Kaan Yücel M.D., Ph.D.

THORACIC WALL CARDIOVASCULAR SYSTEM

01. 10. 2013The Two Fridas 1939 by Frida Kahlo

1. THORAX

the part between the neck and the abdomen

Chest X-ray

1.1. REGIONS/T ERMS

Thoracic cavitycavity between neck and abdomen protected by the thoracic wall.

Thoracic wallbounds the thoracic cavity. formed by the skin, bones, fasciae, and muscles.

Thoracic cagebony portion of the thoracic wallthoracic skeleton

1.2. SURFACES OF THE THORAX

Posterior surface 12 thoracic vertebræ & posterior parts of the ribs

Anterior surfacesternum & costal cartilages

Lateral surfaces ribs, separated by the intercostal spaces

STERNUM & COSTAL CARTILAGES anteriorly12 THORACIC VERTEBRAE & POST. RIBS posteriorlyRIBS & INTERCOSTAL SPACES laterally

1.3. BOUNDARIES OF THE THORAXSuperior• Jugular notch• Sternoclavicular joint• Superior border of clavicle• Acromion• Spinous processes of C7

Inferior • Xiphoid process• Costal arch• 12th and 11th ribs• Vertebra T12

1.4. CONTENTS OF THE THORAX

Organs of the cardiovascular, respiratory, digestive, reproductive, immune, and nervous systems

2. THORACIC WALL

• thoracic cage (skeleton) • muscles between the ribs • skin • subcutaneous tissue• muscles, and fascia covering its anterolateral aspect.

The mammary glands of the breasts lie within the subcutaneous tissue of the thoracic wall.

2.1. FUNCTIONS OF THE THORACIC WALL1) Protects vital thoracic and abdominal organs2) Resists the negative (sub-atmospheric) internal pressures

generated by the elastic recoil of the lungs and inspiratory movements.

3) Provides attachment for and support the weight of the upper limbs.

4) Provides the origins of many of the muscles that move and maintain the position of the upper limbs relative to the trunk.

5) Provides attachments for muscles of the abdomen, neck, back, and respiration.

3. SKELETON OF THE THORACIC WALL1) 12 pairs of ribs and associated costal cartilages2) 12 thoracic vertebrae and the intervertebral (IV) discs

interposed between them3) Sternum

4. THORACIC APERTURES‘Thoracic inlet’

‘Thoracic outlet’

4.1. Superior thoracic aperture

“doorway” between the thoracic cavity and the neck and upper limbbounded: Posteriorly vertebra T1Laterally 1st pair of ribs and their costal cartilagesAnteriorly superior border of the manubrium

Trachea Esophagus nerves, and vessels that supply and drain the head, neck, and upper limbs.

4.2. Inferior thoracic aperture

By closing the inferior thoracic aperture, the diaphragm separates the thoracic and abdominal cavities almost completely.

bounded:Posteriorly 12th thoracic vertebraPosterolaterally 11th and 12th pairs of ribs Anterolaterally joined costal cartilages of ribs 7-10 costal margins Anteriorly xiphisternal joint

5. MOVEMENTS OF THE THORACIC WALL

One of the principal functions of the thoracic wall and the diaphragm is to alter the volume of the thorax and thereby move air in and out of the lungs.During breathing, the dimensions of the thorax change in vertical, lateral, and A-P directions.

Diaphragm contracts DepressionDiaphragm relaxes Elevation (during passive expiration)

Elevation &depression of the ribs

DERMATOMES

Through its posterior ramus and the lateral and anterior cutaneous branches of its anterior ramus, most thoracic spinal nerves (T2-T12) supply a strip-like dermatome of the trunk extending from the posterior median line to the anterior median line.

Skin area supplied by a segment of the spinal cord

T2- Sternal angleT4- NippleT6- Xiphoid processT8- Costal archT10-UmbliculusT12-Midpoint between umbilicus and symphysis pubis

2. BREASTS

Mammary glands & associated skin -connective tissues.

modified sweat glands in the superficial fascia anterior to the pectoral muscles and the anterior thoracic wall.

Reproduction, back painAesthetics, and breast cancer

2. BREASTS Mammary glands: Series of ducts and associated secretory lobules.

Form 15 to 20 lactiferous ducts open nipple.

Nipple is surrounded by a circular pigmented area of skin areola (L. small area).

