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THORACIC WALL
&
CARDIVASCULAR SYSTEM
01.10.2013
Kaan Yücel
M.D., Ph.D.
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Dr.Kaan Yücel
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Thoracic wall & CVS
THORACIC WALL
The thorax is the part of the body between the neck and abdomen. Posterior surface is formed by the 12
thoracic vertebræ and the posterior parts of the ribs. Anterior surface is formed by the sternum and costal cartilages.
Lateral surfaces are formed by the ribs, separated from each other by the intercostal spaces, eleven in number,
which are occupied by the intercostal muscles and membranes. The true thoracic wall includes the thoracic cage and
the muscles that extend between the ribs as well as the skin, subcutaneous tissue, muscles, and fascia covering its
anterolateral aspect. The same structures covering its posterior aspect are considered to belong to the back. The
mammary glands of the breasts lie within the subcutaneous tissue of the thoracic wall.
The thoracic skeleton forms the osteocartilaginous thoracic cage, which protects the thoracic viscera and some
abdominal organs. The thoracic skeleton includes 12 pairs of ribs and associated costal cartilages, 12 thoracic
vertebrae and the intervertebral (IV) discs interposed between them, and the sternum.
One of the principal functions of the thoracic wall and the diaphragm is to alter the volume of the thorax and
thereby move air in and out of the lungs.
During breathing, the dimensions of the thorax change in the vertical, lateral, and anteroposterior directions.
Elevation and depression of the diaphragm significantly alter the vertical dimensions of the thorax. Depression
results when the muscle fibers of the diaphragm contract. Elevation occurs when the diaphragm relaxes.
The breasts are the most prominent superficial structures in the anterior thoracic wall, especially in women.
The breasts (L. mammae) consist of glandular and supporting fibrous tissue embedded within a fatty matrix,
together with blood vessels, lymphatics, and nerves.
CARDIOVASCULAR SYSTEM
The heart has two sides. The right side of the heart (right heart) receives poorly oxygenated (venous) blood
from the body through the superior vena cava (SVC) and inferior vena cava (IVC) and pumps it through the
pulmonary trunk and arteries to the lungs for oxygenation. The left side of the heart (left heart) receives welloxygenated (arterial) blood from the lungs through the pulmonary veins and pumps it into the aorta for distribution
to the body. The four chambers of the heart are: right and left atria and right and left ventricles. The atria are
receiving chambers that pump blood into the ventricles (discharging chambers). The synchronous pumping actions
of the heart's two atrioventricular (AV) pumps (right and left chambers) constitute the cardiac cycle.
The coronary arteries, the first branches of the aorta, supply the myocardium and epicardium. The right and
left coronary arteries arise from the corresponding aortic sinuses. The heart is drained mainly by veins that empty
into the coronary sinus and partly by small veins that empty into the right atrium. The sinuatrial (SA) node is the
pacemaker of the heart. The SA node initiates and regulates the impulses for the contractions of the heart. The
atrioventricular (AV) node distributes the signal to the ventricles through the AV bundle.
The pericardium is a fibroserous membrane that covers the heart and the beginning of its great vessels. The
pericardium is a closed sac composed of two layers. The tough external layer, the fibrous pericardium, is continuous
with the central tendon of the diaphragm. The internal surface of the fibrous pericardium is lined with a glistening
serous membrane, the parietal layer of serous pericardium.
The right and left brachiocephalic veins are formed by the union of the internal jugular and subclavian veins.
They unite to form the SVC and shunt blood from the head, neck, and upper limbs to the right atrium.
The ascending aorta begins at the aortic orifice. Its only branches are the coronary arteries. The arch of the
aorta (aortic arch), the curved continuation of the ascending aorta. The usual branches of the arch are the
brachiocephalic trunk, left common carotid artery, and left subclavian artery. The brachiocephalic trunk, the first
and largest branch of the arch of the aorta divides into the right common carotid and right subclavian arteries.
