Cpwk1 Antatomy 11-4 Middle Mediastinum, Pericardium And Superficial Heart

Front 1

Of the superior mediastinum list the
a. superior/ inferior borders
b. contents (vascular and visceral)

Back 1

a. Borders
i. Superior: Superior Thoracic Aperture
ii. Inferior: 1.
Anterior = Sternal Angle
Posterior= T4-T5 Disc Space
B. Contents:
Great vessels of heart:
i. Aortic Arch: Brachiocephalic Trunk,
Left Common Carotid, Left Subclavian a.
ii. Superior Vena Cava
Vagus n.n.:
-R. and L. Recurrent Laryngeal n.n.
- Phrenic n.n.
- Thoracic duct (Left)
- Trachea (anterior to the esophagus)
- Esophagus
- Thymus

Front 2

Label the superior mediastinum parts

Back 2

1. Right brachio-cephalic v
2. Brachio- cephalic trunk
3. Left brachio-cephalic v.
4. Left vagus
5. aortic arch
6. ligamentrum arteriosum
7. left pulmonary a.
8. pulmonary trunk
9. left auricle (atrial appendage)
10. Left coronary a. (anterior interventricular branch)
11. Right auricle (atrial appendage)
12. Parietal pleura mediastinal part
13. Ascending aorta
14. Superior vena cava
15. Right lung
16. Right phrenic n.

Front 3

Back 3

Front 4

Back 4

Front 5

A 65 y.o. male presents to E.D. with C/C (chief complaint):
sudden onset, tearing chest pain, migrating to interscapular region of back, accompanied by dyspnea (difficulty breathing) and hemoptysis (coughing blood).
Pt.’s primary care physician relates pt. has 20+ year Hx (history) poorly controlled HPTN (hypertension) and hoarseness x 2 months.

What is pt's possible diagnosis and what explains hoarseness for 2 months?

Back 5

dissecting aortic aneurysm

Hoarseness secondary to impingement of the Left Recurrent Laryngeal nerve, which provides
motor and sensory innervation to the larynx, by the enlarged Aortic Arch may also present

Front 6

Explain what an aortic aneurysm is and what causes it...
What is typical clinical presentation...
What is most common type of dissecting aortic aneurysm and where are ruptures?

Back 6

most often caused by HTN
- causes dissection by
inflicting shear stress on intimal layer. The resulting tear (dissection) allows blood between intima and media layers of aortic wall, which is “hammered” distally and/or proximally by each contraction of the left ventricle, creating a false lumen.
Patient Presentation:
Acute onset C/C: “Tearing chest pain radiating to back” is classic, as are signs of cardiac tamponade and absent upper extremity pulses
- Mos common is Stanford Type A- ruptures into pericardial sac

Front 7

Do the following to describe the middle mediastinum...
a. Location
b. Contents

Back 7

a. between anterior and posterior medistinum
b. i. Pericardium
ii. heart
iii. root of great vessels (asc. Aorta, pulm. Trunk, and SVC)
iv. Phrenic n.

Front 8

Where is pericardium located and what are characteristics?

Back 8

located around the heart... most outer layer is a double layered serous sac called the
1. fibrous pericardium
2. Double-walled serous covering of heart has 2 layers
a. Parietal layer of serous pericardium
b. visceral layer of serous pericardium
- in between layers is pericardial cavity

Front 9

The transverse sinus of the pericardium is located between the arterial and venous mesocardia...
What is the clinical significance of it?

Back 9

Clinical significance
pericardial fat etc, may be mistaken for thrombus in a cardiac chamber. Seeing the prominent sinus in multiple views clarifies the diagnosis
- also used in Echocardiographs because it site of fluid accumulation, surgery for routes of grafts,

Front 10

Identify the oblique pericardial sinus in the serous pericardium...
Where is it located, and what is the clinical significance?

Back 10

diverticulum behind heart
- clinical same as transverse
Surgery- offers route to left atrium and mitral valve, used for off-pump coronary artery/myocardial revascularization

Front 11

What is the blood supply to the pericardium that the two white arrows point to?

