Thorax Clinics for Students - PDF

Thorax Netter’s clinical Anatomy 2nd ed. J.T. Hansen Elsevier Clinically oriented anatomy 6th ed. K.L.Moore, A.F. Dalley, A.M.R. Agur LWW 2010 Prometheus atlas of anatomy Gray’s Anatomy for students Sobotta Atlas of human anatomy 1 Skeleton...

Thorax Netter’s clinical Anatomy 2nd ed. J.T. Hansen Elsevier Clinically oriented anatomy 6th ed. K.L.Moore, A.F. Dalley, A.M.R. Agur LWW 2010 Prometheus atlas of anatomy Gray’s Anatomy for students Sobotta Atlas of human anatomy 1 Skeleton of back and thorax Thoracic apertures Superior thoracic aperture is the base of the neck Posteriorly- Body of T1 vertebra Laterally – 1st pair of the ribs Anteriorly – superior border of manubrium. Conveys large vessels, nerves, thoracic lymphatic duct, trachea, and esophagus Inferior thoracic aperture is closed by the diaphragm Posteriorly - body of T12 Posterolaterally – 11th and 12th pairs of ribs Anterolaterally – costal cartilages of ribs 7 – 10 Anteriorly – xiphisternal joint. Conveys inferior vena cava, aorta, esophagus, thoracic lymphatic duct 2 Mediastinum Mediastinum Thorax contains two pleural cavities laterally and a central middle space called mediastinum, divided as follows: Superior mediastinum – compartment that lies above an imaginary horizontal plane that passes through the manubrium of the sternum (sternal angle of Louis and intervertebral disc between the T4 and T5 vertebra. Inferior mediastinum compartment belowe the same horizontal plane, which is further subdivided into an anterior, middle (contains the heart) and posterior mediastinum. 3 Thoracic walls Poits possible to palpate 4 Thoracic walls Topographic Lines: Anterior middle Line Sternal Line Parasternal line Midclavicular line Anterior axillary Line Middle axillary Line Posterior axillary Line Scapular line Paravertebral Line Posterior middle Line 5  Thoracic walls Muscles of thorax Pectoralis major Origins: medial half of clavicle, sternum and related costal cartilages Insertion: lateral lip of the intertubercular groove of humerus. Actions: adduction, flexion and medial rotation of the arm, elevation of the ribs (inspiration muscle) Innervation: lateral and medial pectoral nerves (C6 – T1) Subclavius muscle Origin: inferior surface of the shaft of clavicle Insertion: first rib Action: pulls the tip of the shoulder inferiorly Innervation: subclavian nerve (C5, C6) 6  Thoracic walls Muscles of thoraxPectoralis minor muscle Origin: costal cartilages of the muscles from 2nd to Subclavius muscle 5th Origin: inferior surface Insertion: coracoid process of scapula of the shaft of clavicle Actions: pulls the tip of the shoulder inferiorly, Insertion: first rib elevating the ribs) Action: pulls the tip of Innervation: lateral pectoral nerve (C5 – C6) the shoulder inferiorly Innervation: subclavian nerve (C5, C6) 7 Thoracic walls Subclavius muscle Origin: the inferior surface of the shaft of the clavicle Insertion: first rib Action: pulls the tip of the shoulder inferiorly Innervation: subclavian nerve (C5, C6) 8  Thoracic walls Serratus anterior muscle Muscles of thorax Serratus anterior muscle Origins: lateral parts of the ribs from 1st to 9th Insertions: medial border of the scapula Action: rotates the scapula, protracts scapula, elevates the glenoid cavity, holds the scapula against thoracic wall, elevates the ribs (inspiration muscle) Innervation: long thoracic nerve (C5, C6, C7) Microsoft Visible body atlas 3D 9 Thoracic walls Intrinsic muscles of the thorax Levatores costarum muscles 12 fan-shaped muscles that elevate the ribs. Origin: transverse prosesses from t7 – T11 Insertion: Post surface and angle of rib below Action: Elevates ribs Nerve: Post primary rami C8 – T11 Intercostal muscles: External intercostal muscles Origin: Inferior border of the ribs; direction to the sternum Insertion: Superior border of the ribs; Action: elevate the ribs during inspiration Innervation: intercostal nerves 10 Thoracic walls Intrinsic muscles of the thorax Internal intercostal muscles Origin: Inferior border of the ribs; direction toward the sternum Insertion: Superior border of the ribs Action: depress the ribs during expiration Innervation: intercostal nerves Internal innermost intercostal muscles Origin: Inferior border of the ribs; direction toward the sternum Insertion: Superior border of the ribs; outside the subclavian groove Action: depress the ribs during expiration Innervation: intercostal nerves 11 Thoracic walls Intrinsic muscles of the thorax Subcostal muscles Origin: Internal surface of the lower ribs near their angles Insertion: Superior border of the 2nd or 3rd ribs below Action: depress the ribs during expiration Innervation: intercostal nerves Transverse thoracic muscle Origin: Posterior surface of the lower sternum Insertion: Internal surface of costal cartilages from 2nd to 6th Action: depress the ribs during expiration Innervation: intercostal nerves 12 Thoracic walls Diaphragm – flat muscle which separates the thorax and abdomen. It’s attached peripherally to: xiphoid process of the sternum, costal arches, floating ribs (XI, XII), lumbar vertebras: L1 – L3. Fibers converge from those attachments to join the central tendon. The pericardium is attached to the middle part of the central tendon. In the median sagittal plane, the diaphragm slopes inferiorly from its anterior attachment to the xiphoid, approximately at vertebral level