Thorax Review

Ribs
 Two types of
classification
 True ribs (1-7)
 False ribs (8-10)
 Floating ribs (11-12)

 Typical ribs (3-9)

 Atypical ribs
(1,2,10,11,12)
 Thoracic Outlet Syndrome
 A misnomer, actually it is thoracic inlet syndrome!!
 Types/Classification: Costoclavicular syndrome,
scalenus anticus syndrome or cervical rib syndrome
 S/S-
 Pallor and coldness of skin of upper limb, Diminished
radial pulse [Vascular Symptoms]
 Tingling, numbness or pain in limb [neurogenic
symptoms]
 Results from compression of subclavian artery
between clavicle and 1st rib and/or Lower trunk of
brachial plexus
Sc. Ant
Cervical rib
 Rib arising from
anterior tubercle of
transverse process
of C7
 0.5-1% of persons
 Can causes pressure
on
 Lower trunk of BP
 Subclavian artery
Sternal Angle (Angle of Louis)
 Sternal Angle (Angle of Louis)
 Connects 2nd CC laterally & corresponds with
 Lower border of 4th thoracic vertebra
 Count ribs from this angle
 Bifurcation of trachea
 Ascending aorta ends
 Descending thoracic aorta begins at this level
 Beginning of aortic arch which ends posteriorly at
same level
 Border between superior and inferior mediastinum
 Thoracic duct changes course [from right to left]
at this level
 Esophagus is crossed by left main bronchus
 If a bone marrow needle passes thru
the manubrium....

It can hit aorta

 CLINICAL CASE
 A 25 year old male is brought into the
emergency room following a motorcycle
accident in which he struck an object in the
road and was thrown over the handlebars
striking his left lateral chest against a telephone
pole.
 He is conscious, in considerable pain, his lips
are blue, his respiratory rate is 40/minute, BP is
90/60mmHG, Pulse is 120
 Once his shirt is removed you notice an 8x8 cm
portion of the left lateral chest wall mid axillary
line caves in when he takes a breath in.
Clinical Anatomy of Thoracic wall
 Flail chest-
 Portion of rib cage is separated from rest of
chest wall (multiple rib fractures)
 Due to severe blunt trauma
 Serious fall
 Car accident
 Injured region of chest wall moves
paradoxically
 In on inspiration
 Out on expiration
 Common site of fracture- Middle ribs
 Weakest part of ribs- just anterior to ANGLE
 Vasculature of Breast
 Anterior intercostal A. (from internal thoracic
artery)
 Lateral thoracic A. (from axillary artery)
 Branches of thoracoacromial A.
 Posterior intercostal A.
 Branch of thoracic aorta 2nd, 3rd, & 4th P.I.C.

 Venous drainage-
 Axillary vein (main) [lateral thoracic]
 Internal thoracic vein [anterior intercostal]
 Azygous vein [posterior intercostal]
Lymphatic Drainage of Breast
 Lymph from nipple, areola, and lobules of
mammary glands- subareolar lymphatic
plexus
 From there, a system of interconnecting
lymphatic channels drains lymph to various
lymph nodes
 Majority (75%) of lymph, especially from lateral
quadrants→ pectoral nodes→ axillary nodes
 Remaining lymph, especially from medial
quadrants→ parasternal lymph nodes along
internal thoracic vessels
 Some lymph from lower quadrants→
inferior phrenic nodes

 Lymph from medial quadrants can cross

to opposite breast
 Secondary metastases of breast
carcinoma can spread to opposite breast
in this way
 Lymphatic Pathway
From Supraclavicular Nodes From parasternal Nodes

Subclavian Lymphatic trunk Costo-Mediastinal Trunk

On Rt side
On Lt side On Rt
side On Lt
side
Right
Right Lymphatic
Thoracic Duct Lymphatic Thoracic Duct
Duct Duct

Superior Vena
Cava
Superior Vena Cava
(venous
(venous system) system)
Breast cancer in the medial quadrants can
cross the midline to the opposite breast!
 Spread of Cancer from Breast
Hematogenous
Lymphatic spreadspread
 By
From
venous
Lateral
routes
Quadrant >> Axillary lymphnodes
 From lateral
Medial Portion
side >>>>
Parasternal
Axillary vein,
lymphnode
to Subclavian
and to
potentially
Superiorto
opposite
Vena cavaside and opposite breast.
 From (Infero-)lateral Portion>> Posterior Intercostal, to Azygous
 system to by
After that Superior Vena cavachannels
major lymphatic or Vertebral
into Venous
SuperiorPlexus
vena Cava
[Vertebrae]
 From Medial portion >> Internal Thoracic to subclavian to
Superior Vena Cava

SVC >>> Right Side of Heart >>> LUNGS >>> Left side of Heart >>> all over body
3 diameter of respiration
 1-Vertical diameter
 Above suprapleural membrane
 below mobile diaphragm
 Can be increases by descent of diaphragm

 2-Anteroposterior diameter
 Can be increased by raising ribs and sternum
(pump handle movement) [more in upper ribs]

 3-Transverse diameter
 Can be inccreased by raising out lower ribs (bucket
handle movement) [more in lower ribs]
 Respiratory movements
 Inspiration
 Diaphragm contract & go down
 First rib is fixed by contraction of
scaleni muscle in root of neck
 2nd-12th rib raised toward first rib by
contraction of ICM [pump handle and
bucket handle movement]

ICM = Inter Costal Muscles

 Expiration
 Actually a passive movement by
elastic recoil of lungs
 But when we need, 12th rib is
fixed by quadradratus lumborum
muscle and oblique m. of abd.
 1st-11th rib will be lowered by
contraction of ICM
Structure involved in Quit/Forced
respiration
 Quiet inspiration
 Diaphragm
 ICM [ribs go up and out]

 Forced inspiration
 in addition to above
 Scalenus anterior
 Trapezius, Levator scapulae, rhomboid
muscles
 Pec.minor, pec. major
Structure involved in Quit/Forced
respiration
 Quiet Expiration
 Passive movement
 Elastic recoil of lung