Back 11

top- Pericardiacophrenic a ( runs with phrenic n (C3-5)
bot- Musculophrenic a (branches off internal thoracic a)

Front 12

Describe the position of the heart by describing the following...
a. upper limit
b. right margin
c. left margin
d. lower margin

Back 12

a. level of 3rd costal cartilages and inferior border of 2nd Inf. Border of 2nd L To sup. Border of 3rd R costal cart.
b. 3rd R costal cartilages to 6th R costal cart
c. Connect sup. (2nd L costal cartilage) & inf. Borders (5th ICS at
MCL)
d. End of R border To 5th ICS at left
MCL (apex)

Front 13

What is pericarditis?
How is it caused?
What are signs and symptoms? ,

Back 13

- inflammation of pericardium
Commonly caused by inflammatory response on (visceral pericardial surface after infarcts) 3-5 after MI
- results in pericardial friction rub, which sounds like creaky leather, also known as "high pitched pericardial knock"
s/s
Mid-sternal chest pain radiating to shoulders/neck region. Pain increased with inspiration and supine

Front 14

What is the innervation of the pericardium?

Back 14

1. Vagus n.
Function= unclear
2. Sympathetic trunks
Function= vasomotor
3. Phrenic n.n.
Function=sensory fibers
Pain referred to skin dermatome C3-C5

Front 15

Describe the surfaces and shape of the heart...

Back 15

pyramidal-shaped
• obliquely situated in the chest
• 3 surfaces:
– 1) sternocostal (anterior)
– 2) diaphragmatic (inferior)
– 3) pulmonary (left)

Front 16

Label heart (posterior viewing)

Back 16

1. left superior pulmonary vein
2. left atrium
3. left inferior pulmonary vein
4. inferior vena cava
5. right inferior pulmonary vein
6. right atrium
7. right superior pulmonary vein
8. superior vena cava

Front 17

What forms the base of the heart?

Back 17

Base= top part
all atria and great vessels
where vessels exit and enter heart

Front 18

what is 1?

Back 18

Sulcus Terminalis
– Depression on the surface of the RA- shallow vertical groove separating smooth
& rough parts of atrial wall
– surface demarcation of the Crista Terminalis within the RA.
Importance:
– where the SA Node resides

Front 19

What are lines what are role?

Back 19

sternocostal surface- sits on rib cage
1. coronary sulcus- separates atria and ventricle all the way around
2. anterior interventricular sulcus- divides R/L ventricles

Front 20

Where is a normal healthy apex located?
What are some clinical aspects found when there is pathology (2) how does PMI change?

Back 20

- located 5th inter costal space in mid clavicular line (found with patient in left lateral decubitus position
produces PMI (point of maximal impulse)
Pathology shows-
1. left ventricula hypertrophy- PMI does not displace, but greater in size (quarter)
2. Left ventricular dilation- PMI displaces lateral mid clavicular line (dime)

Front 21

The blue circles represent the sites of the physical valves of the heart and the green circles represent the sites of auscultation...
Which are which?

Back 21

Red arrows:
1. pulmonary valve
2. Aortic valve
3. Left AV valve (mitral)
4. R AV valve (tricuspid)
Green Circles:
1. Aortic valve
2. Pulmonary valve
3. Right AV (tricuspid)
4. Left AV (mitral)
Red-Green Matches
1-2
2-1
3-4
4-3

Front 22

Describe the relative position and distributions of the right coronary arteries

Back 22

Right coronary supplies posterior side with blood-
Origin:R. aortic sinus
Path: Follows the coronary sulcus to the R. around the inferior border,
Terminates: near posterior interventricular sulcus after giving off
Posterior Interventricular Branch.

Front 23

Label important branches off this main artery... which is?

Back 23

R coronary artery
a. sinoatrial (SA) nodal branch
b. Right marginal branch
c. (AV) atrioventricular nodal branch
d. Posterior interventricular branch (posterior descending artery)

Front 24

Label spots

Back 24

1. RCA - right coronary artery
2. Sinuatrial nodal branch
3. right marginal artery

Front 25

Describe this artery and label branches...

Back 25

Left Coronary Artery
Origin: L. aortic sinus
Course: under L. auricle Rapidly bifurcates into:
a. Anterior Interventricular br. /LAD
b. Circumflex br.
1. left coronary artery
2. circumflex branch
3. anterior interventricular branch (left anterior descending)
4. Diagonal branches of anterior interventricular branch)

Front 26

Label part of this artery which is what artery?