TVIII/IX, to its posterior attachment to the median arcuate ligament, crossing anteriorly to the aorta at approximately vertebral level TXII. 13 Thoracic walls Structures travelling between the thorax and abdomen pass through the diaphragm or between the diaphragm and its peripheral attachments: In the central tendon the caval opening provides inferior vena cava at vertebral level T VIII; The oesophagus passes through the muscular part of the diaphragm, just to the left of the midline, approximately at vertebral level TX; together with vagus nerves; 14 Thoracic walls Aortic hiatus is located behind the middle arcuate ligament at vertebral level TXII the thoracic duct passes together with the aorta; Crura of the diaphragm create the arcuate ligaments medial and lateral, behind which two fissures are present. Right medial fissure contains azygos vein, left one hemiazygos vein. Laterally to the aortic hiatus travels the sympathetic trunks and the least splanchnic nerves. The greater and lesser splanchnic nerves penetrate the crura. 15 Thoracic walls The arterial supply to the diaphragm is from: -pericardiacophrenic and musculophrenic arteries - branches of the internal thoracic arteries. - Superior phrenic arteries, which arise directly fromthe thoracic aorta, - small branches from intercostal arteries contribute to the supply. - inferior phrenic arteries, which branch directly from the abdominal aorta. 16 Thoracic walls Venous drainage Venous drainage of the diaphragm is by veins that generally parallel the arteries. The veins drain into: - the brachiocephalic veins in the neck; -the azygos system of veins; - abdominal veins (left suprarenal vein and inferior vena cava). 17  Thoracic walls Gray806.png Innervation The diaphragm is innervated by the phrenic nerves (C3 to C5), which penetrate the diaphragm and innervate it from its abdominal surface. Contraction of the domes of the diaphragm flattens the diaphragm, so increasing thoracic volume. Movements of the diaphragm are essential for normal breathing. 18 Arteries of the thoracic wall Anterior wall Internal thoracic artery (branch of the subclavian artery) -Anterior intercostal arteries (I – VI) - musculophrenic ertery -- anterior intercostal arteries (VII – XI) - superior epigastric artery - pericardiacophrenic artery Lateral thoracic artery (from axillary artery) Superior thoracic artery (from axillary artery) Superior intercostal artery (from costocervical trunk of subclavian artery Posterior wall Thoracic aorta -Posterior intercostal arteries (I – XI) - Subcostal artery 19 Veins of the thoracic wall Veins of the thoracic wall drainage to: Anterior intercostal veins to internal thoracic vein and it’s tributaries superior epigastric vein and musculophrenic vein Posterior intercostal veins and subclavian vein to azygos vein (from the right side) and hemiazygos vein (from the left side 20 Nerves of the thoracic walls Intercostal nerves I to XI and subcostal nerve are anterior branches of the thoracic spinal nerves. They innervate intrinsic muscles of the thorax skin of the anterior thoracic wall and mammary gland. They also innervate parietal (costal) pleura. Intercostal neurovascular bundle runnimg in the costal groove and consist of: intercostal vein, artery, nerve (VAN) 21 Thoracic wall puncture Passage of instruments through the intercostal space is done in the lower space to avoid the intercostal neurovascular structures (as during thoracocentesis) Intercostal nerve block Needle introduced to contact lower border of rib, withdrawn slightly, directed caudal advanced 1/8 inch, to slip under rib and enter intercostal space. To avoid pneumothorax, aspire before injecting anaesthetic. 22 Breast Female Breast extends from second to six rib and from parasternal to midaxillary line. Mammary tissue is composed of 15 to 20 lobes separated by connective tissue septa. Breast – fatty tissue containing glands that produce milk, lies in superficial fascia, which lies above deep pectoral fascia, enveloping pectoralis major muscle 23  Breast Areola - pigmented skin surrounding the nipple Nipple – site of opening for the lactiferous ducts, at the level of fourth intercostal space Axillary tail – extension of mammary tissue superolaterally toward the axilla 24 Breast Deep pectoral fascia Lobules of mammary gland (lactating Fat lobule Lactiferous ducts Lactiferous sinus Nipple 25  Breast Cooper ligaments are suspensory ligaments that attach the mammary gland to the skin to the deep fascia. Tumor presented within the breast can distort the Cooper ligament which result in dimpling of the skin (orange peel – appearence. During the radical mastectomy, the long thoracic nerve may be lesioned during ligation of the lateral thoracic artery. Woman can present a wing scapula and weakness in abduction of the arm above 90 degree The thoracodorsal nerve may be also injured during mastectomy, resulting in weakness of extension and medial rotation of the arm. 26 Breast Arterial supply - Internal thoracic artery (internal mammary) from subclavian artery which supplies the medial aspect of the gland - Lateral thoracic artery a branch of the axillary artery which contributes to the blood supply, to the lateral part of the gland. Artery goes together with the long thoracic nerve Venous supply Venous blood drains to the internal thoracic vein and lateral thoracic vein. 27 Breast Lateral drainage - Most of the lymph from the lateral, superior and inferior quadrants drains to the axillary nodes specially the pectoral group. - From the medial quadrant, most lymph drains to the parasternal nodes, which lie along the internal thoracic vessels. That’s how cancer from the one breast can spread to the opposite breast. 