 Forced Expiration
 Active process
 Anterior abdominal muscle contraction
 Quadratus lumborum with Inter Costal
Muscles [ribs go down and in]
 Latissimus dorsi
  Inspiration:
 Diaphragm descend, >>>
intrathoracic volume
increase >>> result in drop
in intrathoracic pressure
[negative pressure] >>> air
sucked in lung >>>
inspiration happens
 This drop in intrathoracic
pressure cause
 Increase Venous return
during inspiration
 Inward movement of
broken chest piece in flial
chest
 Expiration
 Lung recoil and diaphragm
relaxes and go up >>
reduction in intrathoracic
volume >> increase in
intrathoracic pressure
 This increase intrathoracic
pressure causes
 Decrease venous return on
right side of heart during
expiration
 Downward movement of
paralyzed diaphragm on
expiration
 Outward movement of
broken chest piece in flial
chest
Paralysis of Diaphragm
 Cause- injury to phrenic nerve
 Paralysis of one half does not affect other half
because each dome has a separate nerve
supply
 On X-ray- note its paradoxical movement
 Instead of descending on inspiration, paralyzed
dome is pushed superiorly by abdominal viscera
that are being compressed by active side
 Paralyzed dome descends during expiration as
it is pushed down by positive pressure in lungs
Intercostal Nerve Block
 Local anesthesia of an intercostal space is
produced by injecting a LA agent around
intercostal nerves
 Involves infiltration of anesthetic around
intercostal nerve and its collateral branches
 Because any particular area of skin usually
receives innervation from two adjacent nerves,
considerable overlapping of contiguous
dermatomes occurs
 Therefore, complete loss of sensation usually
does not occur, unless two or more intercostal
nerves in adjacent intercostal spaces are
anesthetized
Lungs - Surface Anatomy
Anterior
View

3 lobes on 2 lobes on
Right Left
Posterior
View
Lateral
View - Rt
Lateral
View - Lt
Pleura
 Each lung is enclosed in a
serous sac (pleura)
 Visceral Pleura invests the
lungs
 Parietal Pleura lines thoracic
cavity (adherent to thoracic
wall, diaphragm &
mediastinum)
 Visceral and parietal pleura
are continuous at hilum of
lung
 Pleural space is a potential
space between parietal and
visceral pleura
 Contains pleural fluid
 Lubrication
 Cohesion
 IMP

Parietal pleura
 Lines the pleural cavities
 Very sensitive to pain
 Intercostal and phrenic nerves [somatic nerves]
 Has 4 parts
 Costal pleura- Lining internal surface of thoracic
wall
 Mediastinal pleura- Covering sides of
mediastinum
 Diaphragmatic pleura- Covering superior surface
of dome of each hemidiaphragm
 Cervical pleura- A dome of pleura extending
superiorly into superior thoracic aperture
Pleural Nomenclature
 Cervical pleura

 Mediasinal pleura

 Costal pleura

 Diaphragmatic
pleura

 Visceral pleura
 IMP

Visceral pleura

Covers the lungs

Cannot be dissected from lung
Insensitive to pain
 Does not have any somatic
sensory innervation but may be
supplied by autonomic nerves which also
supply lung substance
 IMP

Pleural cavity
 Potential space between parietal and visceral pleura
 Contains a thin layer of serous pleural fluid
 Lubricates and allows pleurae to move

smoothly over each other during respiration

 Surface tension keeps lung surface in

contact with thoracic wall

 Due to continuous drainage of lymphatic fluid

out of the pleural cavity there is slight suction

effect resulting in negative pressure in
pleural cavity.
Lines of Pleural Reflection IMP

Lines of pleural reflection are lines along which parietal pleura changes
directions from one wall to another

 Apex of lung at neck or 1st rib

 Inferior margin of lung
 6th rib MCL
 8th rib MAL
 10th rib MSL

 Inferior pleural reflection

 8th rib MCL
 10th rib MAL
 Neck of 12th rib on either side
of the vertebral column
Lines of Pleural Reflection
Lines of Pleural Reflection
 IMP

Pleural effusion
= Fluid in Costodiaphragmatic recess
 IMP

Pleural Effusion

Obliteration of
costodiaphragmatic recess
Left Pleural Effusion
Lateral Chest Film
 IMP

ROOT OF LUNG
 Lung root contains
 Main stem or lobar
bronchi
 Pulmonary vessels and
bronchi.
 Bronchial vessels,
lymphatics, and
autonomic nerves
 Lung root is surrounded by
a pleural sleeve, from
which extends pulmonary
ligament
IMP
IMP
Must be able to Identify
Hilar Structures
 IMP
LEFT RIGHT

• Pulmonary Veins • Pulmonary Veins

Anateriorly and Anateriorly and
Inferiroly Inferiroly
• From Above • From Anetior to
Downwards: Artery, Posterior: Bronchus
Bronchus, Vein Artery, Vein
Know these impressions
 IMP

Trachiobronchial Tree
 Trachea
 Bronchi
 Right and left [primary]
 Lobar [secondary] [3 or 2]
 Segmental [Tertiary] [10]
 Large & Small Intra-segmental
 Bronchiole
 Terminal
 Respiratory
 Alveoli
 Alveolar duct
 Alveolar Sac
 Alveoli
IMP
 IMP

 A bronchopulmonary segment
 Is a pyramidally shaped section of lung with its
base covered by visceral pleura
 Is separated from adjacent segments by
connective tissue septa
 Is aerated by segmental bronchus
 Has its own segmental bronchus and
segmental branch of pulmonary artery and
segmental branch of bronchial artery but not
pulmonary vein
THERE ARE 10 BRONCHOPULMONARY SEGMENTS
ON EACH SIDE
IMP Q – Which is the most dependent area/segment in both
lungs?
Aspiration of Foreign Bodies
 More likely to enter in right bronchus
 Because right bronchus is wider and shorter
and runs more vertically than left bronchus
 Encountered by dentists
 Aspiration of piece of tooth, filling
material, or a small instrument
 IMPORTANT
Location with Aspiration
 1. Standing or Sitting
 Posterobasal segment of Rt. Lower Lobe
 2. Lying Down on back
 Superior segment of Rt. Lower Lobe
 MC site of lung abscess
 3. Lying on Right side
 Rt. Middle Lobe
 Posterior segment of Rt. Upper Lobe
 4. Lying on Left side
 Lingual
 IMP

ANTERIOR
VIEW

Broncho –
Pulmonary
Segments

MEDIAL
VIEW
Aspiration Pneumonia
 Post Surgery or
 Drunk alcoholic found unconscious

 Which lobe & segment?

