The cardiovascular system anatomy

S01 LO Describe the position of the heart and its anatomical and functional relations Appreciate the structure and relations of the mediastinum and pericardium and appreciate the clinical relevance of the spaces within and surrounding the pericardium Identify the external features of the heart and the major blood vessels Describe the internal structure of the four chambers of the heart and their valves and relate this to their function in normal and diseased states Interpret plain film and CT radiography images of the thorax, especially of the heart Describe the arterial supply and venous drainage of the coronary circulation and recognise major features in contrast images Give a basic summary of the embryological development of the heart and great vessels and be able to identify remnants of this development and the consequences in the child and adult of common anomalies

Pericardium Is a fibrous sac that encloses the heart and the roots of the great vessels and occupies the middle mediastinum = fibrous pericardium and serous pericardium Receives blood from the pericardiophrenic, bronchial and oesophageal arteries Nerve vasomotor and sensory fibres from the phrenic and vagus nerves and the sympathetic trunks

Fibrous pericardium Srong, dense fibrous layer that blends with the adventitia of the roots and the great vessels and the central tendon of the diaphragm

Serous pericardium Consist of a parietal layer (lines the inner surface if the fibrous pericardium) and the visceral layer which forms the outer layer, (epicardium) of the heart wal and the roots of the great vessels
Posterior mediastinum: contents
DATES: Descending aorta Azygos and hemiazygous veins Thoracic duct Esophagus Sympathetic trunk/ganglia

Clinical Pericarditis inflammation of the pericardium (may) cardiac tamponade, pericardial effusion and precordial and epigastric pain. percicardial friction rub. Symtoms = dysphagia, dyspnea +cough,inspiratory chest pain and paradoxic pulse

Pericardial cavity Potential space btw the visceral layer of the serous pericardium and the parietal layer of the parietal later of the serous pericardium lining the inner surfaces of the fibrous pericardium

Pericardial sinuses 1. Transverse sinus y Subdivision of the pericardial sac, lying posterior to the ascending aorta and pulmonary trunk, anterior to the SVC and superior to the left atrium and the pulmonary veins Great importance to surgery on aorta or pulmonary artery. A finger can make a ligature through the sinus btw the arteries and veins stopping blood circulation

2. Oblique sinus y Subdivision of the pericardial sac behind the heart, surrounded by the reflection of the serous pericardium around the right and L pulmonary veins and the IVC

Heart

General characteristics The apex of the heart is the blunt rouneded extremity of the heart formed by the left ventricle and lies in the left 5th intercostal space, slightly medial to the midclavicular/ nipple. This location is used clinically for determining the border if the heart and auscultating the mitral valve

Posterior aspect = base formed primarily by the L atrium on only partly by the posterior right atrium. R (acute) border in formed by the SVC, Right atrium and IVC Left (obtuse) is formed by the left Ventricle

The heart wall consists of three layers inner endocardium, middle myocardium and outer epicardium The sulcus terminalis, a groove on the external surface of the R atrium marks the junction of the primitive sinus venous with the atrium in the embryo and corresponds to a ridge on the internal heart surface the crista terminalis The cardiovascular silhouette = the contour of the heart and great vessels seen on posteriorinferior chest radiographs. Its right border is formed by the SVC, the right atrium and the IVC. L border = aortic arch, pulmonary trunk, left auricle and L ventricle. Inferior border is formed by the right ventricle and the left atrium shows no border

Internal anatomy of the heart 1. Right Atrium - Anteiortly situated rough walled atrium proper and the auricle lined with pectinate muscles and posteriorly situated smooth walled sinus venarum, into which the two venae carvae open - Is larger than the left atrium but has a thinner wall, and its sinus venarum btw two venae carvae is separated from the atrium proper by the cristae terminalis - Has a right atrial pressure that is normally slightly lower than the left atrial pressure - Contains the Eustachian valve of the IVC and the theesuab valve of the coronary sinus. 1. Right auricle the conical muscular piuch of the upper anterior portion of the right atrium, which covers the first part of the right coronary artery. 2. Sinus venarum is posteriorly situated, smooth-walled area that is separated from the more muscular atrium proper by the crista terminalis 3. Pectinate muscles are prominent ridges of atrial myocardium located in the interior of both auricles and the right atrium 4. Crista terminalis is a vertical muscular ridge running anteriorly along the right atrial wall from the opening of the SVC to the opening of the IVC, providing the origin of the pectinate muscles y Represents the junction btw the primitive sinus venarum and the right atrium proper and is indicated externally by the sulcus terminalis 5. Venae cordis minimae- are the smallest cardiac veins, which begin in the substance of the heart and end chiefly in the atria at the formanina venarum minimum cordis 6. Fossa ovalis os an oval sped depression in the internal septum and represents the site of the foramen ovale, through which blood runs from the right atrium to the left atrium before birth. The upper rounded margin of the fossa is called the limbus fossa ovale.