FEMALE BREASTS

NON-LACTING WOMEN – PREDOMINANT COMPONENT: FATLACTING WOMEN- PREDOMINANT COMPONENT: GLANDULAR TISSUE

The breast rests on a bed extends transversely from lateral border of the sternum mid-axillary line vertically from the 2nd through 6th ribs

Lymphatic drainage of the breast75% (lateral breast quadrants) Axillary lymph nodes

Most of the remaining (medial breast quadrants) parasternal lymph nodes or to the opposite breast

Lymph from inferior quadrants may pass deeply to abdominal lymph nodes.

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Axillary lymph nodes

Clavicular lymph nodes

Subclavian lypmhatic trunk

Parasternal lymph nodes

Bronchomediastinal lymph trunks

Right or left venous angle

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Trapezoidal in A-P dimensionsTipped-over pyramid in 3-D

crucial organ of the human body

(1)7.3 million

30%

3. HEART

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Right heart (Suction)poorly- oxygenated(venous) blood

from the bodysuperior vena cava & inferior vena cava right atrium right ventricle

pulmonary arteries lungs

Left heart (Pumping)well- oxygenated (arterial) blood

from the lungs pulmonary veins

left atrium left ventricleaorta

the body

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The four chambers of the heartright and left atria & right and

left ventriclesAtrium – plural atria

Receiving chambers

Ventricles

Discharging chambers

cardiac cycle1. Ventricular filling (diastole)2. Ventricular emptying

(systole)Blood pressure120-80 mm/Hg

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The fibrous skeleton of the heart

Keeps the orifices of the AV & semilunar valves patent prevents them from being overly distended by an increased volume of blood.

Provides attachments for the valves & myocardium.

Forms an electrical «insulator»separating impulses of the atria & ventricles they contract independently surrounding and providing passage for the initial part of the AV bundle

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SULCI/GROOVES IN THE HEART coronary sulcus (atrioventricular groove)

between atrium & ventricles

anterior & posterior interventricular (IV) sulci (grooves)

between right and left ventricles

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APEX & BASE OF THE HEARTapex located inferiorly & base located

superiorlyApex projects forward, downward and to the left

Base faces in a posterior direction

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Anterior (sternocostal) surface o mostly of right ventricleo some of the right atrium on the right o some of the left ventricle on the left

Diaphragmatic (inferior) surfaceo formed mainly by the left ventricle o partly by the right ventricleo related to central tendon of diaphragm.

Right pulmonary surface o formed by the right atrium.

Left pulmonary surfaceo left ventricle & a portion of left atrium.

THE FOUR SURFACES OF THE HEART

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RIGHT ATRIUM forms the right border of

the heartReceives venous blood from the SVC, IVC, and coronary sinus.

Through the right atrioventricular orifice, discharges the poorly oxygenated blood it has received

into the right ventricle.

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RIGHT VENTRICLEforms

largest part of the anterior surface of the hearta small part of the diaphragmatic surfacealmost the entire inferior border of the heart.

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Bulges into the cavity of the right ventricle.

Superiorly and posteriorly, a thin membrane, forms the much smaller membranous part of the IVS.

interventricular septum (IVS)

muscular and membranous partsobliquely placed partition between the right and left ventricles, forming part of the walls of each

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LEFT ATRIUM

right and left pulmonary veins enter here. Tubular, muscular left auricle, Its wall trabeculated with pectinate muscles.

forms most of the base of the heart

A semilunar depression in the interatrial septum Floor of the oval fossa

surrounding ridge Valve of the oval fossa

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LEFT VENTRICLEforms the apex of the heart, left (pulmonary) surface & border, most of the diaphragmatic surface.

Compared to the right ventricle Walls 2-3 times thicker Trabeculae carneae finer and more numerousCavity longer Anterior & posterior papillary muscles larger

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aortic valve semilunar valvebetween the left ventricle & ascending aortaobliquely placed.

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Guards the left AV orifice.Has two cusps, anterior and posterior.

mitral valvedouble-leaflet mitral valve

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6. SEMILUNAR VALVESSemilunar cusps of the pulmonary valve anterior-right-left

Seminular cusps of the aortic valve posterior-right-left

concave when viewed superiorlyno tendinous cords to support

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VASCULATURE OF THE HEART

embedded in fat course across the surface of the heart just deep to the epicardium.

coronary arteries & cardiac veins

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ARTERIAL SUPPLY OF THE HEARTcoronary arteriesfirst branches of the aortasupply the myocardium and epicardium

Anastomoses between the branches of the coronary arteries exist, which enables the development of the collateral circulation.

