Anatomy 1C Joshua Montelibano 2nd shift 2015-2016

MEDIASTINUM & HEART

MEDIASTINUM

MEDIASTINUM
 Thick, movable partition
 Contains remains of the thymus, heart, large blood vessels, trachea, esophagus, thoracic duct
and lymph nodes, vagus and phrenic nerves, sympathetic trunks
 Divided into superior and inferior mediastinum by an imaginary plane from the sternal angle
th
anteriorly to the lower border of the body of 4 thoracic vertebra (T4) posteriorly

Superior Mediastinum Inferior Mediastinum

Boundaries
Anterior: Manubrium sterni
Posterior: First four thoracic
vertebra (T1-T4)
Superior: Thoracic outlet and root of
the neck
Inferior: Imaginary plane
Further subdivided into:
1. Middle Mediastinum – consists of pericardium
and heart
2. Anterior mediastinum – space between
pericardium and sternum
3. Posterior mediastinum – between pericardium
and vertebral column

Contains (anterior to posterior): Boundaries

 Thymus Anterior: Body of the sternum
Boundaries
 Large veins Posterior: Lower eight thoracic vertebra (T5-T12)
Superior: Thoracic outlet and root of the neck
 Large arteries Superior: Imaginary plane
Inferior: Diaphragm
 Trachea Inferior: Diaphragm
Anterior: Sternum
 Esophagus and thoracic duct Posterior: Vertebral column (T1 to T12)
 Sympathetic trunks Contains (anterior to posterior):
 Thymus
 Heart in pericardium with phrenic nerves
 Esophagus and thoracic duct
 Descending aorta
 Sympathetic trunks

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Boundaries
Anterior: Manubrium sterni
Posterior: First four thoracic vertebra (T1-T4)
Superior: Thoracic outlet and root of the neck
Inferior: Imaginary plane
Origin: Ascending aorta
Commencement: Behind the manubrium sterni
Termination: Level of the sternal angle (T4, T5)
Brachiocephalic artery
Origin: Arch of the aorta
Commencement: convex surface of the aortic arch
Termination: right sternoclavicular joint
Course:
1. Passes upward and to the right of the
trachea
2. Divides into Right subclavian and
Right common carotid arteries
behind right sternoclavicular joint
Anatomy 1C Joshua Montelibano 2nd shift 2015-2016
SUPERIOR & ANTERIOR MEDIASTINUM
Contains:
 Trachea, thymus, esophagus, and thoracic duct
 Arch of the aorta and its branches
 Brachiocephalic vein
 Phrenic nerve, vagus nerve & left laryngeal nerve
Large Arteries in the Superior Mediastinum
Arch of the Aorta
Course:
1. Arches upward and backward from the manubrium sterni
2. Goes to the left in front of trachea and passes downward to the left terminates at T4
Branches
Left common carotid artery Left subclavian artery
Origin: Arch of the aorta Origin: Arch of the aorta
Commencement: convex surface of the aortic arch Commencement: aortic arch behind the manubrium
Termination: left sternoclavicular joint sterni
st
Termination: Outer border of 1 rib
Course:
1. From aortic arch on the left side of the Course:
brachiocephalic artery 1. Runs upward along left side of the trachea
2. Runs upward and to the left of the trachea and esophagus
3. Enters the neck behind the left 2. Arches over the apex of the left lung
sternoclavicular joint 3. Enters root of the neck
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Large Veins in the Superior Mediastinum

Brachiocephalic Veins Superior Vena Cava
Most superficial vessel Contains all venous blood from the head, neck, and upper limbs
st
Commencement: Root of the neck Commencement: 1 chondro-sternal joint
Union of subclavian and internal jugular veins  Union of Left and Right Brachiocephalic veins
 Passes downward in the middle mediastinum ending in the right
Right Brachiocephalic vein atrium
 Union of the right subclavian and right internal jugular veins Vena azygos – joins the posterior aspect of the superior vena cava before it
enters the pericardium
Left Brachiocephalic vein
 Union of left subclavian and left internal jugular vein
 Longer - Passes obliquely downward and to the right behind the
manubrium sterni and in front of the large branches of the aortic arch

st
Joins right brachiocephalic vein behind 1 chondro-sternal joint – forms
superior vena cava