 Which position on chest wall for abnormal
sound?
Bronchogram
 IMP

Vasculature of lungs
 Pulmonary artery
2 sets of Blood  Carries unoxygenated blood
Supply from heart to lungs
 Each artery gives lobar and
segmental arteries
1.Pulmonary Vessels:
for Gas Exchange
 Pulmonary veins
2. Bronchial Vessels:  Intrasegmental veins drain to
for blood supply to intersegmental veins in pulmonary
lung substance like septa, which drain to two
any other organ pulmonary veins for each lung
 Carry oxygenated blood from
lungs to heart
 IMP

 Bronchial arteries
 Basically supply lung substance
 From thoracic aorta
 Carry oxygenated blood to tissue of lungs,
traveling along posterior surface of bronchi

 Left bronchial arteries- arise from thoracic aorta

 Right bronchial artery- arise from posterior
intercostal A.

 Bronchial veins drain to azygos and accessory

hemiazygos veins
 IMP

Lymphatic drainage
 Lymph from lungs drains to
 Pulmonary lymph nodes (along lobar bronchi)
 Bronchopulmonary lymph nodes (along
main stem bronchi)
 Superior and inferior tracheobronchial lymph
nodes (superior and inferior to bifurcation of
trachea)
 Deep Cervical Lymphnodes
 Costomediastinal Trunk
 Thoracic duct [left side] and Right lymphatic
duct [right side]
 IMP

Lymphatic Drainage of Lung

 Inferior deep cervical
(Scalene) lymph nodes
 Paratracheal nodes
 Aortic node
 Subcarinal nodes
 Hilar nodes
 intrapulmonary nodes

Once cancer spreads beyond hilar nodes it cannot be removed surgically

 IMP

Vagus & Phrenic Nerves

 Vagus nerve
 Phrenic nerve
 Left Recurrent
laryngeal nerve
 Hilum of left lung
 IMP

Lung cancer spreads to regional lymphnodes

Once cancer spreads beyond hilar nodes it cannot be
removed surgically
 Special case of Left Upper Lobe: cancer can spread
to aortic lymphnodes, which can enlarge to compress
the recurrent laryngeal nerve. Since this nerve
supplies vocal cords, compression of the nerve can
lead to paralysis of vocal cord and hoarseness.
 Interestingly left lower lobe cancer are likely to skip
this aortic lymph node as lymphatics from LLL cross
to opposite side & therefore can not cause
hoarseness.
 Obviously right lung cancer do not cause
hoarseness...
 Left Vocal Cord Paralysis Secondary
metastatic involvement of the left
recurrent laryngeal nerve near the
ligamentum arteriosum by lung CA

mi
dli
n e Paralyzed
Vocal fold Vocal Fold

Vestibular fold

aryepiglottic fold epiglottis

 IMP

Normal Chest Xray {Lungs}

• Air filled lungs

• Normal
Pulmonary
Vascular
Marking

• Hilum area

• Clear
Costodiaphrag
matic Recess
Pneumonia
 A bacterial or viral infection of lung
 Can lead to widespread systemic infection
and lung collapse
 Lobar pneumonia
 Confined to a single lobe of one lung
 Broncho pneumonia
 Patches in lung
IMP
 IMP
Lobar Pneumonia: which
lobe of lung?

Right Upper
Lobe

Is this Right Lower

Lobe pneumonia?
No Actually in right middle lobe –
look at the lateral view!
 IMP

Pulmonary Collapse
 If a sufficient amount of air
enters pleural cavity
[=pneumothorax], the surface
tension adhering visceral to
parietal pleura is broken, and
lung collapses
 It can be partial or total
 One lung may be collapsed
without collapsing other
because pleural sacs are
separate
 Other Causes- a growing
tumor, an infection, or even an
inhaled foreign object blocking
a major airway
 IMP

Pneumothorax
 Entry of air into pleural cavity
 S/S- Chest pain, short breath
 Uncomplicated pneumothorax may heal on its
own in a week or two
Pneumothorax - Differentiation
 Spontaneous
Tension
 Quite
Mild tosevere/emergency
moderate
 Leads to partial or
lung
total
collapse
lung collapse
 Decreased breath sounds, trachea shift/pushed
in midline or to
shifted [pulled]
opposite side, diaphragm
to same side,
pushed
diaphragm
down on
normal
affected
or
elevated on affected side
side
 IMP

Pleural effusion
 Excess fluid that accumulates in pleural
cavity
 Can impair breathing by limiting the
expansion of lungs during inhalation
 Types
 Serous fluid (hydrothorax)
 Blood (hemothorax)
 Chyle (chylothorax)
 Pus (pyothorax or empyema)
IMP
 Pleuritis
 Pleurisy
 Inflammation of pleurae
 Makes the lung surfaces rough
 Plural rub is heard with a stethoscope
 Acute pleuritis IMP
 S/S- sharp, stabbing pain, especially on exertion,
such as climbing stairs, when rate and depth of
respiration may be increased even slightly, it also
increases on cough but is relieved by sleeping on
the affected side.
 IMP

Thoracocentesis
 To obtain a sample of
pleural fluid or to
remove blood or pus or
air
 To avoid damage to
intercostal nerve and
vessels, needle is
inserted superior to rib,
high enough to avoid
collateral branches
 Pulmonary embolism
 Blockage of pulmonary artery (or one of its
branches)
 Cause-
IMP
 DVT (Venous thrombus)- thromboembolism
 Fat (trauma), air (diving), clumped tumor cells, and
amniotic fluid (affecting mothers during childbirth)
 S/S-
 Difficult breathing, pain in chest, collapse, circulatory
instability and sudden death
 Treatment-
 Anticoagulant medication (heparin and warfarin) with
thrombolysis or surgery
 IMP