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1. THORACIC WALL
The thorax is the part of the body between the neck and abdomen. Posterior surface is formed by the 12
thoracic vertebræ and the posterior parts of the ribs. Anterior surface is formed by the sternum and costal
cartilages. Lateral surfaces are formed by the ribs, separated from each other by the intercostal spaces, eleven in
number, which are occupied by the intercostal muscles and membranes. The floor of the thoracic cavity is deeply
invaginated inferiorly (i.e., is pushed upward) by viscera of the abdominal cavity.
The thorax includes the primary organs of the respiratory and cardiovascular systems. The majority of the
thoracic cavity is occupied by the lungs, which provide for the exchange of oxygen and carbon dioxide between
the air and blood. Most of the remainder of the thoracic cavity is occupied by the heart and structures involved
in conducting the air and blood to and from the lungs. Additionally, nutrients (food) traverse the thoracic cavity
via the esophagus, passing from the site of entry in the head to the site of digestion and absorption in the
abdomen.
THORACIC WALL
The true thoracic wall includes the thoracic cage and the muscles that extend between the ribs as well as
the skin, subcutaneous tissue, muscles, and fascia covering its anterolateral aspect. The same structures covering
its posterior aspect are considered to belong to the back. The mammary glands of the breasts lie within the
subcutaneous tissue of the thoracic wall.
The domed shape of the thoracic cage provides its components enabling to:
•
Protect vital thoracic and abdominal organs (most air or fluid filled) from external forces.
•
Resist the negative (sub-atmospheric) internal pressures generated by the elastic recoil of the lungs and
inspiratory movements.
•
Provide attachment for and support the weight of the upper limbs.
•
Provide the anchoring attachment (origin) of many of the muscles that move and maintain the position of
the upper limbs relative to the trunk, as well as provide the attachments for muscles of the abdomen, neck, back,
and respiration.
The thorax is one of the most dynamic regions of the body. With each breath, the muscles of the thoracic
wall—working in concert with the diaphragm and muscles of the abdominal wall—vary the volume of the
thoracic cavity, first by expanding the capacity of the cavity, thereby causing the lungs to expand and draw air in
and then, due to lung elasticity and muscle relaxation, decreasing the volume of the cavity and causing them to
expel air.
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SKELETON OF THORACIC WALL
The thoracic skeleton forms the osteocartilaginous thoracic cage, which protects the thoracic viscera and
some abdominal organs. The thoracic skeleton includes 12 pairs of ribs and associated costal cartilages, 12
thoracic vertebrae and the intervertebral (IV) discs interposed between them, and the sternum. The ribs and
costal cartilages form the largest part of the thoracic cage; both are identified numerically, from the most
superior (1st rib or costal cartilage) to the most inferior (12th).
Figure 1. Thoracic cage (skeleton)
http://www.tutorvista.com/content/biology/biology-iv/locomotion-animals/thoracic-cage.php
THORACIC APERTURES
While the thoracic cage provides a complete wall peripherally, it is open superiorly and inferiorly. The
superior opening is a passageway that allows communication with the neck and upper limbs. The larger inferior
opening provides the ring-like origin of the diaphragm, which completely occludes the opening.
Structures that pass between the thoracic cavity and the neck through the superior thoracic aperture:
Trachea
Esophagus
Nerves, and vessels that supply and drain the head, neck, and upper limbs.
Figure 2. Superior and inferior thoracic apertures
http://quizlet.com/4653983/2-thorax-i-flash-cards/
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MOVEMENTS OF THE THORACIC WALL
One of the principal functions of the thoracic wall and the diaphragm is to alter the volume of the thorax
and thereby move air in and out of the lungs. During breathing, the dimensions of the thorax change in the
vertical, lateral, and anteroposterior directions. Elevation and depression of the diaphragm significantly alter the
vertical dimensions of the thorax. Depression results when the muscle fibers of the diaphragm contract.
Elevation occurs when the diaphragm relaxes.
