The mediastinum

Posterior mediastinum
 The pericardium
The pericardium is a "fibro serous sac" formed of two
components:
A) an outer fibrous layer called" fibrous pericardium.
B) an inner serous sac known as "serous pericardium". This
serous sac is reflected to form two layers; a visceral layer
which covers the heart and the root of large vessels, and a
parietal layer which lines the fibrous pericardium.
A. Fibrous pericardium:
• It forms the boundaries of the middle mediastinum .
• Shape : conical having a base, an apex and four surfaces.
1) Base: is directed downwards and fussed with the central
tendon of diaphragm.
2) Apex: directed upwards, extends up till level of angle of Louis
surrounding and fused with the outer coats of the root of the
big vessels arising from the heart .
3) Posterior surface: related to oesophagus and descending aorta
separating them from the oblique sinus & left atrium.
4) Anterior surface: connected to the body of the sternum by
superior and inferior sternopericardial ligaments. The anterior
borders of the two pleurae and lungs separate it from body of
sternum except the lower left half of body of sternum which
lies in direct relation to the pericardium (bare area of
pericardium).
5) Two lateral surfaces: Each surface is related mainly to the
corresponding lung, pleura and phrenic nerve .
Parts of the pericardium
B. Serous pericardium:
The serous pericardium is a closed sac invaginated by the
heart from behind so it is formed of two layers:
1) Visceral layer (epicardium of the heart):
• This layer covers the heart and sends up a single sheath
which surrounds the root of the major vessels; ascending
aorta and pulmonary trunk [both were one vessel in the
embryo].
• The lower half of superior vena cava (S.V.C.) and the
thoracic portion of inferior vena cava (I.V.C.) are coverd
anteriorly and on the sides only. Their posterior surfaces are
bare and not covered by epicardium.
2) Parietal layer: lines the inner surface of fibrous pericardium.

N.B. the pericardial cavity is found between the visceral and

parietal layers and contains thin film of fluid to facilitate the
movements of the heart.

Sinuses of serous pericardium:

a) Transverse sinus:
It is a transverse recess lined by serous pericardium . If we
push a finger from right side in front of superior vena cava
and behind ascending aorta it comes out on left side in front
of left atrium and behind the pulmonary trunk.
*Boundaries of the transverse sinus:
• Anterior: ascending aorta and pulmonary trunk.
• Posterior: superior vena cava and left atrium
• Superior: right pulmonary artery.
Development of the pericardium
 b) Oblique sinus:
Is a recess of serous pericardium lies behind the left atrium.
*Boundaries if oblique sinus:
• Anteriorly: back of left atrium
• Posteriorly: esophagus and descending aorta.
• Superiorly: reflection of the visceral pericardium from
the back of the left atrium to the fibrous pericardium.
• At the sides: pulmonary veins
• Inferiorly: it is continuous with the pericardial cavity.
N.B. if we put a finger in transverse sinus and a finger in
oblique sinus, between the two fingers is the left atrium.
*Nerve supply of pericardium:
• The fibrous pericardium and the parietal layer of serous
pericardium: supplied by sensory fibers from the phrenic
nerve
• The visceral layer of serous pericardium: is supplied by
autonomic fibers (parasympathetic through the vagus and
sympathetic fibers from the cardiac plexuses).

*Arterial supply of the heart:

1) Pericardiophernic artery
2) Musculophernic artery
3) Internal thoracic artery
4) Descending aorta
*Venous drainage: azygos venous system..
Posterior view of the heart and pericardium

Pericardial sinuses
*Applied anatomy :