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STIMULATING, CONDUCTING, & REGULATING SYSTEMS OF HEART

1. sinuatrial (SA) node initiates the heartbeat & coordinates contractions of the four heart chambers2.atrioventricular (AV) node

3.bundleshighly specialized conducting fibers for conducting impulses rapidly

to different areas of the heart

o Propagation of the impluseo Simultaneous contraction of the cardiac striated muscle cells

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SINUATRIAL (SA) NODEpacemaker of the heart

@junction of the SVC & right atriumnear to the superior end of the sulcus terminalis

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stimulated by sympathetic division of the autonomic nervous system to accelerate the heart rate

inhibited by parasympathetic division to return to or approach its basal rate.

SINUATRIAL (SA) NODEpacemaker of the heart

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ATRIOVENTRICULAR (AV) NODEa smaller collection of nodal tissue than the

SA nodein the posteroinferior region of the interatrial septumnear the opening of the coronary sinus

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JOURNEY OF THE SIGNALGenerated @ SA node

Passed through the walls of the right atrium

Propageted by the cardiac muscle

Signal passed from SA node to AV node

Distributed to the ventricles through the AV bundle

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BUNDLES

passes from the AV node through the fibrous skeleton of the heart and along the membranous part of the IVS.

@ junction of membranous & muscular parts of the IVSdivides into : right bundle & left bundle.

AV bundlethe only bridge between the atrial and ventricular myocardium

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right and left bundles proceed on each side of the muscular IVS deep to the endocardium then ramify into

subendocardial branches (Purkinje fibers) extend into the walls of the respective ventricles.

BUNDLES

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INNERVATION OF THE HEARTautonomic nervous system,

cardiac plexus Cardiac plexus

posterior to the ascending aorta and bifurcation of the pulmonary trunk

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Parasympathetic supply presynaptic fibers of the vagus nerves

Slows the heart rateReduces the force of the contractionConstricts the coronary arteries saving energy

INNERVATION OF THE HEARTautonomic nervous system,

cardiac plexus

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sympathetic supplypresynaptic fiberscell bodies in the intermediolateral cell columns (IMLs) of the superior 5 or 6 thoracic segments postsynaptic sympathetic fiberscell bodies in the cervical and superior thoracic paravertebral ganglia of the sympathetic trunks.

causes increased heart rateincreased impulse conduction, increased force of contraction, increased blood flow through the coronary vessels increased activity.

INNERVATION OF THE HEART

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9. SEPTAL DEFECTSAtrial Septal Defects (ASD)

congenital anomaly of the interatrial septum

a hole between the two atriaWhat happens?Oxygenated blood from the lungs

Left atrium Right atrium

Results inenlargement of right atrium & ventricledilation of the pulmonary trunk

More blood in the right heart

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Ventricular Septal Defects (VSD)

What happens?

Results inmembranous part of the IVS common site of VSDs

rank first on all lists of cardiac defects

Oxygenated blood from the ventricles Left ventricle Right ventricle

in pulmonary blood flow severe pulmonary disease

(hypertension) cardiac failure

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10. VALVULAR HEART DISEASES

Disturb pumping efficiency of the heart. Stenosis (narrowing) or insufficiency

Both result in an increased workload for the heart.

Valvuloplasty repairing the heart valves

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Scarring and shortening of the cusps results in insufficiencyRestricts the outflow of the left ventricle Leads to the hypertrophy of the myocardiumDuring ventricular systole, blood regurgitates back to the left atriumA hurt murmur will be heard.

MITRAL VALVE INSUFFICIENCY

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Narrowing of the mitral orifice.Restricts the outflow of the left atrium.A murmur will be heard during atrial contraction.

MITRAL VALVE STENOSIS

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Narrowing of the pulmonary valve due to the fused cusps.Restricts the outflow of the right ventricle. Leads to the hypertrophy of the myocardium.

PULMONARY VALVE STENOSIS

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Incomplete closure of the cusps due to thickening of their free margins due to a disease. During diastole, blood regurgitates back to the right ventricle from the pulmonary trunk.Heart murmur could be heard.