Figure 3. Movements of the thoracic wall
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DERMATOMES
The skin area supplied by a segment of the spinal cord
Through its posterior ramus and the lateral and anterior cutaneous branches of its anterior ramus, most thoracic
spinal nerves (T2-T12) supply a strip-like dermatome of the trunk extending from the posterior median line to
the anterior median line.
Figure 4. Dermatomes
http://sandysscience.wordpress.com/2010/01/04/dermatomes-2/dermatomes-4/
T2- Sternal angle
T4- Nipple
T6- Xiphoid process
T8- Costal arch
T10-Umbliculus
T12-Midpoint between umbilicus and symphysis pubis
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BREASTS
The breasts are the most prominent superficial structures in the anterior thoracic wall, especially in
women. The breasts (L. mammae) consist of glandular and supporting fibrous tissue embedded within a fatty
matrix, together with blood vessels, lymphatics, and nerves. Both men and women have breasts; normally they
are well developed only in women. The mammary glands are in the subcutaneous tissue overlying the pectoralis
major and minor muscles. At the greatest prominence of the breast is the nipple, surrounded by a circular
pigmented area of skin, the areola (L. small area).
The mammary glands within the breasts are accessory to reproduction in women. They are rudimentary and
functionless in men, consisting of only a few small ducts or epithelial cords. Usually, the fat present in the male
breast is not different from that of subcutaneous tissue elsewhere, and the glandular system does not normally
develop.
Female Breasts
The amount of fat surrounding the glandular tissue determines the size of non-lactating breasts. The
roughly circular body of the female breast rests on a bed that extends transversely from the lateral border of the
sternum.
The lymphatic drainage of the breast is important because of its role in the metastasis of cancer cells.
Most lymph, especially from the lateral breast quadrants, drains to the axillary lymph nodes. Most of the
remaining lymph, particularly from the medial breast quadrants, drains to the parasternal lymph nodes or to the
opposite breast, whereas lymph from the inferior quadrants may pass deeply to abdominal lymph nodes.
Figure 5. Internal structure of the breast
http://anthingblissful.blogspot.com/2006/04/anatomy-of-human-breast.html
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Figures 6. Lymphatic drainage of the breast
http://ourhumananatomy.blogspot.com/2008/08/19-breast-lymphatic-drainage.html
http://www.breastdiseases.com/anat.htm
2. HEART
The vascular system is divided for descriptive purposes into (a) the blood vascular system, which
comprises the heart and blood vessels for the circulation of the blood; and (b) the lymph vascular system,
consisting of lymph glands and lymphatic vessels, through which a colorless fluid, the lymph, circulates.
The two systems communicate with each other and are intimately associated developmentally. The heart
is the central organ of the blood vascular system, and consists of a hollow muscle; by its contraction the blood is
pumped to all parts of the body through a complicated series of tubes, termed arteries.
The walls of the blood vessels of the cardiovascular system usually consist of three layers or tunics:
tunica externa (adventitia)-the outer connective tissue layer;
tunica media-the middle smooth muscle layer (may also contain varying amounts of elastic fibers in medium
and large arteries);
tunica intima-the inner endothelial lining of the blood vessels.
Arteries are usually further subdivided into three classes, according to the variable amounts of smooth muscle
and elastic fibers contributing to the thickness of the tunica media, the overall size of the vessel, and its function.
a. Large elastic arteries contain substantial amounts of elastic fibers in the tunica media, allowing expansion and
recoil. This helps maintain a constant flow of blood to the heart. An example is the aorta.
b. Medium muscular arteries are composed of a tunica media that contains mostly smooth muscle fibers. This
characteristic allows these vessels to regulate their diameter and control the flow of blood to different parts of
the body. An example is the radial artery.
c. Small arteries and arterioles control the filling of the capillaries and directly contribute to the arterial pressure
in the vascular system.
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Veins also are subdivided into three classes.
a. Large veins contain some smooth muscle in the tunica media, but the thickest layer is the tunica externa.
