Marilyn Rose

Thoracic vertebrae (12) Posterior boundary

Sternum Anterior boundary

Manubrium-superior- articulate w/first two ribs and clavicles (sternoclavicular joints) Also jugular notch- @ T2-T3

Body- articulate w/ cartilage of 3rd-7th ribs

Xiphoid- inferior- muscle attachment

Ribs (12 pair)• First 7 pairs- true ribs- articulate with

sternum @ costal cartilage• Lower 5 pairs- false ribs- do not attach

to sternum• 11th and 12th are floating- attach only

to vertebrae (no neck or tubercle)

• Head , neck, tubercle, body• Facets of head articulate with vertebral

bodies @ costovertebral joints

• Facets of tubercles articulate with transverse processes @ costrotransverse joints

Costal cartilage• 1st- 7th @ sternum• 8th, 9th, 10th rib attach to costal

cartilage of ….7th rib

retrosternal goiter

scapula coracoid process clavicle trachea (TR) aortic arch (AA) left auricle (LAu) left primary bronchus (LPB) right border of the heart (RB). Remember that the right atrium forms this border. pulmonary vessels (PV) descending aorta (DA) left border of the heart (LB) formed by the left ventricle (LV) right diaphragm (RD) Usually slightly higher that the left diaphragm (LD) vertebral spine (VS) 12th rib lower border of the breast in the female (BR) gas bubble in the stomach (usually gives a clue to where the stomach is

 Pulmonary necrosis in a 48-year-old man after postoperative radiation therapy (60 Gy) for upper right bronchogenic carcinoma. (a, b) Chest radiograph (a) and computed tomographic (CT) scan (b) obtained 1 year after radiation therapy show fibrotic changes in the apex of the right lung. (c, d) Chest radiograph (c) and CT scan (d) obtained 2 years after radiation therapy show a large cavity with a sequestrum. Surgical exploration and histologic examination revealed changes due to radiation necrosis. Neither a bronchial fistula nor an associated infection was identified.

Pulmonary necrosis in a 48-year-old man after postoperative radiation therapy (60 Gy) for upper right bronchogenic carcinoma. (a, b) Chest radiograph (a) and computed tomographic (CT) scan (b) obtained 1 year after radiation therapy show fibrotic changes in the apex of the right lung. (c, d) Chest radiograph (c) and CT scan (d) obtained 2 years after radiation therapy show a large cavity with a sequestrum. Surgical exploration and histologic examination revealed changes due to radiation necrosis. Neither a bronchial fistula nor an associated infection was identified.

Thoracic inlet• Superior• First thoracic

vertebra, first pair of ribs, costal cartilage and manubrium

• Allows for passage of nerves, vessels and neck viscera trachea is displaced to the right at the thoracic

inlet

Chest radiograph and CT scan showing a thoracic inlet neurofibromaPancoast tumor invasion of the subclavian artery

Thoracic outlet• Inferior• Larger than the

superior inlet• 12th thoracic

vertebra, 12th pair of ribs, costal margins and xiphoid

Thoracic outlet syndrome is a combination of pain in the neck and shoulder, numbness and tingling of the fingers, and a weak grip. The thoracic outlet is the area between the rib cage and collar

bone.

Apex- superior to 1st rib

Base- dome of diaphragm

Divided into lobes by fissures• Rt lung= 3 lobes-sup,

(horizontal fissure, mid, (oblique fissure) inf

• Lt lung= 2 lobes-sup, (oblique fissure) inf

• Lt lung has a cardiac notch which is on the medial surface of the sup lobe

Each lobe has a hilum- passage for mainstem bronchi, blood, lymph vessels and nerves.

Wegener's Granulomatosis

Lung carcinoma: Spiral CT detection

Parietal pleura• Outer layer, continuous

with thoracic wall and diaphragm

Visceral pleura• Inner layer, closely covers

the outer surface of the lung and continues into the fissures to enclose each lobe.

Both membranes secrete fluid to lubricate during breathing

Trachea bifurcates-LT/RT mainstem bronchi @ T5….Carina

Rt is wider, shorter and more vertical than LT

Hilum- mainstem bronchi divides into secondary bronchi- corresponding with 3 on the Rt and 2 on the Lt• Secondary bronchi further divide into

tertiary bronchi• Extending into each segment of the

lobes- 10 segments per lung

Bronchial tree continues to divide into bronchi and bronchioles

Finally they terminate into the alveoli Functional unit of the respiratory system Gaseous exchange occurs here..remember?