COMMON SITE OF ORIGIN

OF THROMBUS
 Thrombus in Deep vein >>> got dislodged
>>> thrombo-embolism >>> IVC >>> Rt.
Atrium >>> Mitral valve >>> right ventricle
>>> Pulmonary Valve >>> Pulmonary trunk
and Artery. Stopped the blood flow going to
the lungs
 Pancoast’s Tumor
 Is a malignant neoplasm of the lung apex and causes
Pancoast's syndrome,
 1) Lower trunk brachial plexus compression - severe pain
radiating toward the shoulder and the medial aspect of the
arm, and atrophy of the muscles of the forearm and hand)
 2) Lesion of cervical sympathetic chain ganglia with
Homer's syndrome (ptosis, enophthalmos, miosis,
anhydrosis, and vasodilation).
 The treatment is radiation therapy followed by surgical
resection of tumor and thoracic wall when feasible.
 On RIGHT

ON LEFT
Radiographs of Thorax (Heart)
 Anteroposterior chest films show the contour of the
heart and great vessels—the or cardiac shadow. The
silhouette contrasts with the clearer areas occupied
by the air-filled lungs because the heart and great
vessels are full of blood.
 The silhouette becomes longer and narrower during
inspiration because the fibrous pericardium is
attached to the diaphragm, which descends during
inspiration.
 IMP
Normal Chest X-
Ray
IMP
Pericardial Sac
 Covering of heart
 Two Layers: Fibrous and
Serous
 Serous itself has two layers:
outer – Parietal and inner –
Visceral.
 Pericardial space [between
two layers of serous
pericardium] contains a small
amount of fluid that allows the
heart to function in a
frictionless environment.
Pericardial Sinuses

S
AO
Two spaces within
V
C
pericardial cavity
PA
 Transverse Sinus
 Oblique sinus
PVs
 Transverse Sinus

Lies between
1. Great vessels
anteriorly [aorta
and pulmonary
trunk]
2. SVC posteriorly

During Open heart surgery, clamp is passed here to

block the blood flow while patient is put on artificial
heart-lung machine.
 Pericarditis and Pericardial Effusion
 Inflammation of the
pericardium (Pericarditis)
usually causes chest pain.
Normally, the layers of
serous pericardium make
no detectable sound
during auscultation.
However, pericarditis
makes the surfaces rough
and the resulting friction,
PERICARDIAL FRICTION
RUB, sounds like the
rustle of silk when listening
with a stethoscope.
 Certain inflammatory
diseases may also
produce pericardial
effusion (passage of fluid
from the pericardial
capillaries into the
pericardial cavity). As a
result, the heart becomes
compressed (unable to
expand and fill fully) and
ineffectual.
 Large Pericardial Effusion (fluid)

Pericardial Effusion = excessive fluid in the pericardial cavity

 Hemoparicardium and Cardiac Temponade
 Stab wounds that pierce
the heart causing blood to
enter the pericardial cavity
(= HEMOPARICARDIUM).
 Hemopericardium may
also result from
perforation of a weakened
area of heart muscle after
a heart attack. As blood
accumulates, the heart is
compressed and
circulation fails.
 If it is quite severe then
there is also risk of
producing cardiac
tamponade.
 CARDIAC TEMPONADE
(heart compression) due to
sudden accumulation of
blood or other fluid in
pericardial cavity
 is a potentially lethal
condition because the
fibrous pericardium is tough
and inelastic. Consequently,
heart volume is increasingly
compromised by the fluid
outside the heart but inside
the pericardial cavity
 Pericardiocentesis
• Drainage of serous
fluid from pericardial
cavity
• Is usually necessary
to relieve the
cardiac tamponade.
• To remove the
excess fluid, a wide-
bore needle may be
inserted through the
left 5th or 6th
intercostal space
near the sternum.
Left Paraxyphoid
 HEART

Many of the subsequent

slides are heavy with
Text material. You may
read the descriptive text
about Anatomy of Heart
from either Text book or
the PDF document in
the folder
You should
be able to
identify All
structures
on this
picture
 Heart lies obliquely between 3rd & 5th ribs
 Mainly on left side of midline of thorax, but 1/3 rd
of it slightly to right
 Base-
 Posterior surface (left atrium)
 Apex-
 Most inferior and lateral part of left ventricle
 Left 5th IC space at mid-clavicular line
Surfaces of the Heart
 Roughly shaped like a
tipped over three sided
pyramid with the apex Base
[Lt] Pulmonary
Surface
pointing down and left L. Atrium
Left Ventricle
and the base facing the
spine.
Sternocostal surface (anterior)
Right ventricle

Diaphragmatic (inferior)
surface Apex
Right Ventricle and Left 5th ICS
ventricle
Surfaces of the Heart

Pulmonary Surface
Base
L.Atrium Left Ventricle

Sternocostal surface (anterior)

Right ventricle

Diaphragmatic (inferior)
Base
surface Apex
Right Ventricle and Left
ventricle 5th ICS
 The 4 surfaces of heart
 Anterior/Sternocostal, formed mainly by the right
ventricle.
 Diaphragmatic, formed mainly by the left ventricle
and partly by the right ventricle; it is related to the
central tendon of the diaphragm.
 Left Pulmonary, formed mainly by the left ventricle; it
forms the cardiac impression of the left lung.
 Right pulmonary, formed mainly by the right atrium
[very small surface almost same as right border]
 Posterior Surface or Base of Heart: formed by Right
Atrium
 The 4 borders of the heart
 Right: (slightly convex), formed by the right atrium and
extending between the SVC and the IVC.
 Inferior (nearly horizontal), formed mainly by the right
ventricle and only slightly by the left ventricle.
 Left(oblique), formed mainly by the left ventricle and
slightly by the left auricle.
 Superior, formed by the right and left atria and auricles in
an anterior view; the ascending aorta and pulmonary
trunk emerge from the superior border, and the SVC
enters its right side. [If you imagine heart as pyramidal
shape then this border is described as base of the heart
or posterior surface of heart]
Open Right Atrium

