Chest, femoral and cardiac vasculature

1. Anatomy & PhysiologyAnatomy & Physiology
for the EP professionalfor the EP professional
Part I

2. ObjectivesObjectives
• Describe the anatomic structures of the chest
• Identify the neck, chest and femoral
vasculature.
• Describe vascular access and complications.
• Identify cardiac chambers, valves, arteries &
veins
• Identify blood supply to the conduction system
• Describe the flow of blood through the heart

3. Thoracic CavityThoracic CavityThoracic AnatomyThoracic Anatomy

4. Thoracic AnatomyThoracic Anatomy

5. Thoracic VasculatureThoracic Vasculature

6. Thoracic VeinsThoracic Veins

7. Thoracic CageThoracic Cage
• Houses the right & left Lung
– Right lung has 3 lobes
– Left Lung has 2 lobes
• Heart
• All structures are enclosed by the
parietal pleura

8. Venous landmarks of upperVenous landmarks of upper
chestchest

9. Chest Venous accessChest Venous access
• Most often axillary access for device
implants.
• Internal jugular vein for T-pacer
placement
• Subclavian no longer the access of
choice d/t pneumothorax & subclavian
crush
• Femoral vein for studies

10. Chest venous accessChest venous access
• Axillary vein is lateral to the apex of the
left lobe of the lung
• Less complications of pneumothorax
• Most perform a venogram prior to
accessing the vein for pacemaker lead
implant
• Majority of cardiac devices are
implanted in the left pectoral region of
chest

11. Venogram using
the antecubital or
median basilic
vein allows
visualization of
subclavian,
axillary and
innominate veins
AxillaryAxillary
AnatomyAnatomy

12. Complications- chestComplications- chest
accessaccess
• Subclavian crush –
– Lead positioned via the subclavian vein.
– Subclavian vein lies between the clavicle
and the 1st
rib.
– Deterioration of the insulation material and
the wires leads to failure of the
pacemaker/ICD leads.

13. ComplicationsComplications
• Post device implant swelling at the
pectoral site may be as a result of
– Generally “wet” site due to A/C status
– Inadvertent arterial nick
• Pressure at site may result in
hemostasis
– If extreme, re-open and cauterize
– Often, device site pain relieved with
elevation to 30 degrees and ice compress.

14. ComplicationsComplications
• Pneumothorax
– Because the subclavian vein is situated
between the clavicle and the first rib, often
times the needle must be bent to access
vein.
– Lung extends above the clavicle
approximately 1 inch
– Angle of the needle to be at least 20-30º

15. Cross section of theCross section of the
Clavicle & 1Clavicle & 1stst
RibRib

16. Internal JugularInternal Jugular
accessaccess
• Was used for the coronary sinus wire
insertion
• Access of choice for T -Pacers

17. IJ ComplicationsIJ Complications
• Difficult puncture for many due to
location of vein
• Arterial puncture complication
– Difficult to obtain hemostasis if A/C levels
are high

18. IJ AnatomyIJ Anatomy

19. Femoral accessFemoral access
• Most often used for all EP studies
• As many as 4 sheaths in the veins at once
(Can have 3 sheaths on one side)
• Occasionally an arterial sheath is inserted
during some studies
• All venous lines must be connected to fluid
and at KVO rate
• Arterial lines must be connected to pressure
during and after the case, until the line is
D/C’d

20. Femoral AnatomyFemoral Anatomy

21. Femoral ArterialFemoral Arterial
ComplicationsComplications
• Hematoma is number one complication of
arterial stick

22. Vascular ComplicationsVascular Complications
• Treatment – Hematoma
– Manual pressure at site
• DO NOT try to “squeeze out” blood
• Goal is hemostasis
– Pressure dressing
– Needle aspiration
– Surgical evacuation
• May require surgical repair of artery/vein

23. Femoral ComplicationsFemoral Complications
• Arterial
– Hematoma
• May rapidly increase in size
– Bleeding
• Lack of hemostasis
– Pseudoaneurysm
• a.k.a. “false aneurysm”
• Hematoma outside of and adjacent
to artery
• Communication with arterial lumen
• Treat with compression or surgery

24. Femoral ComplicationsFemoral Complications
• Arterial complications (cont’d)
AV fistula
Inadvertent cannulation of artery thru the
vein
May require surgical repair
Retroperitoneal bleed
Damage to posterior artery
– Blood collects in peritoneal cavity
– Flank/lower back pain
– Requires surgical repair
– Usually emergent repair

25. Femoral ComplicationsFemoral Complications
• Venous
– Hematoma
• Collection of blood underneath skin
• Manual compression to stop bleeding
• DO NOT try to “squeeze out”
• Mark the hematoma edges with sharpie
pen and time the marking
• Bleeding
– Manual compression at site of
bleeding

26. Gross Cardiac A & PGross Cardiac A & P

27. Location of the HeartLocation of the Heart
• Lies roughly in
the center of
thoracic cavity
• Attached to
thorax via the
great vessels

28. Location of the HeartLocation of the Heart
• Apex (bottom)
– Formed by tip of left ventricle
– Points anterior and inferior
• Base (top)
– Approximately 2nd intercostal space
– Angle of Louis
• Anterior surface
– Primarily right ventricle
• Inferior (diaphragmatic) surface
– Right and left ventricles, predominantly left

