1
Q
How to distinguish anterior portion of heart from posterior
A
- anteriorly: apex points to the patients left; can see SVC/IVC, aorta, pulmonary trunk, R&L auricles
- posteriorly: coronary sinus, posterior interventricular A, pulmonary veins
2
Q
Pericardium of heart
- layers
- What is layer of the pericardium are you touching when touching the outside surface of the heart
- innervation
- which layer does NOT feel pain of pericarditis
A
- Fibrous pericardium and Serous Pericardium which is made up of parietal pericardium and Visceral pericardium
- Visceral layer of serous pericardium (epicardium)
- Visceral is innervated by vagus while the rest is innervated by the phrenic
- Visceral layer
3
Q
Which layer of the pericardium can you not feel pain in?
A
Visceral pericardium while fibrous and srous is innervated by phrenic
4
Q
Occlusion of … will cause …. - RCA - LAD/posterior descending artery - Right/left marginal artery - Circumflex - Left main coronary artery
A
- Right atrium, SA and AV nodes, and posterior part of IVS - Right and left ventricles and both anterior and posterior parts of IVS - Left ventricle, right ventricle, and apex - Left atrium and left ventricle - Most of left atrium and ventricle, IVS, and AV bundles; may supply AV node
5
Q
How does coronary artery occlusion affect conduction system of heart?
A
- Arterial supply to both SA and AV nodes usually derived from RCA. However, AV bundle traverses center of Inter Ventricular Septum (anterior 2/3 supplied by septal branches of anterior IV branch of LCA). Thus, coronary occlusion may somewhat impede conduction of the heart but not completely stop it due to anastomses.
6
Q
How to differentiate between left and right dominant heart? -importance?
A
- Dominance of the coronary arterial system is defined by which artery gives rise to the posterior interventricular (IV) branch (posterior descending artery) - left-dominant hearts, this can be more dangerous in the case of an occlusion in the left coronary artery because there would be no way to effectively perfuse the heart because this would prevent flow into the left circumflex artery, left marginal artery, anterior interventricular artery, and posterior interventricular artery.
7
Q
Veins of heart - anterior - posterior
A
- great cardiac vein to left side, and small cardiac vein to right side (patients view) - (L to R) left marginal vein, left posterior ventricular vein, middle cardiac vein
8
Q
What section of heart does each vein drain? Where are they going to?
A
- great cardiac vein: anterior interventricular; begins near apex and ascends w/ anterior LCA- drains anterior portion of L ventricle - middle cardiac vein: drains posterior portion of right lateral aspect of heart - small cardiac vein: accompanies right marginal branch of RCA, drains anterior right ventricle and atrium
9
Q
Where does the coronary sinus drain?
A
into the R Atrium
10
Q
Compare and Contrast the atrium
- Forms
- Recieves
- Walls
- Auricle
- Embryonic remnants
- Pressure
- Size
A
- R: forms right border; L forms most of the bade
- R: receoves blood from SVC, IVC, coronary sinus; L: from pulmonary veins
- R: walls posteriorly are smooth and thin, anteror and rough bc of pectinate muscles, and crista terminalis separates smooth and roguh parts; L: walls are smooth and slightly thicker
- R: conical and pectinate muscles; L: trabeculated with pectinate
- R: oval fossa (oval foramen) and sinus venarum (sinus venosus); L: single pulmonary trunk remnants
- R: pressure is slightly lower, L: pressure is high
- R: slightly larger, L: smaller
11
Q
Structure and function of right atrium - smooth - rough - orifice
A
• smooth: where SVC, IVC, and coronary sinus open, • rough: anterior wall composed of pectinate muscles • right AV orifice: where right atrium pushes blood into right ventricle
12
Q
Structure and function of left atrium - smooth - auricle - pulm veins - thickness of wall - interatrial septum
A
· larger smooth: larger than RA - auricle: smaller, containing pectinate muscles - 4 pulmonary veins (2 superior and 2 inferior) entering its smooth posterior wall carrying oxygenated blood into heart -slightly thicker wall than R atrium - interatrial septum: slopes posteriorly and to right
13
Q
Impact of congenital and atrial septal defect on heart function
A
allows oxygenated blood to flow from the left atrium to the right atrium. There, it mixes with deoxygenated blood and is pumped to the lungs. Leading to potential lung complications and systemic circulation disorders.
14
Q
What happens with occlusion traveling into heart when patient has atrial septum defect? - where can clot end up?
A
- can potentially travel into the lungs causing pulmonary embolism, however with the congenital defect, it can travel straight into systemic circulation - right atrium: lungs; left atrium: coronary artery or carotids (stroke)
15
Q
Right ventricle vs Left Ventricle - thickness - trabeculae carneae - conical cavity - papillary muscles
A
- LV walls are 2/3 x as thick as those of the right ventricle. - walls that are mostly covered with a mesh of trabeculae carneae are finer and more numerous than those of the right ventricle. - LV has a conical cavity that is longer than that of the right ventricle. - anterior and posterior papillary muscles that are larger than those in the right ventricle.