Vagus Nerve Phrenic Nerve

Supply the lungs and esophagus
Right Vagus nerve
 Posterolateral to the
Brachiocephalic artery
 Lateral to trachea, medial to
terminal part of azygos vein
 Passes behind root of right
lung – forms pulmonary
plexus
 Passes on posterior surface
of esophagus – forms
esophageal plexus
 Passes through the
diaphragm behind the
esophagus – reaches the
stomach
Gives off cardiac branches
Left vagus nerve
 Between left common carotid and left
subclavian arteries
 Crosses left side of aortic arch – crossed
by the left phrenic nerve
 Turns backward behind the root of the
left lung – forms pulmonary plexus
 Passes on anterior surface of the
esophagus – forms esophageal plexus
 Passes through the diaphragm in front of
the esophagus – reaches the stomach
Gives origin to left recurrent laryngeal
 Supplies muscles acting on the vocal cord
 Hooks around ligamentum arteriosum
 Ascends between trachea and esophagus
rd th th
Arise from the anterior rami of the 3 , 4 , and 5 cervical nerves in the neck
 Afferent fibers – sensory fibers; pericardium, pleura, mediastinal tissues
 Efferent fibers – motor fibers; diaphragm
Right Phrenic nerve Left Phrenic nerve
 Descends in the thorax along the  Descends in thorax along left side
right of the brachiocephalic vein of left subclavian artery
and superior vena cava  Crosses left of the aortic arch –
 Passes in front of the root of the crosses left side of left vagus
right lung  Passes in front of the root of the
 Runs along the right of the left lung
pericardium - separates nerve  Descends over pericardium –
from right atrium separates nerve from left
 Descends on right of the inferior ventricle
vena cava to the diaphragm  Terminal branches supply central
 Terminal branches supply central part of the peritoneum
part of the peritoneum

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THYMUS

 Flattened, bilobed structure

 Lies between the sternum and pericardium in the anterior mediastinum
 In newborn infants – reaches largest size relative to body size; may
extend up through the superior mediastinum in front of the great vessels
into the root of the neck
 Continues to grow until puberty; eventually undergoes involution
 Pink, lobulated appearance
 Site for development of T (thymic) lymphocytes – plays important role in
immune defense mechanisms of the body

 Inferior thyroid artery

Blood Supply of the Thymus  Internal thoracic artery
Nerve Supply of the Thymus  Sympathetic fibers

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Phrenic Nerve and Great Blood Vessels in the Superior Mediastinum

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MIDDLE MEDIASTINUM
PERICARDIUM Pericardial cavity
 Fibroserous sac – encloses the heart and roots of the great vessels  Slitlike space between the
 Lies within the middle mediastinum parietal and visceral layers
 With pericardial fluid
Boundaries (about 50mL) – tissue fluid
nd th
Anterior: Body of the sternum and 2 to 6 costal cartilages which acts as a lubricant to
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Posterior: 5 to 8 thoracic vertebrae (T5-T8) facilitate heart movements
Superior: Great blood vessels
Inferior: Diaphragm Pericardial Sinuses
Function:  No clinical significance
1. Restrict excessive movements of the heart as a whole  Formed as a consequence of the
2. Serve as lubricated container way the heart bends during
development
Fibrous Pericardium  Oblique sinus – on posterior surface
 Strong outer fibrous part of the sac of the heart; recess due to reflection
 Firmly attached below to the central tendon of the diaphragm via the of the serous pericardium around large veins
pericardio-phrenic ligament  Transverse sinus – on posterior surface
 Attached in front to the sternum via the sternopericardial ligaments short passage between the reflection of serous pericardium
 Apex fuses with outer coats of the great blood vessels passing through it: around the aorta ad pulmonary trunk and reflection around
 Aorta the large veins
 Pulmonary trunk
 Superior and inferior vena cavae Nerve Supply of the Pericardium
 Pulmonary veins Phrenic Nerve
 Fibrous and parietal layer of the serious pericardium
Serous Pericardium
 Lines the fibrous pericardium and coats the heart Sympathetic trunks and Vagus nerve
 Divided into parietal and visceral layers  Visceral layer of the seruos pericardium