Examples of large veins are the superior vena cava, and the inferior vena cava.
b. Small and medium veins contain small amounts of smooth muscle, and the thickest layer is the tunica
externa. Examples of small and medium veins are superficial veins in the upper and lower limbs and deeper veins
of the leg and forearm.
c. Venules are the smallest veins and drain the capillaries.
The arteries undergo enormous ramification in their course throughout the body, and end in minute
vessels, called arterioles, which in their turn open into a close-meshed network of microscopic vessels, termed
capillaries. After the blood has passed through the capillaries it is collected into a series of larger vessels, called
veins, by which it is returned to the heart. The passage of the blood through the heart and blood-vessels
constitutes what is termed the circulation of the blood. Looking trapezoidal in the anterior-posterior dimensions,
but in 3-D a tipped-over pyramid, the heart is a cruical organ of the human body, as we can only stand for five to
six minutes without blood travelling in our vessels. You can see the heart as a self-adjusting suction and pressure
pump, function of which is to send blood to all parts of the body.
2.1. The two sides of the heart: right heart & left heart
The right side of the heart (right heart) receives poorly oxygenated (venous) blood from the body through
the superior vena cava (SVC) and inferior vena cava (IVC) and pumps it through the pulmonary trunk and arteries
to the lungs for oxygenation. The left side of the heart (left heart) receives well-oxygenated (arterial) blood from
the lungs through the pulmonary veins and pumps it into the aorta for distribution to the body.
2.2. The four chambers of the heart
The heart has four chambers: right and left atria and right and left ventricles. The atria are receiving
chambers that pump blood into the ventricles (the discharging chambers). The synchronous pumping actions of
the heart's two atrioventricular (AV) pumps (right and left chambers) constitute the cardiac cycle. The cycle
begins with a period of ventricular elongation and filling (diastole) and ends with a period of ventricular
shortening and emptying (systole).
2.3. The heart sounds
Two heart sounds are heard with a stethoscope: a lub (1st) sound as the blood is transferred from the
atria into the ventricles and a dub (2nd) sound as the ventricles expel blood from the heart. The heart sounds are
produced by the snapping shut of the oneway valves that normally keep blood from flowing backward during
contractions of the heart.
2.4. The layers of the heart
The wall of each heart chamber consists of three layers, from superficial to deep:
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•
Endocardium, a thin internal layer
•
Myocardium, a thick, helical middle layer composed of cardiac muscle.
•
Epicardium, a thin external layer
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2.5. Fibrous skeleton of the heart (Cardiac skeleton)
The cardiac skeleton is a collection of dense, fibrous connective tissue in the form of four rings with
interconnecting areas in a plane between the atria and the ventricles. The four rings of the cardiac skeleton
surround the two atrioventricular orifices, the aortic orifice and opening of the pulmonary trunks. They are the
anulus fibrosus.
The fibrous skeleton of the heart:

Keeps the orifices of the AV and semilunar valves patent and prevents them from being overly distended by
an increased volume of blood pumping through them.

Provides attachments for the leaflets cusps of the valves and myocardium as well.

Forms an electrical “insulator,” by separating the myenterically conducted impulses of the atria and ventricles
so that they contract independently and by surrounding and providing passage for the initial part of the AV
bundle of the conducting system of the heart.
2.6. Sulci/Grooves in the heart
Externally, the atria are demarcated from the ventricles by the coronary sulcus (atrioventricular groove),
and the right and left ventricles are demarcated from each other by anterior and posterior interventricular (IV)
sulci (grooves).
2.7. Apex and base of the heart
The heart has one apex located inferiorly, and one base located superiorly. Placed in the thoracic cavity, the apex
of this pyramid projects forward, downward, and to the left, whereas the base is opposite the apex and faces in a
posterior direction.
The apex of the heart:

Is formed by the inferolateral part of the left ventricle.

Lies posterior to the left 5th intercostal space in adults, usually approximately 9 cm (a hand's breadth) from
the median plane.

Remains motionless throughout the cardiac cycle.