16
Q
Importance of pap muscle in circulation
A
- help contract the ventricle in controlling the stroke volume and heart rate. - prevent prolapse of the mitral and bicuspid valve to prevent regurgitation.
17
Q
How does weakness of septomarginal trabeculae affect electrical conduction of the heart?
A
septomarginal trabecula carries part of the right bundle branch of the AV bundle to the anterior papillary muscle. A weakness in this can delay or prevent conduction signals.
18
Q
How do valves relate to heart sounds?
A
First heart sound “lubb” corelates to closing of the atrioventricular valves. Second heart sound “dubb” corelates to closing of the semilunar valves
19
Q
Projection of heart valves on anterior thoracic wall
A
- Aortic semilunar valve: projection is behind the sternum opposite the 3rd intercostal space - Pulmonary semilunar valve: surface projection is on the left side of the sternum opposite the left 3rd intercostal junction - Tricuspid Valve: surface projection is behind the sternum opposite the 4-5th intercostal junction - Mitral Valve - surface projection is to the left of the 4th intercostal junction
20
Q
Innervation of heart: Sympathetic
A
Lateral horn of spinal cord –> ventral horn –> ventral rootlets –> ventral roots –> spinal nerve –> primary ventral rami –> white communicans rami –> sympathetic trunk/chain (aka parasympathetic ganglion) [THIS IS WHERE SYNAPSE OCCURS]–> cardiopulmonary splanchnic nerve –> heart
21
Q
Innervation of heart: Parasympathetic
- why is pain of ischemia perceived as originating from skin of upper limb?
A
- Vagus nerve –> atrial wall and interarterial septum near the SA and AV nodes and coronary arteries
- heart is insensitive to touch, cutting, cold and heat but build up of metabolites from ischemia can stimulate pain endings in myocardium. The afferent pain fibers run centrally in the middle and inferior cervical branches and especially in the thoracic cardiac branches of the sympathetic trunk and the axons of these pimary sensory neurons enter spinal cord segments T1 through T4/5 especially on the left side
22
Q
Outline flow of blood through heart
A
Right atrium -> Right ventricle -> pulmonary circulation -> left atrium -> left ventricle -> systemic circulation
23
Q
Major types of cardiovascular dx
A
- CAD - Stroke - HTN
24
Q
Branches of RCA
A
- SA nodal - Right marginal - Posterior IV - AV nodal
25
Distribution of branches of RCA - SA nodal - Right marginal - Posterior IV - AV nodal
- Pulmonary trunk and SA node - Right ventricle and apex of heart - Right and left ventricles and posterior third of IVS - AV node
26
Branches of LCA
- SA nodal - Anterior interventricular (anterior descending) - Circumflex - Left marginal - Posterior IV (sometimes)
27
Distribution of branches of LCA - SA nodal - Anterior interventricular (anterior descending) - Circumflex - Left marginal - Posterior IV (sometimes)
- Left atrium and SA node - Right and left ventricles and anterior two thirds of IVS - Left atrium and left ventricle - Left ventricle - Right and left ventricles and posterior third of IVS
28
How would a physician treat a patient with an obstruction of coronary artery? - how does it work? - most common used? why?
- CABG - segment of an artery or vein is connected to the ascending aorta or proximal part of that coronary artery and and then the the coronary artery distal of the block - great saphenous: about same width as coronary artery, easily dissected, offers lengthy portion with little to no valves
29
Coarctation of the aorta
- what is it?
- usual presentation? why?
- types
- compensation
- effect
- aorta is narrowing/ constriction in a portion of the aorta
- HTN, because the heart is having to pump harder to get blood out to the system
- pre-ductal and post ductal
- developing collaterals around the coarctation region between the proximal and distal parts od he aorta through intercostal and internal thoracic arteries
- decreases blood flow to the inferior portion of the body
30
Describe types of coarctation of the aorta
- 1) Pre ductal - before the ductus arteriosus - infant - the arteriosus can be kept open with prostaglandins to supply the aorta - 2) Post ductal - after the ductus arteriosus - adult - late onset, sometimes asymptomatic
31
What nerve could be affected by aneurysm of arch of aorta?
left recurrent laryngeal nerve
32
boundaries of superior mediatinum - superior - inferior - anterior - posterior
- 1st rib
- imaginary line from sternal angle to IV disk between 4th and 5th thoracic vertebrae
- manubrium of sternum
- T3-4 vertebrae
33
boundaries of posterior mediatinum - superior - inferior - anterior - posterior
- ssuperior mediastinum - diaphragm - middle mediastinum - T5-12
34
Structure in superior mediastinum - vasculature (6) - nerves (5) - organs (3)
- where do veins lie in respect to the arteries?
