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Anatomy teaching Session 2 CVR anatomy and RadiologyDisclaimer • The following presentation has been made for students by students and we are not held accountable for any inaccuracies. This is a learning tool that has not been reviewed by the University of Sheffield and therefore the use of this session is to facilitate your learning only.Aims and objectives • Understanding what is meant by the mediastinum, the divisions and the organs in each part. • Understanding the external features of the heart including the pericardium and its innervations. • Understanding the position of the heart borders and surfaces. • Describing the blood supply of the heart and the position of the coronary arteries. • Describing the internal structures of the atrium and ventricles. • Being able to identify the surface anatomy of the heart and how to listen to the heart sounds. • Being able to describe the path of the electrical stimulation in the heart. • Describing the bone structure of the thorax and the breasts including innervations and blood supply. • Describing the position of the pectoralis major, minor and the serratus anterior. • Understanding the position of the intercostal neurovascular bundle. • Understanding the pleura, and the structure of the lungs including the trachea. • Being able to describe the mechanics of breathing and diaphragm. • Being able to identify basic structures on an X-ray. • Understanding how a normal chest X-ray looks like.Mediastinum Anatomy handbook. University of Sheffield. School of medicine and population health. https://www.saintjohnscancer.org/thoracic/conditions/mediastinal-tumors/ Cardiovascular and respiratory anatomy.Arch of the aorta https://en.wikipedia.org Ductus arteriosus and foramen ovale Does anyone know why do we have ductus arteriosus and foramen ovale in an unborn person? https://en.wikipedia.org/wiki/Patent_ductus_arteriosus closure/www.fhvvi.com/service/patent-foramen-ovale-pfo-Superior Mediastinum • Two large veins carrying deoxygenated blood enter the right atrium: the superior vena cava and the inferior vena cava. The superior vena cava (SVC) returns blood to the heart from the head, neck, and upper limbs. • The oesophagus is a muscular tube that extends stomach. ‘Waves’ of contractions of smoothk to the muscle in the oesophageal wall move swallowed food and fluid distally (peristalsis). • The left and right phrenic nerves, from the C3, C4 and C5 spinal nerves, innervate the diaphragm and pericardium. https://www.youtube.com/watch?app=desktop&v=xZ120mL3l98Vagus nerve and thoracic duct • The left and right vagus nerves (CN X) arise from the brainstem and contain somatic sensory, somatic motor and parasympathetic fibres. • They each give rise to a recurrent laryngeal nerve (RLN). The left recurrent laryngeal nerve loops under the arch of the aorta • The thoracic duct is a major channel for lymphatic drainage • Trachea divides at T4/5 at level of Carina cartilage. Anatomy handbook Pericardium The Pericardium Thepericardiumisa tough, fibroussac that enclosesthe heart a tough, outer fibrous layer a thin, inner serous layer whichhastwo parts: the parietallayer linestheinner aspect of thefibrous pericardium, and thevisceral layercoversthesurfaceof theheart. Thenarrowspacebetween thetwo layersof serous pericardiumisthepericardialcavity. It containsa small amount of pericardialfluid that lubricatestheserous membranes. The left and right phrenic nerves give rise to sensory rdial-disease/evelandclinicmeded.com/medicalpubs/diseasemanagement/cardiology/perica branches thatinnervate the fibrous pericardium. Commonexamquestion!!! Heart Surfaces Thesurfacesof theheart arethe: •posteriorsurface – it ‘faces’ posteriorly, against the oesophagusand descending aorta. •inferiorsurface – it restson thediaphragm, so isalso called thediaphragmaticsurface. •anteriorsurface – it ‘faces’ thesternumand ribs. •Theleft and right sidesof theheart ‘face’ thelungs. Thesurfaces correspond to specific partsof theheart, as summarised below: •Base/posterior surface= left atrium, part of theright atrium •Inferior/diaphragmatic surface= left and right ventricle •Anterior /sternocostal surface= right ventricle https://www.youtube.com/watch?v=63AcotLgSJ4 •Left pulmonary surface= left ventricle •Right pulmonary surface= right atrium.X-ray HandbookBorders of the heart • Right