Examen 3 Anatomía PDF

Thoracic Wall Copyright- This presentation is intended for educational purpose only. No part of this presentation may be reproduced or transmitted in any form without written permission.  Outline The Thoracic Wall – Skeleton – Joints – Movements – Breasts – Muscles –...

Thoracic Wall Copyright- This presentation is intended for educational purpose only. No part of this presentation may be reproduced or transmitted in any form without written permission.  Outline The Thoracic Wall – Skeleton – Joints – Movements – Breasts – Muscles – Nerves – Vasculature The Thorax 1. Thoracic Wall * bones & cartilage (& joints) * muscles, nerves and vessels 2. Thoracic Cavity * heart * thymus * distal part of trachea * most of the esophagus * lungs  Thoracic Wall Functions: Protects thoracic & abdominal organs Resists negative internal pressure generated by recoiling of lungs & inspiratory movement Provides attachment & supports the weight of the upper limbs, neck, abdomen, back & muscles of respiration Mammary glands (of breast) located in subcutaneous tissue overlying pectoral muscles  = Suprasternal notch THORACIC SKELETON of Louis (between T4-T5) Functions: Protection Framework BONES: Sternum Manubrium (T3-T4) Body (T5-T9) Costal notches Xyphoid process (T10) Midline marker for superior level of liver, central tendon of diaphragm, inf. border heart  Transverse ridges (Manubriosternal joint = Fibrocartilage joint) Sternum (xiphisternal joint) Bone Marrow Biopsy * Marrow biopsy: Since sternum possesses red hematopoeietic marrow through life, it is a common site for marrow biopsy. It may also be split to get access to the heart, great vessels and thymus.  12 Thoracic vertebrae (T1-T12) 12 Ribs (+ costal cartilages): 1-7 True; 8-10 False; 11-12 Floating Osteocartilaginous thoracic cage  Ribs & Costal cartilages True (vertebrocostal) ribs (1-7) – attach directly to sternum through own costal cartilages False (vertebrochondral) ribs (8-10) – attach to sternum through rib 7 costal cartilage; indirectly Floating (free) ribs (11-12) – have rudimentary cartilages that end in post. abdominal musculature  Typical rib (3-9) 1. Head a. Sup. articular facet (art. costal facet = costovertebral joint) b. Crest c. Inf. articular facet (art. costal facet) 2. Neck 3. Tubercle a. articular part (art. transverse facet = costotransverse joint) b. Non-articular part (attachment of costotransverse ligament) 4. Body (shaft) a. angle rib turns anterolaterally b. costal groove (costal nerves & vessels)  Atypical ribs (1-2, 10-12) 1st rib - broadest & shortest - 2 grooves for subclavian vessels - grooves separated by scalene tubercle 2nd rib - thinner, less curved & longer Rib 1 - 2 facets on head for aticulation of T1&T2 10th to 12ve ribs - only 1 facet on head T1-T2 11th & 12ve - short - no neck or tubercle Rib 12 1. Superior thoracic - anatomical thoracic inlet Thoracic Apertures -communication w/ neck & upper limbs - trachea, esophagus, great vessels & nerves Bounded: Post. by T1 Lat. by 1st pair of ribs & costal cartilages Ant. sup. border of manubrium 2. Inferior thoracic - anatomical thoracic outlet - communicates w/ abdomen - diaphragm floor Bounded: -structures pass through Post. T12 Postlat. R11 y R12 (caval & esophageal Antlat. costal cartilages of R7-R10; costal margin hiatus) & post (aorta) Ant. xiphisternal joint Thoracic Apertures  Joints of Thoracic wall 1. Intervertebral joint 2. Costovertebral joints 1. Costotransverse 3. Sternocostal joint 4. Sternoclavicular joint 5. Costocondral joint 6. Interchondral joint 7. Manubriosternal joint 8. Xiphisternal joint Costovertebral joints Anterior Thorax Ligaments Posterior Thorax Ligaments  VAN Contents of a typical intercostal space NAV 10th & 11th intercostal arteries are supplied by posterior intercostal a. which arises from thoracic aorta. Deep cervical a. Anastomosis Action: External Intercostal Muscle of respiration Elevation of ribs during inhalation to Muscle and increase transverse dimensions Membrane (anterior-posterior, medial-lateral) of