Back 26

Branches of the LCA
1. anterior interventricular branch
2. circumflex branch
3. left coronary artery

Front 27

HPI: a 55 yo female presents to the ED with acute onset crushing substernal chest pain. Pain is 10/10 in severity, and radiates down left arm. Pt. is dyspneic, diaphoretic, and has difficulty speaking because of pain. Emergent fluoroscopy reveals almost total occlusion of the Anterior Interventricular a. / Left Anterior Descending a.. What is diagnosis most likely and why?

Back 27

Acute Myocardial Infarction (MI)
Patient was diagnosed with acute Anterior Myocardial Infarction caused by 90% occlusion of the Anterior Interventricular a. / Left Anterior Descending a. A
Coronary Artery Bypass Graft (CABG) using the internal thoracic artery was performed.

Front 28

What in order are the two most common Coronary artery occlusion areas?

Back 28

1. anterior interventricular branch (where does it originate?)
2. Right coronary artery

Front 29

HPI: A 55 yo female 7 days post-MI presents to the ED with C/C: abrupt onset chest pain with tearing sensation. Physical exam reveals tachycardia and hypotension, and emergent echocardiogram most likely confirms?
\

Back 29

confirms cardiac tamponade.
Course: Emergent pericardiocentesis, using a fluoroscopic-guided subcostal
approach preserves the patient’s life long enough for the cardiothoracic
surgeon to repair the left ventricular free-wall defect.

Front 30

What is a pericardiocentesis and where is it performed?
What exactly is a cardiac Tamponade?

Back 30

Basically draining blood out of area
Site of Pericardiocentesis:
– Just below left xiphochondral junction.
– needle insertion in posterosuperior
direction, fluoroscopically-guided.

Cardiac Tamponade:
-Fluid accumulation in the pericardial space. May result from pericardial effusion, ventricular rupture or aortic aneurysm rupture.
• Use pericardiocentesis to get fluid out and release pressure from heart then GET TO OR!

Front 31

What are the main veins of the heart?
What does the coronary sinus vein associate with?

Back 31

1. coronary sinus- does not associate with coronary arteries, remnent of the left superior vena cava (gone after born)
2. anterior cardiac veins
3. smallest cardiac veins

Front 32

Describe the Coronary sinus

Back 32

Main vein of coronary circulation
• posterior part of coronary sulcus
• ends in posterior wall of RA
between the IVC and tricuspid
valve.
• a single semilunar valve
• Remnant of the embryological Left Superior Vena Cava.

Front 33

What are the spots

Back 33

The Coronary sinus vein and tributaries that are important
1. coronary sinus vein
2. posterior vein of left ventricle
3. Great cardiac (antieror interventricular vein)
4. Oblique vein of left atrium (Marshall)
5. Middle cardiac (posterior interventricular vein)

Front 34

Back 34

Front 35

Describe the vein labeled #1

Back 35

Anterior Cardiac Veins
• 3 or 4 small vessels that collect blood from the anterior aspect of the RV
• Open directly into the RA

Front 36

1. The heart is in what part of the mediastinum?
2. How many layers does the pericardium contain?

3. Where is the pericardial cavity?

4. What are the pericardial sinuses?

Back 36

1. middle
2. 2 (fibrous and serous-parietal & visceral)
3. between parietal & visceral serous pericardium
4. transverse and oblique pericardial sinuses pericardium is folded over

Front 37

5. What vessels supply blood to the pericardium?

6. What provides sensory innervation to the pericardium?

7. Where do the coronary arteries originate?

8. What are (usually) the branches of the RCA?

Back 37

5.pericardicophrenic, musculophrenic, thor aorta(bronchial, esophageal, sup. Phren.), cor.a.
6. phrenic n.
7. ascending aorta (aortic sinus)
8. SA nodal br. , atrial br., R marginal br., post interventricular br., AV nodal br.

Front 38

9. What are (usually) the branches of the LCA?

10. What are some cardiac veins that drain the heart?

Back 38

9. ant interventricular br (diagonal br.), circumflex br., L marginal br.,

10. coronary sinus (great cardiac v, middle cardiac v, small cardiac vein, post. V. of LV), anterior and smallest cardiac veins