 Pectinate muscles
 Christa terminalis
 Tricuspid valve
 Fossa ovalis
 Coronary sinus [Vein]
opening
 Right Atrium
 The Right Atrium forms the right border of the heart
and receives venous blood from the SVC, IVC, and
coronary sinus.
 The ear-like Right Auricle is a small, conical muscular
pouch that projects from the right atrium. [it is
primordial atrium represented in the adult].
 Coronary Sinus lies in the posterior part of the
coronary groove and receives blood from the cardiac
veins.
 The part of the embryonic venous sinus incorporated
into the primordial atrium becomes the smooth-walled
of the adult right atrium.
 The separation between the primordial atrium and the
sinus venarum is indicated externally by the (terminal
groove) and internally by the (terminal crest).
 The Interior of Rt Atrium
has
 A smooth, thin-walled posterior part (the sinus venorum), on
which the SVC, IVC, and coronary sinus open, bringing poorly
oxygenated blood into the heart.
 A rough, muscular wall composed of Pectinate Muscle.
 The Opening of SVC is into its superior part, at the level of the
right 3rd costal cartilage.
 The opening of IVC is into the inferior part, almost in line with
the SVC at approximately the level of the 5th costal cartilage.
 The Coronary sinus is between the right AV orifice and the IVC
orifice.
 A Right RV Orifice, through which the right atrium discharges
the poorly oxygenated blood into the right ventricle.
 The Interatrial Septum, separating the atria, has an oval,
thumbprint-size depression, the (L. ), a remnant of the oval
foramen and its valve in the fetus
 Course of blood through the Right
Atrium
Normal flow of blood: from SVC and IVC>>> Rt.
Atrium >>> Right Ventricle

 Fossa ovalis: SVC

 A closed but depressed area
in the Atrial septum
 In Fetal Circulation this
represents a Foramen Ovale;
 Most of the blood from IVC
entering the Rt Atrium is
diverted towards this Foramen
ovale and thereby goes to Left
Atrium...
 This is a normal course of IVC
blood during fetal circulation
 Atrial Septal Defect
 Congenital anomalies of the interatrial septum—
usually related to incomplete closure of the oval
foramen—are (ASDs).
 A probe-size patency (defect) appears in the superior
part of the oval fossa in 15–25% of people. [PFO=
patent foramen ovale]
 These small ASDs, by themselves, are usually of no
clinical significance;
 however, large ASDs allow oxygenated blood from
the lungs to be shunted from the left atrium through
the defect into the right atrium, causing enlargement
of the right atrium and ventricle and dilation of the
pulmonary trunk.
LEFT to RIGHT
shunt
Open Right Ventricle
aorta

 Main pulmonary artery

 Conus artereosus/Infundibulum
 Septal papillary muscle
 1. Anterior leaflet TV
 2. Septal leaflet TV
 3. Posterior leaflet TV
 Moderator band
 Trabeculae carne
 Right Ventricle
 The right ventricle forms the largest part of the anterior
surface of the heart, a small part of the diaphragmatic
surface, and almost the entire inferior border of the heart.
 Superiorly it tapers into an arterial cone, the Conus
Artereosus (infundibulum), which leads into the pulmonary
trunk.
 The interior of the right ventricle has irregular muscular
elevations called Trabeculae Carneae.
 A thick muscular ridge, the SupraVentricular Crest,
separates the ridged muscular wall of the inflow part of the
chamber from the smooth wall of the conus arteriosus or
outflow part of the right ventricle.
 The inflow part of the right ventricle receives blood from the
right atrium through the Tricuspid orifice, located posterior
to the body of the sternum at the level of the 4th and 5th
intercostal spaces
 The Tricuspid Valve guards the right AV orifice. The
bases of the valve cusps are attached to the fibrous ring
around the orifice.
 Tendenous Cords(L. Cordae Tendineae ) attach to the
free edges and ventricular surfaces of the anterior,
posterior, and septal cusps—much like the cords
attached to a parachute.
 Because the cords are attached to adjacent sides of two
cusps, they prevent separation of the cusps and their
inversion when tension is applied to the cords throughout
ventricular contraction (systole)—that is, the cusps of the
tricuspid valve are prevented from prolapsing (being
driven into right atrium) as ventricular pressure rises.
Thus regurgitation of blood (backward flow of blood)
from the right ventricle into the right atrium is blocked by
the valve cusps
 The Papillary muscles form conical projections with their
bases attached to the ventricular wall and tendinous cords
arising from their apices. There are usually three papillary
muscles (anterior, posterior, and septal) in the right
ventricle that correspond in name to the cusps of the
tricuspid valve.
 The papillary muscles begin to contract before contraction
of the right ventricle, tightening the tendinous cords and
drawing the cusps together. Contraction is maintained
throughout systole.
 The Septomarginal Trabecula (moderator band) is a
curved muscular bundle that runs from the inferior part of
the interventricular septum to the base of the anterior
papillary muscle
 Moderator band is important because it carries part of the
right bundle branch of AV bundle of the conducting system of
the heart to the anterior papillary muscle. This “short cut”
across the chamber of the ventricle seems to facilitate
conduction time.
 When the right atrium contracts, blood is forced through the
into the right ventricle, pushing the cusps of the tricuspid
valve aside like curtains. The inflow of blood into the right
ventricle (inflow tract) enters posteriorly, and the outflow of
blood into the pulmonary trunk (outflow tract) leaves
superiorly and to the left. Consequently, the blood takes a U-
shaped path through the right ventricle. The inflow (AV)
orifice and outflow (pulmonary) orifice are approximately 2
cm apart.
 The Pulmonary Valve at the apex of the conus artereosus is
at the level of the left 3rd costal cartilage. Each of the 3
semilunar cusps of the pulmonary valve (anterior, right, and
left) is concave when viewed superiorly.
 Inter Ventricular Septum

 Membraneous
ventricular RV
septum
 Muscular
LV
ventricular
septum LV

RV

Note: relationship of membraneous septum to

aortic valve!
 The Interventricular Septum, composed of
membranous and muscular parts, is a strong,
obliquely placed partition between the right
and the left ventricles, forming part of the
walls of each.
 The superoposterior [Membranous] part is
thin and is continuous with the fibrous
skeleton of the heart. The Muscular part of IV
septum is thick and bulges into the cavity of
the right ventricle because of the higher blood
pressure in the left ventricle.
Ventricular Septal Defects[VSD]

 VSD:
 VSD most common congenital heart defect
 The membranous part of the IV septum develops
separately from the muscular part
 Membranous part is the common site of VSD .
 A VSD causes a left-to-right shunt of blood
through the defect. A large shunt increases
pulmonary blood flow, which causes pulmonary
disease (pulmonary hypertension, or increased
blood pressure) and may cause cardiac failure.
Left Atrium and Ventricle
 L. atrial appendage
 Left atrium
 Valve of the fossa
ovalis
 Pulmonary veins
 Aortic valve
 Membranous
ventricular septum

Mitral valve removed

Anterior Surface Posterior Surface
 Left Atrium
Interior:
 The left atrium forms  A larger smooth-walled part and a
smaller muscular auricle
most of the base of the containing pectinate muscles.
heart.  Four pulmonary veins (two
superior and two inferior) entering
 The pairs of valveless its posterior wall.
right and left  A slightly thicker wall than that of
pulmonary veins enter the right atrium.
 An interatrial septum
the left atrium.  A left AV orifice through which the
 The left auricle forms left atrium discharges the
the superior part of the oxygenated blood it receives from
the pulmonary veins into the left
left border of the heart ventricle.
and overlaps the
pulmonary trunk
IMP: Which chamber of heart is just
anterior to esophagus?