thoracic cavity Origin or Superior attachment: Inferior border of rib (ribs 1-11) Insertion or Inferior attachment: Superior border of rib below (ribs 2- 12) Innervation: Intercostal nerves (ventral rami of T1-11 spinal nerves) Comment: Continuous with external intercostal membrane near sternum Action: Internal Intercostal Muscle of respiration Depression of ribs during forced exhalation to decrease transverse dimensions (anterior- posterior, medial- lateral) of thoracic cavity Origin or Superior attachment: Inferior margin of costal cartilage and inner lip of costal groove Insertion or Inferior attachment: Superior border of immediate inferior rib Innervation: Intercostal nerves (ventral rami of T1-11 spinal nerves) Comment: Continuous with internal intercostal membrane lateral to vertebral column Action: Muscles of respiration Innermost Intercostal Contract during forced expiration Origin: inner surface of the costal groove of the ribs, deep to the origin of the internal intercostal muscles Insertion: Superior border of next rib (below) Innervation: Intercostal nn. Comment: Intercostal nerves and posterior intercostal vessels pass between innermost and internal intercostal muscle layers  Transversus Thoracis Action: Weak depression of ribs 2 – 6 during forced expiration Origin: Posterior surface of inferior sternum Insertion: Posterior surface of rib cartilage above (ribs 2-6) Innervation: Intercostal nerves (ventral rami of T1-11 spinal nerves)  Subcostal Action: Weak depression of ribs during forced expiration Origin: Internal surface of ribs (near angle of rib) Insertion: Internal surface of rib (2-3 levels below origin) Innervation: Intercostal nerves  Levatores costarum Action: Elevation of ribs Origin: Transverse process of C7 – T11 Insertion: Superior border/external surface of rib one level below origin Innervation: Posterior rami of spinal nerves T1 – T12 Action: Dome of diaphragm flattens during inspiration Diaphragm Contraction increases vertical dimension of thoracic cavity Origin: Sternal part (not always present): xiphoid process Costal part: ribs 5-10 and their costal cartilages Lumbar part: arcuate ligaments and L1-3 vertebral bodies Insertion: Central tendon Innervation: Phrenic nerve Comment: Primary muscle of respiration Contraction (flattening) decreases intrathoracic pressure and increases intra-abdominal pressure  Serratus Posterior Superior Action: Elevation of ribs 2-5 Origin: Spinous processes of C7-T3 vertebrae Insertion: Ribs 2-5 (superior border) Innervation: Ventral rami of T1-3 spinal nerves (intercostal nerves)  Serratus Posterior Inferior Action: Depression of ribs 9-12 Origin: Spinous processes of T11-L2 vertebrae Insertion: Ribs 9-12 (Inferior border) Innervation: Ventral rami of T10-11 spinal nerves (intercostal nerves) Ventral ramus of T12 spinal nerve (subcostal nerve) Dermatomes & Myotomes  Surface Anatomy: Thorax Thoracic Surface Anatomy Planes  Breast Anatomy Contain Mammary gland: modified sweat glands present in the breast tissue. Surrounded by fat. Grow during puberty (8-15 yrs) because of glandular development & increased fat deposition. of Cooper Breast size & shape results from racial & genetic factors. Extend from midaxillary line to 2nd Nipple & 6th ribs 2/3rds rest on pectoral fascia (pectoralis mayor) 1/3 rest on fascia from serratus ant. Retromammary space: between breast & deep pectoral fascia 20-40 Innervated by ant. & lateral Gland cutaneous branches of 4th – 6th 15 - 20 intercostal nerves Breast quadrants Vasculature of breast  Lymphatic drainage of breast 2nd 3rd 1st Medial breast quadrant 75% of drainage by lateral breast quadrant 4th 6 Internal Posterior Thoracic Wall Muscles (Posterior) (11 pairs) Muscles of respiration  Arteries of the Thoracic Wall: Thoracic aorta: - Posterior intercostal a. - Subcostal a. Subclavian artery: - Internal thoracic a. (anterior intercostal a.) - Musculophrenic a. (ant. intercostal) - Supreme or superior intercostal a. (costocervical trunk- supplies 1st & 2nd post. intercostal spaces) – posterior intercostal