CARDIOVASCULAR

ANATOMY

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

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.

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).

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.

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

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.

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.

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

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

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

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.

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.

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.

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

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

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

Indicate where the bicuspid (mitral),

tricuspid, pulmonary (pulmonic) semilunar,

and aortic semilunar valves are located in

the heart.

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

Distinguish the dermatomes to which

visceral pain arising from the heart, lungs

and esophagus will be referred.

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

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

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.

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)

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

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

Distinguish a hemothorax from open,

tension, and spontaneous forms of

pneumothorax.

Identify the transverse level of the tracheal

bifurcation in the thorax.

• T4 - Carina

Distinguish the anatomical relationships of

the right and left pulmonary arteries to the

right and left main primary bronchi.

Discuss the significance of the variation in

the morphology of the right and left main

bronchi with respect to aspiration

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.

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

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

Identify the lymph nodes whose

enlargement in bronchogenic carcinoma

can distort the normal appearance of the

esophagus and carina.

• Inferior Tracheobronchial Lymph Nodes

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.

Right Atrium

Right Ventricle

Left Atrium

Left Ventricle

Right Coronary Artery

Left Coronary Artery

CV IMAGING

Index levels of CV Imaging

• Supra-aortic vessels

• Aortic arch

• Aorticopulmonary (AP) window

• Left Pulmonary Artery

• Right Pulmonary Artery

• Superior heart

• Inferior heart.

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

Aortic Arch

Aortic ArchSVC

A : Aorta

D : SVC

J : Esophagus

4 : Sternum

5 : Trachea

AP Window

Trachea

Ascending

Aorta

Descending

AortaAzygous V.

SVC

B : Ascending Aorta

C : Descending Aorta

D : SVC

K : Azygos Arch

5 : Trachea

AP Window

Clean Notch – no lymphadenopathy

AP Window

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

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

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

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

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

For lateral CXR, the X-Ray is placed on

the patient’s right side to minimize

magnification of the heart.

Right lung

RUL

RML RLL

Oblique (Major) Fissure

Minor Fissure

Left lung

LUL

LLL

Oblique (Major) Fissure

Trachea

Carina

Right Upper Lobe Bronchus

Anterior Segmental Bronchus

Posterior Segmental Bronchus

Right Superior Pulmonary V.

Bronchus Intermedius

Left Mainstem Bronchus

Right Bronchus Intermedius

Left Upper Lobe Bronchus

Left Upper Lobe Bronchi

Left Lower Lobe Bronchi

Horizontal Fissure

RLL

RUL

Right Middle Lobe Bronchus

PA

Right Middle Lobe Bronchus

Superior Segmental Bronchi of

Lower Lobes