LEFT ATRIUM

 Transesophageal
echocardiogram
illustrating a basal
inferior left ventricular
aneurysm (An).
Arrowheads indicate the
connection between the
left ventricle and the
aneurysm
 Left Ventricle
The left ventricle forms the apex of the heart, nearly all of its left
(pulmonary) surface and border, and most of the diaphragmatic surface.
Because arterial pressure is much higher in the systemic than in the
pulmonary circulation, the left ventricle performs more work than the right
ventricle and therefore more thick.
 A double-leaflet Mitral Valve that guards the left AV orifice.
 Walls that are two to three times as thick as that of the
right ventricle.
 A conical cavity that is longer than that of the right
ventricle.
 Walls that are covered with thick muscular ridges,
trabeculae carnae, that are finer and more numerous than
those in the right ventricle.
 Anterior and posterior papillary muscles that are larger
than those in the right ventricle.
 A smooth-walled, non-muscular, superoanterior outflow
part the Aortic Vestibule, leading to the aortic orifice and
aortic valve
Left Ventricle
 The Mitral Valve closing the orifice between the left
atrium and left ventricle has two cusps, anterior and
posterior.
 Located posterior to the sternum at the level of the 4th
costal cartilage. Each of its cusps receives tendenous
cords from more than one papillary muscle.
 These muscles and their cords support the mitral valve,
allowing the cusps to resist the pressure developed
during contractions (pumping) of the left ventricle.
 The tendinous cords become taut, just before and
during systole, preventing the cusps from being forced
into the left atrium.
 The ascending aorta , begins at the aortic orifice.
 The Aortic Valve, obliquely placed, is located
posterior to the left side of the sternum at the level of
the 3rd intercostal space.
 The Aortic Sinuses are the spaces at the origin of the
ascending aorta between the dilated wall of the
vessel and each cusp of the aortic (semilunar) valve.
 The mouth of the right coronary artery is in the right
aortic sinus and the mouth of the left coronary artery
is in the left aortic sinus and no artery arises from the
posterior [non coronary] aortic sinus
Aortic Valve

Noncoronary cusp = posterior cusp

Aortic-Mitral
Continuity
Nomenclature of Aortic and
Pulmonary Valve Cusps
Posterior

Anterior
Heart Diastole (Ventricles Relaxed & Filling)
A R
 Pulmonary valve
L
 Aortic valve L R
P
 Mitral valve

 Tricuspid valve
Heart in Systole, Ventricles Contracting

 Pulmonary Valve

 Aortic Valve

 Mitral valve

 Tricuspid valve
 Normal Heart Sounds
 The First Heart Sound = S1 = described as
“Lub”
 Closure of mitral [M1] and Tricuspid valve [T1]
 At beginning of Systole
 Second Heart Sound = S2 = Described as
“Dub”
 Closure of Aortic [A2] and Pulmonic Valves
[P2]
 At beginning of Diastole

Think- What would be the best places to hear the S1 and S2 respectively?
Auscultation Areas for Heart Valves

 2nd ICS, RSB:

Aortic valve
 2nd ICS, LSB:
Pulmonary Valve
 5th ICS, LSB:
Tricuspid valve
 5 ICS, MCL:
Mitral valve
 Valve Surface Projection Best Heard

Tricuspid (right Inferior middle Over inferior middle

atrioventricular) valve sternum sternum

Bicuspid (left Fourth costal Over apex of heart

atrioventricular) valve cartilage and 4th (5th intercostal space
intercostal space at midclavicular line)

Pulmonary valve Third left costal 2nd left intercostal

cartilage space, just lateral to
sternum

Aortic valve Fourth left costal 2nd right intercostal

cartilage space, just lateral to
sternum
 Abnormal Heart Sound

 When a valve is stenotic or damaged, there is

problem in opening of those valves and as a
result the abnormal turbulent flow of blood
produces a murmur which can be heard during
the normally quiet times of systole or diastole.
This murmur may not be audible over all areas of
the chest, and it is important to first note where it
is heard best.

Think: Murmurs from 4 different damaged valves will be

heard at what places?
Murmurs of Valvular Stenosis
 Mitral Stenosis
 Lt. 5th ICS near MCL [midclavicular line]
 Tricuspid Stenosis Diastolic
 Lt. 5th ICS at LSB [lateral sternal border] Murmur
 Aortic Stenosis
 Rt. 2nd ICS at RSB
Systolic
 Pulmonic Stenosis Murmur
 Lt. 2nd ICS at LSB

For Med 1 Not For Med 1

Identify the pointed
structures
 Strokes or Cardiovascular Accidents

 Thrombi(clots) form on the walls of the left

atrium in certain types of heart disease.
 If these thrombi detach or pieces break off,
they pass into the systemic circulation
[=remobilization] and occlude peripheral
arteries.
 Occlusion of an artery in the brain results in a
stroke or Cerebrovascular Accidents(CVA),
which may affect, for example, vision,
cognition, or sensory or motor function of
parts of the body previously controlled by the
now-damaged area of the brain.
Endocarditis
 Infective or non infective inflammation of
endocardium covering the heart valves.
 Lead to small vegetations [collection of
platelet, fibrin, +/- bacterial colony, fibrin etc]
over the heart valves
 May lead to defect in closing the valves and
therefore murmurs.
 Conduction System
Where?
• SA node
• AV node
• AV bundle
• Right and
Left Bundle
branches
• Purkinje
fibers
Be able to label the arteries!