a. Axillary artery: - Superior thoracic a.: supplies blood to the muscles and skin of the 1st two intercostal spaces. - Lateral thoracic a.  11 post. intercostal veins 1 subcostal vein Ant. intercostal veins (drain ant. thorax into internal thoracic and (Drains 4-7, sometimes 8 musculophrenic veins) intercostal space) *Post. intercostal v. drains the lateral & post. thorax - Superior intercostal (1 - 3) – Drains to L. Brachiocephalic v. Accessory hemiazygous (4-7, (Crosses at T9) 8) Hemiazygous (L) – (9 – 11) Azygous vv (R) – (4-11) *Hemiazygous drains into Azygous to Superior Vena Cava *Accessory hemiazygous drains into azygous or L. Brachiocephalic vein * Intercostal nerves: - Ventral primary ramus of T1-T11 - Run in the costal groove between the internal intercostal muscle and innermost intercostal muscles. * Subcostal nerve – Primary ventral ramus of T12 * Intercostal nerve injury - is shown by a sucking (inspiration) and bulging out (expiration) of the affected intercostal space. THORACIC CAVITY Two pulmonary cavities - with the lungs, they occupy most of the thoracic cavity Mediastinum - space between the lungs, occupied by the heart, thoracic part of great vessels, trachea, esophagus, etc.  REFERENCES Color Atlas of Anatomy, 4th Ed. Rohen, Yokochi & Lutjen- Drecoll Atlas of Human Anatomy, 8th Ed. (2023) Frank Netter Clinically Oriented Anatomy, 9th Ed. (2023) Moore & Dalley Anatomy & Physiology Revealed 4.0 McGraw Hill ACKNOWLEDGEMENTS Dra. Nivia Pérez Acevedo Dra. María Sosa  Lungs & Pleura Copyright- This presentation is intended for educational purpose only. No part of this presentation may be reproduced or transmitted in any form without written permission.  Outline Anatomy of Lungs – Pleurae – Surface Anatomy – Blood Supply – Lymphatic – Nerve  Thoracic Cavity Compartments: 1. Lateral - pulmonary cavities – completely separated from each other – occupy majority of space 2. Central – mediastinum – extends from superior aperture to diaphragm – heart – great vessels – trachea – esophagus – thymus – lymph nodes  Endothoracic fascia Thin fibroareolar layer between internal thoracic cage & parietal pleura It invests the internal & innermost intercostal mm., subcostal & transverse thoracic mm. Allows surgeons to separate the parietal pleura from thoracic wall, providing access to intrathoracic stuctures  1. Serous pleural sac a. Visceral pleura b. Parietal pleura 2. Pleural cavity - Fluid 10-20 mL 3. Root of lung (Hilum) Bronchus: The bronchus enters the lung at the hilum Pulmonary artery: Located in the middle of the root Pulmonary veins: The upper two pulmonary veins are 4th costal cartilage located anteriorly Bronchial vessels: Located 6th costal cartilage posteriorly Pulmonary plexus of nerves: A network of nerves that innervates the lungs Lymphatic vessels: Drain into the lymphatic system Bronchial lymph Dome of diaphragm: Reaches 5th costal nodes: Located at the hilum cartilage during quiet expiration Areolar tissue: Part of the root  PLEURAL SAC & PLEURAL Main bronchi (1ry) CAVITY Cervical pleura Pleural cavity Visceral pleura Costal pleura Carina: sternal angle Root of lung (Hilum) Mediastinal pleura Parietal pleura Diaphragmatic pleura Visceral pleura = pulmonary pleura Parietal pleura – adheres to mediastinum, thoracic wall & diaphragm Pleural cavity - Potential space between the layers of pleura - It contains a film of fluid that lubricates the surface of pleura and facilitates lung movement Pulmonary ligament = inf. to root of lung; visceral + parietal pleura  LUNGS: Lobes and Fissures Hilum Vital organs of respiration Light, soft and spongy They are elastic and recoil one-third size when the thoracic cavity is opened  RIGHT LEFT Apex Oblique Anterior border fissure Oblique fissure Superior lobe Superior lobe Horizontal fissure Middle lobe Cardiac notch Inferior lobe Inferior lobe Lingula Three surfaces – costal, mediastinal & diaphragmatic Three borders – anterior, inferior & posterior RIGHT LUNG LEFT LUNG Root of Lungs https://www.youtube.com/watch?v=P_UoRq37iyU  BRONCHI & BRONCHOPULMONARY SEGMENTS - The anatomical, functional and surgical unit of the lungs consists of a tertiary bronchus, a segmental branch of the pulmonary artery, and a segment of the lung tissue surrounded by a connective tissue septum. - Surgeon can remove a segment of the lung without disrupting the surrounding tissue  BRONCHI SEGMENTS 1ry bronchi: main 2ry bronchi: lobar 3ry bronchi: segmental bronchi which supply bronchopulmonary segments  Bronchopulmonary segments Pyramidal in shape Largest subdivision of a lobe Separated by connective tissue septa Supplied by a tertiary bronchus and a segmental branch of the pulmonary artery Named according to segmental bronchi supplying them Drained by intersegmental parts of pulmonary veins Surgically resectable Usually, 10 in the right lung and 8-10 in the left lung  Bronchopulmonary Segments Right Left Segmental bronchi Segmental bronchi Superior lobar Superior lobar 1 Apical 1 Apical 2 Posterior 2 Posterior 3 Anterior 3 Anterior 4 Superior lingular Middle lobar 5 Inferior lingular 4 Lateral 5 Medial Inferior lobar 6 Superior Inferior lobar 7 Medial basal 6 Superior 8 Anterior basal 7 Medial basal 9 Lateral basal 8 Anterior basal 10 Posterior basal 9 Lateral basal 10 Posterior basal Bronchial tree 20 – 23 times airway divides to reach the alveoli  Rohen, et al., 2002 Bronchial tree in situ Jugular notch T2 – T3 level Trachea bifurcate at T4 – T5 level Bronchi branch at T5 – T6 level Bronchopulmonary segments  Pulmonary Circulation = Sternal angle Pulmonary artery (1 ea/side) Pulmonary veins (2 ea/side) - supplying blood - draining blood - arise from pulmonary trunk * lobar v. * lobar a. * segmental v. * segmental a.  1ry bronchi: main 2ry bronchi: lobar 3ry bronchi: segmental bronchi which supply bronchopulmonary segments Terminal bronchioles Respiratory bronchioles INTERNAL Alveolar ducts (2-11) Alveolar sacs (5-6) STRUCTURE OF LUNGS Respiratory zone: respiratory bronchioles, alveolar duct, alveolar sac, and alveoli.  Rohen, et al., 2002 Right pulmonary a. Right pulmonary v. Left pulmonary v. BLOOD VESSELS: Lungs: Pulmonary arteries (aa. arise from 6th pharyngeal or aortic arch, same as ductus arteriosus) Bronchial arteries (branches of the aorta) Left – arises from the descending aorta Right – may arise from Descending aorta R. intercostal a. R. subclavian R. Internal thoracic Pleural membranes: Visceral pleura Bronchial arteries Parietal pleura Intercostal arteries Internal thoracic artery Musculophrenic artery  Veins: Bronchial veins drain only part of the blood supplied by the bronchial arteries Remainder of blood drained by pulmonary veins Right bronchial vein drains into azygos vv. Left bronchial vv. drains into accessory hemiazygos vv. or left sup. intercostal vein  LYMPHATIC DRAINAGE: 4 3,4 Deep Superficial lymphatic lymphatic plexus 6 plexus - located deep to 5 5 visceral pleura - located in submucosa - drains lymph from the surface of the lung --drain structures (parenchyma) to the that form root of hilum and visceral lung pleura 3 -drainage follows - lymphatic vessels from bronchi, arteries & the plexus drain into the veins bronchopulmonary (hilar) lymph nodes 1,2 - Lymphatic vessels from plexus drain to pulmonary 1 lymph nodes in * Lymph from lobar bronchi parietal pleura drains into nodes of thoracic wall  NERVES: Lungs & Visceral Pleura: Nerve fibers from pulmonary plexus - Parasympathetic (vagus, CN X): Constriction of bronchial smooth m. Vasodilation of pulmonary vessels Secretion of alveolar glands - Sympathetic: (from sympathetic trunks, cardiopulmonary splanchnic C4-T5) Dilation of bronchial smooth m. Vasoconstriction of pulmonary vessels Inhibition of secretion of alveolar glands Pleural membranes: Visceral pleura (insensitive to pain) Same innervation as lungs Parietal pleura (sensitive to pain) -Costal and cervical portions - intercostal n. -Mediastinal and central part of diaphragmatic pleura - phrenic n. MEDIASTINUM  The Superior & Posterior Mediastinum Mediastinum- structures near the midline of the thoracic cavity 