Left atrium Is smaller and has thicker walls than the R atrium, but its walls are smooth, except for a few pectinate muscles in the auricle Is the most posterior part of the four chambers, lying posterior to the R atrium but anterior to the oesophagus and shows no structural borders on posteroanterior radiograpgh Receives oxygenated blood through 4 pulmonary veins

Right Ventricle Makes up the major portion of the anterior surface of the heart 1. Trabeculae carnae crdis y Antagonising muscular ridges of myocardium in the ventricles

2. Papillary muscles y Are coned shaped muscles enveloped by endocardium y Extend from ant and post ventricular wall and the septum, chorda tendinae y F: contract to tighten the chordae tendinae, preventing the cusps of the tricuspid valve from being everted into the atrium. Prevents regurgitation of ventricular blood into the R atrium 3. Chordae tenindae y Extend from one papillary muscle to more than one cusp of the tricuspid valve y Prevent eversion of the valve cusps into the atrium during ventricular contraction 4. Infundibulum y Is the upper smooth walled portion of the right ventricle, which leads to the pulmonary trunk 5. Septomarginal trabecular (moderator band) y Is an isolated band of trabeculae carnae that forms a bridge btw the IV septum and the base of the anterior papillary muscle of the anterior wall of the R ventricle 6. IV septum y Is the origin of the septal papillary muscle y Is mostly muscular but has a small membranous upper part, which is common site of ventricular septal defects

Left Ventricle Lies at the back of the heart, and its apex is directed downward, forward and to the left Is divided into the ventricle proper and the aortic vestibule, which is the upper anterior part of the left ventricle aand leads into the aorta Contains 2 papillary muscles (ant and post) with their chordae tendinae and a meshwork of muscular ridges m the traveculae carnae cordis Performs harder work, has a thicker (2-3x) wall and is longer, narrower and more conical shaped

Coronary arteries

Arise from the ascending aorta and are filled during diastole Have min blood flow during diastole and min during systole because of compression of the arterial branches in the myocardium during systole

1. Right coronary Artery (RCA) y Arises from the anterior root of the aortic sinus of the ascending aorta, runs btw the pulmonary trunk and the R auricle, runs btw the R auricle and the pulmonary trunk and then descends in the R coronary sulcus. And generally supplies the R atrium and ventricle y o SA nodal artery passes btw the R atrium and the root of the ascending aorta, encircles the base of the SVC and supplies the SA node and the R atrium o Marginal Artery runs along the inferor border toward the apex and supplies the inferior margin of the right ventricle o Posterior IV artery is a larger terminal branch and supplies the IV septum and L ventricle and AV node o AV nodal artery arises opposite the origin of its posterior IV artery and supplies the AV node 2. Left coronary Artery y Arises from the left aortic sinus of the ascending aorta, just above the aortic semilunar valve y Is shorter than the right coronary artery and is usually distributed to more of the myocardium

y  1. Anterior IV generally supplies anterior aspects of the R and L ventricles and is the chief source of blood to the IV septum and Apex Circumflex artery runs in the coronary sulcus , gives off the left marginal artery, supplies the L atrium and L ventricle and anastomoses with the terminal branch of the right coronary artery

Cardiac veins and coronary sinus 1. Coronary sinus o Is the largest vein draining the heart and lies in the coronary sulcus , which separates the atria from the ventricles y Opens into the right atrium before opening the IVC and the AV opening y Has a one cusp valve at the right margin of its aperture y Receives the great, middle, and small cardiac veins; the oblique vein of the left atrium and the posterior vein of the L ventricle 2. Great cardiac vein, y begins at the apex of the heart and ascends along with the IV branch of the left coronary artery y turns o the left to lie in the coronary sulcus and continues in the coronary sinus 3. middle cardiac vein y begins in the apex of the heart and ascends in the posterior IV groove, with the posterior IV branch of the RCA y drains into the R end of the coronary sinus 4. small cardiac vein y runs along the R margin of the heart in company with the marginal artery and then posteriorly in the coronary sulcus to end in the rigt end of the coronary sinus 5. oblique vein of the left atrium y descends to empty into the coronary sinus near its left end 6. anterior cardiac vein y drains into the anterior right ventricle, crosses the coronary groove and ends directly in the R atrium 7. smallest cardiac veins y begin in the wall of the heart and empty directly into its chambers