Is where the sounds of mitral valve closure are maximal (apex beat); the apex underlies the site where the
heartbeat may be auscultated on the thoracic wall.
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Figure 7. Apex of the heart
http://apex-of-the-heart.anatomyofthehearts.com/apex-of-the-heart/
The base of the heart:

Is the heart's posterior aspect (opposite the apex).

Is formed mainly by the left atrium, with a lesser contribution by the right atrium.

Receives the pulmonary veins on the right and left sides of its left atrial portion and the superior and inferior
venae cavae at the superior and inferior ends of its right atrial portion.
2.8. The four surfaces of the heart
1.
Anterior (sternocostal) surface, faces anteriorly and consists mostly of the right ventricle with some of the
right atrium on the right and some of the left ventricle on the left
2.
Diaphragmatic (inferior) surface, formed mainly by the left ventricle and partly by the right ventricle; it is
related mainly to the central tendon of the diaphragm.
3.
Right pulmonary surface, faces the right lung, is broad and convex, and is formed by the right atrium.
4.
Left pulmonary surface, faces the left lung, is broad and convex, and consists of the left ventricle and a
portion of the left atrium.
2.10. RIGHT ATRIUM
The right atrium forms the right border of the heart and receives venous blood from the SVC, IVC, and
coronary sinus. Through the right atrioventricular orifice, the right atrium discharges the poorly oxygenated
blood it has received into the right ventricle.
The ear-like right auricle is a conical muscular pouch that projects from this chamber like an add-on room,
increasing the capacity of the atrium as it overlaps the ascending aorta. Rough, muscular anterior wall composed
of pectinate muscles (L. musculi pectinati).
The opening of the coronary sinus, a short venous trunk receiving most of the cardiac veins, is between
the right AV orifice and the IVC orifice. The interatrial septum separating the atria has an oval, thumbprint-size
depression, the oval fossa (L. fossa ovalis), which is a remnant of the oval foramen (L. foramen ovale) and its
valve in the fetus.
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Figure 8. Right atrium
http://europace.oxfordjournals.org/content/9/suppl_6/vi3.full
2.11. RIGHT VENTRICLE
The right ventricle forms the largest part of the anterior surface of the heart, a small part of the
diaphragmatic surface, and almost the entire inferior border of the heart. The right ventricle receives blood from
the right atrium through the right AV (tricuspid) orifice. The interventricular septum lies between the two
ventricles, bulging into the right ventricle.
The interior of the right ventricle has irregular muscular elevations (trabeculae carneae). The right
ventricle receives blood from the right atrium through the right AV (tricuspid) orifice.
Tendinous cords (L. chordae tendineae) attach to the free edges and ventricular surfaces of the cusps,
much like the cords attaching to a parachute. The tendinous cords arise from the apices of papillary muscles,
which are conical muscular projections with bases attached to the ventricular wall. The papillary muscles begin to
contract before contraction of the right ventricle, tightening the tendinous cords and drawing the cusps
together. Thanks to the cords, attached to adjacent sides of two cusps, the cusps of the tricuspid valve are
prevented from prolapsing (being driven into the right atrium) as ventricular pressure rises. Thus regurgitation of
blood (backward flow of blood) from the right ventricle back into the right atrium is blocked during ventricular
systole by the valve cusps.
The interventricular septum (IVS), composed of muscular and membranous parts, is obliquely placed
partition between the right and left ventricles, forming part of the walls of each. The septomarginal trabecula
(moderator band) is a curved muscular bundle which carries part of the right branch of the AV bundle, a part of
the conducting system of the heart. This “shortcut” across the chamber seems to facilitate conduction time.
2.12. LEFT ATRIUM
The left atrium forms most of the base of the heart. The valveless pairs of right and left pulmonary veins
enter the atrium. The tubular, muscular left auricle, its wall trabeculated with pectinate muscles, forms the
superior part of the left border of the heart and overlaps the root of the pulmonary trunk. A semilunar
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depression in the interatrial septum indicates the floor of the oval fossa; the surrounding ridge is the valve of the
oval fossa (L. valvulae foramen ovale).