 Lines the fibrous pericardium

 Reflected around the roots of the great vessels -
Parietal layer
becomes continuous with the visceral layer at base of the
heart
Visceral layer
 Closely applied to the heart
(Epicardium)

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Pericardial Sac and Heart in situ

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EXTERNAL HEART
Heart Borders of the Heart
 Hollow muscular organ somewhat pyramidal in shaped
 Lies freely within the pericardium  Formed by the right atrium
  From the 3 to 6 right intercostal space (about
rd th
Connected only at its base to the great blood vessels Right border
 Does not rest on its base; it rests on its diaphragmatic surface 3cm and 1.5cm respectively from midsternal line)
 Formed by the left auricle and left ventricle
Left border
 From the 2 to 5 left intercostal space
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Surfaces of the Heart
 Has an Apex – directed downward, forward, and to the left  Formed by the great vessels of the heart
Superior
 With 3 surfaces: Sternocostal, Diaphragmatic, Base  From the 3 right costal cartilage to 2 left costal
rd nd
border
Right border: Right atrium cartilage
Left border: Left ventricle, part of the left atrium  Formed by the right ventricle (partially by the right
Inferior atrium) and the apex
Sternocostal (anterior)  Formed by the right atrium and ventricle – border  From the 6 right intercostal space to the 5 left
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separated by the atrioventricular groove midclavicular intercostal space

 Anterior interventricular groove – separates right
ventricle from left ventricle
 Formed by the right and left ventricles – separated
by the posterior interventricular groove
Diaphragmatic (inferior)  Also formed by the inferior surface of the right
atrium where inferior vena cava opens
 Formed by the Left atrium – where 4 pulmonary
Base (posterior) veins open ; Lies opposite the apex
 Formed by the Left ventricle
 Lies at the level of 5 left intercostal space 3.5
th
Apex
inches (9cm) from the midline

Heart Valves
Surface anatomy Clinical auscultation areas
rd nd
Pulmonary 3 left rib (medial end) Medial end of 2 left ICS
rd nd
Aortic 3 left parasternal ICS Medial end of 2 right ICS
th th
Mitral 4 left parasternal rib Apex (5 left midclavicular ICS)
th th
Tricuspid 4 right parasternal ICS 6 ICS (lower end of sternum body)

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Anterior Exposure and Base and Diaphragmatic surface of the heart

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Arterial Supply of the Heart

Right coronary artery Left coronary artery
Origin: Anterior aortic sinus of the ascending aorta  Usually larger than the right coronary artery
Commencement: Between pulmonary trunk and right auricle  Supplies major part of the heart – left atrium, left ventricle,
Termination: Posterior Interventricular groove ventricular septum

Course : Origin: left posterior aortic sinus of the ascending aorta

1. Runs forward between the pulmonary trunk and right auricle
2. Descends in right atrioventricular groove
3. At the diaphragmatic surface (inferior border) of the heart – continues
posteriorly along the atrioventricular grove
4. Anastomoses with left coronary artery in posterior interventricular groove
Branches
Supplies:
Right Conus 1. Anterior surface of the pulmonary conus
artery (Right ventricle infundibulum)
2. Upper part of the anterior right ventricle wall
 Two to three in number; supplies anterior surface
Anterior
of right ventricle
Ventricular
 Marginal branch – largest; runs along the lower margin of
branches
the costal surface reaching the apex
Posterior
 Usually 2 in number
Ventricular
 Supplies diaphragmatic surface of the right ventricle
branches
 Runs toward the apex in posterior interventricular groove
Posterior
 Gives off branches to right and left Ventricles
Interventricular
 Supplies posterior part of the ventricular septum from the
(descending)
artery
anterior interventricular branch of the left coronary artery
 Atrioventricular node – supplied by a large septal branch
 Supplies anterior and lateral faces of the right atrium
 One branch supplies posterior surface of right and left atria
Atrial branches
 Artery of the sinoatrial node – supplies node and right and
left atria (35% of individuals – from left coronary artery)
Commencement: Between pulmonary trunk and left auricle
Termination: Atrioventricular groove
Course:
1. Passes forward between pulmonary trunk and left auricle
2. Enters atrioventricular groove
3. Divides into anterior interventricular branch and circumflex
branch
Branches
 Runs downward in the anterior interventricular
groove to the apex
 In most individuals – passes around the apex to
enter posterior interventricular groove;
Anterior
anastomoses with terminal branches of the
interventricular right coronary artery
(descending)
 Supplies right and left ventricles, and
branch
anterior part of the ventricular septum
 Left diagonal artery – may arise directly from
left coronary artery trunk
 Left conus artery – supplies pulmonary conus
 Winds around left margin of the heart in
atrioventricular groove
 Left marginal artery – large branch supplying
Circumflex left margin of the left ventricle to the apex
artery  Anterior and posterior ventricular branches –
supply the left ventricle
 Atrial branches – supply left atrium

