Segmental Approach to Congenital Heart Disease

  • Start with the Principles
  • Know the Anatomy
  • What is the RA
    • parts/size/shape/position/character/time/connected to
      • Most unique
        • SVC and IVC and coronary sinus
    Entrance into the Right Atrium
    Thebesian Valves
    The anterior wall has been removed In this waxed specimen created after distending the heart, allowing a window into the right atrial cavity and a focus on the fenestrated Thebesian valve which marks the entrance of the coronary sinus into the right atrium. The coronary sinus entrance lies just anterior and inferior to the Eustachian valve and the IVC, and just posterior to the tricuspid apparatus. right atrial appendage = RAA
     Courtesy Ashley Davidoff TheCommonVein.net
    06412cc02.81s
    IVC, Right Atrium and Right Atrial Appendage
    In this anatomic specimen the SVC and IVC are well seen and their lateral relationship to the right atrium is appreciated.  They are embryological remnants of the sinus venosus and their similarity and conjoined structural origin and functionality can be well appreciated in this image. Davidoff MD
    Key Words 
    heart cardiac RA right atrium thebesian valves coronary sinus Eustachian valve sulcus terminalis fossa ovalis foramen ovale septum secundum superior limbic band IVC inferior vena cava anatomy normal gross anatomy post mortem specimen
    Courtesy Ashley Davidoff MD 2019  01707.6
    NORMAL RIGHT ATRIUM – SAGITTAL MRI WIT SVC AND IVC

    Right Ventricle

    parts/size/shape/position/character/time/connected to

    Most unique

    papillary muscles attached to the septum
    trabeculations

    Characterizing the Left Ventricle of the heart
    Anterolateral and Posteromedial Papillary Septal Anterolateral Muscles of the Right Ventricle attached to the Ventricular Septum
    Ashley Davidoff MD
    TheCommonVein.net
    Muscles Bands Between the Inflow and Outflow Tract of the Right Ventricle (RV)
    The superior aspect of the septal band (green in right image) has two limbs – the “Y” of the septal band. and the conal septum (lime green) embeds itself in the Y of the septal band. The (chordae) of the conal papillary muscle(aka papillary muscle of Lancisi- black arrow) also inserts in the “Y ” of the septal band. The anterolateral papillary muscle (purple )originates from the septal band) amd subtends the anterior leaflet of the tricuspid valve . The moderator band (not shown) connects the septum top the the free wall, and the parietal band (blue) completes the muscular ring that separates the inflow from the outflow tract. The pulmonary valve (white arrows) define the border between the RVOT and conus with the pulmonary artery.
    Ashley Davidoff MD
    06409c02
    Normal Size of the Right Ventricle and Left Ventricle in the Axial projection During Diastole    The axial gated CT scan through the right and left ventricle at end diastole shows the normal size and shape of the right ventricular inflow tract and left ventricle. The right ventricular inflow (underlying the RV measurement)  looks smaller than the LV in volume, in this view, since essentially it makes up for the volume in its second “floor” which sits more cranially as the right ventricular outflow tract. The left ventricle only has a single level or floor. Thus in this view the RV looks and measures smaller then the LV. Note also that the apex of the left ventricle protrudes slightly more anteriorly than the RV even though it is the posterior ventricle, because it is the chamber that forms the apex of the heart. The septum also bulges toward the right ventricle due to the higher pressure in the left ventricle.
    Courtesy of: Ashley Davidoff, MD
    aka 37758b01c01.8s
    aka heart anatomy P 040

    Left Atrium

    parts/size/shape/position/character/time/connected to

    Most unique

    U shaped septum primum

     