PULMONARY VALVE INCOMPETENCE

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Blood is unable to flow freely from left ventricle to aorta.A result of degenerative calcification, fusion of the aortic cups as a result. Causes extra work for the heart, resulting in left ventricular hypertrophy.

AORTIC VALVE STENOSISmost frequent valve

abnormality

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During diastole blood regurgitates from aorta back to the left ventricle.A hurt murmur will be heard during diastole.

AORTIC VALVE INSUFFICIENCY

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could be heard by stethoscope.

produced due to the turbulence caused by the blood passing from a narrow opening into a larger vessel or chamber.

HEART MURMURa pathologic sound

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tricuspid valve behind the right half of the sternum opposite 4th intercostal spacemitral valve behind the left half of the sternum opposite 4th costal cartilagepulmonary valve behind the medial end of the 3rd left costal cartilage and adjoining part of the sternum

aortic valve behind the left half of the sternum opposite 3rd intercostal space.

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S1 produced by contraction of the ventricles closure of the tricuspid & mitral valves (AV valves) S2produced by the sharp closure of the aortic & pulmonary valves hear sounds produced at each valve with the minimum of distraction or interference

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tricuspid valve right half of lower end of the body of the sternum

pulmonary valve medial end of the second left intercostal space

aortic valve medial end of the second right intercostal space

mitral valve apex beat fifth left intercostal

space, 9 cm from the midline

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PERICARDIUM

a closed sac with two layersfibrous pericardium

serous pericardiumparietal layervisceral layer –heart & great vessels.

fibroserous membrane, covers the heart & beginning of its great vessels

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Continuous inferiorly w/ central tendon of the diaphragm Attached anteriorly to the sternum by sternopericardial ligamentsSite of continuity pericardiacophrenic ligament Inner surface lined by parietal layer of the serous pericardium Protects the heart against sudden overfilling.

fibrous pericardiumcontinuous superiorly w/ tunica adventitia of the great vessels & w/pretracheal layer of deep cervical fascia

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contains a thin film of fluid : pericardial fluidenables the heart to move and beat in a frictionless environment.

pericardial cavity potential space between opposing layers of the parietal & visceral layers of serous pericardium

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GREAT VESSELS

posterior to the sternoclavicular (SC) joints.

brachiocephalic veins unite to form the SVC.

@ inferior border of the 1st right costal cartilage

shunt blood from the head, neck, & upper limbs right atrium.

RIGHT & LEFT BRACHIOCEPHALIC VEINS formed by the union of internal jugular & subclavian veins

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Returns blood from all structures superior to the diaphragmexcept the lungs

& heart.

Passes inferiorly and ends by entering right atrium of the heart.

SUPERIOR VENA CAVA (SVC)

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begins at the aortic orifice.

only branches coronary arteries, arising from the aortic sinuses.

ASCENDING AORTA

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begins posterior to the 2nd right sternocostal (SC) joint at the level of the sternal angle. ligamentum arteriosum remnant of the fetal ductus arteriosus

root of the left pulmonary artery inferior surface of the arch of the aorta

The usual branches of the arch 1) brachiocephalic trunk2) left common carotid artery3) left subclavian artery.

Arch of the aorta (Aortic arch)curved continuation of the

ascending aorta

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arises posterior to the manubrium. ascends superolaterallydivides into right common carotid & right subclavian arteries.

BRACHIOCEPHALIC TRUNKfirst and largest branch of the arch of the aorta

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arises o posterior to the manubrium, o slightly posterior and to the left of the brachiocephalic trunk.

LEFT COMMON CAROTID ARTERYsecond branch of the arch of the aorta

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arises from the posterior part of the arch

posterior to left common carotid artery.

ascends lateral to trachea & left common carotid artery.

Leaves the thorax and enters the root of the neck.

LEFT SUBCLAVIAN ARTERYthird branch of the arch of the

aorta

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CAROTID BODY

CAROTID SINUSmonitor changes in blood pressure

responsible for detecting changes in blood chemistry, primarily oxygen content

CN IXCN X

CN IX

71Abdominal aorta

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External iliac artery

Femoral artery

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Popliteal artery

Anterior tibial artery Posterior tibial artery

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Anterior tibial artery

Dorsal pedis artery

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U Superficial

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