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Arterial Supply of the Heart

Coronary artery Anastomoses
 Collateral circulation between terminal branches of the right and left
coronary arteries
 Not large enough to provide adequate supply to cardiac muscle if blocked by
a disease
 Sudden block of the larger branches – usually leads to myocardial death
(myocardial infarction)

Arterial Supply to the Conducting System
 Sinoatrial node – Right coronary artery (sometimes by the left)
 Atrioventricular node and bundle – Right coronary artery
 LBB – Right and Left coronary arteries
 RBB – Left coronary artery

Summary of Overall Arterial Supply

1. Right ventricle (except for small area to the right
of the anterior interventricular groove)
2. Variable part of the diaphragmatic surface of the
left ventricle
3. Posteroinferior 1/3 of the ventricular septum
Right coronary artery
4. Right atrium
5. Part of the left atrium
6. Sinoatrial node and atrioventricular node and
bundle
7. Left bundle branch (LBB)
1. Left ventricle
2. Small area of the right ventricle to the right of
the interventricular groove
Left coronary artery 3. Anterior 2/3 of the ventricular septum
4. Most of the left atrium
5. Right bundle branch (RBB)
6. LBB

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Venous Drainage of the Heart

Coronary sinus
 Principal venous drainage of the heart walls into the right atrium
 Lies in the posterior part of the atrioventricular groove
(coronary sulcus)
 Continuation of the Great cardiac vein (opens into the right atrium to
the left inferior vena cava)
Tributaries: Small and Middle Cardiac veins

Anterior cardiac vein - drain directly into the right atrium

Vena cordis minimae – small veins that drain directly to heart chambers

Nerve Supply of the Heart

Cardiac plexus
 Innervates the heart via sympathetic and parasympathetic fibers of the
autonomic nervous system
1. Superficial Cardiac Plexus – situated below the arch of the aorta (Vagus)
2. Deep Cardiac Plexus – In front of the trachea on the bifurcation of the
right and left primary bronchi (Vagus and sympathetic trunk)

From the cervical and upper thoracic portions of

Sympathetic supply
Parasympathetic supply
Postganglionic
sympathetic fibers
Postganglionic
parasympathetic fibers
Afferent fibers
the sympathetic trunks
Vagus nerves
 Terminate on the SA and AV nodes, cardiac
muscle fibers, and coronary arteries
 Results to cardiac acceleration, increased
force of contraction, and coronary dilatation
 Termination on SA and AV nodes, and
coronary arteries
 Results in reduction in rate and force of
contraction, arterial constriction
 Run with sympathetic nerves - carry nervous
impulses that normally do not reach
consciousness (Carry pain impulse)
 Run with vagus –cardiovascular reflex

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GREAT VESSELS OF THE HEART

Arteries
Ascending Aorta Pulmonary Trunk
 Lies within fibrous pericardium  Conveys deoxygenated blood from the right ventricle to the lungs
 Enclosed with the pulmonary trunk in a sheath of serous  About 2inches (5 cm) long and divides into right and left pulmonary arteries at
pericardium the aortic arch
 At its root – with 3 bulges (sinuses of the aorta) – one behind each  Together with the ascending aorta – enclosed in fibrous pericardium and sheath
aortic valve cusp of serous pericardium

Origin: Left ventricle Origin: Right ventricle

Commencement: Base of left ventricle Commencement: Upper part of the right ventricle
Termination: Behind the right half of the sternum (level of sternal angle) Termination: Concavity of the aortic arch