Figure 9. Right ventricle and right atrium
http://home.comcast.net/~wnor/thoraxlesson4.htm
SVC= superior vena cava
SA node= sinuatrial node
AA= ascending aorta
FO= fossa ovalis
RA= right atrium
AV= atrioventricular node
CS= coronary sinus
VIVC= valve of inferior vena cava
ICV= inferior vena cava
TC= trabecula carnea
SMB= septomarginal trabecula (moderator band)
RV= right ventricle
LV= left ventricle
PM= papillary muscles
CT= chordae tendineae
LA= left atrium
IVS= interventricular septum
PV= pulmonary vein
2.13. LEFT VENTRICLE
The left ventricle forms the apex of the heart, nearly all its left (pulmonary) surface and border, and most
of the diaphragmatic surface. Because arterial pressure is much higher in the systemic than in the pulmonary
circulation, the left ventricle performs more work than the right ventricle.
The interior of the left ventricle has:
• A smooth-walled, non-muscular, superoanterior outflow part, the aortic vestibule, leading to the aortic orifice
and aortic valve.
• A double-leaflet mitral valve that guards the left AV orifice.
Figure 10. Heart chambers
http://www.starsandseas.com/SAS%20Physiology/Cardiovascular/Cardiovascular.htm
Both atria and ventricles have muscular elevations in order to increase the strength of the pumping
function.
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2.14. VASCULATURE OF THE HEART
The blood vessels of the heart comprise the coronary arteries and cardiac veins, which carry blood to and
from most of the myocardium.
2.14.1. Arterial Supply of the Heart
The coronary arteries, the first branches of the aorta, supply the myocardium and epicardium. The right
and left coronary arteries arise from the corresponding aortic sinuses. Anastomoses between the branches of the
coronary arteries exist, which enables the development of the collateral circulation. The coronary arteries supply
both the atria and the ventricles. The right coronary artery (RCA) arises from the right side of the ascending
aorta. The left coronary artery (LCA) arises from the left side of the ascending aorta.
2.14.2. Venous Drainage of the Heart
The heart is drained mainly by veins that empty into the coronary sinus and partly by small veins that empty into
the right atrium.
Figure 11. Arterial supply of the heart; coronary arteries
http://medical-dictionary.thefreedictionary.com/coronary+artery+disease
2.15. STIMULATING, CONDUCTING, AND REGULATING SYSTEMS OF HEART
The conducting system consists of nodal tissue that initiates the heartbeat and coordinates contractions of the
four heart chambers, and highly specialized conducting fibers for conducting them rapidly to the different areas
of the heart. The impulses are then propagated by the cardiac striated muscle cells so that the chamber walls
contract simultaneously. Impulse generation and conduction can be summarized as follows:
• The SA node (pacemaker of the heart; in the right atrium) initiates an impulse that is rapidly conducted to
cardiac muscle fibers in the atria, causing them to contract.
• The impulse spreads by myogenic conduction, which rapidly transmits the impulse from the SA node to the AV
node (in the right atrium).
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• The signal is distributed from the AV node through the AV bundle and its branches (the right and left bundles),
which pass on each side of the IVS to supply subendocardial branches to the papillary muscles and the walls of
the ventricles.
3.15.1. Innervation of the Heart
Innervation of the heart is through the autonomic nerves (both sympathetic and parasympathetics) from the
cardiac plexus.
Figure 12. SA and AV nodes
http://www.mountnittany.org/articles/healthsheets/7488
SEPTAL DEFECTS
Atrial Septal Defects (ASD): is a congenital anomaly of the interatrial septum, a hole between the two atria.