border = lateral to the right sternal edge, from the right 3rd costal cartilage.to the right 6th costal • Left border = extends from the left 2nd intercostal space to the left 5th intercostal space in the midclavicular connecting the superior extents of the right and left borders • Inferior border = along the line connecting the inferior end of the right border with the apex https://clincasequest.hospital/x-ray-heart-borders/ Chest X-rays What part of the heart What artery could this be? What part of the heart https://app.lecturio.com/#/article/1212Chest X-ray https://app.lecturio.com/#/article/1212 circles at the left side of the patient below diaphragm?Coronary arteries • Right: • Branches to sinoatrial node and AVN. • Posterior interventricular (posterior descending) • Right marginal • Left: • Left anterior descending (anterior interventricular)àdiagonal branches • Left circumflexà left marginal Are most people left or right dominant? https://www.researchgate.net/figure/Anatomy-of-the-coronary-arteries_fig1_324479069Left or right dominant? • Most people have a right dominant circulation; the PIVA arises from the right coronary artery. In these people, both the right and left coronary arteries supply the left ventricle. In those with a left-dominant circulation, the PIVA arises from the circumflex artery, so the left coronary artery supplies the entire left ventricle. • What is the clinical significance if someone is left dominant?Cardiac veins https://guysandstthomasspecialistcare.co.uk/treatments/coronary-sinus-reducer/Structures of the heart https://med.libretexts.org/Bookshelves/Anatomy_and_Physiology/Human_Anatomy_%28Lange_et_al.%29/17%3A_Cardiovascular_System_-_Heart/17.02%3A_Heart_AnatomyHeart sounds • Aortic = 2nd intercostal space, just to the right of the sternum. • Pulmonary = 2nd intercostal space, just to the left of the sternum. • Tricuspid = 5th intercostal space, just to the left of the sternum. • Mitral = 5th intercostal space, left midclavicular line. https://journals.rcni.com/nursing-standard/how-to-auscultate-for-heart-sounds-in-adults-ns.2017.e10965Conducting system of Heart https://www.heart-valve-surgery.com/heart-surgery-blog/2007/08/23/diagram-of-cardiac-conduction-system/Innervations • Sympathetic à cardiopulmonary splanchnic nerve • Have you heard inotropic and chronotropic? • Vagus nerve parasympathetic • Visceral afferent • Referred pain. Can someone explain it?Case • Case Presentation: A 72-year-old male presents to the emergency department with progressive shortness of breath over the past week, worsening leg swelling, and fatigue. He has a history of hypertension and ischemic heart disease. On examination, he is tachypnoeic, with bilateral pitting oedema to the knees and crackles at both lung bases. His blood pressure is 150/90 mmHg, heart rate is 98 bpm, and oxygen saturation is 89% on room air. • Key Investigations: • Blood tests: Elevated BNP levels • Chest X-ray: Awaiting interpretation https://radiopaedia.org/articles/congestive-cardiac-failure Heart failure BNP is B type natriuretic peptide produced by ventricles. https://www.researchgate.net/figure/Chest-X-ray-of-congestive-heart-failure-14_fig4_356460418 Sternum What are the 3 parts: Manubrium Body Xiphoid https://www.innerbody.com/image_chest1/skel16.html Ribs 7-10 costal margin 1-7 true 8-10 false 11-12 floating Costovertebral and Costochondral joints Anatomy handbook Typically,theheadofthe ribarticulateswiththe vertebral bodyandthe tubercleofthe ribarticulateswiththe transverseprocessofthe vertebra.Surface anatomy • A series of imaginary vertical lines provide a second coordinate: • Midclavicular line • Anterior axillary line • Mid-axillary line • Posterior axillary line • Ylandmarks on yourself:dentify and palpate these bony • clavicle (collarbone) • manubrium, body, and xiphoid process of the sternum • sternoclavicular joints • suprasternal notch • sternal angle and the second rib at the level of the sternal angle • costal margin. https://en.wikipedia.org/wiki/List_of_anatomical_lines Breast • The surface landmarks of the nipple (dermatome T4) and the umbilicus (dermatome T10) help us make estimates of the other dermatomes when examining patients. The breast is primarily supplied with arterial blood by branches of the internal thoracic artery (which arise from the subclavian artery) and the axillary artery Apical node is the