Branches: Branches
 Right coronary artery – from the anterior aortic sinus  Right pulmonary artery – runs to the right behind the ascending aorta and
 Left coronary artery - from the left posterior aortic sinus superior vena cava; enters root of the right lung
 Left pulmonary artery - runs to left in front of the descending aorta; enters
root of the left lung
 Ligamentum arteriosum
 Fibrous band connecting the bifurcation of the pulmonary trunk to the
lower concave surface of the aortic arch
 Remains of the ductus arteriosus – in fetus – conducts blood from
pulmonary trunk to the aorta
 Left recurrent laryngeal nerve hooks around the lower border
Veins
Pulmonary veins Superior vena cava Inferior vena cava
 Two pulmonary veins leave  Contains all venous blood from the head, neck, and upper limbs  Pierces central tendon of the diaphragm
each lung  Union of Left and Right Brachiocephalic veins opposite the eight thoracic vertebra (T8)
 Carries oxygenated blood to the  Vena azygos - joins the posterior aspect of the superior vena  Enters lowest part of the right atrium
left atrium cava
th
Commencement: Level of 5 lumbar vertebra (L5)
st rd
Commencement: 1 chondro-sternal joint Termination: Right atrium at 3 costal cartilage
rd
Termination: Right atrium at 3 costal cartilage

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INTERNAL HEART
CHAMBERS OF THE HEART
Right Atrium Left Atrium
 Consists of a main cavity and small out-pouching (right auricle)  Consists of a main cavity and a left auricle
Sulcus terminalis  Situated behind the right atrium
 Vertical groove on the outside of the heart between right atrium and  Forms the greater part of the base (posterior surface of the heart)
right auricle  Oblique sinus of the serous pericardium lies behind it
 Crista terminalis – ridge inside the sulcus terminalis  Fibrous pericardium – separates it from the esophagus
 Smooth wall – main part of the atrium posterior to the ridge;  Interior is smooth
derived from the sinus venosus  Left auricle – with muscular ridges
 Roughened area – front of the ridge with musculi pectinati (pectinate
muscles; muscle fiber bundles of the RA) - run from the crista terminalis to Openings into the LA
the auricle 1. Pulmonary veins (4) – 2 from each lung opens through the posterior
 Anterior part of the atrium – derived from primitive atrium wall; no valves
2. Left atrioventricular orifice – guarded by the mitral valve
Openings into the RA
1. Superior vena cava – opens into the upper part returning blood from
upper half of the body; no valve
2. Inferior vena cava - larger than the superior vena cava; opens into the
lower part returning blood from lower half of the body; guarded by a
rudimentary, non-functioning valve
3. Coronary sinus - drains blood from heart wall; opens into the right atrium
between the inferior vena cava and atrioventricular orifice; with a
rudimentary, non-functioning valve
4. Right atrioventricular orifice – anterior to the inferior vena caval opening
with tricuspid valve
5. Anterior cardiac vein - drains directly to the RA

Fetal Remnants – lie on the atrial septum

Fossa ovalis
 Shallow depression; site of the foramen ovale in the fetus
(foramen ovale brings blood directly to LA in fetus)
1. Upper margin – Annulus ovalis – formed from the lower edge of the
septum secundum
2. Floor of the fossa – represents persistent septum primum of the heart

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Right Ventricle Left Ventricle

 Communicates with RA though the atrioventricular orifice (with tricuspid valve)  Communicated with the LA through the atrioventricular orifice
and the pulmonary trunk though the pulmonary orifice (with pulmonary valve) (with mitral valve) and with the aorta though the aortic orifice
 Becomes funnel shaped (infundibulum) as it approaches the pulmonary orifice (with aortic valve)
 Thicker walls than RA  Aortic vestibule – part of the ventricle below the aortic orifice
 Cross section – crescentic (due to bulging of ventricular septum in RV cavity)  Walls – 3x thicker than RV (left intraventricular blood pressure is
6x higher than in the RV)
Trabeculae carnae (muscle fiber of the RV)  Cross section – circular
 Internal projecting ridges giving a spongelike appearance to the ventricular wall
 With 3 types: Trabeculae carnae (muscle fiber of LV) – well developed
1. Papillary muscles (3) 1. Papillary muscles (2)
 Project inward attached to bases of the ventricular wall 2. No moderator band
 Apices connected by chordae tendinae (fibrous chords) to cusps
of the tricuspid valve
2. Moderator band
 Attached at ends to the ventricular wall, free in the middle
 Crosses ventricular cavity from septal to anterior wall
 Conveys right branch of the atrioventricular bundle
(RBB of bundle of His)
3. Prominent ridges (etchings) – attached along lengths to ventricle wall