lympathetic vessels of the heart receives lymph from the myocardium and epicardium

follow the right coronary artery to empty into the anterior mediastunal nodes and follow the LCA to empty into a tracheobronchial node

Cardiac plexus receives the superior, middle and inferior cervical and thoracic cardiac nerves from the sympathetic trunks and vagus nerve is divisible into the superficial cardiac plexus (which lies beneath the arch of the aorta) and the deep cardiac plexus which lies posterior to the arch of the aorta infront of the bifurcation of the trachea Richly innervates the conducting system of the heart, the R sympathetic and parasympathetic bracnhes terminate chiefly in the area of the SA node The L branches terminate largely in the AV node. The cardiac motor fibres are devoid of motor endings and are activated by the consucting system Supplies the heart with sympathetic fibres, which HR and fprce of the heartbeat & dilatation of the coronary arteries.

Great vessels (4)

1. Ascending aorta y Origin is from the left ventricle within the pericardial sac and ascends behind the sternum to end at the level of the sternal angle y Lies in the middle mediastinum, has three aortic sinuses locates immediately above the cusps of the aortic valve and gives off the right and L coronary artery 2. Arch of the aorta y Within the superior mediastinum, begins at the continuation of the ascending aorta, and arches over the right pulmonary artery and L main Bronchus y Forms a prominence that is known as the aortic knob. y Gives rise to the brachiocephalic, left common carotid and left subclavian arteries
"Know your ABC'S": Aortic arch gives rise to: Brachiocephalic trunk left Common Carotid left Subclavian Beware though trick question of 'What is first branch of aorta?' Technically, it's the coronary arteries.

3. Superior vena cava (svc) y Is formed by the union of the R & L brachiocephalic veins and returns blood from all structures superior to the diaphragm except the lungs and the heart 4. Pulmonary trunk y Arises from the conus arterioris of the R ventricle, passes obliquely up and backwards across the origin and on the left side of the ascending aorta within the fibrous pericardium. y Birfurcates into the R and L pulmonary arteries in the cibcavity of the aortic arch 5.

Cornonary artery anatomy

In the majority of cases, the SA and AV nodes are supplied by the RCA. 80% of the time, the RCA supplies the inferior portion of the left ventricle via the PD artery ( = right dominant). 20% of the time, the PD artery arises from the CFX

Coronary artery occlusion occurs most commonly in the LAD, which supplies the anterior intraventricular septum Coronary arteries fill during diastole The most posterior part of the heart is the left atrium, enlargement can cause dysphagia (due to compression of the oesophageal nerve) or hoarseness due to compression of the recurrant laryngeal nerve. A branch of the vagus.

Clinical correlations (AP)

May affect the recurrent laryngeal nerve invoved in phonation

Aortic stenosis characteristics
SAD: Syncope Angina Dyspnoea

S02 The arterial abd venous tree

LO Identify the major named blood vessles in the body and summarise the tissues they supply Identify the major blood vessels from angiograms and note any abnormalities Descrive the vascular supply of the following: head and neck, digestive system, limbs, thoracic and abdominal walls Correlate yourknowledge of the blood supply of a region with damage due to infact Rction, haemorrhage or disease Descrivbe how the different composition of arteries and veins influences their function, and their response to traumoa Discuss the role of the muscle pump im the venous rurn of the heart Understand and discuss the distinction btw superficial and deep vessels and recognise why this is understanding is so important in clinical practice

Upper limb Branches of the subclavian artery 1. suprascapular a

is a branch of the thyrocervicical trunk Passes over the superior scapular ligament Anastomoses with the deep branch of the transverse cerical a (dorsal scapular a) and th circumflex scapular a around the scapula, providing collateral circulation Supplies the supraspinatus muscle and the shoulder abnd acromioclavicular joints

