cardiovascular anatomy
TRANSCRIPT
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CARDIOVASCULAR
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ANATOMY
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Describe the dermatomal distribution of
the T1 ventral ramus. Identify the
dermatomal level of the nipple.
• T1 covers chest and inner arms
• T4 is level of nipple
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Describe the blood supply and innervation
of body wall tissues within and adjacent to
an intercostal space.• Blood supply:
• Subclavian artery —> internal thoracic artery —> Anterior intercostal
arteries in each intercostal space, enter the costal groove on the
internal surface of a rib.
• Descending (thoracic) aorta —> posterior intercostal arteries in each
intercostal space, anastomose with anterior intercostal arteries
• Innervation: intercostal nerves (ventral rami of T1-T11 spinal nerves),
sympathetic trunk also runs down the vertebral column near the
costovertebral joints.
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The intercostal neurovascular bundle
• The intercostal neurovascular bundle passes between the internal
and innermost intercostal muscles near the angle of the rib. There it
enters the costal groove.
• Near the angles of the ribs the intercostal nerves and arteries give off
collateral branches that immediately descend within the intercostal
space to course along the superior border of the rib below.
• Within the groove the arrangement of the components of the
neurovascular bundle is, from superior to inferior, vein, artery, nerve
(VAN).
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Describe the purpose of an intercostal
nerve block and indicate where within an
intercostal space the needle is inserted.
• Purpose: to relieve pain associated with Herpes Zoster (shingles) or
rib fracture. Also used in gall bladder surgery anesthesia.
• Insertion: Posterior angle of the rib along the lower border of the rib.
The needle penetrates: superficial fascia connective tissue
serratus anterior external intercostals internal intercostals.
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Functions of the diaphragm, intercostal
and accessory respiratory muscles in
breathing.
• Diaphragm is needed for passive and active breathing.
• Intercostal muscles and accessory respiratory muscles are needed
for active breathing (like in exercise or COPD)
• Accessory respiratory muscles: pectoralis major, pectoralis minor,
serratus anterior, scalenes, sternocleidomastoid
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Describe the normal movement of the
diaphragm during contraction and its
effect on thoracic dimensions
• During contraction, diaphragm becomes flatter/lower. This increases
intrathoracic volume (increases length, width & depth of thorax)
reduced intrathoracic air pressure inspiration
• Each dome of the diaphragm has a separate nerve supply. Therefore,
paralysis of one half of the diaphragm due to injury of the phrenic
nerve does not affect the other half.
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Describe paralysis of the diaphragm and
its paradoxical movement.
• Paralysis of diaphragm: usually due to injury of C5 component of
phrenic nerve.
• The paralyzed dome of the diaphragm doesn’t descend during
inspiration and is therefore forced upward due to higher abdominal
pressure than intrathoracic pressure.
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Motor innervation to the intercostal
muscles and the diaphragm
• The diaphragm is primarily innervated (motor and sensory) by the
phrenic nerves (ventral primary rami of C3-5)
• The periphery of the diaphragm receives its sensory innervation from
the intercostal nerves
• The intercostal muscles are innervated by the intercostal nerves
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Distinguish the areas of the diaphragm
that receive their sensory innervation from
the phrenic nerve versus the lower
intercostal nerves.
• Periphery of diaphragm = sensory innervation by intercostal nerves
• irritation of these areas causes pain localized to the skin over the costal margins of
the anterolateral abdominal wall
• Majority of diaphragm = motor/sensory innervation by phrenic nerves
• pain is referred to the shoulder and neck, due to innervation by the phrenic nerves
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Distinguish the innervation of the visceral
and parietal layers of the body’s serous
sacs (body cavities) and relate this to the
perception of pain.
• Visceral: region in contact with organs. Derived from splanchnic
mesoderm - innervated by autonomic neurons.
• VISCERAL PAIN often dull and poorly localized
•
• Parietal: region in contact with body wall. Derived from somatic
mesoderm - innervated by somatic neurons.
• SOMATIC PAIN often sharp and well-localized
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List the three layers of the pericardium
and identify the location of the pericardial
cavity relative to them.
• From outside to inside of heart
• Fibrous pericardium
• Parietal pericardium - shiny to lubricate
• Visceral pericardium - shiny to lubricate (aka epicardium)
• Pericardial cavity is between the Parietal and visceral pericardium.
• The fibrous pericardium is derived from the body wall mesenchyme of
the embryonic pleuropericardial folds.
