The Mediastinum

The thoracic mediastinum (L. middle septum) is the

space between the two pleura sacs.
It contains all the structures of the thorax except
the lungs and the pleura.
It extends from the superior thoracic aperture to
the diaphragm inferiorly; from the sternum and costal
cartilages anteriorly to the bodies of the thoracic
vertebrae posteriorly.
The structures in the mediastinum are surrounded by loose
connective tissue, nerves, blood and lymphatic vessels,
and fat.
In a living person, the looseness of the connective tissue
and fat, and the elasticity of the lungs and pleura enable
the mediastinum to accommodate movement and changes
in volume in the thoracic cavity.
Subdivisions of the Mediastinum
The mediastinum is descriptively divided into inferior and
superior parts by a plane passing though the sternal
angle and the inferior border of T4 vertebra,
themanubriosternal plane.
The superior mediastinum is from the superior thoracic
aperture to this plane.
The inferior mediastinum is from the plane to the
diaphragm and is further subdivided into three
compartments by
the pericardium (anterior, middle andposterior).
The Superior Mediastinum
This subdivision is superior to the manubriosternal plane.
Structures in the superior mediastinum are:
the thymus (or its remains) anteriorly; the great vessels
related to the heart in the middle; and
the oesophagus, tracheaand thoracic duct posteriorly.
The Anterior Mediastinum
This is the smallest subdivision of the mediastinum.
It is located anterior to the pericardium and posterior
to the sternum and transversus thoracis muscles.
Although this mediastinum is small in adults, it is relatively
large in childhood as the thymus extends into it from the
superior mediastinum.
The Middle Mediastinum
This subdivision is of the highest clinical importance as it
contains the pericardium and the heart and the
immediately adjacent parts of the great
arteries, phrenic nerves, main bronchi, and other
structures in the root of the lungs.
The Posterior Mediastinum
This subdivision is located posterior to the pericardium and
diaphragm, and anterior to the bodies of the inferior eight
thoracic vertebrae.
Its main contents are the oesophagus and
the descending thoracic aorta, which have descended
into it from the superior mediastinum.
The Heart
The heart is a double self-adjusting muscular pump,
the two parts of which normally work in unison.
The right side of the heart receives deoxygenated blood
and pumps it to the lungs and the left side of the heart
receives oxygenated from the lungs and pumps it into the
aorta for systemic distribution.

The heart has four chambers. Each side consists of

an atrium (L. antechamber), a receiving area that pumps
blood into a ventricle (L. little belly), a discharging
chamber.
The wall of each chamber consists of three layers: an
internal layer or endocardium; a middle layer of cardiac
muscle or myocardium; and an external layer
orepicardium.
The myocardium forms the main mass of the muscle.
The heart and the roots of the great vessels occupy
the pericardium, which is located in the middle
mediastinum.
The heart is situated obliquely in the middle
mediastinum. It is not in the median plane and is located
about 2/3 to the left and 1/3 to the right of it.
The heart has a base (posterior aspect), apex (inferolateral
aspect end), three surfaces (sternocostal, diaphragmatic,
and pulmonary), and four borders (right, inferior, left, and
superior).
The Base of the Heart
The base is located posteriorly and is formed mainly by
the left atrium.
It lies opposite T5 to T8 (supine position) and T6 to
T9 vertebrae (erect position) and faces superiorly,
posteriorly and towards the right shoulder.
The base or posterior aspect of the heart is quadrilateral
in shape and it is from its most superior part from which
the ascending aorta and pulmonary trunk emerge, and
into which the superior vena cava enters.
The base is separated from the diaphragmatic surface of
the heart by the posterior part of the coronary groove (L.
sulcus).
The heart does not rest on its base. The term refers to
the somewhat conical shape of the heart with the base
being opposite the apex.
The Apex of the Heart
This blunt apex is formed from by the left ventricle, which
points inferolaterally.
The apex is located posterior to the left 5th intercostal
space in adults, 7 to 9 cm from the median plane, and just
left of the midclavicular line.
The apex beat is an impulse imparted by the hear; it
is its point of maximal pulsation or the lowest, most
lateral point at which pulsation can be felt.
The Sternocostal (Anterior) Surface of the Heart
This surface of the heart is mainly formed by the right
ventricle and is visible in PA radiographs of the thorax.
The Diaphragmatic (Inferior) Surface of the Heart
The surface of the heart is usually horizontal or slightly
concave.
It is formed by both ventricles, mainly the left one.
The posterior interventricular sulcus divides this
surface into a right 1/3 and a left 2/3.
The Pulmonary (Left) Surface of the Heart
This surface of the heart is mainly formed by the left
ventricle and occupies the cardiac notch of the left lung.
The Borders of the Heart
The heart has four borders: right, inferior, left, and
superior.