lymph node that they all rain to from the 5 lymph nodes. https://www.researchgate.net/figure/Arterial-Supply-of-the-Female- Breast_fig1_347361059 Muscles • Pectoralis major is the most superficial muscle of the anterior thoracic wall. It attaches to the proximal humerus, the sternum, clavicle and the upper six ribs. • Pectoralis minor is a smaller muscle that is located deep to pectoralis major. It attaches to the scapula (shoulder blade) and ribs 3-5. • Serratus anterior is a superficial muscle that sweeps around the lateral aspect of the thoracic cage. It attaches to the scapula and the upper eight ribs. Anatomy booklet Accessory muscles of breathing. Intercostal muscles Why if we want to put a needle in the space we go for the bottom half of the intercostal space? The bundle is between innermost and internal intercostal muscle Is external intercostal muscle active in expiration or inspiration? https://www.orchardhealthclinic.com/intercostal-muscle-strain/ Pleura The cervical pleura covers the apex of the lung. The costal pleura is adjacent to the ribs. The mediastinal pleura is adjacent to the heart and mediastinum. The diaphragmatic pleura is adjacent to the diaphragm. What are the costomediastinal and costodiaphragmatic recesses? https://www.learnanatome.com/cavity Lungs Can come up in the exam both SBA and SAQ • Costal surface - adjacent to the ribs. • Mediastinal surface - adjacent to the heart and mediastinum. • Diaphragmatic surface - the inferior surface of the lung. • The inferior border of the lungs is located at the level of the: • 6th rib anteriorly (midclavicular line) • 8th rib laterally (midaxillary line) • 10th rib posteriorly (just lateral to the vertebral column). • The parietal pleura extends to the: • 8th rib anteriorly (midclavicular line) • 10th rib laterally (midaxillary line) lungs///courses.lumenlearning.com/suny-ap2/chapter/the- • 12th rib posteriorly (just lateral to the vertebral column).Innervations • Autonomic nerves innervate the lungs: • Parasympathetic fibres stimulate constriction of bronchial smooth muscle (bronchoconstriction) and secretion from the glands of the bronchial tree. • Sympathetic fibres stimulate relaxation of bronchial smooth muscle (bronchodilation) and inhibit secretion from the glands. • Lymph from the lungs ultimately drains into the venous system via the thoracic duct or right lymphatic duct. Hilum of the lung RALS. Right anterior, Left superior Good exam question! https://www.youtube.com/watch?app=desktop&v=iUyJBwHWhdwBronchi On right side 3 lobar and 2 on the left and 10 segmental on both Handbook Diaphragm • The diaphragm is a broad, thin, and domed sheet of skeletal muscle. • The diaphragm is attached to the xiphoid process, central part of the diaphragm is not muscular, but fibrous - the central tendon. • What nerve innervates the diaphragm and what are its origins? • Starts with Phr Common exam question: https://www.yoganatomy.com/diaphragm-muscle/ T8, T10, T12 : Vena Cava, Oesophagus and aorta Breathing Intercostal muscles and diaphragm Inspiration is active Is expiration usually active? Thepleuraeand pleural fluid areintegral to ventilation. Thepleural fluid createssurface tensionbetween theparietal pleura lining the thoracic cavityand thevisceral pleura on the surfaceof thelung. Accessory muscles of breathing:(sternocleidomastoid, pectoralis major https://www.abpischools.org.uk/topics/breathing-and-asthma/breathing/ and minor, serratus anterior)Case Patient: Mr. James Thompson, 62, presents with worsening shortness of breath, dry cough, and chest discomfort. Key Findings: •Exam: Reduced breath sounds and dull percussion on the right side. •Vitals: BP 140/85, HR 98, RR 24, SpO2 88% (room air). •Background: History of congestive heart failure and a recent episode of pneumonia treated with antibiotics. Questions: 1.What are your differentials? 2.What investigations do you order? 