, 24852
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 05:22:16 WEST 2013.
http://ebooks.cambridge.org/ebook.jsf?bid=CBO9781139028561
Cambridge Books Online Cambridge University Press, 2013
Index
E
Ebsteins malformation 117, 2024, 262
in congenitally corrected transposition 289, 290
ectopia cordis 3656
Eisenmengers syndrome 323
endocarditis of the aortic valve 218
epicardium 1416
Eustachian ridge 23, 29
Eustachian valve 156, 260, 323
exteriorisation of the heart 3656
hemitruncus 345
hepatic veins 322
Holmes heart 248, 315, 316
Horners syndrome 12
hypoplastic left heart syndrome 140, 260,
2636
I
indeterminate ventricle 140, 254, 256
inferior caval vein see caval veins, inferior
infundibular artery 93, 99
infundibulum 38, 39, 41, 83, 151
absent in ventricular septal defect 196, 197
atretic 2356, 237
in double-outlet ventricle 297, 2989, 303
morphological analysis 1458
stenosis 300
in transposition 278
interatrial groove see Waterstons groove
intercostal arteries 467, 336
intercostal spaces
fourth 3, 12
fth 6
sixth 3, 8
intercostal veins 6, 8, 910
interrupted aortic arch 3001, 33740
interventricular arteries
anterior 88, 96, 1001, 103, 366
inferior 89, 978, 100, 101, 105
F
Fallots tetralogy see tetralogy of Fallot
brous tissue
aortic valve 79, 81
aorticmitral brous curtain 45, 56, 58, 79
central brous body 313, 45, 579, 186
brous trigones 33, 56, 57
Fontan procedure
combined mitral and aortic atresia 2601
conduction axis and 121, 1245
double-inlet ventricle
left dominant 247, 24852
right dominant 254
tricuspid atresia 125, 25760, 261
foramen ovale see oval fossa
G
gastric veins 331, 333
Gerbode defects 34, 1647
Glenn procedure 162, 250
H
heart
malposition 364
criss-cross 145, 3669
exteriorisation 3656
right-sided 3478, 364, 366
position 2, 148
surface anatomy 14, 1619
K
Kochs triangle 258, 2930, 72, 112, 119, 152
Konno procedure 80, 83
L
laryngeal nerve see recurrent laryngeal nerve
lateral thoracotomy
left 36
right 612
latissimus dorsi 3
left atrium 345
access 15, 19, 34
appendage 17, 34, 36, 129, 130, 131
isomerism 19, 12930, 131, 132, 133, 36974
vestibule 35, 37
left bundle branch 45, 85, 112, 115
in congenitally corrected transposition 281
in double-inlet ventricle 252
left ventricle 435
double-outlet 303
incomplete 254, 255
in univentricular atrioventricular connections
1378, 145
ventriculoarterial junction 52, 54
left ventricular dominance 136, 1845, 24753
Fontan procedure 247, 24852
Holmes heart 248, 315, 316
parallel arterial trunks 31417
septation procedure 2523
M
macro-reentrant atrial tachycardia 125
Mahaim connections 114, 119
median sternotomy 23, 5, 16
mediastinum 2, 3, 3
membranous septum 324, 45, 79, 151
aneurysm 274
ventricular septal defect 186
mitral atresia 137, 141, 199, 254, 258, 2601, 323
mitral valve
anatomy 53, 6170, 177
clefts 206, 208
conduction axis and 68, 69, 85
coronary arteries and 70, 71, 889
coronary sinuses and 70, 867
dilation 201
brous support 45, 56, 58, 59, 61
imperforate 1401, 261, 266
leaets 44, 612, 63, 667, 66, 171, 173
aortic 56, 64, 65, 66
mural 62, 65, 667, 68
offset with respect to tricuspid valve 26, 30
overriding 1423
papillary muscles 44, 68, 69, 200
parachute deformity 2078, 209
prolapse 64, 66, 205, 2068
straddling 142, 200
tendinous cords 62, 634, 678
zone of apposition 56, 667
see also atrioventricular valves; mitral atresia
moderator band 41, 147, 148, 153, 155
in tetralogy of Fallot 231, 232
muscle of Lancisi (medial papillary muscle) 40,
70, 73
Mustard procedure 266, 26970
N
Nikaidoh procedure 275
nodal arteries
atrioventricular 28, 31, 70, 89, 105, 118
sinus see sinus node, artery
nodule of Arantius 74
non-branching bundle 181, 252, 280, 2856
non-coronary sinus 78, 92
Norwood procedure 247, 260
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 05:22:16 WEST 2013.