STRUCTURE OF THE HEART

Heart wall – with thick layer of myocardium (cardiac muscle) covered externally by the Cardiac Skeleton
epicardium, lined internally by the endocardium  Consists of fibrous rings surrounding the atrioventricular, pulmonary,
and aortic orifices
Atrial portion  Continues with the membranous upper part of the ventricular septum
 Relatively thin walls  Forms basis of electrical discontinuity between atria and ventricle
 Divided by the atrial (interatrial) septum – runs from the anterior wall (act as electrical insulators)
backward to the right
Ventricular portion Fibrous rings around the atrioventricular orifices
 Thick walls  Separate muscular walls of the atria from the ventricles
 Divided by the ventricular (interventricular) septum – placed obliquely, one  Support the bases of the valve cusps
surface facing forward and to the right; other surface facing backward and to  Prevent valves from stretching
the left
 Upper part of septum – thin and membranous; Annulus fibrosus – surrounds AV orifices with extensions around the aortic
lower 2/3 – thick and muscular and pulmonary openings into the fibrous components of the 4 cardiac valves

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HEART VALVES

SEMILUNAR VALVES
 Guards pulmonary orifice at the RV
 With 3 semilunar cusps – from endocardium folds with
some enclosed connective tissue
1. One posterior (left cusp)
2. Two anterior (anterior and right cusp)
 Curved lower margins and sides – attached to arterial
wall (prevents cusps from prolapsing)
 Open mouths directed to pulmonary trunk
Pulmonary
 No chordae or papillary muscles
Valve
 With sinuses (3 dilatations at the root of the pulmonary
trunk) at external of each cusp

 During Systole – cusps are pressed against the wall of

the pulmonary trunk by the outrushing blood
 During Diastole – blood flows back toward the heart and
enters the sinuses - cusps get filled – closes pulmonary
orifice
 Guards the aortic orifice at the LV
 Similar to pulmonary valve – 3 cusps
1. One anterior (right cusp)
Aortic 2. Two posterior(posterior and left cusps)
Valve  Behind each cusp- aortic wall bulges forming an aortic
sinus
 Aortic sinus – gives origin to the right coronary artery
 Left posterior sinus – gives origin to left coronary artery

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HEART VALVES

ATRIOVENTRICULAR VALVES
 Guards atrioventricular orifice at RV
 With 3 cusps – formed by a endocardium fold
1. Anterior cusp
2. Septal cusp – lies against the ventricular septum
3. Inferior (posterior) cusp
 Bases of the cusps – attached to fibrous cardiac skeleton
Tricuspid
 Free edges and ventricular surfaces of the cusps – attached
Valve
to chordae tendinae
 Chordae tendinae - connect the cusps to the papillary
muscles; connected to adjacent parts of 2 cusps

 Systole – papillary muscles contract; prevent cusps from

being forced into the atrium
 Guards atrioventricular orifice at the LV
 With 2 cusps
1. One anterior – larger, intervenes between the
Mitral atrioventricular and aortic orifices
Valve 2. One posterior
 Similar to tricuspid valve cusps
 Attachment of chordae tendinae to cusps and papillary
muscles – similar to tricuspid valve

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CONDUCTING SYSTEM OF THE HEART