28 Lower respiratory development complications Pulmonary hypoplasia or aplasia is part of the spectrum of malformations characterized by incomplete development of lung tissue. It is a condition characterized by a reduction in the number of lung cells, airways, and alveoli that results in a lower organ size and weight. Pulmonary hypoplasia can be either unilateral or bilateral. http://emedicine.medscape.com/article/1005696-overview 29 Pleura and pleural cavity Parietal pleura Lines the attaches to the inner surface of the chest wall, diaphragm and mediastinum. Is divided into: - costal parietal pleura - Diaphragmatic parietal pleura - Mediastinal parietal pleura - Cervical parietal pleura (dome of pleura, pleural coupula) Visceral pleura adheres and covers the lung 30 Pleura and pleural cavity Innervation of the parietal pleura comes from: - Intercostal nerves for costal pleura - Phrenic nerve for central portion of the diaphragmatic pleura and mediastinal pleura Visceral pleura is supplied by the visceral sensory nerves that course with autonomic nerves. 31  Pleural cavity Pleural cavity is the potential space between the parietal and visceral layers http://upload.wikimedia.org/wikipedia/commons/thumb/0/0d/2313_The_Lung_Pleurea.jpg/400px-2313_The_Lung_Pleurea.jpg of the pleura. It contains a small amount of the serous fluid that lumbricates the opposing parietal and visceral layers. Introduction of the air into the pleural cavity may cause the lung to collapse resulting in a pneumothorax which causes shortness of breath and painfull respiration. The lung collapses due to the loss of a negative pressure of the pleura cavity during a pneumothorax. 32  Pneumothorax Open pneumothorax It occurs when there is a pneumothorax associated with a chest wall defect, such that the pneumothorax communicates with the exterior. File:Pneumothorax CT.jpg Pathophysiology During inspiration, air is entrained into the chest cavity not through the trachea but through the hole in the chest wall. This is because the chest wall defect is much shorter than the trachea, and hence provides less resistance to flow. This results in inadequate oxygenation and ventilation, and a progressive build-up of air in the pleural space. 33 Pneumothorax Tension pneumothorax Tension pneumothorax is the progressive build-up of air within the pleural space, usually due to a lung laceration which allows air to escape into the pleural space but not to return. Positive pressure ventilation may exacerbate this 'one-way-valve' effect. Progressive build-up of pressure in the pleural space pushes the mediastinum to the opposite hemithorax, and obstructs venous return to the heart. This leads to circulatory instability and may result in traumatic arrest. The classic signs of a tension pneumothorax are deviation of the trachea away from the side with the tension, a hyper-expanded chest, an increased percussion note and a hyper-expanded chest that moves little with respiration. The central venous pressure is usually raised, but will be normal or low in hypovolaemic states. 34 Lungs Surfaces and regions - Costal surface - Mediastinal surface – contains the cardiac impression and root of the lung - Diaphragmatic surface (base) - apex (cupola) – projects into the root of the neck and is adjacent to subclavian vein, subclavian artery. 35 Lobes and fissures - Right lung – 3 lobes (superior, middle, inferior) separated by oblique and horizontal fissures. Left lung – 2 lobes (superior and inferior) separated by an oblique fissure. Lingula of the upper lobe corresponds to the middle lobe of the right lung. Right lung is slightly larger than the left one because of cardiac impression of the left. -Superior lobe of the right lung projects anteriorly to the chest wall above the 4th cartilage and the middle lobe projects anteriorly below the 4th rib. Almost entire inferior lobe projects to the posterior chest wall, with the small portion anteriorly below the 6th cartilage. 36 Lobes and fissures Horizontal fossure extends along line of 4th rib, present on the right lung only. Oblique fissure extends from T2 to 6th costal cartilage, present on both lungs Impressions of the lungs are made by adjacent structures. Hilum is the place where structures enter or leave lungs: main bronchus, pulmonary artery, pulmonary veins superior and inferior, bronchial arteries and veins, autonomic nerves and lymphatics. 37 Lobes and fissures Lingula is tongue-shaped feature of left lung. Cardiac notch is irregularity in the anterior margin of the left lung. Pulmonary ligament hangs up from the root of the lung and directs to the diaphragma to reflects the visceral pleura into the parietal pleura. Is created by double layer of parietal pleura. Each lung has 10 bronchopulmonary segments supplied by segmental bronchus, artery and vein pulmonary circulation. 