• The fibrous pericardium is attached to the central tendon of the
diaphragm, thus the heart moves with the diaphragm during
inspiration and expiration.
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Identify the locations of the transverse and
oblique sinuses. Understand the surgical
significance of the transverse sinus.
• Transverse sinus - behind the aorta and pulmonary artery. In front of
Vena cava.
• This is where surgeons tie to cut off blood for a bypass surgery
• Oblique sinus - between the inferior vena cava, left pulmonary vein,
and right pulmonary vein. Inferior to the pulmonary veins.
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Coronary Sinus
• The coronary sinus is a
common “venous sac” that
receives blood from most
of the veins draining the
myocardium. The coronary
sinus drains directly to the
right atrium.
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Identify the nerve carrying sensory info
from the fibrous pericardium. Identify the
dermatomes to which pain from the
fibrous pericardium will be referred.
• Phrenic nerve: sensory information from fibrous pericardium. Refers
pain to C3-C5 dermatomes
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Identify the structures that form the apex
and base of the heart. Identify the
structures that form the left, right, anterior
and inferior surfaces of the heart.
• Apex - LV and
part of RV
• Base - LA and
part of RA
• Right - RA
• Left – LV
• Inferior - LV
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Be able to trace the flow of blood through
the heart and lungs from the superior and
inferior vena cavae to the ascending
aorta.• Vena cavae & coronary sinus
• Into the RA
• Through the Tricuspid valve
• Into RV
• Through pulmonary valve into pulmonary arteries
• Lungs
• Through Pulmonary veins
• Into LA
• Through mitral valve
• Into LV
• Through aortic valve
• Into aorta• Part goes into coronary arteries
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Indicate where the bicuspid (mitral),
tricuspid, pulmonary (pulmonic) semilunar,
and aortic semilunar valves are located in
the heart.
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List the components of the conduction
system of the heart and identify their
location within the heart.• Sinoatrial (SA) Node: wall of the right atrium at the junction of superior
vena cava and right atrium• Supplied by sinoatrial nodal artery (often branch of right coronary artery)
• Atrioventricular (AV) Node: right side of interatrial septum, superior to opening of coronary sinus
• Atrioventricular (AV) Bundle (Bundle of His): in membranous portion of interventricular septum. Splits into right and left bundle branches that travel on right and left sides of muscular portion of interventricularseptum• Supplied by atrioventricular nodal artery (branch of posterior interventricular artery)
• Subendocardial branches (Purkinje Fibers): networks of nerve branches from right and left bundle branches in walls and papillary muscles of right and left ventricles
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Distinguish the dermatomes to which
visceral pain arising from the heart, lungs
and esophagus will be referred.
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Identify the vertebral levels of the aortic
arch, the aortic hiatus and the aortic
bifurcation.
• Aortic Arch: T4
• Aortic Hiatus: T12 where the aorta passes through the diaphragm
• Aortic Bifurcation: L4 into R and L common iliac arteries
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Describe the relationship of the left vagus
nerve and its recurrent laryngeal branch to
the aortic arch.
• Left vagus nerve lies on anterolateral surface of the aortic arch. Left
recurrent laryngeal branch passes inferior to the aortic arch then turns
superiorly to reach tissues of the larynx
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Describe the course of the azygos vein in
the thorax and abdomen. Discuss the
significance of the azygos system.
• Azygos vein collects blood from right intercostal veins as well as from
hemiazygos vein (& sometimes accessory hemiazygos vein), which
collects blood from multiple posterior intercostal veins on left
azygos vein drains into superior vena cava immediately superior to
root of the right lung
• Azygos vein also connects with inferior vena cava in abdomen
providing alternate route of venous drainage from thorax, abdomen,
and back in case of obstruction of either superior or inferior vena
cava.
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List four anatomical subdivisions of
mediastinum & structures contained within
each.• Superior
• Trachea, esophagus, thymus, phrenic nerves, azygous vein, SVC, brachiocephalic artery and veins, aortic arch, left common carotid artery, left subclavian artery, & thoracic duct
• SUP/INF divided by line from sternal angle of Louis to the T4-5 intervertebral disc
• Inferior• Anterior: Thymus, fat, lymph nodes, & connective tissue
• Middle: Heart, pericardium, phrenic nerves, ascending aorta, SVC, & coronary arteries and veins
• Posterior: Descending aorta, esophagus, thoracic duct, azygos vein, splanchnic nerves, and vagus nerves (CN X)
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Define pleuritis and distinguish the pain
expected with inflammation of the visceral
vs. parietal pleura.