1. Pericarditis is inflammation in the pericardium usually cause chest

pain and pericardial rub on auscultation .
2. Accumulation of clear serous fluid or pus in the pericardial cavity is
called pericardial effusion leading to dullness around the normal cardiac
dullness on percussion and distal heart sounds on auscultation .
3. Accumulation of blood in the pericardiac cavity is called
haemopericardium ( usually due to infarction , cardiac operation or
cardiac trauma ) .
4 . Cardiac tamponate is cardiac compression by haemopericardium
usually leathal due to impairment of cardiac falling and cardiac output.
5 . Pericrdiocentesis is drainage of fluid from the pericardial cavity by a
wide bore needle inserted parasternally in the left 5th. or 6th. intercostals
space ( i.e bare area of pericardium to avoid injury of left pleura , left lung
and left internal thoracic vessels ) . The pericardial sac can also be reached
vis the left infrastenal angle by passing the needle right postersuperior to
avoid left lung & left pleura .
 The Heart
*The heart is a hollow muscular organ which pumps the blood to
the big vessels (muscular pump).
* Site: it lies obliquely in the middle mediastinum inside the
pericardium.
* Size: larger than a closed fist.
* Shape: conical having an apex directed downwards & to the left
, base directed upwards & to the right and 2 surfaces
* Position: the axis of heart is a line passing from the base to the
apex i.e. passing from behind forwards, downwards and to the
left.
* Parts of the heart: it has four chambers; two atria (right and
left) and two ventricles (right and left).
* Sulci: it has
1- Atrio-ventricular sulcus or coronary sulcus:
Forms "a circle" around the heart separating the two atria from
two ventricles.
2- The anterior and inferior interventricular sulci:
Separates the two ventricles from anterior and inferioe surface.
They form together a loop encircling the heart like a crown.
*Surfaces of the heart:
A. Sternocostal (anterior) surface :
• It is directed forwards and separated from the body of
sternum and costal cartilages by the pericardium , anterior
border of the lungs and pleurae except at the bare area of the
heart .
• It is formed of:
1- Four chambers:
-This surface is fomed mainly by right ventricle .
-The right atrium & its auricle and the right ventricle
forms the right 2/3 of the sternocostal surface .
- The left ventricle and small part of left auricle forms the
left 1/3 of the sternocostal surface
 2 -Four borders:
a. Right border: formed by the right atrium only.
b. Lower border: formed mainly by the right ventricle and
near the apex by a part of the left ventricle.
c. Left border: formed mainly by the left ventricle & in its
upper part by the tip of left auricle.
d. Upper border : Hiden by ascending aorta and pulmonary
trunk . It is formed by the 2 atris mainly by left atrium.The 2
pulmonary arteries run along this border.

Borders of the heart

Sternocostal surface of the heart
 • Two grooves :
1.Anterior interventricular groove which contains:
-Anterior interventericular artery
- Great cardiac vein.
2. Atrioventrricular sulcus (coronary sulus)

B. Inferior or diaphragmatic surface :

-It is directed downwards and related to the central
tendon of diaphragm which separates the pericardium and
the heart from the liver and fundus of stomach .
- It is formed by:
• The right 1/3 is formed by the right ventricle
• The left 2/3 are formed by the left ventricle
- The 2 ventricles are separated by the inferior
interventricular sulcus which contains:
• The inferior interventricular artery
• Middle cardiac vein.
C.Base (posterior surface):
- It is directed backwards opposite the middle 4 thoracic
vertebrae (5, 6, 7 and 8).
- It is quadrilateral and flat. It has four borders and four
angles.
-It is formed of two atria mainly the left atrium which is
separated from the vertebral column by pericardium ( fibrous &
oblique sinus),descending aorta and oesophagus