3.Analyze the provided X-ray https://jetem.org/pleural-effusion/Pleural effusion • This occurs where excess fluid occurs between the pericardial layers. This will look the same as Haemothorax but haemothorax is excluded because of the case of heart failure. • Heart failure can lead to pleural effusion due to increased pressure in the pulmonary circulation. When the heart fails to pump efficiently, blood backs up in the veins, raising pressure in the capillaries around the lungs. This causes fluid to leak from the capillaries into the pleural space, leading to a transudative pleural effusion.A patient is under respiratory distress meaning they sat down and are using extra muscles for breathing. Which of the following is an accessory muscle of breathing? • A) External intercostal muscle • B) Internal intercostal muscle • C) Sternocleidomastoid • D) External obliqueA patient is under respiratory distress meaning they sat down and are using extra muscles for breathing. Which of the following is an accessory muscle of breathing? • A) External intercostal muscle • B) Internal intercostal muscle • C) Sternocleidomastoid • D) External obliqueWhich of the following is found in the middle mediastinum? • A) Aorta • B)Thymus • C)Heart • D)Azygos veinWhich of the following is found in the middle mediastinum? • A) Aorta • B)Thymus • C)Heart • D)Azygos veinDiaphragm is a muscle involved in inspiration. Which one of the following nerves innervates the diaphragm? • A) Vagus nerve • B) Accessory nerve • C)Glossopharyngeal nerve • D) Phrenic nerveDiaphragm is a muscle involved in inspiration. Which one of the following nerves innervates the diaphragm? • A) Vagus nerve • B) Accessory nerve • C)Glossopharyngeal nerve • D) Phrenic nerveA patient is admitted to the hospital with cough and chest pain. The doctor uses his stethoscope to listen to his heart sound. Where should he place his stethoscope to hear the aortic valve sound? • A) 2nd intercostal space, just to the right of the sternum. • B) 2nd intercostal space, just to the left of the sternum. • C) 5th intercostal space, just to the left of the sternum. • D) 5th intercostal space, left midclavicular line.A patient is admitted to the hospital with cough and chest pain. The doctor uses his stethoscope to listen to his heart sound. Where should he place his stethoscope to hear the aortic valve sound? • A) 2nd intercostal space, just to the right of the sternum. • B) 2nd intercostal space, just to the left of the sternum. • C) 5th intercostal space, just to the left of the sternum. • D) 5th intercostal space, left midclavicular line.Which one of the followings is found in the ventricles? • A) Pectinate muscles • B) Papillary muscles • C) Fossa Ovalis • D) Pacemaker cellsWhich one of the followings is found in the ventricles? • A) Pectinate muscles • B) Papillary muscles • C) Fossa Ovalis • D) Pacemaker cellsThanks for listening Session 2 psanikhani1@Sheffield.ac.ukReferences • Anatomy handbook. University of Sheffield. School of medicine and population health. Cardiovascular and respiratory anatomy. • https://www.saintjohnscancer.org/thoracic/conditions/mediastinal-tumors/ • https://en.wikipedia.org • https://en.wikipedia.org/wiki/Patent_ductus_arteriosus • https://www.fhvvi.com/service/patent-foramen-ovale-pfo-closure • https://www.youtube.com/watch?app=desktop&v=xZ120mL3l98 • https://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/cardiology/pericardial-disease/ • https://www.youtube.com/watch?v=63AcotLgSJ4 • https://clincasequest.hospital/x-ray-heart-borders/ • https://app.lecturio.com/#/article/1212 • https://www.researchgate.net/figure/Anatomy-of-the-coronary-arteries_fig1_324479069 • https://guysandstthomasspecialistcare.co.uk/treatments/coronary-sinus-reducer/ • https://med.libretexts.org/Bookshelves/Anatomy_and_Physiology/Human_Anatomy_%28Lange_et_al.%29/17%3A_Cardiovascular_System_- _Heart/17.02%3A_Heart_Anatomy • https://journals.rcni.com/nursing-standard/how-to-auscultate-for-heart-sounds-in-adults-ns.2017.e10965References • https://www.heart-valve-surgery.com/heart-surgery-blog/2007/08/23/diagram-of-cardiac-conduction- system/ • https://radiopaedia.org/articles/congestive-cardiac-failure • https://www.researchgate.net/figure/Chest-X-ray-of-congestive-heart-failure-14_fig4_356460418 • https://www.innerbody.com/image_chest1/skel16.html • https://en.wikipedia.org/wiki/List_of_anatomical_lines • https://www.researchgate.net/figure/Arterial-Supply-of-the-Female-Breast_fig1_347361059 • https://www.orchardhealthclinic.com/intercostal-muscle-strain/ • https://www.learnanatome.com/cavity • https://courses.lumenlearning.com/suny-ap2/chapter/the-lungs/ • https://www.youtube.com/watch?app=desktop&v=iUyJBwHWhdw • https://www.yoganatomy.com/diaphragm-muscle/ • https://www.abpischools.org.uk/topics/breathing-and-asthma/breathing/ • https://jetem.org/pleural-effusion/