38  Lung Circulation Lungs have double circulation Systemic circulation provided by: -Pulmonary artery (from pulmonary trunk) - pulmonary veins superior and inferior Nutrient circulation provided by: -Bronchial arteries: anterior from internal thoracic artery and posterior directly from thoracic aorta http://www.hwcrc.org/Health/Disea se/circulatory%20system.htm - Bronchial veins: anterior drainage blood into internal thoracic vein (brachiocephalic vein tributary) and posterior into azygos veins system 39  Lung innervation Lungs get autonomic innervation from two sources: - Sympathetic fibers from Sympathetic trunk - thoracic part, for bronchodilators muscles. - Parasympathetic fibers from vagus nerves for bronchoconstrictors muscles, increasing mucus secretion. http://corposcindosis.blogspot.com/2013/05/lu ngs.html 40 Lymphatic drainage Drains by way of superficial and deep lymphatic plexuses. Supeficial plexus is immediately under the visceral pleura. Deep plexus is deep in the lungs and drains through pulmonary nodes. The major nodes involved: - Bronchopulmonary (hilar) nodes – get the lymph from both plexuses and drain tnto tracheobronchial nodes - Tracheobronchial nodes – at bifurcation of the trachea and drain into bronchomediastinal nodes and trunk - bronchomediastinal nodes on the right and left sides of the trachea and drain to right lymphatic duct and thoracic duct. 41 Lymphatic drainage Lymphatic drainage of the left lung can drain to the right bronchomediastinal lymphatic trunk and nodes, then to the right lymphatic duct. This is the most important according to analysis of the metastases of the lung cancer. 42 Lymphatic drainage Thoracic duct carries the lymph from the inferior part of the body under the diaphragm (lower limbs, pelvis, abdomen) and left side of the superior part of the body (left superior limb, left half of the thorax, and left half of the head). The right lymphatic duct drains the lymph from the right superior part of the body (right upper limb, right half of the thorax and right side of the head. 43 Breath sounds To listen the breath sounds of the superior lobe of both lungs you shuld place stethoscope on the superior area of the anterior chest above 4th cartilage. The breath sounds from the middle lobe of the righ lung – anterior chest wall inferior to the 4th cartilage. The inferior lobes of both lungs – posterior chest wall 44  Pulmonary embolism Pulmonary embolism is when one or more pulmonary arteries in your lungs become blocked. In most cases, pulmonary embolism is caused by blood clots that travel to the lungs from the legs or rarely other parts of the body (deep vein thrombosis, or DVT). Causes are called Virchow’s triad: -Venous stasis - trauma - coagulation disorders http://www.mayoclinic.org/diseases- Pulmonary embolism can be life- conditions/pulmonary- embolism/multimedia/pulmonary- threatening. embolism/img-20006463 45  Lung cancer Bronchogenic tumour may impinge adjacent structures: A Pancoast tumour arises in the lung apex and invades the surrounding soft tissues. May result in thoracic inlet syndrom: injuries to the subclavian vessels and brachial plexus, narve palsy most often - C8 – T1 roots (ulnar nerve) or Horner syndrom. Miosis – constricted pupi, Ptosis – minor droping of the upper eyelid Anhidrosis – lack of sweating Flushing – subcutaneous vasodilation www. radiopaedia.com 46 Respiratory tree Conducting zone: nose, pharynx, trachea, bronchi, bronchioles and terminal bronchioles. Cartilage is present only in the trachea and bronchi. Brings air in and out. Warms, humidifies, filters air. Anatomic death space. Walls of conducting airways contain smooth muscle. Resipiratory zone Consists of respiratory bronchioles, alveolar ducts and alveoli. Participates in gas exchange. 47 Trachea Is the single airway tube starting at the level of cricoid cartilage CVI and extends to it’s bifurcation at the T4 (sternal angle Louis) level. Is composed of 16 – 20 C shaped cartilages connected by the annular ligaments. Lies anterior to the esophagus and posterior to the aortic arch. At bifurcation trachea shows carina – internal keel – like cartilage. Posterior part of the trachea consists of membranous wall, created by the muscular fibers: longitudinal and circular creating the tracheal muscle. 48  Bronchi Aspiration of a foreign body is more often to the right primary bronchus because of their shape differences. Right bronchus is shorter, wider and more vertical located than the left one. Usually aspired forign body is present in posterior basal segment of the right inferior lobe. Main bronchi (primary) divides into - Lobar bronchi (secondary) 2 or 3 - - segmental bronchi (tertiary) for 10 bronchopulmonary segments The bronchi and respiratory airways continue to divide until they terminate in alveolar sac. 49 Fetal circulation Oxygenated blood from placenta to the fetus passes through the umbilical vein. Three vascular shunts develop in the fetal circulation. 1. Ductus venosus bypass the sinusoids of the liver into the IVC. 2. Foramen ovale allow oxygenated blood to bypass the pulmonary circulation. Right – left shunting. 3. Deoxygenated blood from IVC drains to right atrium. To the right ventricle and pulmonary trunk. Ductus arteriosus shunts deoxygenated blood from pulmonary trunk to the aorta to bypass pulmonary circulation Right to left pressure gradient provide the blood by foramen ovale and ductus arteriosus. 50 Postnatal circulation -Change in pressure gradient provide to closing those three shunts: - Foramen ovale closure is the result of left atrial pressure increase and right atrial pressure reduction - Ductus arteriosus closure is the result of contraction of the smooth muscles in it’s walls and oxygen tension. 