29. Size and Shape of theSize and Shape of the
HeartHeart
• Cone-shaped
• Adult heart size:
– ~5 inches (12 cm) long
– ~3.5 inches (9 cm)
wide
– ~2.5 inches (6 cm)
thick
– About the size of a
man’s fist

30. Size and Shape of theSize and Shape of the
HeartHeart

31. Heart ChambersHeart Chambers
• Four chambers
• Two upper
– Right atrium
– Left atrium
• Two lower
– Right ventricle
– Left ventricle

32. AtriaAtria
Thin-walled
Low-pressure
Separated by
interatrial
septum
“Atrial kick”
Due to atrial
contraction
25-30% of CO

33. VentriclesVentricles
• Right ventricle
– Pumps venous blood to lungs
– Low pressure chamber
• Left ventricle
– Pumps arterial blood to body
– High pressure chamber
• Chambers separated by
interventricular septum

34. • The Fibrous Skeleton of the heart
consists of:
– AV Valves (semi-lunar)
• Tricuspid valve separates the
right atrium from the right
ventricle
• Mitral valve separates the left
atrium from the left ventricle
• Fibrous skeleton is electrically inert
ValvesValves

35. Valvular orientationValvular orientation

36. Valvular orientationValvular orientation

37. Accessory Pathway Locations based on Valve LandmarksAccessory Pathway Locations based on Valve Landmarks

38. ValvesValves
• Pulmonic Valve
Prevents blood from flowing
backwards into the right
ventricle
• Aortic Valve
Prevents blood from flowing
backwards into the left ventricle.

39. Valves cont’dValves cont’d
Normal Valve Areas Critical
Aortic 2.5 – 3.5 cm2 .7cm2
Pulmonic 4-6 cm2
Mitral 2.5-3.5 cm2 <1.0 cm2
Tricuspid 8-10 cm2

40. Anatomy and PhysiologyAnatomy and Physiology
• Coronary Blood Supply
– RCA
– Left Main
• LAD
• LCX

41. Coronary VasculatureCoronary Vasculature

42. Coronary Vasculature – Inferior viewCoronary Vasculature – Inferior view

43. CoronaryCoronary
ArteriesArteries

44. Right Coronary ArteryRight Coronary Artery
• Originates from the right coronary cusp
of the aorta
• Passes along the atrioventricular sulcus
between the right atria and ventricle
• Marginal branch of the RCA supplies the
RA and RV

45. Right Coronary ArteryRight Coronary Artery
• The coronary artery that gives rise to the
posterior descending artery (PDA) is
known as the “dominant” coronary artery
and most often is the RCA
• The PDA supplies blood to the posterior
surface of both walls of the ventricles.

46. • PDA supplies the posterior third of the
interventricular septum.
• In 50-60% a branch of the RCA supplies
the SA node.
• In 85-90% of hearts the RCA also
branches into the AV nodal artery.
RCA cont’d

47. Left Coronary ArteryLeft Coronary Artery
• Arises from the left coronary cusp of
the aorta.
• Consists of the left main coronary
artery.
• The left main artery bifurcates into the
left circumflex artery (LCX) and the left
anterior descending artery (LAD).

48. Left Coronary SystemLeft Coronary System
• LAD travels along anterior
interventricular sulcus and supplies
blood to the anterior surface of both
ventricles.
• LAD branches include the diagonal
and septal arteries.

49. Left Coronary SystemLeft Coronary System
• LCX passes along the left atrioventricular
sulcus between the left atria and ventricle.
• Supplies the lateral wall of the LV
• May also supply the inferior portion of the
LV.
• LCX artery supplies the SA node in 40-
60%.
• LCX supplies the AV node in 10-15%.

50. Blood SupplyBlood Supply
• The SA and AV nodes are supplied by
the RCA and LCX.
• The bundle branches are supplied by
the LAD.
– Thus an occluded RCA may cause nodal
dysfunction.
– An occluded LAD may cause a BBB.
– The possibility of reentrant arrhythmias is
present with any infarct.

51. CirculationCirculation
• Blood in the atrium is ejected into the
ventricles during atrial contraction.
• Passive filling of the ventricles occurs.
• Ventricles eject blood thru the
pulmonary artery to the alveoli for
oxygenation and thru the aorta for
systemic oxygenation.
• Coronary artery perfusion occurs
during diastole.

52. ReferencesReferences
• Netter, F H (1987) The CIBA collection of medical Illustrations.
Volume 5 The heart. Colorpress, New York NY
• Mazgalev, T.N., Tchou, P.J. (2000) Atrial AV Nodal
Electrophysiology; A view from the millennium. Futura, Armonk,
NY
• Podrid, P.J., Kowey, P.R. (2001) Cardiac Arrhythmia,
Mechanisms, Diagnosis & Management, 2nd
Ed. Lippincott,
Williams & Wilkins. Philadelphia PA
• Anderson, R.H. (2000) Electrical Anatomy of the Atrial
Chambers. Medtronic USA
• Anderson R.H., Ho, S.W. ( n.d.) The Anatomy of the
Atrioventricular Node. Article review by Sechler, D.A., RN