N.B. the base shows

1. Right and left pulmonary arteries run along the upper border.
2. Coronary sulcus which contains coronary sinus and
circumflex artery run along the lower border .
3. The superior vena cava & the inferior vena cava enters at the
superior end & inferior end of the right atrial portion.
4. The 2 left & 2 right pulmonary veins enter at left & right sides
of left atrial portion .
Inferior surface and base of the heart
* The apex:
- It is formed by the left ventricle only.
-It lies opposite 5th left intercostal space 3.5 inches (9cm) from
midline (just medial to the midclavicular line).
Chambers of the heart
A. The atria
• The right atrium lies anterior and to the right, while the left atrium
lies posterior and to the left, being separated by the "interatrial
septum"
• Thickness of the atrial wall is about 3 mm.
• Each atrium has an auricle projecting up and forwards.
*Different between right and left atria*
1. Right atrium
*Type of -It receives venous (non-oxygenated) blood
blood : from all parts of the body.
*Site : -It lies anterior and to the right to the left
atrium.
-Forms right border of the heart.
*Relations -Anteriorly and on the right: the right lung,
pleura, pericardium, and right phrenic nerve.
-Posteriorly: the left atrium and right
pulmonary veins
-Left side: it is related to the ascending aorta
and pulmonary trunk.
2.Left atrium
-It receives oxygenated blood
from the lungs.
-It lies posterior and to the left to
the right atrium.
-Forms main part of upper border
& main part of the base
-Anteriorly:The transverse
sinus of pericardium separates
the left atrium from ascending
aorta and pulmonary trunk.
-Posteriorly:The oblique sinus
of pericardium separates the left
atrium from descending aorta
and esophagus.
-The left atrium lies between the
transverse and oblique sinuses
of pericardium.
*Interior 1.The crista terminalis - Smooth, except the auricle
2 .Anterior wall: Rough, due to the presence which contains few musculi
of musculi pectinati .
3 .Posterior wall :It is smooth with S.V.C. & pectiniti.
I.V.C. and the coronary sinus open in this wall.
4.The septal wall (the interatrial septum )
presents The fossa ovalis & the annulus ovalis

*Orifices a. Superior vena cava (S.V.C.) orifice: has no a.Four pulmonary veins: two
valve, it lies in superior part of posterior wall . from each side open into upper
b. Inferior vena cava (I.V.C.) orifice: opens in part of posterior surface.
the lower part of posterior wall , it has a b.Mitral orifice: It is the
remnant of embryological valves (in the atrioventricular orifice which lies
embryo this valve directs blood through on the lower part and guarded by
foramen ovale to the left atrium). the mitral valve.
c. Coronary sinus orifice: on the left side of
the opening of inferior vena cava (I.V.C.)
between it and the tricuspid orifice. It has a
valve "valve of coronary sinus".
d. Orifices of venae cordis minimae and
anterior cardiac veins.
e. Tricuspid orifice (right atrioventricular
orifice): present in the inferior part of right
atrium. It is guarded by the tricuspid valve.

The inside of the right atrium

 The inside of the heat

o The interior of right atrium presents:

1.The crista terminalis:
A thick muscular vertical ridge extending from the opening of superior
vena cava to the opening of inferior vena cava and corresponds on the
outside to sulcus terminalis. The crista terminalis divides the right atrium
to anterior and posterior walls.
2 .Anterior wall:
• Rough, derived from the atrium proper of the embryo.
• It is rough due to the presence of musculi pectinati (which are
parallel muscle ridges directed from the crista terminalis to the left
auricle. It prevents over distention of the right atrium during diastole
3 .Posterior wall :
It is smooth and derived from the absorbed right horn of sinus venosus
of the embryo.
 The superior vena cava (S.V.C.), inferior vena cava (I.V.C.) and the
coronary sinus open in the posterior wall.
4.The septal wall (the interatrial septum ) presents:
• The fossa ovalis: is present in the lower part of the septum above
the orifice of the inferior vena cava (it is the remains of foramen
ovale of the embryo).
• The annulus ovalis : a curved ridge forms the anterior and superior
margins of the fossa ovalis .

B. The ventricles
o The two ventricles are separated from each other by the
interventricular septum which corresponds on the outside to the
anterior and inferior interventricular sulci.
o The interventricular septum: convex anterior and to the right and
concave posterior and to the left. It's derived from 2 sources in
embryo that is why it is formed of 2 parts;
1. Membranous part: thin, present above and posterior.
2. Muscular part: thick, forming the remaining part.
*Different between right and left ventricles*
1.Right ventricle 2.left ventricles
- Forms main part of sterno- - Forms small part on the
costal surface. left side of sternocostal
surface.
- Forms right 1\3 of - Forms left 2\3 of
diaphragmatic surface. diaphragmatic surface.
*General features : - Forms most of lower border - Forms most of left border &
except at apex . lower border at the apex .-
-The septum is convex toward it The septum is concave
toward it .
- Is semilunar in T.S. - Is circular in T.S.