51 Fetal circulation remnants Medial umbilical ligaments – after closure of the umbilical arteries Ligamentum teres of the liver – after closure of the umbilical vein Ligamentum venosum – after closure of ductus venosus Fossa ovalis – afetr closure of foramen ovale Ligamentum arteriosum – after closure of ductus arteriosus 52 Atrial septal defect ASD – congenital heart defect is more common in female than in man. ASD result in left to right shunting and non – cyanotic conditions. 53  Ventricular septal defects Membranous VSD Results in left to right shunting of the blood. Patients complain excessive fatigue upon exertion. It’s not cyanotic condition but causes increased blood flow and pressure to the lung (pulmonary hypertension) which in result provide to proliferation of tunica intima pulmonary muscular arteries. http://www.medscape.org/viewarticl Pulmonary resistance becomes higher e/557721 than systemic and causes right to left shunting which is already cyanotic. Eisenmenger complex 54  Patent ductus arteriosus Is the specific condition when ductus arteriosus fails to close after birth. In fetal period shunt is right to left. In neonatal period lung resistance decreasing and becomes left to right (from aorta to pulmonary trunk) and is not cyanotic. Infants present „machine like” murmur. Patency is maintained by PGE synthesis http://medmovie.com/library_id/58 55/topic/cvml_0064a/ and low oxygen tension. Sometimes PDA is kept opened on purpose by PGA administration in certain heart defects (transposition of the great vessels). Administration of endomethacin, ACh, histamine and catecholamines end patency of PDA. 55  Tetralogy of Fallot Tetralogy of Fallot Most common cyanotic congenital heart defect. Pulmonary stenosis Right ventricular hypertrophy Overriding aorta (receives blood from both ventricles Ventricular septal defect (membranous) This cause the right to left shunting of http://www.childrenshospital.org/heal blood with cyanosis present sometimes th-topics/conditions/tetralogy-of- after birth (Boot shape heart because fallot-tof-tet 56 Transposition of great vessels Transposition of great vessels occurs due to failure aortopulmonary septum to spiral. Without surgical correction, most infants die whitin the first few months of life. Aorta arising from the right ventricle and the pulmonary trunk arising from the left venricle. This causes right – left shunt and cyanosis. Not compatible with life unless a shunt is present to allow adequate http://www.mayoclinic.org/diseases- mixing of blood (VSD, PDA, patent conditions/transposition-of-the-great- foramen ovale) arteries/multimedia/transposition-of- the-great-arteries/img-20008845 57  Persistent truncus arteriosus There is only partial development of aorticopulmonary septum. In result only one large vessel leaves the heart that receives blood from both the right and left ventricles. This causes right to left shunt and cyanosis. It is always accompanied by membranous VSD. http://www.stanfordchildrens.org/en /topic/default?id=truncus-arteriosus- 90-P01826 58  Congenital heart defects Non-cyanotic (left to right shunt) 1. Atrial septal defect 2. Ventricular septal defect 3. Patent ductus arteriosus Cyanotic (right to left shunt) 1. Transposition of great vessels 2. Tetralogy of Fallot 3. Persistent truncus arteriosus http://www.mayoclinic.org/diseases- conditions/transposition-of-the-great- arteries/multimedia/transposition-of- the-great-arteries/img-20008845 59 Heart Middle mediastinum Contains pericardium, heart and great vessels – ascending aorta and pulmonary trunk and also phrenic nerves. Pericardium is fibroserous membrane covering heart and begginings of great vessels. Is composed of the fibrous pericardium. The inner surface of the fibrous pericardium is lined with parietal layer of serous pericardium which covers the heart directly by its visceral layer. The inferior wall of the fibrous pericardium is attached with central tendon as the perocardiacophrenic ligament. 60 Heart The pericardial cavity is the potential space between parietal and visceral layers of serous pericardium. It contains a little amount of fluid which enables the heart to move and beat. Pericardial sinus -Transverse is a passage within pericardial cavity between anterior walls of the atrias and posterior walls of aorta and pulmonary trunk - Oblique is a passage limited from the right side by superior vena cava and right pulmonary veins superior and inferior and from the left side by left pulmonary veins superior and inferior. 61 Cardiac tamponade Is the pathological accumulation of fluids within the pericardial cavity.. It might be the serous fluid of the blood which compresses the heart and restricts venous filling during diastole. During pericardiacocentesis the needle is placed at the left infrasternal angle throug the cardiac notch of the left lung to remove the fluid. 