Rt. Coronary artery in

the Atrioventricular
groove
Rt. [Acute] Marginal Br.

Post. Interventricular
Br.

SA nodal br.

AV nodal br.
Be able to label the arteries!
Lt. Coronary artery in
the Atrioventricular
groove & divides into
2 branches.:
1. Circumflex branch
turns around the right
border in AV groove
Left marginal [Obtuse Marginal]
is imp br. of circumflex art
2. Lt. anterior descending
or Ant. Interventricular
runs in interventricular
groove to meet with post.
Interventricular br. of right
coronary
Diagonal branch from LAD
Most coronary flow is in diastole.

WHY?
 Area of Distribution
Right Right atrium, SA and AV nodes, Right ventricle and posterior part of
coronary IV septum

SA nodal SA node
Right/Acute Right ventricle and apex of heart
marginal
Posterior IV [in67%] posterior third of septum and Right and left ventricles
AV nodal AV node
Left Most of left atrium and ventricle, IV septum, and AV bundles; may
coronary supply AV node

Anterior IV Right and left ventricles; anterior two thirds IV septum

(LAD) &
Diagonal br.
Circumflex Left atrium and left ventricle
Left /Obtuse Left ventricle
marginal
Posterior IV [in33%] posterior third of septum and Right and left ventricles
 Coronary Artery Disease

>>> Angina &/or Heart

Attack [=Myocardial
Infarction]
Blockage of Artery may be
due to any one or
combination of
• Cholesterol Plaque
• Thrombus
• Vasospasm
 Coronary
Angiography

Visualizationof
Coronary artery by
radio opaque die
Injected by

catheter in femoral
artery reaching up
to aorta and
coronary openings
 TREATMENT OPTIONS
of Coronary Blockages

PTCA
[=Percutaneous Transluminal
Coronary Angioplasty]

• A balloon at the tip of catheter is

introduced at the blockage and
then inflated to break up the
plaque

A balloon Angioplasty can be

followed by placement of STENT
to prevent reblockage.
 CABG: Coronary Artery Bypass Grafting
 Two
Common
Vessels used
from
patients
own body
for grafting
 Internal
Thoracic
Artery
 Great
Saphenous
 Clinical Case
 A 45 year old man with a history of
smoking 1 pack of cigarettes per day since
age 20 presents with anterior chest pain
radiating to his left arm & nausea. His
blood pressure is low and an EKG shows
injury to the diaphragmatic / inferior RCA/Rt.
marginal
surface of the heart.
 What coronary is likely to be involved?
 Do we need to worry about injury to his
conduction system? [whichtopart of
AV node [leading
heart block]
conducting system]
 Clinical Case
 A 45 year old man with a history of
smoking 1 pack of cigarettes per day since
age 20 presents with anterior chest pain
radiating to his left arm & nausea. His
blood pressure is low and an EKG shows
injury to the Posterior surfaceDistal of the
RCA, Cx
or PDA
heart.
 What coronary is likely to be involved?
 Do we need to worry about injury to his
conduction system? [whichtopart of
AV node [leading
conducting system]
heart block]
 Clinical Case
 A 45 year old man with a history of
smoking 1 pack of cigarettes per day since
age 20 presents with anterior chest pain
radiating to his left arm & nausea. His
blood pressure is low and an EKG shows
injury to the anterior /Sternocostal
LAD
surface of the heart.
 What coronary is likely to be involved?
 Do we need to worry about injury to his
conduction system? Bundle Branches
damage lead to
Bundle branch Block
 Clinical Case
 A 45 year old man with a history of
smoking 1 pack of cigarettes per day since
age 20 presents with anterior chest pain
radiating to his left arm & nausea. His
blood pressure is low and an EKG shows
injury to the Lateral surface ofCircumflex/
the left
heart. marginal

 What coronary is likely to be involved?

 Do we need to worry about injury to his
conduction system?No, not this time!
Which wall Which artery comment
infarction blocked
Diaphragmatic Proximal RCA or Rt. If proximal RCA then - AV
node ischemia > heart
or inferior marginal block
surface If Rt. Marginal then – AV
node spared, so no
rhythm irregularity
True Posterior Distal RCA, PDA, If Distal RCA or Distal Cx
then AV node ischemia >
surface Distal Cx [in case of left heart block
dominance] If PDA then Mostly AV
node is spared – No
rhythm irregularity
Anterior wall LAD Bundle branch blocks

Lateral Wall Cx, Lt. marginal or No rhythm irregularity

diagonal br of LAD
 True Posterior wall
infarct

Antero-lateral infract
Diaphragmatic or Anterior wall infarct
Inferior wall infarct
Coronary Veins (anterior view)
Coronary Veins (posterior view)
Parts of Mediastinum
 Green, superior
mediastinum;
 Purple, anterior
mediastinum;
 Yellow, middle
mediastinum;
 Blue, posterior
mediastinum.
 Purple +Yellow +
 Superior Mediastinum
Contents
 Thymus, a primary lymphoid organ.
 Great vessels related to the heart and pericardium:
 Brachiocephalic veins.
 Superior part of SVC.
 Arch of aorta and roots of its major branches:
 Brachiocephalic trunk.
 Left common carotid artery.
 Left subclavian artery.
 Vagus and phrenic nerves.
 Cardiac plexus of nerves.
 Left recurrent laryngeal nerve.
 Trachea.
 Esophagus.
 Thoracic duct.
 Superior Vena Cava Syndrome
 Compression of SVC
 Mostly due to
malignancy (cancer)
 Mostly Lung cancer
 S/S
 Dyspnea (difficulty in
breathing)
 Facial swelling
(swelling of UL/Trunk)
 Enlarged neck veins
How many
arteries can you
label in this
arteriogram?
Flow of O2 rich blood
[IVC] in Fetus =
Role of Ductus venosus
Flow of CO2 rich blood
= Role of Ductus artereosus
[SVC] in Fetus
 Patent Ductus Arteriosus
Patent Ductus
Arteriosus (What are
the two ends
connected to?)

 Pulmonary Artery
 Aorta

Normally closes at birth.