1. Superior Mediastinum 2. Posterior Mediastinum 3. Relations * anterior & posterior * superior & inferior * left & right 4. Differences * left & right sides 1. Superior Mediastinum Located superior to the pericardium and the transverse thoracic plane, a horizontal plane passing through the sternal angle to the intervertebral disc between T4 and T5 It contains the following major structures: Thymus Great vessels Vagus & Phrenic nerves Cardiac plexus of nerves Trachea Recurrent laryngeal nerves Esophagus Thoracic duct Prevertebral muscles  Thymus Immediately posterior to the manubrium. Prominent during infancy & childhood (immune system). Scarcely recognizable in adulthood, although it still produces T-lymphocytes.  Great Vessels 1. Brachiocephalic veins (2): Right & Left * position: Run posterior to R. & L. sternoclavicular joints Sternoclavicular lig. Right: short, almost vertical; post. to 1st 1st costal cartilage costal cartilage receives R. lymphatic duct Left: longer, passes from left Sternal angle to right; receives thoracic duct  Great Vessels 2. Superior vena cava (SVC): * Position: - forms posterior to 1st right intercostal space - ends at 3rd costal cartilage where it enters R. atrium Anterolateral to the trachea and posterolateral to the ascending aorta Drains: All structures superior to the diaphragm  Great Vessels 3. Arch of the aorta: Position: -Starts at 2nd right sternocostal joint (sternal angle) curves superoposteriorly - Ends by becoming descending thoracic aorta posterior to 2nd left sternocostal joint * features: ligamentum arteriosum (ductus arteriosum) – holds aorta & pulmonary artery together a. brachiocephalic trunk b. left common carotid c. left subclavian  Nerves 1. Phrenic nerves: Pass anterior to anterior scalene and root of lungs Right *Runs post. to subclavian v. and parallel to r. brachiocephalic and SVC Left *Runs post.to subclavian v., ant. to descending aorta & left pulmonary a.  Nerves 2. Vagus nerves: Pass anterior to subclavian a. & posterior to roots of the lungs. Contribute to form cardiac, pulmonary and esophageal nerve plexuses Right *contributes fibers to the cardiac plexus of nerves and gives off the right recurrent laryngeal nerve, which hooks around the right subclavian artery. Left *gives off the left recurrent laryngeal nerve, which hooks around the ligamentum arteriosum and passes superiorly on the right side of the arch of the aorta. Nerves Great Vessels Brachiocephalic v. SVC Arch of the aorta Great Vessels IDENTIFY  Nerves Phrenic ns. Laryngeal recurrent ns. Vagus ns.  Nerves Phrenic ns. Rrecurrent Laryngeal ns. Vagus ns. Esophageal plexus  Nerves Cardiac plexus Right and Left pulmonary plexus  Trachea to Bronchi – - Pseudostratified ciliated columnar epithelium Relations Deep to - Goblet cells & Seromucous tracheal glands Superficial Bronchioles: simple columnar to cuboidal epith. Alveoli: Thin simple squamous epithelium allows for gas exchange Trachea and Esophagus A B  T3 T3-T4 T4-T5 2. Posterior Mediastinum Located anterior to T5 to T12 It contains the following major structures: A. Thoracic descending aorta B. Azygos and hemiazygos veins C. Thoracic duct D. Esophagus E. Intercostal vessels and nerves F. Sympathetic trunk  Thoracic descending aorta Descends to the left sides of T5 to T12 vertebrae, tending towards the midline as it approaches the diaphragm. It enters the abdomen through the most posterior opening in the diaphragm, the aortic hiatus, at the level of T12 Principal branches: * bronchial arteries * esophageal * posterior intercostal & subcostal Asymmetric system consisting of veins on each side of the vertebral column. Azygos vein (Right side) Drains back, thoracic & abd. wall Connects Sup. & Inf. vena cava * Receives blood from posterior intercostal veins 4-12 (intercostal spaces) on the right side. - Superior intercostal veins drain 2-4 intercostal spaces into azygus - Brachiocephalic vein drains both 1st intercostal spaces Azygos system of veins (Left side) Hemiazygos vein Crosses to the right near T9 to join the azygos vein *receives blood from inferior posterior intercostal veins (9-12) on the left side T8 T9 Accessory hemiazygos vein *descends behind the thoracic aorta close to the left sides of T12 the bodies of T4, T5-T8 *crosses to the right near T8 to join the azygos vein *receives blood from left posterior intercostal veins 4-8 Thoracic Duct It is the main lymphatic duct. Lymph from all areas of the body, except the right: upper limb, shoulder, neck & head, drain here. Lymph from these other areas drain into the right lymphatic duct. The thoracic duct drains into the venous system at the junction between the left subclavian and internal jugular vein. IDENTIFY Esophagus Relations anterior posterior Reaches the abdomen through the esophageal hiatus of the diaphragm, at the level of T10 T10 T12 Esophagus After it supplies branches to the esophageal plexus, L. vagus nn. R. vagus nn. the left vagus n. becomes the anterior Anterior Posterior vagal trunk vagal trunk vagal trunk and the right vagus nerve becomes the posterior vagal trunk Posterior view Antterior view  Caval opening (T8)- Inf. Vena cava + R. phrenic nn. Diaphragmatic apertures Esophageal hiatus (T10)- Esophagus + Ant + post Vagal trunks + Esophageal aa. Aortic hiatus (T12)- Descending thoracic aorta + azygous vv. + thoracic duct  Sympathetic cervical ganglia Superior cervical g. targets: within the head, including the pineal gland, the blood vessels in the cranial muscles and the brain, the choroid plexus, the eyes, the lacrimal glands, the carotid body, the salivary glands, and thyroid gland. Middle cervical g. targets: heart and neck Inferior cervical g. targets: heart, lower neck, arm, posterior cranial arteries  Sympathetic trunks The sympathetic trunks or chain of ganglia are found adjacent to the vertebral bodies. They give off rami communicantes to the spinal nerves and other branches that will join to form thoracic splanchnic nerves  Sympathetic trunks R L Sympathetic trunks  REFERENCES Color Atlas of Anatomy, 4th Ed. Rohen, Yokochi & Lutjen-Drecoll Atlas of Human Anatomy, 3rd Ed. Frank Netter Clinical Oriented Anatomy, 5th Ed. (2005) Moore & Dalley Anatomy & Physiology Revealed 4.0 McGrawHill ACKNOWLEDGEMENTS: Dra. Nivia Pérez Acevedo Dra. María Sosa  Heart Anatomy Copyright- This presentation is intended for educational purpose only. No part of this presentation may be reproduced or transmitted in any form without written permission.  HEART & PERICARDIUM OUTLINE 1. Systemic and pulmonary circulation 2. Mediastinum and Pericardium 3. Heart Surface Anatomy Chambers Valves Arterial Supply Venous Drainage Cardiac Cycle Conducting System Autonomic Innervation  SYSTEMIC AND PULMONARY CIRCULATION LUNGS INPUT OUTPUT BODY LUNGS OUTPUT INPUT BODY  PULMONARY CIRCULATION PULMONARY VEINS – CARRY BLOOD WITH OXYGEN PULMONARY ARTERIES – CARRY BLOOD WITHOUT OXYGEN  MEDIASTINUM Refer to structures near the midline of the thoracic cavity Posterior Anterior Superior Mediastinum (Ascending Aorta / Superior Portion: Great Vessels) Inferior Mediastinum - Anterior Mediastinum - Middle Mediastinum (Heart) - Posterior Mediastinum (Thoracic Aorta)  PERICARDIUM Refers to the fibroserous sac that encloses the heart and the roots of the great vessels and occupies the middle mediastinum Fibrous Pericardium Tough outer open sac Is continuous with adventitia of the great vessels and central tendon of the diaphragm Protects heart from overfilling Serous Pericardium Closed sac Two layers Parietal and Visceral Pericardial cavity Serous fluid to minimize friction (~20 ml)  PERICARDIUM Pericardial sinuses: Recesses or areas of potential spaces are formed around the sites where the parietal and visceral layers of serous pericardium are continuous. Transverse pericardial sinus: Formed behind the point of origin of the aorta and the pulmonary trunk. Oblique pericardial sinus: Formed around the point of entry of the pulmonary veins and the inferior vena cava.  