62 Heart Surfaces of the heart: - Anterior (sternocostal surface), mainly right ventricle, right atrium, small part of the left ventricle with the apex, ascending aorta, SVC, pulmonary trunk. Directed anteriorly toward the posterior surface of the sternum and the ribs. -Diaphragmatic (inferior) surface, mainly left ventricle and partly by the right ventricle; right atrium with termination of ICV, related to the central tendon - Right pulmonary surface mainly right atrium - Left pulmonary surface – mainly left ventricle; it forms the cardiac impression in the left lung 63 Heart Borders of the heart Right border – right atrium between SVC and IVC Inferior border – right ventricle and left ventricle Left border – left ventricle and left auricle Superior border – both atrias and auricles, ascending aorta, pulmonary trunk 64 Heart wall structure Three layers Endocardium Innermost layer, lines the cavities of the heart. Single layer of flat epithelium, continuous with vascular endothelium in blood vessels. Myocardium Middle layer and the thickest part of heart wall. Complex arrangement of muscle fibers. Epicardium Outermost layer of the heart wall part of the pericardium. Serous membrane. 65 Heart wall Is created by three muscular layers External oblique Intermediate circular – the strongest Internal - longitudinal 66 Heart Heart Lies at the level of T6 – T9 vertebrae, posterior, superior and on the right side of the chest. Basis of the heart creates the heart crown containing beggining of the great vessels. Apex of the heart is formed mainly by the left ventricle. Lies posterior to the left 5th intercostal space, medially to the midclavicular line. The atria are demarcated from the ventricles by the coronary sinus, right and left ventricles are demarcated by anterior and posterior interventricular grooves. 67 Heart Surface projections of the heart Upper right aspect of the heart is located at the level of 3rd right costal cartilage Lower right aspect of the heart reaches sixth right costal cartilage Upper left aspect of the heart reaches left second costal cartilage Apex the heart is located in the left intecostal space at midclavicular line. 68 Heart Chambers of the heart Right atrium receives blood from the SVC, IVC and coronary sinus. Part of the right atrium: right auricle is muscular pouch that projects from the atrium increasing its capacity. Is derived from fetal atrium. Anterior muscular wall is composed of pectinate muscles Sinus venarum – is thin posterior part with openings of two vessels SVC and IVC is the smooth- walled portion of the atrium. 69 Heart Right atrium Crista terminalis is the ridge that separates the smooth part from the rough one. It extends longitudinally from the openings of IVC and SVC. The SA node is the upper part of the crista terminalis. Fossa ovalis is the remnant of the foramen ovale present in fetal circulation. Tricuspid valve communicates with the right ventricle 70 Heart Right ventricle It creates largest part of the anterior surface of the heart. Superiorly it tapers into the conus arteriosus which leads into pulmonary trunk. The interior of the right ventricle has irregular muscular elevations (trabeculae carnae). Papillary muscles project into the cavity of the ventricle and attach to cusps of the AV valve by the strands of chordae tendineae. They correspond to the cusps of the tricuspid valves 71 Heart Right ventricle -Anterior papillary muscle the biggest one arises from anterior wall it’s tendinous cords attach to the anterior and posterior cusps of the tricuspid valve - Posterior papillary muscle smaller may cosist oom the several parts, its arises from the posterior wall, it’s tendinous cords (chordae tendinae) attach to the posterior and septal cusp - Septal papillary muscle arises from interventricular septu, and it’s chordae tendinae attach to the anterior and septal cusps. 72 Heart Right ventricle Interventricular septum (IVS) Is composed of muscular (bigger) and membranous part (smaller), forming part of the walls of each. Septal cusp of the tricuspid valve is attached to the membranous part of the septum. Septomarginal trabecula is muscular bundle that traverses the right ventricle from the inferior part of the IVS to the base of the anterior papillary muscle. This trabecula carries part of the right branch of the AV bundle. 73 Heart Left atrium Creates the base of the heart Right and left pulmonary veins (superior and inferior 4) drain oxygenated blood from the lungs. The tubular muscular left auricle has trabeculated wall with pectinate muscles. Bicuspid valve (mitral) lies between left atrium and left ventricle in the left atrioventricular orifice 74 Heart Left ventricle Blood enters the left ventricle by mitral valve and is pumped out to the aorta. Trabeculae carneae are usually thicker than those in right ventricle Papillary muscles usually two large: anterior and posterior and attached by the chordae tendineae to the cusps of the bicuspid valve. Chordae tendineae are the same as in the right ventricle Aortic vestibule – leads to the aortic semilunar valve 75 Cardiac skeleton and valves Heart has 4 valves which are attached to the fibrous rings of dense collagen creating the fibrous skeleton of the heart. Created by: Fibrous rings right and left for atrioventricular valves and aortic and pulmonary rings for semilunar; Fibrous trigons: left and right Tendon of infundibulum and membranous part of IVS 76 Cardiac skeleton and valves Valves: Right atrioventricular valve – tricuspid Auscultation point: 5th intercostal space on the right (or left) sternal line. Left atrioventricular valve – bicuspid Auscultation point: 5th intercostal space on the left midclavicular line Aortic valve Auscultation point: 2nd intercostal space on the right sternal line Pulmonary valve Auscultation point: 2nd intercostal space on the left