These borders are actually the borders of its sternocostal

surface.
The right border is formed by the right atrium. It is
slightly convex and is almost in line with the superior
and inferior vena cavae.
The inferior border is sharp and thin, and nearly
horizontal.
It is formed mainly by the right ventricle and only slightly
by the left ventricle.
The left border is formed mainly by the left ventricle and
only slightly by the left auricle.
The superior border is where the great vessels enter and
leave the heart. It is formed by the right and left
auricles and the superior conical portion of the right
ventricle, the conus arteriosus (infundibulum), between
them.
The pulmonary trunk arises from the conus arteriosus.
Surface Anatomy of the Heart
The cardiac apex corresponds approximately to the apex
beat. The true cardiac apex is actually further
inferolaterally and does not contact the thoracic wall in
systole.
The right border of the heart corresponds to a line from
the right 3rd costal cartilage's superior border (1.2 cm from
the sternal margin) to the 6th costal cartilage's junction
with the sternum.
The left border of the heart is marked by a line from the
apex beat to the lower border of the left 2nd costal
cartilage 1.2 cm from the sternal margin.
Areas for auscultation:
Mitral valve: at the apex.
Tricuspid valve: left sternal edge, 4th intercostal space.
Aortic valve: 2nd right intercostal space.
Pulmonary valve: 2nd left intercostal space.
Radiological Anatomy of the Heart
In PA radiographs of the thorax, the right border of the
cardiovascular silhouette is formed by (superior to
inferior): (1) the superior vena cava; (2) the right
atrium; (3) the inferior vena cava.
The left border of the cardiovascular silhouette is
formed by: (1) the arch of the aorta, which produces a
characteristic aortic knob; (2) the pulmonary trunk; (3)
theleft auricle; (4) the left ventricle.
Chambers of the Heart
The heart has 4 chambers, two atria and two ventricles.
The coronary sulcus encircles most of the superior part
of the heart and separates the atria from the
ventricles.
The division of the ventricles is by the anterior and
posterior interventricular sulci.
The Right Atrium
This chamber forms the right border of the heart between
the SVC and IVC.
It receives blood from these large vessels and
the coronary sinus.
The internal wall of the right atrium consists of: (1) a
smooth posterior part, called the sinus venarum (sinus of
the venae cavae), which receives the venae cavae and
coronary sinus, and (2) a rough anterior part, which has
internal muscular ridges (musculi pectinati) that
resembles the teeth of a comb (L. pectin).