http://ebooks.cambridge.org/ebook.jsf?bid=CBO9781139028561
Cambridge Books Online Cambridge University Press, 2013
379
380
Index
O
oblique ligament 16
oblique sinus 1516
omphalocele 3656
ostium primum defects 1556, 16685, 209
ostium secundum defects see oval fossa, defects
outow tract tachycardias 123
oval fossa 23, 2728, 151, 152
defects 156
absent 158
decient 22, 157
perforated 157
P
papillary muscles
mitral valve 44, 68, 69, 200
tricuspid valve
anterior 41, 231
medial 40, 70, 73
parachute deformity
mitral valve 2078, 209
tricuspid valve 208
parallel arterial trunks (with concordant
ventriculoarterial connections) 31317
and discordant atrioventricular connections
31719
patent arterial duct 9
aortic coarctation 334, 336
common arterial trunk 311
surgical closure 34851
tetralogy of Fallot 232, 233
pectinate muscles 19, 22
atrial arrangements 129, 131132
penetrating atrioventricular bundle see
atrioventricular bundle (bundle of His)
pericardial cavity 1416
oblique sinus 1516
transverse sinus 1415, 45, 59, 68, 99
pericardial fold 15
pericardium 1416
phrenic nerve 23, 4, 5
left 6, 8, 46
right 6, 7, 7
portal vein 331, 3323
primary atrial septum (septum
primum) 151
pulmonary arteries
aortic origin 3456, 347
common arterial trunk 30713
left 49
arising from right 3467, 3489
in pulmonary atresia with intact ventricular
septum 238
in pulmonary valve insufciency 23941
right 12, 4950, 347
spiral arrangement of arterial trunks 313, 314
mirror-image 315
in tetralogy of Fallot 224, 2324
total cavopulmonary connection 24850, 252,
259
R
Rastelli classication 1712, 174
Type A 174
Type B 175
Type C 175
Rastelli procedure 275
recurrent laryngeal nerve
closure of patent arterial duct 350
left 46, 9, 46
right 11, 12
right atrium 1934
access 19
appendage 17, 19, 129, 130, 131
anomalous pulmonary venous connection
132, 330, 369
isomerism 129, 130, 132, 133, 143, 369,
3702
pulmonary venous drainage to 330, 331
septal surface 225, 27
S
scimitar syndrome 330
secondary atrial septum (septum secundum) 151
secundum defects see oval fossa, defects
semilunar valves see aortic valve; pulmonary
valve
Senning procedure 266, 270
septal band see septomarginal trabeculations
septal perforating arteries 42, 100, 104, 105
septation procedure 2523
septomarginal trabeculations (septal band) 401,
42, 1478, 153, 226
in tetralogy of Fallot 226, 231, 232
in ventricular septal defect 1945
double-outlet ventricle 297
septoparietal trabeculation 41, 42
hypertrophy in tetralogy of Fallot 225, 229,
2301
see also moderator band
serratus anterior 3
Shones syndrome 208
sinus node 19, 21
artery
course 19, 202, 236, 36, 99, 101,
1023
oval fossa and 156, 158
preservation 34, 159, 251, 25960,
2667
variants 21, 23, 102, 1034, 106, 269
horseshoe 20, 21
isomerism of the atrial appendages
1301, 369
sinus venosus defects 1589, 163
transposition 266
sinus venosus defects 1569, 1602, 3323
sinutubular junction 45, 47, 52, 75, 77
pulmonary stenosis 219, 221
supravalvar aortic stenosis 218, 21921
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 05:22:16 WEST 2013.