sternal line 77  Cardiac skeleton and valves Heart sounds First sound (S1) comes from closing atrioventricular valves; Second sound (S2) is the result of closing aortic and pulmonary valves; Heart murmurs Is the disease of the heart connected with insufficiency or stenosis of the During ventricular diastole mitral valves. valve should be opened and aortic During ventricular systole, mitral valve valve should be closed so thypical should be closed and aortic valve diastolic defects are: mitral should be opened so thypical systolic stenosis and aortic insufficiency. defects are: mitral insufficiency Sounds are heard downstream (regurgidation) and aortic stenosis 78 from the valve. Coronary arteries Coronary arteries arise from the aortic sinuses right and left, parts of the ascending aorta. Blood flow enters the coronary arteries during diastole. Right coronary artery Courses in the coronary sulcus and supplies major parts of the right atrium and the right ventricle. Consist of major branches: sinoatrial SA nodal, right marginal, posterior interventricular (posterior descending), atriovantricular (AV) nodal 79 Coronary arteries Left coronary artery Travels between the left auricle and ventricle and divides into 2 branches: Left anterior descending (LAD) artery and circumflex artery -The anterior interventricular artery descends inside anterior interventricular groove and supply anterior left ventricle wall, anterior 2/3 of the interventricular septum, bundle of Hiss, and apex. - The circumflex artery courses around the left border of the heart in the coronary sulcus and supplies the left border of the heart via the marginal branch ends on the posterior aspect of the left ventricle and supplies the posterior-inferior left ventricular ventricular wall. 80  Coronary occlusion Myocardial infarction Is usually connected with LAD occlusion (in 50% cases), less often it’s connected with right coronary artery occlusion (in 30% cases) and with circumflex artery obstruction (in 20% of cases). http://d1vzuwdl7rxiz0.cloudfront.net/content/ehj/early/2012/08/23/eurheartj.ehs184/F2.medium.gif http://eurheartj.oxfordjournals. org/content/early/2012/08/23 /eurheartj.ehs184 81 Cardiac veins Venous drainage of the Heart Is provided by the veins accompanying the arteries. -Coronary sinus is the biggest coronary vein, it lies in the posterior coronary sulcus. It drains blood to the right atrium. - Great cardiac vein lies in the anterior interventricular groove with the LAD artery. Drains to the coronary sinus. - Middle cardiac vein lies in the posterior interventricular groove with the posterior interventricular artery. Drains to coronary sinus. - Venae cordis minimae (thebesian veins) and anterior cardiac veins open directly to the heart chambers. 82 Conduction system of the heart Is created by few important elements which are responsible for heart automathism (it produces the impulses for heart contraction). Conduction system of the heart consists of cardiac muscle cells and conducting fibers (not nervous tissue) that are specialized for initiating impulses and conducting them rapidly through the heart. Is created by: - Sinuatrial node -Atrioventricular node - Atrioventricular bundle (Hiss) - Purkinje fibers 83 Conduction system of the heart Sinuatrial node – initiates the impulses for the heart contraction. Is also called the heart „pacemaker”. Is located at the superior end of crista terminalis. At the point of SVC opening to the right atrium. Sends impulses for 60 – 100 heart beats per minute. Sympathetic stimulation can speeds up the heart, parasympathetic (vagal) slows down. Has arterial supply from right coronary artery. 84 Conduction system of the heart Atrioventricular node Receives impulses from SA node. Is located in the right atrium in the interatrial septum over the right fibrous trigone. It can also produce the impulses for the heart about 50 er minut. It’s supplied by the right coronary artery. Bundle of Hiss Originates in AV node conducting the impulses to the right and left ventricles. It’s supplied by the LAD artery In the right ventricle septomarginal trabecula contains right bundle branch. Purkinje fibers spread from the bundle branches and reach the papillary muscles and ventricular myocardium. 85 Conduction system of the heart Innervation Cardiac plexus is created by sympathetic and parasympathetic fibers: Sympathetic stimulation increases heart rate. Pain fibers follow the sympathetic fibers back to the spinal cord segments T1 – T5. Parasympathetic stimulation slows the heart rate. Sensory nerves which take part in reflex arches of the heart creation travel with the vagus nerve. 86  Mediastinum Mediastinum Is the central middle space between two pleural cavities. Superior mediastinum Space located between manubrium of the sternum and bodies of the superior thoracic vertebras T1 – T4. Containes: -Thymus visible in chidren (best till 2 years old) then becomes athrophic and change into fat tissue https://anatomytopics.wordpress.com /2008/12/09/the-mediastinum-the- - Brachiocephalic veins and their histology-of-the-esophagus- tributaries: subclavian veins and jugular fertilization-and-cleavage/ veins (venous angles), - beggining of SVC which drains to the right atrium deep to 3rd right costal cartilage 87 Mediastinum Branches of the arch of aorta: Brachiocephalic trunk (divides into right common carotid artery and right subclavian artery), Left common carotid artery and Left subclavian artery Trachea is located posterior to the aortic arch starts at the level of C6 and bifurcates at the level of T4 into main bronchi creating carina as internal projection of cartilage at bifurcation Esophagus is posterior to the trachea and then to the left bronchus. 