    The most unique feature of the left atrium is the U shaped septum primum
    Courtesy Van Praagh and Van Praagh
    Ashley Davidoff
    Flap Valve – Septum Primum This diagram shows a coronal section of the atria with right atrium noted in blue on the patients right (our left) and the left atrium in red.  The septum primum or flap valve (white) is noted with inferior part attached to the inferior limbic band (green) and the superior aspect lying on the left atrial side behind the superior limbic band (also green)  Although not shown the most superior aspect of the septum primum is the foramen ovale.  When right atrial pressure is higher than LA pressure, blood will flow from right to left (fetal situation).  When LA pressure rises postnatally as pulmonary arterial resistance decreases, then higher pressure in the LA causes the valve to close against the superior limbic band and eventually seal except for 30% of the population where a fixed seal does not occur.  The unsealed state is called a patent foramen ovale.07538c06
    Davidoff art copyright 2008 all rights reserved
    Diagram of Fossa Ovalis Foramen Ovale
    The green rim is septum secundum with the superior aspect called superior limbic band and the inferior aspect called the inferior limbic band.  The white membrane is called the septum secundum, the superior aspect of which is the foramen ovale which in general closes over in later years.
    key words
    heart cardiac interatrial septum fossa ovalis foramen ovale superior limbic band inferior limbic band septum secundum septum primum tricuspid valve patent foramen ovale Davidoff art Courtesy Ashley Davidoff MD
    Fused Foramen Ovale from the Left Atrial SideThe anatomical specimen shows an opened left atrium with each of the pulmonary veins entering and the left atrial appendage positioned in the upper right hand corner of the image. The septum primum is overlaid in pink, and the characteristic crescent shaped superior border is seen at about 1’oclock on the left atrial side of the septum secundum shown in green. This is an example of a fused foramen ovale.heart left atrium LA pulmonary veins septum primum atrial septum interatrial septum fossa ovalis foramen ovale septum secundum anatomy normal                                                                                        Courtesy Ashley Davidoff MD copyright 2008 all rights reserved                                               06426c01.8s
    Fetal Ultrasound The fetal ultrasound shows the right atrium in blue, left atrium in red, limbic band in green and the septum primum white, which is open and lies on the left atrial side.06428c03 heart cardiac atrial septum RA septum secundum superior limbic band inferior limbic band endocardial cushions ventricular septum fossa ovalis fetal echocardiogram LA left atrium normal anatomy Courtesy Ashley Davidoff MD copyright 2008

    Left Ventricle

    parts/size/shape/position/character/time/connected to

    Most unique

    papillary muscles NOT attached to the septum

    smaller trabeculations

    Characterizing the Left Ventricle of the heart
    Anterolateral and Posteromedial Papillary Muscles of the Left Ventricle neither of which is attached to the Ventricular Septum
    Ashley Davidoff MD
    TheCommonVein.net
    The Normal Left Ventricle
    This normal anatomical specimen has been sectioned in long axis along the ventricular septum; then opened like a book with the septal wall seen on the left side of the image, and the free wall with the pair of papillary muscles seen on the right of the image.  Note the fibrous continuity of the anterior leaflet of the mitral valve with the cusps of the aortic valve..
    code 15389c05.8s Courtesy Ashley Davidoff MD copyright 2009
    The left ventricle that has been opened along the ventricular septum shows the septal wall to your left and the free wall with the papillary muscles to your right. Note the glistening endothelium which has a whitish sheen. The myocardium lies directly under the endocardium. Note also the two sets of papillary muscles, and the fibrous continuity of the mitral valve with the aortic valve. A VSD is noted on the superior aspect of the septum.
    Ashley Davidoff MD
    Interventricular Septum As Seen on a Coronal CT examination
    key words right atrium heart cardiac RA tricuspid valve TV left atrium LA MV mitralvalve RV right ventricle anterolateral papillary muscle interventricular septum left ventricle LV CTscan
    Ashley Davidoff MD
    34780

    Aorta

    parts/size/shape/position/character/time/connected to

    Most unique

    Brachiocephalic vessels arise from the aorta and never arise from the pulmonary artery

     

      1. Where is the Right Atrium?
    2. Situs Solitus Situs Inversus and Situs Ambiguus
      Segmental Approach to Congenital heart Disease
      Courtesy Van Praagh and van Praagh
      TheCommonVein.net
      keywords # liver stomach heart left atrium right atrium
      1. Where is the Right ventricle? (D or L)
    3. Normal size of the ventricular Walls in Diastole
      Ashley Davidoff MD
      TheCommonVein.net
      1. Where is the Aorta? (D or L)
          1. S,D,D / S,L,L/  I,D,D / I,L,L/  A,D,D/A,L,L
      2. Are they Connected correctly?

     PAPVR/TAVR/TOF/TGA/DORV/Truncus/DOLV

      1. Associated Anomalies?

    VSD ASD PS AS Atresia Hypoplasia