Orientation of the Heart

The heart is located within the middle mediastinum between the lungs. The heart lies obliquely within the chest cavity, with the interventricular septa angled approximately at 45 degrees to the transaxial plane. The atrioventricular valves (mitral and tricuspid) are at right angles to the interventricular septum. The right atrium is anterior and inferior to the left atrium, and the right ventricle forms the majority of the anterior border of the heart. The left atrium is the most posterior chamber.

Pericardium

The pericardium envelops the heart within the middle mediastinum and consists of two components, the fibrous pericardium and the serosal pericardium. The fibrous pericardium, the outer component, is made of tough connective tissue and is not attached to the heart itself. Superiorly, the fibrous pericardium is continuous with the adventitia of the great vessels, and inferiorly, it is continuous with the central tendon of the diaphragm. Anteriorly, it is attached to the posterior surface of the sternum. The serosal pericardium has visceral and parietal layers. The visceral layer is attached to the myocardium and great vessels and forms the epicardium. A reflection of the visceral layer connects the epicardium with the parietal serous pericardium, which is adherent to the fibrous pericardium. These reflections also give rise to the transverse and oblique sinuses, which are potential spaces. The transverse sinus lies posterior to the aorta and pulmonary trunk and anterior to the atria. The oblique sinus is a cul de sac that lies posterior to the left atrium. Several pericardial recesses are also formed that may become visible on CMR if they contain fluid ( Fig. 13-2 ). The postcaval recess is located posterior to the junction of the right atrium and the superior vena cava (SVC) and lies between the right pulmonary artery and the right superior pulmonary vein ( Fig. 13-3 ). The right and left pulmonary venous recesses lie between the superior and inferior pulmonary veins on either side. The superior aortic recess (superior pericardial recess) extends from the transverse sinus to the right of and posterior to the ascending aorta and anterior to the proximal right pulmonary artery. The inferior aortic recess extends inferiorly from the transverse sinus between the ascending aorta and the right atrium.

Axial black-blood axial image at the level of the main pulmonary artery. 1, Main pulmonary artery; 2 , left pulmonary artery; 3, right pulmonary artery; 4, ascending aorta; 5, superior vena cava; 6, esophagus. Note also the location of the internal mammary vessels (asterisks); scrutinizing these vessels is important because they are a common location for lymph node metastases (especially from breast cancer). Note also the transverse pericardial recess (arrowhead). This should not be mistaken for lymphadenopathy, and it may be quite prominent.

Axial black-blood axial image at the level of the left atrium. 1, Right inferior pulmonary vein; 2, left inferior pulmonary vein. Scrutinizing the pulmonary vein ostia carefully after pulmonary vein ablation is important to exclude pulmonary vein stenosis. Ao, Aorta (descending); LA, left atrium; LV, left ventricle; RA, right atrium; RVOT, right ventricular outflow tract.

Right Atrium

The right atrium has a posterior smooth-walled venous component, a muscular anterior component, and a right atrial appendage. The venous component receives the inferior vena cava (IVC), the SVC, and the coronary sinus. It is separated from the anterior component by a smooth internal muscular ridge called the crista terminalis that correlates with the embryonic location of the right venous valve ( Fig. 13-4 ). The IVC drains into the inferior aspect of the posterior right atrium. At the anterior and right lateral aspect of the IVC orifice is the eustachian valve or eustachian ridge. This valve is a fold of endocardium that is much larger in utero, at which time it serves to direct oxygenated blood returning from the placenta through the foramen ovale in the interatrial septum and into the left atrium. This anatomic configuration makes transeptal puncture easier using an IVC approach. The eustachian valve is continuous inferiorly with the valve of the coronary sinus (thebesian valve), which covers the lower part of the orifice of the coronary sinus. The thebesian valve may be complete, incomplete or fenestrated, or absent. The coronary sinus lies within the left atrioventricular groove and drains into the right atrium medial and superior to the IVC orifice ( Fig. 13-5 ). The pectinate muscles extend from the crista terminalis into the right atrial appendage, which is a broad-based triangular structure that extends around the anterior and right lateral aspect of the ascending aorta.

Steady-state free precession image in the four-chamber view at the level of the left ventricle (LV). The crista terminalis (arrow) is an embryonic ridge in the right atrium (RA; normal structure) that can be mistaken for thrombus or tumor. Note the normal pericardium (arrowhead) anterior to the right atrioventricular groove; it should not exceed 4 mm in thickness. Note also lipomatous hypertrophy of the interatrial septum (asterisks) showing a characteristic dumbbell-shaped appearance with sparing of the fossa ovalis. Ao, Aorta (descending); LA, left atrium; RV, right ventricle.

Axial black-blood axial image at the level of the coronary sinus (CS). The CS lies within the left atrioventricular groove and drains into the right atrium (RA) medial and superior to the inferior vena cava (IVC) orifice. Occasionally, the thebesian valve (asterisk) may be seen at its ostium with the RA. If the CS appears particularly enlarged, assess images for a left-sided superior vena cava, or possibly an unroofed CS or a coronary artery–to–CS fistula. The azygos vein (arrowhead) is a small vein in the posterior mediastinum. If it is enlarged, assess images for azygos continuation of the IVC. Ao, Aorta (descending); E, esophagus; LV, left ventricle; RV, right ventricle.

The interatrial septum separates the left atrium from the right atrium and usually bows into the right atrium because of slightly higher pressure in the left side of the heart. On the right side of the interatrial septum is the fossa ovalis. A peripheral muscular limbus with a central depression above and to the left of the orifice of the IVC represents the valve of the fossa ovalis. A small slit may be present at the superior aspect of the valve that allows communication with the left atrium. This is called a patent foramen ovale and is present in one third of people.

The normal area of the right atrium, viewed on the four-chamber view during ventricular systole and as measured on CMR, is 21 cm ² . The upper limit of normal is 24 cm ² .