The right auricle (atrial appendage) is a small, conical

muscular pouch that projects to the left from the right
atrium and overlaps the ascending aorta.
The two distinct parts of the right atrium are separated
externally by a shallow vertical groove on the anterolateral
aspect of the right atrium, called the sulcus terminalis,
and internally by a vertical crest or ridge called the crista
terminalis.
The crista extends between the two vena caval orifices.
The interatrial septum forms the thin posteromedial wall
of right atrium.
A prominent feature of this thin dividing septum is
the thumbprint sized fossa ovalis, a large, shallow
translucent oval depression.
The fossa ovalis has an incomplete sharp margin known as
the limbus fossae ovalis.
The small opening of the coronary sinus is located
between the right atrioventricular orifice and
the orifice of the IVC.
Atrioseptal Defect (ASD)
A probe-sized atrial septal defect (ASD) appears in the
superior part of the fossa ovalis in up to 25% of people.
Before birth, there is such a communication (the foramen
ovale) between the right and left atria, but it
normally closes before birth.
A small ASD is usually of no clinical significance, but a
large ASD allows recently oxygenated blood from the lungs
in the left atrium to be shunted back to the right atrium
(due to the higher pressure in the LA).
Consequently, the RA and right side of the heart is
overworked.
The RA, SVC and IVC dilate to accommodate the excess
volume of blood.
An elevated jugular pulse is seen in the neck and due to
the dilation of the RA, the right cardiac margin enlarges to
the right.
The Right Ventricle
This chamber forms the largest part of the sternocostal
surface of the heart, a small part of the diaphragmatic
surface, and almost the entire inferior border of the heart.
Its superior left angle tapers into a cone-shaped pouch,
called the infundibulum or the conus
arteriosus (L. infundibulum, funnel), which leads to
the pulmonary trunk.
Its internal wall is smooth, whereas the rest of the right
ventricular wall is roughened by a number of irregular
muscle bundles, and muscular ridges and bridge known
as trabeculae carneae.
The septomarginal trabecula crosses the cavity of the
ventricle from the interventricular septum to the base
of the anterior papillary muscle.
The carries the right branch of the atrioventricular
bundle, which is part of the conducting system of the
heart.
A thick, muscular ridge, the supraventricular crest,
arches toward and over the anterior cusp of the right
atrioventricular (tricuspid) valve, and separates the
ridged muscular wall of the ventricle from the smoothwalled conus arteriosus.
The papillary muscles are conical projects with their
bases attached to the wall of the ventricle.
A number of slender fibrous bands, called chordae
tendineae, arise from the apices of these muscles and
are attached to the free edges and ventricular surfaces of

1.
2.

the cusps of the right atrioventricular (tricuspid)

3.
valve.
The chordae tendineae prevent the cusps of the tricuspid4.
valve from being driven into the right atrium when
ventricular pressure rises.
There are usually three papillary muscles in the right
ventricle (anterior, posterior and septal).
The Left Atrium
The left atrium extends anteriorly left of the pulmonary
trunk.
Four pulmonary veins (two on each side) enter the left
atrium.
The valvule of the foramen ovale lies on
the interatrial septal wall corresponding to the floor of
the fossa ovalis on the right atrial side.
The left atrium opens into the left atrioventricular
orifice to the left ventricle. The left atrioventricular valve
or mitral valve is bicuspid.
The musculi pectinati are fewer and smaller than in the
right atrium.
The Left Ventricle
The left atrioventricular orifice with the mitral
valve opens into the left ventricle.
It is similar to the right ventricle in that it has trabeculae
carneae, chordae tendineae and papillary muscles, except
that it only has two papillary muscles (anterior and
posterior) for the corresponding mitral valve leaflets.
The aortic vestibule leads to the semilunar aortic
valve.
The aortic valve has three cusps (left, right and
posterior), each with lunules and nodules as for the
pulmonary valve.
The interventricular septum has muscular (inferior)
and membranous (superior) parts; the latter part lies
towards the aortic valve and is partly confluent with the
fibrous support of the right and posterior cusps.
The left ventricular wall is 2-3 times thicker than the right
ventricular wall.
General Structure of the Cardiac Wall
It consists of three layers:
The endocardium, the internal layer. This layer is
continuous with the endothelium of the great vessels.
The myocardium, the muscular layer.
The epicardium, the subepicardial fat and connective
tissue beneath the visceral layer of the serous
pericardium.
The intercellular spaces between the conducting and
contractile elements of the heart are filled with connective
tissue.
The Cardiac Fibrous Skeleton
This is a complex framework of dense collagen, with
membranous, tendinous and fibro-areolar extensions,
approximately along the plane of the coronary sinus, and
intimately related to the valve orifices of the
atrioventricular and semilunar valves.
Its functions include:
To ensure electrophysiological discontinuity between
the atria and ventricles (only connection is via the
atrioventricular bundle).
To provide mechanical attachment for the atrial and
ventricular muscles.