• Pleuritis: inflammation of the pleura
• VISCERAL pleura: no pain because receives no nerve fibers of
general sensation
• PARIETAL pleura: sharp, local pain and referred pain. Innervated by
intercostal nerves and phrenic nerve so may be referred to the
thoracic wall and root of the neck respectively
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Identify some of the common causes of
inadvertent injury to the pleura.
• Surgery: posterior approach to kidney – when rib 12 is very short, 11
can be mistaken for rib 12. Incision prolonged to level of rib 11 will
damage pleura.
• Incision at right infrasternal angle: pleura extends beyond the rib cage
in this area
• Stellate ganglion nerve block
• Brachial plexus nerve block
• Knife wound to chest wall above clavicle
• Fracture of lower ribs
• Lungs: root of neck – rib 8 medially / rib 10 laterally
• Pleura: extend two ribs below
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Distinguish a hemothorax from open,
tension, and spontaneous forms of
pneumothorax.
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Identify the transverse level of the tracheal
bifurcation in the thorax.
• T4 - Carina
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Distinguish the anatomical relationships of
the right and left pulmonary arteries to the
right and left main primary bronchi.
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Discuss the significance of the variation in
the morphology of the right and left main
bronchi with respect to aspiration
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Differentiate pulmonary arteries from
bronchial arteries functionally. Differentiate
pulmonary veins from bronchial veins
functionally.
• Pulmonary Arteries: carry deoxygenated blood from the heart to the lungs
• Bronchial Arteries: carry oxygenated blood to the lung parenchyma
• Pulmonary Veins: carry oxygenated blood from the pulmonary capillary system to the left atrium; also transport deoxygenated bronchial blood
• Bronchial Veins: carry deoxygenated blood from the lung parenchyma and drain into the Azygos (rt) and Accessory Hemiazygos (lt) Veins.
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Describe the blood supply of
bronchopulmonary segments. Distinguish
pneumonectomy, lobectomy and
segmentectomy.
• A bronchopulmonary segment is served by a specific tertiary bronchi and its own arteries (one bronchial and one pulmonary artery per segment)
• Pneumonectomy
• Surgical procedure to remove a lung
• Lobectomy
• Removal of just one lobe of the lung
• Segmentectomy
• Removal of one segment of the lung
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Distinguish the bronchopulmonary lymph
nodes of the lung from the
tracheobronchial lymph nodes.
• Bronchopulmonary lymph nodes
• A group of tracheobronchial lymph node found in the hilum of each
lung
• Tracheobronchial lymph nodes
• Tracheal lymph nodes - on either side of the trachea
• Bronchial - in the angles between the lower part of trachea and
bronchi and in the angle between two bronchi
• Bronchopulmonary
• Pulmonary - in the lung parenchyma, on larger branches of bronchi
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Identify the lymph nodes whose
enlargement in bronchogenic carcinoma
can distort the normal appearance of the
esophagus and carina.
• Inferior Tracheobronchial Lymph Nodes
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Distinguish the patterns of lymph drainage
of the right and left lungs.
• All lymph from the lungs drains to the bronchopulmonary (hilar) nodes.
• Bronchopulmonary nodes inferior and superior tracheobronchial nodes paratracheal nodes
• Vessels from these node groups join with those draining the anterior mediastinum to form the right and left bronchiomediastinal trunks.
• Lymph from the R. lung ultimately drains into the right bronchomediastinal trunk, which empties into the junction of the right internal jugular vein and right subclavian vein.
• L. superior lung drains into the left bronchomediastinal trunk, which empties into the junction of the left internal jugular vein and left subclavian vein (or into the thoracic duct at this location).
• Lymph from the L. inferior lung drains into the right lung pathway crossing over the midline inferior to the tracheal bifurcation, where inferior tracheobronchial nodes from right and left sides communicate freely.
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Right Atrium
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Right Ventricle
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Left Atrium
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Left Ventricle
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Right Coronary Artery
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Left Coronary Artery
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CV IMAGING
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Index levels of CV Imaging
• Supra-aortic vessels
• Aortic arch
• Aorticopulmonary (AP) window
• Left Pulmonary Artery
• Right Pulmonary Artery
• Superior heart
• Inferior heart.
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Supra-aortic vessels
RBV
LBV
LCCA
L. Subclavian A.
Brachiocephalic A.
I : Left Brachiocephalic V.