88 Mediastinum Superior mediastinum provides also vagus and phrenic nerve Vagus nerve is CN X which take part in cardiac and pulmonary plexuses. Vagus nerve gives off laryngeal recurrent nerve passing inside the groove between the esophagus and the trachea to reach the Larynx. Right recurrent laryngeal nerve passes under right subclavian artery, left under the arch of aorta. Phrenic nerve arise from C3 – C5 ventral rami of the spinal nerves and supply the diaphragm in motoric and sensory fibers.89 Mediastinum Mediastinum Anterior mediastinum Is located between the sternum (body) and anterior surface of pericardium. Contains: - Areolar tissue - anterior mediastinal lymph nodes (parasternal) - internal thoracic artery and vein 90  Posterior mediastinum Posterior mediastinum is located between posterior surface of pericardium and T2 – T12 thoracic vertebrae. Descending aorta is the continuation of the arch of aorta and ascending aorta leaving the left vantricle of the heart. It gives of: - bronchial, - esophageal http://www.imaios.com/en/Medi - posterior intercostal branches a/Images/e- Passes through the aortic hiatus at the T12 anatomy/mediastinum-anatomy- vertebral level to became the abdominal illustrations/thoracic-aorta- ascending-descending-aortic- aorta isthmus 91  Posterior mediastinum Ascending aorta is present in middle mediastinum and gives off: - Right coronary artery - left coronary artery -- anterior intercostal artery -- circumflex artery Arch of aorta located between superior and middle inferior mediastinum, gives off: http://www.imaios.com/en/Medi -Brachiocephalic trunk (right) a/Images/e- -- right common carotid artery anatomy/mediastinum-anatomy- -- right subclavian artery illustrations/thoracic-aorta- ascending-descending-aortic- -Left common carotid artery isthmus - Left subclavian artery 92  Posterior mediastinum Esophagus Lies posteriorly to the left main (primary) bronchus and the left atrium. Reaches innervation from esophageal plexuses anterior and posterior mainly created by the branches of vagal nerves Passes through the esophageal hiatus at the level of T10, providing two vagal trunks. Has three phisiological constrictions: Superior betweem pharynx and esophagus. Middle when it crosses the left primary bronchus. Inferior at the esophageal hiatus level. Structure of esophageal wall is: Fibrous layer – outer http://www.merckmanuals.com/hom e/digestive_disorders/esophageal_an Muscular layer (2 layers: longitudinal and circular) d_swallowing_disorders/overview_of Mucous layer – Inner, with longitudinal folds. _the_esophagus.html 93  Posterior mediastinum Thoracic duct Lies between thoracic aorta and azygos vein, posterior to the esophagus Ascends by posterior and superior mediastinum and drains lymph to the venous angle (junction between internal jugular vein and subclavian vein) It arises from the cisterna chyli in the abdomen and goes together with the abdominal aorta to enter the thorax. http://apbrwww5.apsu.edu/thompsonj/An atomy%20&%20Physiology/2020/2020%2 0Exam%20Reviews/Exam%202/CH20%2 0Gross%20Anatomy%20of%20the%20Ly mphatic%20System.htm 94 Posterior mediastinum Azygos system of veins Azygos vein drains the posterior thoracic wall It starts in the abdomen by the connection of ascending lumbar vein and small brach of the right renal vein. Ascends on the right side of the vertebral column and enters the mediastinum by the medial right diaphragmatic crus fissure. Drainage: - Right intercostal veins - Right subcostal vein - Esophageal veins - Posterior pericardial veins -Superior right intercostal vein Reaches the SVC at the T5 level terminate by arching over the root of the right lung. 95 Posterior mediastinum Hemiazygos vein It starts in the abdomen by the connection of ascending lumbar vein and small brach of the left renal vein. Ascends on the left side of the vertebral column and enters the mediastinum by the medial left diaphragmatic crus fissure. Drainage: - Left intercostal veins - Left subcostal vein - Esophageal veins - Posterior pericardial veins Drains to the azygos vein at the T7 level. Hemiazygos accessory vein Is created by the left superior intercostal vein Drainage: Superior left intercostal veins over T6 96  Thorax CT Aortic arch Pulmonary trunk Superior vena Left atrium cava Left Right atrium ventricle Left costodiaphragmatic recess 97  Thorax CT Right ventricle Left Left ventricle atrium Right dome of diaphragme Left dome of diaphragme 98 Thorax CT 99  Thorax CT brachiocephalic trunk left right brachiocephalic vein brachiocephal ic vein Left common carotid artery Left subclavian artery Trachea Esophagus 100  Superior vena cava SVC Thorax CT Arch of aorta trachea esophagus 101  Thorax CT Pulmonary trunk Ascending aorta Carina tracheae SVC Descending aorta 102  Thorax CT Right ventricle Left atrium Right atrium Left ventricle esophagus Descending aorta 103  Thorax CT Interventricular septum Right ventricle Right atrium Left ventricle Left atrium Descending aorta esophagus 104 Thorax CT 105 Thorax CT 106 Thorax CT 107 Thorax CT 108 Thorax CT 109 Coronarography 110