Midline thoracic cavity Between pleural cavities of lungs Superior-thoracic inlet Inferior- diaphragm Anterior- sternum Posterior- thoracic vertebrae

Superior compartment Inferior compartment- anterior,

middle and posterior

Structures= thymus gland, trachea, esophagus, lymph nodes, thoracic duct, heart, great vessels and nerves

Bi-lobed gland of lymph tissue

Superior mediastinum posterior to manubrium

Primary lymphatic organ for development of cellular immunity- T Lymphocytes

Thymus reaches max size at puberty and decreases in size as an adult

Secrete thymosin- develop/ maturation of T lymphocytes

Thymoma is the most common neoplasm of the anterior mediastinum which originates within the cells of the thymus

Trachea • runs anterior to

esophagus• Cross section- round

air-filled bifurcating @ carina

Esophagus• Cross section-oval • Descend to stomach at

gastroesophageal junction

Bronchiectasis with slight mediastinal shift and pleural thickening, and adhesions tenting the left side of the diaphragm. The destroyed lung which results from primary (nonimmune) tuberculosis almost always affects only one lung. The other lung remains normal apart from over-expansion.

Lymph nodes in mediastinum are clustered around- great vessels, esophagus, bronchi, and carina.

Nodal stations-lung cancer staging.

Lymph vessels- interstitial fluid into venous circulation

Thoracic duct- drains tissue below diaphragm• Begins inferior to diaphragm @ L2

and ascends into diaphragm between azygous vein /descending AO- empties into LT subclavian.

• Smaller Rt lymphatic duct collects lymph from Rt upper side and extremities into Rt subclavian.

Mediastinal tuberculous adenopathy. Axial contrast-enhanced CT scan demonstrates multiple enlarged mediastinal lymph nodes with central areas of low attenuation and peripheral enhancement

4 chambered muscular organ

Oblique and fist sized

Base- most superior and posterior- formed by the atria

Apex- points inferiorly, anteriorly and to the LEFT -at the level of the 5th intercostal space. Formed by the LT ventricle…

The heart is enclosed in a pericardial sac

Double layered serous membrane• Parietal- lines inner

surface• Visceral (epicardium)-

cover the outer surface Pericardial cavity- potential

space between the two layers with serous fluid

Between the pericardium and the heart wall is epicardial fat

pericardial effusion and enhancing pericardium

Heart wall• Epicardium- thin outer layer• Myocardium- thick middle layer• Endocardium- thin endothelial

lining

2 atria- divided by interatrial septum• Embryonic development-

foramen ovale• Blood flowed between the atria

during lung development, and at birth it closes

2 ventricles- divided by interventricular septum

Rt atrium- rt border- DO blood from S/IVC,coronary sinus, cardiac veins

Rt vent- on the diaphragm, anterior heart- DO blood from RA and sends it to the pulmonary trunk- lungs (vent walls- papillary muscles

Lt atrium- most posterior surface, O2 blood comes directly from lungs via 4 pulmonary veins

Lt Vent- forms the apex, left border, morst inferior surface- O2 blood from Lt atrium and pumps into the AO (myocardium is 3X thicker in the LT vent)

RVOTRt vent-Pulm art

LVOTLt vent-Aorta arch

4 chamber heart

Four valves One-way directional blood flow

Atrioventricular• 2- one at each entrance to the

vents• Attached to papillary by

chordae tendineae Rt has 3 leaflets- tricuspid Lt has 2 leaflets- bicuspid

(Mitral)

Semilunar• Junction of vents and great

vessels Pulmonary semilunar- at RV

and pulm art AO semilunar is btw LV and

Ascending AO

The classic form-Tetralogy of Fallot includes 4 defects within the heart structures:

Ventricular septal defect • (hole between the right and

left ventricles) Narrowing of the pulmonary

outflow tract • (tube that connects the heart

with the lungs) An aorta that grows from both

ventricles, rather than exclusively from the left ventricle

A thickened muscular wall of the right ventricle (right ventricular hypertrophy)

AO• Largest artery• Ascending, arch, descending• Base of LV- sternal angle, curves superiorly

and posteriorly as the arch- top of arch (T3)- descending AO anterior and LT of vertebral column

Pulm Arteries• Pulm trunk- within pericardial sac• Attached to AO by ligamentum arteriosum=

renmant fetal blood vessel- ductus arteriousis linking pulmonary/systemic circuit

• Arises from RV and bifurcates at (T4) into Rt and LT pulm art. Rt -lateral, post to AO/cava, ant to

esophagus, and enters hilum of Rt lung- divides into two branches

Lt – shorter, smaller and most superior of pulm vessels-enters Lt lung hilum superior to mainstem bronchus

Pulmonary Veins• Anterior and Inferior to pulm

arteries• Two each sup/inf extends from

each lung to the LT atrium of the heart- continuous with capillaries of the pulm arteries.