E : Right Brachiocephalic A.
H : Right Brachiocephalic V.
F : Left Common Carotid A.
G : Left Subclavian A.
5 : Trachea
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Aortic Arch
Aortic ArchSVC
A : Aorta
D : SVC
J : Esophagus
4 : Sternum
5 : Trachea
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AP Window
Trachea
Ascending
Aorta
Descending
AortaAzygous V.
SVC
B : Ascending Aorta
C : Descending Aorta
D : SVC
K : Azygos Arch
5 : Trachea
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AP Window
Clean Notch – no lymphadenopathy
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AP Window
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Left Pulmonary Artery
SVC
Ascending
Aorta
Descending
Aorta
LPA
Azygous V.
B : Ascending Aorta
C : Descending Aorta
D : SVC
N : Truncus Anterior
P : Left Pulmonary A.
1 : Right Superior Pulmonary V.
7 : Trachea
8 : Anterior segment Right upper bronchus
9 : Posterior segment Right upper bronchus
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Right Pulmonary Artery
Ascending
Aorta
Descending
Aorta
LPA
RPA
L. Superior
pulmonary v.
Azygous V.
R. Superior
pulmonary v.
B : Ascending Aorta
C : Descending Aorta
D : SVC
O : Right Pulmonary A.
P : Left Pulmonary A.
1 : Right superior pulmonary V.
2 : Left superior pulmonary V.
3 : Azygoesophageal Recess
10 : Bronchus intermedius
11 : Left upper lobe bronchus
12 : Left upper lobe spur
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Left Atrium
LA
RA
SVCAscending
Aorta
Descending
Aorta
Azygous V.
Pulmonary
Outflow Tract
C : Descending Aorta
S : Root of Aorta
T : Pulmonary Outflow Tract
U : Left Atrium
V : Right Atrium
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Superior Heart
LA
RV
RALV
MOST ANTERIOR CHAMBER IS RIGHT VENTRICLE
TV
MV
IVS
IAS
C : Descending Aorta
U : Left Atrium
V : Right Atrium
W : Right Ventricle
Y : Left Ventricle
RCA
LAD
LCFX
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Inferior Heart
RV
LV
IVC Myocardium
Coronary Sinus
Pericardium
C : Descending Aorta
J : Esophagus
L : Azygos V.
M : Hemiazygos V.
R : Coronary Sinus
Q : Pericardium
W : Right Ventricle
X : Interventricular Septum
Y : Left Ventricle
Z : IVC
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For lateral CXR, the X-Ray is placed on
the patient’s right side to minimize
magnification of the heart.
![Page 70: Cardiovascular Anatomy](https://reader034.vdocuments.site/reader034/viewer/2022052602/55a19b651a28abfd748b4847/html5/thumbnails/70.jpg)
Right lung
RUL
RML RLL
Oblique (Major) Fissure
Minor Fissure
Left lung
LUL
LLL
Oblique (Major) Fissure
![Page 71: Cardiovascular Anatomy](https://reader034.vdocuments.site/reader034/viewer/2022052602/55a19b651a28abfd748b4847/html5/thumbnails/71.jpg)
Trachea
![Page 72: Cardiovascular Anatomy](https://reader034.vdocuments.site/reader034/viewer/2022052602/55a19b651a28abfd748b4847/html5/thumbnails/72.jpg)
Carina
![Page 73: Cardiovascular Anatomy](https://reader034.vdocuments.site/reader034/viewer/2022052602/55a19b651a28abfd748b4847/html5/thumbnails/73.jpg)
Right Upper Lobe Bronchus
Anterior Segmental Bronchus
Posterior Segmental Bronchus
Right Superior Pulmonary V.
![Page 74: Cardiovascular Anatomy](https://reader034.vdocuments.site/reader034/viewer/2022052602/55a19b651a28abfd748b4847/html5/thumbnails/74.jpg)
Bronchus Intermedius
Left Mainstem Bronchus
Right Bronchus Intermedius
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Left Upper Lobe Bronchus
Left Upper Lobe Bronchi
Left Lower Lobe Bronchi
Horizontal Fissure
RLL
RUL
![Page 76: Cardiovascular Anatomy](https://reader034.vdocuments.site/reader034/viewer/2022052602/55a19b651a28abfd748b4847/html5/thumbnails/76.jpg)
Right Middle Lobe Bronchus
PA
Right Middle Lobe Bronchus
Superior Segmental Bronchi of
Lower Lobes