2. Dorsal scapular or descending scapula a - Arises from the subclavian a but may be a deep branch of the transverse cervical a - Accompanies the dorsal scapular nerve - Supplies the levator scapulae, rhomboids and serratus anterior muscles

Axillarry a Is considered to be the central structure of the axilla Extends from the outer border of the 1st rib to the inferior border of the teres major muscle, where it becomes the brachial a. The axillary a is borderd on its medial side by the axillary vein The pec minor muscle divides the axillary a into 3 parts

1. Superior thoracic a supplies the intercostal muscle in the first and second anterior intercostal spaces and adjacent muscles 2. Thoracoacromial a y Is a shorr trunk from the 1st or 2nd part of the axillary a and has a pectoral, clavicula, acromial and deltoid ranches y Pierces the costocoracoid membrane 3. Lateral thoracic a y Runs along the lateral border of the pec minor muscle y Supplies the pec majorm pec minor and serratus ant muscles and the axillary lymph nodes and gives rise to the lateral marammary branches y

Blood vessels to the head and neck Rjk089

Subclavian a Is a branch of the brachiocephalic trunk on the right but arises directly from the arch of the aorta on the left Divided into 3 parts by the anterior scalene muscle. 1. Passes the origin of the vessel to the medial margin of the anterior scalene. 2. Lies posterior to the M. 3. Passes from the lateral margin of the M to the outer border of the 1st Rib.

Branches 1. Vertebral A Arises from the 1st part of the subclavian a and ascends btw the anterior scalene and longus colli muscles Ascends through the transverse foramina of vertebrate C6-1. Winds around the superior articular process of the atlas and passes through the foramen magnum into the cranial cavity

o o

3. Thyrocervical trunk - Is a short trunk from the 1st part of the subclavian that divides into the following a A. Inferior thyroid a ascends in front of the anterior scalene, turns medially behind the carotid sheath but in front of the vertebral vessels and then arches to the lower pole of the thyroid - Gives rise to an ascending cervical a, which ascends on the anterior scalene muscle medial to the phrenic nerve B. Transverse cervical a runs laterally across the anterior scalene, phrenic N, and trunks of the brachial plexus, passing deep to the trapezius - Divides into a superficial branch and a deep branch, which takes the place of the dorsal scapular a. C. suprascapular a

D. internal thoracic a arises from the 1st part of the subclavian a, descends through the thorax behind the upper six costal cartilages, and ends in the sixth intercostal space by divding into the superior epigastric and the musculophrenic a E. Costocervical trunk Arises from the posterior aspect of the 2ns part of the subclavian. Behind the anterior scalene muscle. deep cervical a and the superior intercostal a F. Dorsal scapular a

Common carotid a Right common carotid begins at the bifurcation of the brachiocephalic a. L common carotid arises from the aortic arch Ascend within the carotid sheath abd divide at the level of the upper border of the thyroid cartilage into the external and internal carotid a Receptors o Carotid body lies at the bifurcation of the CC as an ovoid body 1. Is a chemoreceptor that is stimulated by chemical changes 2. N = from the vagus and the carotid sinus branch is from the glossopharyngeal N o Carotid sinus is a spindle shaped dilation located at the origin of the internal carotid a which functions as a baroreceptor 1. Internal carotis a o Has no branches in the neck and ascends within the carotid sheath with the vagus N and the internal jugular V. o Enters the cranim through the carotid canal in the petrous part of the temporal bone o In the middle cranial fossa ophthalmic a and the anyerior and middle cerebral a and parcipitates in the formation of the circle of willis. Which is an important anastomoses btw 4 a. the 2 vertebrals and the 2 carotids. 2. External carotid o Extends from the level of the thyroid cartilage to he neck of the mandible, where it enters the parotid gland by dividimng into the maxillary and superficial temporal a 8 named branches

Sister Lucy's Powdered Face Often Attracts Silly Medicos": Before entering the parotid gland: Superior thyroid Lingual Posterior auricular Facial Occipital Ascending pharyngeal Ends as: Superficial temporal and Maxillary bifurcating in the in the parotid gland

1. Superior thyroid a

o o

Arises below the level of the greater horn of the hyoid bone Descends obliquely forward in the carotid triangle and passes deep to the infrahyoids M to reach the superior pole of the thyroid Arises at the level of the the horn of the hyoid and passes deep to the hyoglossus to reach the tongue

2. Lingual a o 3. 4. 5. 6. 7. 8.

Facial a Ascending pharyngeal a Occipital a Posterior auricular a Maxillary a Superficial temporal a