Heart contraction
 70-90 beats per minute in a resting adult
 Rhythmic contractile process – originates spontaneously in the
conducting system; impulse travels to different regions of the heart
 Slight delay in impulse passage – allows time for atria to empty their
blood into the ventricles
Conducting system
 Generates rhythmic cardiac impulses
 Conducts impulses rapidly throughout the myocardium of the heart so
different chambers contract in a coordinated and efficient manner
 Influenced by the autonomic nervous system: Parasympathetic – slows
down the rhythm and diminish conduction rate
 Composed of the:
1. Sinoatrial node
2. Atrioventricular node
3. Atrioventricular bundle (Bundle of His)
4. Right and Left Purkinje fibers
Atrioventricular bundle (Bundle of His)
 Only pathway of cardiac muscle connecting the atria and ventricle
myocardium (only route along cardiac impulse from atria to ventricle)
 Descends through the cardiac skeleton
 Descends behind the septal cusp of the tricuspid valve – reaches inferior
border of the membranous part of the ventricular septum
 At upper border – divides into 2 branches – 1 for each ventricle until it
becomes continuous with the Purkinje fibers
1. Right Bundle Branch (RBB) – passes down on right ride of the
ventricular septum to reach the moderator band
2. Left Bundle Branch (LBB)
 Pierces the septum and passes down on the left side
beneath the endocardium
 Usually divides into 2 branches (anterior and posterior)

Sinoatrial Node
 Located in right atrium wall in the upper part of the sulcus terminalis,
right of the superior vena cava opening
 Spontaneously give rhythmic electrical impulses – spread in all directions
through the cardiac muscle of the atria

Atrioventricular Node
 Located at the lower part of the atrial septum above the attachment of
the septal cusp of the tricuspid valve
 Stimulated by the excitation wave as it passes through the atrial
myocardium
 Speed of conduction in AV node – about 0.11 seconds – allow sufficient
time for atria to empty their blood into the ventricles before systole

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 Anatomy 1C Joshua Montelibano 2nd shift 2015-2016

POSTERIOR MEDIASTINUM
Posterior Mediastinum Right side:
Boundaries: 1. Mediastinal pleura
Anterior: Pericardium and Heart 2. Terminal part of the azygos vein
Posterior: Lower eight thoracic vertebra (T5-T12) Left side:
Superior: Imaginary plane at level of sternal angle 1. Left subclavian artery
Inferior: Diaphragm 2. Aortic arch
3. Thoracic duct
Contains: Esophagus, Thoracic duct, Descending aorta, Azygos and 4. Mediastinal pleura
Hemiazygos veins, Sympathetic trunks
At level of the roots of the lungs
ESOPHAGUS  Vagus nerve – leave pulmonary plexus and join with sympathetic nerves – form
 Tubular structure about 10 inches (25 cm) long the esophageal plexus
 In thorax – passes downward to the left through the superior and  Left vagus nerve – anterior to the esophagus
posterior mediastinum  Right vagus nerve – posterior to the esophagus
 At level of sternal angle – aortic arch pushes it over the midline At the opening in the diaphragm
 Accompanied by the 2 vagi nerves, branches of the left gastric blood vessels,
th
Commencement: Laryngopharynx opposite the 6 cervical vertebra (C6) and lymphatic vessels
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Termination: 10 thoracic vertebra (T10 - esophagogastric junction, passed  Fibers from right crus of the diaphragm – pass around the esophagus as a sling
through the diaphragm to join the stomach)  Diaphragmatic constriction - slows food passage
At the abdomen
Relations in the neck:  Descends for about 0.5 inches (1.3cm) and then enters the stomach
Anterior: Trachea and Recurrent laryngeal nerves  Relations: Anterior: left lobe of the liver; Posterior: left crus of the diaphragm
Posterior: Vertebral column
Lateral: Lobes of the thyroid gland Upper 1/3 Middle 1/3 Lower 1/3
With cervical constriction at the pharyngo-esophagogastric junction Inferior thyroid Descending aorta Left gastric artery
Arterial Supply
artery branches branches
Relations in the thorax
Inferior thyroid Left gastric vein
Anterior: Venous Drainage Azygos veins
veins (portal vein)
1. Trachea and left recurrent laryngeal nerve
2. Left principal bronchus – thoracic constriction (constricts the Superior and Left gastric blood
Deep cervical
esophagus together with the arch of the aorta) Lymph Drainage posterior vessel nodes and
nodes
3. Pericardium – separates esophagus from left atrium mediastinal nodes celiac nodes
Posterior: Parasympathetic and sympathetic efferent and afferent fibers
1. Bodies of the thoracic vertebrae Nerve Supply  Vagi and Sympathetic trunks (Ganglia 1-5)
2. Thoracic duct, azygos vein  Esophageal nerve plexus (at lower part)
3. Right posterior intercostal arteries, Descending thoracic aorta

