9.1.1 External configuration

The ventral surface of the heart is formed mainly by the anterior wall of the right ventricle and a small part of the left ventricle. Between the ventricles is the anterior interventricular groove in which runs the anterior interventricular artery, a branch of the left coronary artery.

In our techniques, it is mostly the ventral part that we contact through the intermediary of the ribcage.

9.1.2 Excitability of the cardiac fibers

The cardiac muscle has a neuromuscular conduction system that ensures the transmission of nerve impulses from fiber to fiber and coordinates the cardiac cycle. The heart is able to beat without the participation of external nerves, thanks to its autonomous nervous system.

The excitation comes from the sinoatrial (SA) node, first described in 1907 by Keith and Flack. The contraction signal spreads through the musculature of both atria to the atrioventricular (AV) node (Tawara’s node) from where, via the bundle of His and its two branches, it reaches the Purkinje network, which carries the impulse to the ventricular muscle.

The conducting system of the heart cannot initiate a new stimulation until the cardiac muscle is in diastole. Therefore it is important that the heart avoid any form of spasmodic contracture.

9.1.3 The great vessels of the heart

At the ventral heart:

Fig. 9.1 Heart and great vessels.

9.1.4 Landmarks simplified

Figure 9.2 provides a simplified view of the anterior thoracic relationships of the heart. Variations certainly exist, depending on constitutional differences among people.

Fig. 9.2 Anterior thoracic relationships of the heart.

9.1.5 Fibrous skeleton of the heart

From a transverse section of the upper heart it is apparent that all the valves are grouped closely together. The fibrous skeleton is a complex framework of dense collagen configuring four fibrous rings which surround the orifices of the valves (Fig. 9.3).

Fig. 9.3 Fibrous skeleton of the heart.

The firmest areas on compression are formed by the valves (aortic, tricuspid, and mitral) and the fibrous connective tissue that unites them. The fibrous skeleton functions as a stable but deformable base for attachment of the leaflets and cusps of the valves.

NB: The pulmonary valve is not anchored to the fibrous skeleton of the heart, and it is less firm on compression palpation. Nevertheless we are beginning to be able to palpate its distinctive area of resistance.

When compressing different parts of the heart, some areas are clearly more firm and resistant than others. These are located towards the upper heart, which is the base.

It is understandable that some are skeptical of the ability to differentiate particular parts of the heart by manual compression. Nevertheless, there is a methodical protocol of approach that allows such subtlety of perception.

9.2.1 Chest pain

Who has never felt, at one time or another, pain in the heart region without having a heart problem? Nevertheless, caution must be observed. Even if our patients have excellent medical care, we must be on our guard.

We have seen about ten patients with coronary problems where the location of the pain led us to assume a banal mechanical rib restriction. In one instance the patient assured us that it was after excessive exertion that he felt intercostal pain, and that it was of purely mechanical origin. It turned out to be a heart problem that the physical strain had awakened.

Conversely, we have had a patient hospitalized under the care of a cardiologist on account of simple costovertebral fixations.

Listed below are a few questions to ask in case of suspicious precordial pain. When the patient responds in the affirmative to most questions, a medical examination is imperative.

At the end of the questionnaire the essential characteristics of pain of mechanical origin are provided.