In fetal circulation allows blood from SVC>RA>RV>PT to enter
Aorta.
 In fetal circulation allows blood from
SVC>RA>RV>PT to enter Aorta. Hypoxemia
keeps this duct open during fetal circulation.
 At birth due to restoration of pulmonary
circulation O2 content of blood increases and
duct closes.
 If it does not close at birth, then it will lead to
passage of some blood from aorta to
pulmonary trunk after birth due to pressure
difference between two vessels. This is like a
Left to Right shunt seen in ASD and VSD
 Some drugs like Indomethacin help close this
PDA.
Association with PreMature
Birth

Why?
 Ligamentum Arteriosum
 The remnant of the fetal ductus arteriosus,
passes from the root of the left pulmonary
artery to the inferior surface of the arch of
the aorta.
 The left recurrent laryngeal nerve [a
branch of Vagus nerve] hooks beneath the
arch immediately lateral to the ligamentum
arteriosum and then ascends between the
trachea and esophagus
Coarctation of the Aorta

Hypertension in children
POSTDUCTAL
Effects of Co-
arctation of aorta

• Asymetrical
hypertension
• Prestenotic
aortic dilatation
and regurgitation
• Lt Ventricular
Hypertrophy.
 Thoracic Aortic Aneurysm
 aneurysm is a localized or diffuse dilation of an artery with a
diameter at least 50% greater then the normal size of the
artery.
 abdominal aortic aneurysm are more common than thoracic
 Can occur due to connective tissue diseases like Marfan
syndrome or Ehler Danlos syndromes OR due to infection like
syphilis
 symptoms:
 Mostly asymptomatic or chest pain
 If compress SVC- SVC syndrome [distended neck veins, red face,
distress, decreased BP etc]
 If compress Esophagus – Dysphagia = difficulty in swallowing
 If compress Lt. Recurrent laryngeal nerve – Hoarseness of voice
 If compress trachea – stridor[=harsh sound of breathing], wheeze[=
sound of laborious or difficult breathing], cough
 If cause dilatation of aortic valve then – Aortic Regurgitation murmur
 Aortic Dissection
 tear in the wall of the
aorta that causes blood to
flow between the layers
of the wall of the aorta
and force the layers apart
 High degree of mortality
 s/s: Sever Tearing Chest
Pain which radiates to the
back. Syncope or cerebro-
vascular stroke,
asymmetrical radial pulse
etc.
 Injury to the Recurrent Laryngeal Nerves

 The recurrent laryngeal nerves supply all the

intrinsic muscles of the larynx, except one.
 Consequently, any investigative procedure or
disease process in the superior mediastinum
may involve these nerves and affect the voice.
[=Hoarseness of Voice]
 Because the left recurrent laryngeal nerve
hooks around the arch of the aorta and
ascends between the trachea and the
esophagus, it may be involved when there is
 a bronchial [Lung] cancer
 esophageal cancer,
 enlargement of mediastinal lymph nodes, or
 an aneurysm of the arch of the aorta.
 Esophagus has 3 areas of
compression or narrowing

 Aortic arch

 Left main bronchus

 Diaphragm T10
(esophageal hiatus)

• These are sites where swallowed foreign bodies may lodge!

 Ab N Esophageal
Constrictions

 Aortic Aneurism
 Left Atrial Enlagement

 Mitral Stenosis
 Passing thru’ Diaphragm

T8 – IVC
T10- Esophagus

T12 - Aorta
 Thoracic Duct
 The thoracic duct conveys most lymph of the body to the venous system
(that from the Both lower limbs, pelvic cavity, abdominal cavity, left side of
thorax, left side of head, neck, and left upper limb).
 The thoracic duct originates from the Cycterna Chyli in the abdomen and
ascends through the aortic hiatus in the diaphragm.
 The thoracic duct is usually thin walled and dull white; often, it is beaded
because of its numerous valves. It ascends between the thoracic aorta on
its left, the azygos vein on its right, the esophagus anteriorly, and the
vertebral bodies posteriorly.
 At the level of the T4–T6 vertebrae, the thoracic duct crosses to the left,
and ascends into the superior mediastinum.
 The thoracic duct receives branches from the middle and upper intercostal
spaces of both sides through several collecting trunks. It also receives
branches from posterior mediastinal structures.
 Near its termination, it often receives the jugular, subclavian, and
bronchomediastinal lymphatic trunks.
 The thoracic duct usually empties into the venous system near the union of
the left internal jugular and subclavian veins, the LEFT VENOUS ANGLE or
origin of the left brachiocephalic vein.
 Right Lymphatic Duct
 Receives jugular, subclavian, and
bronchomediastinal lymphatic trunks from
the right side
 drain lymph from right side of thorax,
right side of head, neck, and right upper
limb
 It also drains in Right venous angle
 AZYGOUS SYSTEM OF VEINS
 The Azygous system, on each side
of the vertebral column, drains
the back and thoracoabdominal
walls as well as the mediastinal
viscera.
 The azygos system exhibits much
variation, not only in its origin but
also in its course, tributaries,
anastomoses, and termination.
 Aygous system veins provide
collateral pathway between SVC
and IVC, which may open up in
case of SVC or IVC obstruction.
 Azygous vein arches over the
superior aspect of the root of
the right lung to join the SVC.
 Sympathetic Ganglion
Please ignore black and
green lines at this stage
 Sympathetic Ganglion

 Dorsal root Ganglion

 Lateral Horn
 Spinal Nerve
 Gray Ramus
 White Ramus
 Splanchnic N.

Notice the relationship between somatic and autonomic

system here…
Autonomic
innervation
of Heart and
Lungs
 Innervation of tracheobronchial tree
 Sympathetic:
 Inhibits the
parasympathetic
 Bronchodilation
 Decreased secretion
 Parasympathetic
 Constricts bronchi
(conserving energy)
 Promotes bronchial
secretion
 Innervation of the heart
 Sympathetic
 Increases rate and
strength of contraction
 Inhibits parasympathetic
nerves allowing coronary
vessels to dilate
 Parasympathetic
 Decreases rate and
strength of contraction
(conserving energy)
 Constricts coronary
vessels in response to
reduced demand
Sectional View of Mediastinum and
CT scans
 http://www.anatomyatlases.org/HumanAn
atomy/3Section/Topc.shtml
 First look at these sectional images of
thorax and then look at the CT scans in
subsequent slides.
A
B
C