- 27 mm| i.e 3times thicker

*Thickness of the wall - 9 mm since it pushes blood in all
parts of body.
* Interior :
A. Rough part (inflow
part):
1.Trabeculae carnae - Are few and coarse. -Are multiple and fine.
( thick muscular bundles)
-Is thick muscle band between
the septum and anterior wall
- It prevent over distention of
2. Moderator band Absent
the right ventricle .
- Transmit the right branch of
AV bundle .
Are conical muscular projections to to the apex of each muscle
are attached cordae tendae which connect them to the margin
and ventricular surfaces of A-V cusps .

3.Papillary muscle -Three papillary muscles : - Two papillary muscles :

anterior , posterior & septal anterior & posterior .
- small in size -larger in size .

B. Upper smooth outflow

Infundibulum Aortic vestibule
part is known as

- Right atrio-ventricular ( inlet ) - Left atrio-ventricular ( inlet)

* Orifices orifice: tricuspid orifices orifices :] mitral orifices
- Outlet orifice : pulmonary - Outlet orifice: aortic orifice
orifices
 Inside of the right ventricle

Tricuspid valve
 Inside of the left ventricle

Aortic v
 Orifices of the heart
1. Tricuspid or right arterio-ventricular orifice:
• It is large ( allow the tip of 3 fingers ) and oval, surrounded by a
fibrous ring, which gives attachment to 3 cusps anterior, posterior
and septal.
• Their atrial surfaces are smooth while their ventricular surfaces are
rough.
• Chordae tendinae connect the margin of their ventricular sufrace to
papillary muscles.
2. Pulmonary orifice:
• It is present above the infundibulum of the right ventricle.
• It has three semilunar cusps: two anterior and one posterior,
3. Mitral (left atrioventricular) orifice:
• It is narrower ( allow the tip of 2 fingers ) than tricuspid orifice;
• It is surrounded by a fibrous ring which gives attachment to two
cusps anterior and posterior.
• The anterior cusp is larger than the posterior, the cusps are smooth
on both surfaces, the cordae tendinae are attached cusps to
anterior and posterior papillary muscles in the left ventricle
4. Aortic orifice:
• It is anterior and to the right of mitral orifice and lies above the
aortic vestibule of the left ventricle.
• It has three semilunar cusps: one anterior and 2 posterior similar
to those of pulmonary orifice, but are larger and thicker.
Orifices of the heart
 Surface anatomy of the heart

*Borders of the heart:

▪ Upper border: straight line joining Point (1 ): at the lower border
of 2nd left costal cartilage 1.5 inch from median plane and Point
(2): at the upper border of 3rd right costal cartilage one inch from
median plane.
▪ Right border: a line, slightly convex to the right connecting Point
(2) and Point (3): at the 6th right costal cartilage one inch from the
median plane.
▪ Lower border: horizontal line, passing at xiphisternal joint
between Point (3) and Point (4) [apex of the hart]: 5th left
intercostal space about 3.5 inches (9 cm) from midline.
▪ Left border: a line joining Points (4) and (1).

*Cardiac valves
▪ Pulmonary valve [P]: opposite left 3rd sternocostal junction.
▪ Aortic valve [A] : opposite left 3rd intercostal space.
▪ Mitral valve [M]: opposite left 4th sternocostal junction.
▪ Tricuspid valve [T]: opposite the 4th intercostal space behind the
center of body of sternum.

*Atrio-ventricular sulcus: is represented by a line slightly convex to

the right drawn between 3rd left costal cartilage and 6th right sternocostal
junction.
*Heart sounds:
The sounds of closure of the valves are not heard exactly at their
anatomical sites but are propagated to other positions. They can be best
heard as follows:
▪ Pulmonary: at left 2nd intercostal space.
▪ Aortic: at right 2nd intercostal space.
▪ Mitral: at the apex of the heart.
▪ Tricuspid: at xiphisternal junction.