PERICARDIUM Arterial supply: Pericardiacophrenic aa. Musculophrenic aa. Bronchial, Esophageal, Superior phrenic aa. Coronary aa. (visceral layer) serous pericardium Venous drainage: Pericardiacophrenic vv. Azygos system Nerve supply: Phrenic (C3-C5) - sensory Vagus Sympathetic trunks  HEART CHAMBERS ANTERIOR POSTERIOR Coronary sulcus Sinus (atrioventricular goove) venarum Sulcus terminalis Interventricular groove Interventricular groove contains the anterior interventricular artery + great cardiac vein (anterior portion) or posterior interventricular artery + middle cardiac vein (posterior portion). Atrioventricular groove contains right coronary artery + small cardiac vein (right side) or left coronary artery + great cardic vein (left side).  HEART CHAMBERS The heart is a double self-adjusting muscular pump consisting of four chambers. Each side has an atrium (antechamber) and a ventricle (discharging chamber): RIGHT LEFT Right atrium & auricle Right ventricle LA Left atrium & auricle RA Left ventricle RV LV  HEART CHAMBERS The right side of the heart receives blood low in oxygen from the body and pumps it into the lungs. The left side receives oxygenated blood from the lungs and pump it into the aorta for distribution to the body.  HEART CHAMBERS Each heart chamber consists of 3 layers: 1.Endocardium: Thin internal layer of endothelium 2. Myocardium: Thick middle layer (cardiac muscle) 3.Epicardium: Thin external layer (mesothelium) formed by the visceral layer of serous pericardium Fibrous skeleton of the heart: 1.Attachment for myocardium 2.AV and semilunar valves 3.Electrical “insulator”  HEART – SURFACE ANATOMY Surfaces: Apex Base (posterior) Sternocostal (anterior) Diaphragmatic (inferior) Apex Borders: Superior (great vessels) Right (right atrium) Inferior (right & left ventricle) Left (left ventricle/left auricle) Apex  HEART – SURFACE ANATOMY The outline of the average heart can be traced on the anterior 2 surface of the chest by 3 using costal cartilages, intercostal spaces and the sternum as 5 guidelines. 6 CARDIAC AUSCULTATION POINTS  HEART CHAMBERS Right atrium: Sinus venarum Tricuspid opening of coronary sinus (CS) valve of IVC and SVC fossa ovalis (foramen oval) CS limbus of fossa ovalis pectinate muscle crista terminalis interatrial septum Tricuspid Valve (right atrioventricular valve) Right ventricle: conus arteriosus/ infundibulum supraventricular crest Supraventricular crest septomarginal trabeculae interventricular septum trabeculae carnae papillary muscles anterior, posterior & septal chorda tendinae Tricuspid valve Pulmonary Valve  HEART CHAMBERS Left atrium: left auricle (pectinate muscle) orifices pulmonary veins Mitral or Bicuspid valve (left atrioventricular valve) Left ventricle: trabeculae carnae papillary muscles (anterior & posterior) chorda tendinae interventricular septum Aortic valve Left Ventricle – Thick Myocardium (Systemic Circulation) HEART CHAMBERS Interventricular septum Membranous part Muscular part Difference in thickness of myocardium wall: Wall of left ventricle is thicker (pumps with higher pressure) HEART CHAMBERS Right Ventricle Right Atrium Left Ventricle Left Atrium Level of T7 HEART CHAMBERS Right Atrium Left Ventricle Right Ventricle Esophagus Left Atrium Thoracic Azygos Descending Vein Aorta Level of T7-T8 disc  HEART CHAMBERS Papillary Pericardium Right Ventricle Muscle Left Ventricle Esophagus Right Atrium Thoracic Descending Aorta Azygos Vein Level of T8  Semilunar: HEART VALVES Pulmonary & Aortic Blood When ventricles relax, semilunar valves close to prevent blood from flowing back into the Tricuspid and Mitral ventricles. Valve When ventricles contract (ventricular systole)AV valves close preventing blood flow to atria. HEART VALVES HEART VALVES  PULMONARY VALVE HEART VALVES AORTIC VALVE TRICUSPID VALVE MITRAL VALVE A L R L R A P P A S P  HEART VALVE DEFECTS The most common valve defect occurs in the mitral or aortic valves. Heart valves are structures that can be damaged for a variety of reasons: Inflammation (Rheumatic Heart Disease) Infections, as seen in bacterial endocarditis Drug reactions, as seen with Fenfluramine / Phentermine Calcification