Veins 1. Retromandibular vein i. Is formed by the superficial temporal and maxillary veins ii. Divides into an anterior branch, which joins the facial vein to form the common facial vein, and a

posterior branch which joins the posterior auricular vein to form the external jugular 2. Exrternal jugular vein i. Is formed by the union of the posterior auricular vein and the posterior branch of the retromandibular vein ii. Crosses the sternomastoid obliquely under the platysma and ends in the subclavian vein. iii. Receives the suprascapular, transverse cervical and the anterior jugular vein 3. Internal jugular vein i. Begins in the jugular foramen as a constinuation of the sigmoid sinus, descends in the carotid sheath ends in the brachiocephalic vein ii. Has the superior bulb at its beginning and the inferior blb just above its termination iii. Receives the facial, lingual and superior and middle thyroid veins

Blood vessels to the face and scalp

Thorax Structures in the posterior mediastinum Thoracic aorta Begins at the level of the T4 Decends on the left side of the vertebral column and then approaches the median plane to end in front of the vertebral column by passing through the aortic hiatus of the diaphragm Gives rise to 9 pairs of posterior intercostal a and one pair of subcostal a Also gives rise to the pericardial, bronchial one right and 2 left, oesophageal, mediastinal and superior phrenic branches

Azygous system Is formed by the union of the right ascending lumbar and R subcostal veins. Its lower end is connected to the IVC Enters the thorax through the aortic opening in the diaphragm Receives the R intercostal veins, the R superior intercostal veinand the him azygous and the accessory hemiazygous veins Arches over the rooy of the right lung and empties into the SVCa of which it is the first tributary

Hemi azygous vein Is formed by the union of the left subcostal and ascending lumbar veins. Its lower end is connected yp yje ;eft renal vein on the L side of the vertebral bodies behind the thoracic aorta, receiving the 9th, 10th and 11th posterior intercostal vein

Accessory hemizygous vein Begins at the 4th-5th intercostal space receiving the 4th, 5th to 8th intercostal veins

Superior intercostal vein Posterior intercostal veins

Abdomen Blood vessels of the anterior abdominal wall

1. 2. 3. 4. 5. 6. 7.

Superior epigastric a Inferior epigastric a Deep circumflex iliac a Superficial epigastric a Superficial circumflex iliac a External pudendal a Thoracoepigastric V

Coeliac trunk and mesenteric a Arises from the front of the abdominal aorta immediately below the hiatus of the diaphragm btw the right and left crura Divides into the L gastuc, splenic and common hepatic a

L gastric a Is the smallest branch Runs and to the L toward the cardia, giving rise to the oesophageal and hepatic branches and then turns R and runs along the lesser curvature within the lesser omentum to anastamose with eth R gastric a

Splenic a Is the largest branch Runs a highly tortuous course along the superior border of the pancreas and enters the lienorenal ligament Dorsal pancreatic a A few short gastric a to reach the fundus of the stomach The L gastroepiploic a. which reaches the greater omentum through the lienogastric ligament abnd runs along the greater curvature to distribute to the stomach and the greater omentum

Common hepatic a Runs along the right alon the upper border of the pancreas and divides into the proper hepatic a, the Gastroduodenal a and possibly the R gastric a 1. Proper hepatic a - in the free edge of the lesser omentum amd divides near the porta hepatis into the L and R hepatic a/ the R hepatic a the cystic a. gives rise to the R gastric A 2. R gastric a = runs to the pylorus and then along the lesser curvature of the stomach and anastomoses with the L gastric a 3. Gastroduodenal a

Superior mesenteric a

Arises from the aorta behind the neck of the pancreas

Inferior mesenteric

Posterior abdominal blood vessels Aorta Passes through the aortic hiatus in the diaphragm at the level of T12 . anterior to the vertebral bodies and bifurcates into the R and L common ilac arteries anterior to L4
Descending abdominal aorta: seven divisions
"Sometimes Intestines Get Really Stretched Causing Leakage": Suprarenals [paired] Inferior mesenteric Gonadal [paired] Renals [paired] Superior mesenteric Celiac Lumbar [paired]

IVC

Inferior vena cava tributaries

"I Like To Rise So High": Illiacs Lumbar Testicular Renal Suprarenal Hepatic vein. Think of the IVC wanting to rise high up to the heart.