Surface anatomy of the heart and its valves

 The fibrous skeleton of the heart

It is a framework of dense fibrous tissue formed of:

1. Right and left atrio-ventricular rings: of tricuspid and mitral
valves. The right fibrous ring is larger but weaker than the
left.Both form 8-shaped structure that gives attachment to base of
tricuspid and mitral valves.
The fibrous ring is attached also to the fibrous part of the
interventricular septum as well as the musculature of atria and
ventricles.
2. Fibrous rings around the opening of the ascending aorta and
pulmonary trunk, these fibrous rings give attachment to the root of
the ascending aorta and pulmonary trunk and their semi lunar
cusps.
3. Right fibrous trigone: it is a large mass of fibrous tissue between
the aortic ring and right atrio-ventricular ring.
4. Left fibrous trigone: it is a small mass of fibrous tissue between
the aortic ring and mitral ring.
5. The tendon of infundibulum connects the posterior surface of
infundibulum to the aortic ring.
Functions: of the fibrous skeleton of the heart:
a. Ensures electrophysiological discontinuity between the atrial and
ventricular myocardium.
b. Provides a strong mechanical attachment to the ventricular and
atrial musculature.
c. Maintains the position of the heart within the pericardium.
d. Provides a stable strong base for attachment of fibrous cores of the
cusps of the valve.
 The conducting system of the heart

The conducting system of the heart is formed of specialized

cardiac muscle fibers that generate rhythmic cardiac impulses and
conduct these impulses throughout the myocardium of the heart.
It consists of:
1. Sino-atrial node (S.A.N.): is present in the wall of right atrium, at
the upper end of sulcus terminalis just to the right of the opening of
the superior vena cava. It is the pace maker of the heart.
2. Atrio-ventricular node (V.A.N.): is present in the lower part of the
right side of the interatrial septum, immediately above the
attachment of the septal cusps of tricuspid valve.
 Both nodes are made of unstriated muscle cells mixed with nerve
cells and nerve fibers.
3. Atrio-ventricular bundle (A.V.B.):Bundle of Hiss
It is a neuromuscular bundle about the thickness of a match.
It begins from the A.V node and descends deep to the septal cusp of
the tricuspid valve. It pierces the fibrous skeleton of the heart. At the
upper border of the muscular part of the interventricular septum. It
divides into two branches, one for each ventricle.
a. The right bundle branch (RBB): descends on the right side of the
interventricular septum till it reaches the moderator band. Then it
leaves the septum and passes along the moderator band to reach
the anterior wall of the right ventricle.
b. The left bundle branch (LBB): pierces the interventricular
septum, and descends on the left side of the septum, it usually
divides into two or more branches.
4. Purkinje fibers: The right and left branches end as subendocardial
plexus of Purkinje fibers in the wall of the right and left ventricles.
 Conducting system of the heart

The atrio-ventricular bundle is the only muscular connection between

the muscles of the atria and the muscles of the ventricles.
Arterial supply of the conducting system:
o S.A node: 60% right coronary & 40% left coronary.
o A.V node: 80% right coronary & 20% left coronary.
o A.V bundle: right coronary.
o Right branch of A.V. bundle: right coronary.
o Left branch of A.V. bundle: two coronaries (Rt. & Lt.)

Fixation of the heart in position

The factors that keep the heart in position are;

1) The pericardium : fixed to its surrounding structures:
o Above: continuous with the pretracheal fascia and the adventitia of
big vessels and the carotid sheath. this play an important role in
suspending the heart indirectly to the base of the skull and the
visceral skeleton of the neck " sharing in the cardiac sling
mechanism "
 o Below: it is blended with the central tendon of the diaphragm.
o In front: it is attached to the sternum by the superior and inferior
sternopericardial ligaments.
o On the sides: it is blended with the mediastinal pleura [support the
heart from sides].
2) The big vessels connected to the heart:" cardiac sling mechanism ":
o The hooking of the aortic arch and the left pulmonary artery over
the left main bronchus.
o The hooking and right pulmonary artery above the right main
bronchus.
o The hooking of azygos arch from behind the right main bronchus.
o The overall hanging the subclavian vessels across the 1 st rib at the
thoracic inlet.