and stiffness Congenital malformations These diseases can lead to two types of problems: ✓ Stenosis - When the damaged valve has a smaller opening or is obstructed ✓ Insufficiency or incompetence - When the damaged valve allows blood to flow backward (Regurgitation)  HEART VALVE DEFECTS Symptomatology: - Emesis - Elevated Blood Pressure - Abnormal EKG - Pulmonary Congestion - Fatigue - Regurgitation - Heart Murmur Treatment: - Catheterization - Trans Esophageal Echocardiogram (Detection) - Valve Replacement (Open Heart Surgery)  VALVE REPLACEMENT (PORCINE OR ARTIFICIAL)  HEART VALVES S2 (“dub”) Cardiac Cycle: Diastole (ventricular relaxation) “dub” (Closure of Semilunar Valves) Atria transfer blood to the ventricles Systole (ventricular contraction) “lub” (Closure of AV Valves) S1 (“lub”) Ventricle contraction transfer blood towards the body (Systemic Circulation) Diastole – Relaxation of Myocardium Systole – Contraction of Myocardium HEART VALVES – CARDIAC CYCLE End-Diastolic Volume  Normal Blood Pressure Blood pressure is primarily produced when 120 mmHg the heart muscle contracts. It is the pressure NBP = of blood upon the walls of the blood vessels. 80 mmHg There are two recordings, a high one (systolic) and a lower one (diastolic). * Normal: 90 – 120/ 60-80 mmHg Sinus node- junction of the crista terminalis in upper wall of the r. atrium and opening of SVC Atrioventricular node - lower back section of interatrial septum near opening of coronary sinus  Electrocardiogram (EKG) https://www.youtube.com/watch?v=RYZ 4daFwMa8 Records electrical impulses during the cardiac cycle P wave – begins when SA node (pacemaker) fires (atrial depolarization) QRS complex – Q: depol. Interventricular septum; R: depol L. ventricle; S: depol R. ventricle (AV node excites ventricles) T wave – ventricular repolarization (ventricles resting state) Adapted from Dr. Guido Santacana Lecture  Cardiac Arrhythmias Normal Rhythm Normal Heart Rate (60-99 beats per minute) Bradycardia Heart Rate slower than 60 beats per minute (Increase in Vagal Tone (Parasympathetic), SA node disease etc) Tachycardia Heart Rate is faster than 100 beats per minute (Increased automaticity of the SA node, due to sympathetic stimulation, cardiac toxicity, etc)  HEART PREDOMINANT INNERVATION TONE!!! Sympathetic Parasympathetic (Thoracolumbar) (Craniosacral) * ** Some Cranial T1 – L2 nuclei & S2-S4 T1 – T5 Medulla Cardiopulmonary Vagus nn. (**) splanchnic nn. (*) Formed by Formed by Presynaptic Fibers Postsynaptic Fibers Presynaptic: ACh Presynaptic: ACh Postsynaptic: NE Postsynaptic: ACh  HEART INNERVATION Cardiac plexus of nerves: Autonomic fibers from… Vagus nerve (Parasympathetic) and Cardiopulmonary splanchnic n. (Sympathetic) Localization: * Anterior to bifurcation of trachea * Posterior to arch of aorta * Superior to bifurcation of pulmonary trunk Sympathetic stimulation * Increases Heart Rate * Increases force of Heart Beat * Causes dilation of coronary aa. Parasympathetic stimulation * Slows heart rate * Reduces force of Heart Beat * Causes constriction of coronary aa.  ARTERIAL SUPPLY OF HEART (LAD) In coronary sulcus ARTERIAL SUPPLY OF HEART Coronary sulcus & interventricular sulcus R L meet VENOUS DRAINAGE OF HEART Post. veins of left ventricle L R VENOUS DRAINAGE OF HEART Ant. interventricular vein Ant. veins of right ventricle R. marginal vein CORONARY ARTERY OCCLUSION CORONARY ARTERY OCLUSSION - ANGIOPLASTY STENT Dilated Coronary Artery with Balloon Stent REVIEW REFERENCES: ✓ Essential Clinical Anatomy, 4th Edition, Keith E. Moore & Dalley, Lippincott Williams & Wilkins (Thorax Chapter) ✓ Atlas of Human Anatomy, 4th or 5th Edition, Frank H. Netter, MD (Thorax Chapter – All Heart Plates) NOTE: THIS LECTURE DOES NOT INTEND TO COVER ALL THE MATERIAL RELATED TO THE HEART AND CARDIOVASCULAR FUNCTION, BUT INTEND TO COVER THE FUNDAMENTAL CONCEPTS OF THE CARDIAC ANATOMY. PLEASE STUDY FROM YOUR TEXTBOOK TO CLARIFY CONCEPTS, AND ALL NETTER’S PLATES RELATED TO THE HEART FOR THEORETICAL AND PRACTICAL (DISSECTION) PURPOSES DURING EXAMINATION.