To maintain the cardiac position within the

pericardium.
To provide a stable but deformable base for the
valvular fibrous cores.
The aortic and two atrioventricular valves are
intimately interconnected through their basal collagenous
frameworks.
The pulmonary valve is remote from the others, being
connected by the long deformable tendon of the conus
arteriosus.
Myocardial Architecture
Atrial fibres form two layers: superficial, common to
both atria, and deep, confined to each.
Ventricular fibres also consist of superficial and deep
layers, where the deep layers also contribute to
the papillary muscles.
The ventricular myocardium is regarded as a series of
nested spiral laminae.
These fibre-pathways have varying obliquity so that the
myocardium is capable of reducing all the dimensions of
the ventricles simultaneously.
The Cardiac Cycle
The cardiac cycle is a description of the mechanical
activity of the heart as it pumps blood. The cardiac cycle
has been neatly broken down into four (4) stages. In each
case, the stage is named after what is going on in the
ventricle, as the ventricle is the structure that ejects blood
from the heart under high (or relatively high) pressure.
In understanding the cardiac cycle, you must never forget
that blood will always flow from an area of high pressure
towards an area of low pressure. You need to also
understand the Physiologist's view of the heart. Below is a
labeled diagram of the heart seen throught the eyes of a
physiologist. Note, it is not anatomically correct.
Filling
The filling stage is the stage where the ventricle is filling
with blood that has just returned to the heart from a vein.
As filling begins, the heart is relaxed (not contracting). If
blood is entering the ventricle from the atria, then the
pressure in the ventricle must be lower than that in the
atria (remember, blood must flow from high to low
pressure). That also means that the AV valves must be
open (otherwise, how can blood flow into the ventricle!).
These valves are open because the blood in the atria
(under higher pressure) pushes open the valves to enter
the ventricle. The valves are constructed so that blood
trying to enter the ventricle from the atria will be able to
push the valve open and allow blood to flow. If the
pressure in the ventricle was higher than that in the atria,
then the blood would try to move into the atria. The blood
would push on the walls of the valve leaflets and this
would force the valves to close, preventing blood from
flowing in the wrong direction. The pressure in the
ventricle is much lower than that in the artery. Therefore
the blood wants to flow from the artery into the ventricle
(the wrong way!), however, as the blood tries to move into
the ventricle, it pushes on the valve leaflets of the
semilunar valves closing the valve and preventing the
backflow of blood. Approximately 70-80% of the blood that
enters the ventricle during the filling in a resting individual
does so passively, without the benefit of atrial contraction.
Near the end of filling, however, the atira does contract,
pushing more blood into the ventricle. So in the filling

stage, the Pvent < Patria so the AV valves are open and the
Pvent < Partery so the semi-lunar valves are closed.
Isovolumetric Contraction
The pressure in the ventricle gradually increases because
of the accumulation of blood in the ventricle. The pressure
in the atria begins to lower as the atria relaxes. At this
time, the ventricle begins to contract. This further
increases the pressure in the ventricle so that the pressure
in the ventricle now is greater than that in the atria. This
results in the closing of the AV valves (due to the blood
trying to move back into the atria). The closing of the AV
valves is so forceful that it makes a sound (the 'lub' or first
heart sound). Th pressure in the ventricle during this stage
is still lower than that in the artery so the semi-lunar
valves are still closed. Therefore, there is no movement of
blood into or out of the ventricle as both sets of valves are
closed thus the term isovolumetric. So in the
isovolumetric contraction stage, the Pvent > Patria so the AV
valves are closed and the Pvent < Partery so the semi-lunar
valves are closed.
Ejection
As the ventricle continues to contract, the pressure builds
up until the pressure in the ventricle eventually becomes
greater than the pressure in the artery. At this point, the

semi-lunar valves will swing open due to the rush of blood

from the higher pressure ventricle to the lower pressure
artery. Blood then moves into the artery under high
pressure, which is the purpose of the heart. The
ventricular pressure is now very high and much greater
than that in the atria so the AV valves are still closed. So in
the ejection stage, the Pvent < Patria so the AV valves are
closed and the Pvent > Partery so the semi-lunar valves are
open.
Isovolumetric Relaxation
As the ventricle begins to relax, the pressure in the
ventricle begins to decline. The pressure in the artery
(which now has all the ejected blood) is now greater than
that in the ventricle. The blood now closes the semi-lunar
valve as it tries to go from the artery into the venticle
preventing any backflow. Although the pressure in the
ventricle is declining, it is still greater than that in the atria
so the AV valves are still closed. Thus as the ventricle is
relaxing, the volume of blood in the ventricle is not
changing. This stage will continue until the ventricular
pressure becomes lower than the atrial pressure and the
filling stage starts again. So in the isovolumetric relaxation
stage, the Pvent > Patria so the AV valves are closed and the
Pvent < Partery so the semi-lunar valves are closed.