- brachiocephalic v and a, SVC, arch of aorta, left common carotid, left subclavian,
- vagus, phrenic, cardiac plexus, left recurrent larygenal, thoracic duct
- trachea, esophagus, thymus
- anterior
35
Origin and course of cardiac plexus
- O: cervical and cardiac branches of vagus nerve and cardiopulmonary splanchnic nerve from sympathetic trunk - C: From arch of aorta and posterior surface of heart the fibers extend alonf coronary arteries and to SA node
36
Origin and course of pulmonary plexus
- O: vagus nerve and ardiopulmonary splanchnic nerve from sympathetic trunk -C: forms on root of lung and extends along bronchial subdivision
37
Where do recurrent laryngeal nerves travel - R - L
- Loops around subclavian on R - left runs around arch of aorta
38
Intercostal nerves - Origin - Course - Distribution
- Anterior rami of T1-11 - Run in intercostal spaces beteween internal and innermost layers - Muscles and skin over intercostals
39
Phrenic nerve - Origin - Course - Distribution
- C3-C5 - Passes through Superior thoracic aperture and runs between medistinal pleura and pericardium passing anterior to lungs - mediastinal parietal pleura, pericardium, muscle, pleura, and peritoneum of central diaphragm
40
Which nerve can be compressed by the descending aorta dissection? - what could indicate this?
- Left recurrent laryngeal nerve because it passes inferior to the arch of the aorta, - S&S of hoarseness of voice d/t left vocal cord paralysis
41
Superior Vena Caval Syndrome - what is it? - sxs it can cause? why? - collateral drainage?
- occurs when a person's superior vena cava is partially blocked or compressed - hoarseness, progressive swelling of his face/neck, and visible collateral veins -\> veins cant drain which is causing swelling and right recurrent laryngeal goes around the right sublcavian and since it cant drain the nerve becomes compressed and therefore is causing hoarseness
42
What is in the posterior mediastinum? - arteries - veins - lymph - nerve
- thoracic aorta, esophageal arteries \*, left bronchial arteries \*, posterior intercostal arteries \*, superior phrenic arteries \* (\* all on aorta), - thoracic duct, -azygous vein, accessory hemiazygous, posterior intercostal veins - esophagus nerve plexus, thoracic sympathetic trunks, thoracic splanchnic
43
What is imaging most used for heart? Why? limitations?
Chest xray because fast, cheap readily available; limited contrast and low temporal resolution so cant see Coronary arteries or how heart/blood is moving
44
Imaging modalit and body part?Abnormality? Dx?
PA CXR; cardiomegaly, hilar enlargement and pulmonary vascular congestion; CHF
45
How do you know if there is vascular congestion?
evident by "cloudy" appearance of the lungs--lungs normally full of air which is dark/black!
46
How do you diagnose cardiomegaly on CXR?
When transverse diameter of hear exceeds 50% of transverse diameter of lower chest
47
Imaging modality and body part? Abnormality?
PA CXR; cardiomegaly and left base atelectasis
48
Imaging modality and major organ depicted? Abnormality? Dx?
echo/cardiac sonogram; heart is normal size but the pericardial cavity is expanded; pericardial effusion
49
imaging modality, body part, orientation, and window? Abnormality? Dx?
C+ CT chest, axial, soft tissue; There is pericardial fluid surrounding the heart; Pericardial effusion
50
Imaging modality and boday part? Identify the chambers. Abnormality?
Echocardiography; RV(on left) and LV (on right) at top; atrial septal defect
51
Uses and advantages of echo?
Fast, noninvasive, no radiation, high temporal resolution and can visualize internal structures, determine important characteristics of heart function (flow), 3D view
52
53
Imitations of echo?
Need to be trained to perform and read one! Can take longer to interpret, may be more expensive than a simple ultrasound, medium-ish contrast and spatial resolution, can't really visualize the vessels
54
imaging modality, body part, orientation, window? IV contrast? Describe the abnormalities
Calcium scoring coronary CT, axial, soft tissue; No; Bright white calcium deposits in the right and left coronary arteries
55
Significance of coronary calcium/agaston score?
Scores the possibility of patient haveing a cardiovascular eent in the next 5 years
0: non idetified; 1-10: minimal; 11-100: mild; 101-400: Moderate; \>400: High
56
imaging modality and body part depicted? Contrast?
coronary computed tomography and angiogram; yes;
57
imaging modality and abnormalities depicted? When would you order this?
CCTA, coronary artery disease; If someone has acute or chronic chest pain--\>assess the vasculature of the heart and determine pathology or risk of adverse cardiovascular event
58
59
imaging modality and boday part depicted? when yould this be ordered?