• Rt/Lt sup pulm vein and Rt/Lt inf pulm vein

Superior Venae Cavae• Junction of brachiocephalic-

blood from thorax, up limbs, head and neck- post and lat to ascd AO

• Enters upper portion of RA Inferior Venae Cavae

• Juction of common iliac veins in pelvis

• RT of abd AO and anterior to vertebral column- enters inferior Rt Atrium

Left image shows contrast in the right ventricle (RV) being pumped into the pulmonary trunk (PT). The image on the right shows contrast distribution to the right pulmonary artery (yellow arrow) and left pulmonary artery (green arrow). The right pulmonary artery runs just posterior to the ascending aorta and in front of the tracheal bifurcation. The left pulmonary artery is shorter and smaller and runs anteroinferior to the descending aorta

3 branches: Brachiocephalic (innominate) trunk

• 1st and largest branch, divides into: Rt common carotid- lat to trachea

at C4-Int/Ext carotid art Rt subclavian arteries- post to

clavicle into axilla

LT common carotid artery• 2nd- lt of trachea @ C4 where it too –

Int/Ext carotid art

Lt subclavian artery• Post to LC carotid, arches laterally

toward axilla

20-days old male presented with heart failure. The arch is interrupted between left CCA and SCA. The pulmonary artery is markedly dilated and connected to descending aorta via large PDA giving the appearance of a low aortic arch. The PA is much larger than ascending aorta. Other associated anomalies in this case included VSD and large sinus venosus ASD

Thoracic aortic dissection is commonly divided according to the Stanford classification into type A (involving the ascending aorta or aortic arch) and type B (involving the descending thoracic aorta only). The main causes of dissection are hypertension, atherosclerosis, Marfan’s syndrome, Ehlers-Danlos syndrome, vasculitis, pregnancy and iatrogenic (aortic catheterisation).

SVC receives blood from head/neck via internal/ external jugular veins and from the upper ext via the subclavian.

Subclavians arise from axillary – receive blood from external jugular before joining the internal jugular continue as brachiocephalic vein

Lt brachio- runs anterior to AO and unites with Rt brachio- post to costal cartilage of 1st rib

Union of the Lt/Rt brachio= Superior Vena Cava- which empties into RA of heart

Superior vena cava syndrome

hypoattenuating thrombus that fills the superior vena cava- use anticoagulants.

Multiple serpentine vessels are visualized in the left anterior and posterior chest walls. Contrast is also visualized within the azygos vein, there is also dilatation of the azygos vein. There is no contrast visualized in the superior vena cava and there appears to be a hypodense abnormality within the lumen. This most likely represents thrombus

Heart requires continuous O2 blood

Coronary circulation supplies blood to the heart

Coronary arteries- 1st branch of AO• Rt coronary

rt marginal branch to apex posterior interventricular

branch (post descending)• Lt coronary

circumflex (branches to Lt marginal)

left anterior interventricular (ant descending)- LAD

LAD= “widow maker”

left circumflex coronary artery

Coronary sinus Posterior Main vein of the

heart• Great• Small• middle

Collateral circulation Between the inferior and

superior venae cavae Divided into two:

• Azyogs-ascends along Rt vert column

• Hemiazygos vein- ascends along Lt vert column

Hemiazygos crosses behind the AO and joins the azygos (T7-9) and emties into the posterior SVC.

Intercostal

Serrtus posterior sup/inf

Diaphragm• Crura of diaphragm- tendons

that attach to lumbar spine• Aortic hiatus, caval hiatus

and esophageal hiatus

Pectoralis major/minor

Subclavius

Serratus anterior

First step: is a Norwood thenA Glenn and a Fontan… Perhaps a Berlin Heart and finallyA Heart Transplant is needed asThe final fix to the condition

Mesothelioma Rt lung

LAD!

Name the valves…