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 Anatomy 1C Joshua Montelibano 2nd shift 2015-2016

THORACIC DUCT THORACIC SYMPATHETIC TRUNK

Origin: Cisterna Chyli (dilated sac below in the abdomen)  Continuous above with the cervical and below with the lumbar parts of the
Commencement: L1 & L2 sympathetic trunks
Termination: Root of the neck – drains into the left brachiocephalic vein  Most laterally placed structure in the mediastinum
 Runs downward on the heads of the ribs
Course:
 th
Leaves the thorax on the side of the body of the 12 thoracic vertebra (T12)
1. Ascends through the aortic opening in the diaphragm on the right side of
– passes behind the medial arcuate ligament
the descending aorta
2. Crosses median plane behind the esophagus  With 12 (or 11) segmentally arranged ganglia – with white and gray ramus
3. Reaches the left border of the esophagus at the sternal angle (T4) communicans
4. Runs upward along the left edge of the esophagus – enters root of the neck
5. Bends laterally behind the carotid sheath and in front of the phrenic nerve Stellate ganglion – formed from fusion of first ganglion with the inferior cervical
6. Crosses subclavian artery to enter the beginning of the left brachiocephalic ganglion
vein
Branches:
At root of the neck – thoracic duct receives: 1. Gray rami communicantes – go to all thoracic spinal nerves
1. Left jugular lymph trunk Postganglionic fibers – distributed through branches of the spinal nerves
2. Subclavian lymph trunk to blood vessels, sweat glands, and arrector pili muscles of the skin
3. Bronchomediastinal lymph trunk 2. First 5 ganglia – give postganglionic fibers to the
heart, aorta, lungs, and esophagus
Thoracic duct conveys to the blood all lymph from the: 3. Lower 8 ganglia – preganglionic fibers – forms splanchnic nerves: supply
 Lower limbs the abdominal viscera (enter the abdomen via piercing the diaphragm
 Pelvic cavity crura)
 Abdominal cavity  Greater splanchnic nerve – from ganglia 5-9
 Left side of the thorax  Lesser splanchnic nerve – from ganglia 10 & 11
 Left side of the head , neck  Lowest splanchnic nerve – from ganglion 12
 Left arm

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 Anatomy 1C Joshua Montelibano 2nd shift 2015-2016

DESCENDING THORACIC AORTA AZYGOS VEINS

Origin: Arch of the aorta  Drains blood from posterior parts of the intercostal spaces, abdominal wall,
Commencement: Sternal angle (lower border of T4 body) pericardium, diaphragm, bronchi, and esophagus
th
Termination: Behind the diaphragm in the midline (12 thoracic vertebra; T12)
Azygos vein
Course:  Origin varies
1. Runs downward the posterior mediastinum  Union of the right ascending lumbar vein + right subcostal vein
2. Inclines forward and medially to reach the anterior surface of the Course:
vertebral column 1. Ascends through the aortic opening in the diaphragm on the right side
3. Passes behind the diaphragm in the midline at level of T12 of the aorta (T5 level)
4. Becomes continues with the abdominal aorta 2. Arches forward above root of the right lung
3. Empties into the posterior surface of the superior vena cava
Branches Tributaries
1. 8 lower right intercostal veins
Parietal branches 2. Right superior intercostal vein
1. Posterior intercostal arteries - given off to the lower 9 intercostal spaces 3. Superior and inferior hemiazygos veins
2. Subcostal arteries - given off on each side, run along the lower border of 4. Mediastinal veins
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the 12 rib to enter abdominal wall
3. Superior Phrenic artery Inferior Hemiazygos Vein
Visceral branches  Union of the left ascending lumbar vein + left subcostal vein
4. Pericardial, esophageal, bronchial, mediastinal arteries - small branches Course:
distributed to the respective organs 1. Ascends through the left crus of the diaphragm end (T8 level)
2. Turns to the right and joins azygos vein
Tributaries
1. Lower left intercostal veins
2. Mediastinal veins

Superior Hemiazygos Vein

 Union of 4 – 8 intercostal veins
th th

 Joins azygos vein at T7

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