Cardiac cath/flouroscopy; During a procedure to see real-time flow of blood through the arteries, can watch for proper positioning of stents
60
imaging modality and body part depicted? when woukd it be ordered?
nuclear medicine; stress/resting radiac perfusion examination; If someone is having chest pain and concerned for blockage--\>induce stress on the heart to identify areas of decreased flow
61
imaging modality and boday part depicted?
Cardiac positron emission tomography
62
imaging modality and body part? Anatomic orientations depicted? Primary dx? explain.
Cardiac MRI; right top: short axis, left top: 2 chamber, left bottom: 4 chamber, right bottom: 3 chamber; hypertrophic cardiomyopathy because there is ventricle wall thickening
63
What is happening?
- on left there is abnormal fibers with vacuolizations at margins of infarct--due to intracellular accumulation of Na+ and H2O in the SR; on right there is normal fibers
- at this point this is reversible injury and
64
What is happening? What are band of darker pink in the myocytes indicative of?
neutrohpil accumulation within 1-3 days after MI; reperfusion injury by sudden rush of Ca into damaged cells causing sarcoemeres to remain contracted
65
what is happening? why?
accumulation of macrophages because Macrophages remove necrotic tissue (day 3-7)--tissue becomes thinner and is susceptible to new injury (i.e. rupture)
66
What is this? When does this happen? What stain is used?
collagen deposition, Damaged area replaced by highly vascularized (bright red areas) granulation tissue (loose collagen); occurs 1-2 weeks post-infarct; trichrome
67
What is happening?
Fibrous tissue takes the place of granulation tissue causing scarring and there is compensatory hypertrophy of remaining myocytes
68
What is this? Name the layers. What is the first region affected by ischemia?
What is this? Name the layers. What is the first region affected by ischemia?
69
Based on the gross images of the cross sections of an infarcted heart predict what cardiac complications the patient could have dies from?? Moving from superior to inferior.
- What did the patient die from?
The MI affected the sub endocardial layer anteriorly and as you move inferiorly the damage is more transmural and affects the anterior, posterior, septal wall and begins to go more lateral the further down you go
- MI from occlusion of coronary artery
70
Based on the cross section of an infarcted herat predict complication that led to patients death
- how does this happen?
Pericardium is full of [coagulated] blood--\>increased external pressure on the heart preventing filling--\>cardiac tamponade; source of bleeding is the rupture anterolateral LV wall (circled)
- perforation of a weakened area of a heart from previous MI -\> allows for blood to pull in pericardium which produces cardiac tamponade which does not allow full expansion of heart and decfreases cardiac output
71
Discuss etiology and pathogenesis of ishemia that led to this pattern of hemorrhagic necrosis
circumferential necrosis (equal distribution around the vertntricle)--likely etiology is hypotension (like in hemorrhage, shock)--\>hypotension affects all the coronary arteries, so none of them are receiving the proper amount of blood and oxygen to supply their corresponding heart areas--\>necrosis (sub-endocardial because necrosis because does not span full thickness of the wall); RV not as affected because LV requires greater pressures to adequately perfuse
72
Azygous system of Veins
- what drains right side? where does it start and what does it go into?
- what drains left side? (2) here does it start and what does it go into?
- azygous vein drains (2nd-11th R post intercostal veins, vertebral plexus, mediatinal, esophageal, and bronchial veins), starts at the R common illiac via R ascending lumbar --\> ends at the SVC
- hemi-azygous vein (9-11th L posterior intercostal, inferior esophageal, and mediastinal vein), starts at teh left common illiac via ascendin lumbar vein and the left subcostal veins --\> ends at the azygous vein at level of T9
- accessory hemi-azygous vein (left bronchial vein and left superior intercostal); starts at the 4th-8th left posterior intercostal --\> ends at the azygous vein at T7/8
73
Where do each of the thoracic splanchnic nerves come from?
- what are their targets?
Presynaptic fibers deom 5th-12th sympathetic ganglia
- abdominal viscera
74
Lymph of posterior mediastinum
- what is the beginning and end of the thoracic duct
- what is position of thoracic duct?
- cisterna chylii and left venous angle
- to the left is the thoracic aorta, to the right is the azygous veins, anterior is the esophagus and posterior is the vertebral bodies
75
Identify
- 19
- 27
- 22
- 38
- 4 & 39
- esophagus
- Thoracic descending aorta
- Thoracic duct and azygous vein
- Left mainstem bronchus
- Right and Left pulmonary aa
76
Patient with dysphagia undergoes upper endoscopy which showed lesion to esophagus. Chemotherapy was given. On post op day 9 left pleural effusion drainage increased and changed to milky white color.
- what is diagnosis?
- what happened?
- chylothorax
- thoracic duct laceration during surgery
Unit 6: SXS
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