http://ebooks.cambridge.org/ebook.jsf?bid=CBO9781139028561
Cambridge Books Online Cambridge University Press, 2013
Index
T
tachycardia see supraventricular tachycardia;
ventricular tachycardia
TaussigBing malformation 200, 297, 299, 3001
tendon of Todaro 25, 32, 59, 63, 112, 113
terminal crest 19, 22
terminal groove 19, 20
tetralogy of Fallot 146147, 22534
absent pulmonary valve syndrome 239
aortic connection 2312
conduction axis 226, 2289
left superior caval vein 323
pulmonary atresia 224, 2324
subpulmonary obstruction 22731
ventricular septal defects 226, 227, 228, 230
Thebesian valve 1067, 108, 323
thoracic artery, internal 2, 3, 7
thoracic duct 6, 10, 10710, 337, 350
thoracotomy
left-sided 36
median sternotomy 23, 5, 16
right-sided 612
thymus gland 2, 3, 4, 45
arterial supply 2
venous drainage 2, 5
thyroid artery, inferior 2
tissue tags
aortic stenosis 217
subpulmonary obstruction
in congenitally corrected transposition
288, 289
in transposition 275
total cavopulmonary connection 24850, 252, 259
trabeculations
comparison of left and right ventricles 43,
132, 134
left ventricle 445
right ventricle 3743
see also moderator band; septomarginal
trabeculations; septoparietal trabeculation
tracheo-oesophageal compression 342
transposition 26178
aorta 2758
with complicating lesions 2705
coronary arteries and the arterial switch
procedure 278, 27982
similarities in parallel arterial trunk 318
terminology 2614, 276
venous switch procedures 26670
see also congenitally corrected transposition
transverse sinus 1415, 45, 59, 68, 99
triangle of Koch 258, 2930, 72, 112, 119, 152
tricuspid atresia 137, 141, 199, 203, 251,
25460
tricuspid valve
anatomy 34, 616, 702
conduction axis and 85
Fontan procedure 125, 25960, 261
straddling valve 200, 201
coronary arteries and 72, 75, 89, 97, 98, 100
dilation 201
dysplasia 205, 206
Ebsteins malformation 117, 2024, 262
in congenitally corrected transposition
289, 290
brous annulus rare/absent 59, 62, 72
imperforate 1401, 142, 260, 2612
leaets 367, 389, 612, 63, 701
anteriosuperior 70
inferior 71
septal 70, 73, 190
offset with respect to mitral valve 26, 30
papillary muscles
anterior 41, 231
medial 40, 70, 73
parachute deformity 208
straddling/overriding 1423, 189, 199, 200,
2013
in congenitally corrected transposition 2901
in transposition 2723
tendinous cords 62, 634, 70, 71, 74
in ventricular septal defect 189, 190, 199
transposition 2701, 2723
zones of apposition 37
see also atrioventricular valves; tricuspid atresia
truncal valve 303, 307, 3089
truncus arteriosus see common arterial trunk
381
U
univentricular atrioventricular connections 1369,
145
unroong of the coronary sinus 15962, 1634, 334
V
vagus nerve 2, 4, 5, 46
closure of patent arterial duct 350
valvar annulus, in echocardiography 55,
60, 77
valve of Vieussens 107
vascular pedicle 47
vascular rings 3405
vascular sling 3467, 3489
venae cavae see caval veins
venous duct 331
venous sinus
pulmonary 35
systemic 19, 20, 26
venous switch procedures 26670
ventricle(s) 1719
margins 1819
morphological analysis 1323, 134, 143
univentricular atrioventricular connections
1369, 145
ventricular relationships 1435
solitary 136, 139, 140, 254, 256
superoinferior 3669
see also left ventricle; right ventricle
ventricular pre-excitation 11319
ventricular septal defects 18699
categorisation 186, 188
in common arterial trunk 3067
conduction axis 18791
in congenitally corrected transposition 2838,
291
in double-inlet ventricle 2478
large defects not to be confused with 247, 254,
257
in double-outlet ventricle 2949
doubly committed and directly juxta-arterial
187, 1958, 300
congenitally corrected transposition
286, 288
tetralogy of Fallot 226, 230
transposition 273, 274, 277
in interrupted aortic arch 339, 340
muscular 186, 1915
tetralogy of Fallot 226, 228
transposition 270, 272, 272, 273
perimembranous 18691, 199
congenitally corrected transposition 287
and doubly committed 198
tetralogy of Fallot 226, 227
transposition 270, 271, 272
in tetralogy of Fallot 226, 227, 228, 230
in transposition 2703, 277
tricuspid valve and
atresia 260
cleft 190
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 05:22:16 WEST 2013.
http://ebooks.cambridge.org/ebook.jsf?bid=CBO9781139028561
Cambridge Books Online Cambridge University Press, 2013
382
Index
W
Warden operation 159
Waterstons groove (interatrial groove) 19, 22, 26,
28, 34, 35, 251
WolffParkinsonWhite syndrome 11419
X
xiphoid process 2
Downloaded from Cambridge Books Online by IP 113.166.95.77 on Fri Sep 13 05:22:17 WEST 2013.
http://ebooks.cambridge.org/ebook.jsf?bid=CBO9781139028561
Cambridge Books Online Cambridge University Press, 2013