Clinically significant ASDs vary widely in size and
location and may occur as part of more complex congenital
STIMULATING,
heart disease. Large ASDs allow oxygenated blood from the lungs to be shunted from the left atrium through the
CONDUCTING,
ASD into the right atrium, causing enlargement
of the right atrium andAND
ventricle and dilation of the pulmonary
REGULATING
trunk. This left to right shunt of blood overloads the pulmonary vascular system, resulting in hypertrophy of the
right atrium and ventricle and pulmonary arteries.
SYSTEMS
Ventricular Septal Defects (VSD): The membranous
part OF
of theHEART
IVS is the common site of ventricular septal
STIMULATING,
defects (VSDs). VSDs rank first on all lists of cardiac defects. A VSD causes a left to right shunt of blood through
the defect. A large shunt increases pulmonary blood flow, which causes severe pulmonary disease (hypertension,
CONDUCTING,
or increased blood pressure) and may cause
cardiac failure.
AND
REGULATING
SYSTEMS OF HEART
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Figure 11. ASD and VSD
http://www.mountnittany.org/assets/images/krames/104530.jpg
VALVULAR HEART DISEASES
Disorders involving the valves of the heart disturb the pumping efficiency of the heart. Valvular heart
disease produces either stenosis
(narrowing) or insufficiency.
Stenosis is the failure of a valve to open fully,
STIMULATING,
CONDUCTING,
slowing blood flow from a chamber. Insufficiency or regurgitation, on the other hand, is failure of the valve to
AND REGULATING SYSTEMS
close completely, usually owing to nodule formation on (or scarring and contraction of) the cusps so that the
edges do not meet or align. This allows a variable
of blood (depending on the severity) to flow back into
OFamount
HEART
the chamber it was just ejected from. Both stenosis and insufficiency result in an increased workload for the
STIMULATING, CONDUCTING,
heart. Because valvular diseases are mechanical problems, damaged or defective cardiac valves can be replaced
surgically in a procedure called
valvuloplasty.
AND
REGULATING
Mitral Valve Insufficiency:
SYSTEMS
OF HEART
Scarring and shortening of the cusps results in insufficiency
Restricts the outflow of the left ventricle and leads to the hypertrophy of the myocardium
During ventricular systole, blood regurgitates back to the left atrium
A hurt murmur will be heard.
Mitral Valve Stenosis:
Narrowing of the mitral orifice.
Restricts the outflow of the left atrium.
Pulmonary Valve Stenosis:
Narrowing of the pulmonary valve due to the fused cusps.
Restricts the outflow of the right ventricle and leads to the hypertrophy of the myocardium.
Pulmonary Valve Incompetence:
Incomplete closure of the cusps due to thickening of their free margins due to a disease.
During diastole, blood regurgitates back to the right ventricle from the pulmonary trunk.
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Heart murmur (a pathologic sound) could be heard by a stethoscope. Murmur is produced due to the
turbulence caused by the blood passing from a narrow opening into a larger vessel or chamber.
Aortic Valve Stenosis:
Aortic valve stenosis is the most frequent valve abnormality.
Blood is unable to flow freely from left ventricle to aorta.
Aortic stenosis causes extra work for the heart, resulting in left ventricular hypertrophy.
Aortic Valve Insufficiency:
During diastole blood regurgitates from aorta back to the left ventricle.
Figure 12. Mitral Valve Insufficiency
Figure 13. Mitral Valve Stenosis
http://www.yalemedicalgroup.org/stw/Page.asp?PageID=STW022880
http://heart.templehealth.org/content/mitral_valve_stenosis.htm
Figure 14. Pulmonary Valve Stenosis
Figure 15. Pulmonary Valve Incompetence
http://www.metrohealth.org/body_HV.cfm?id=1529
http://mykentuckyheart.com/images/pictures/pulmonary-regurgitation.jpg
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Figure 16. Aortic Valve Stenosis
http://clickit3.ort.org.il/InAttach/7c9d4dbd-d8e3-4c8b-acc5-cf4925a6847e/ac23e363-1496-4c21-a721-21715997f0d0.jpg
Figure 17. Aortic Valve Insufficiency
http://www.heart-valve-surgery.com/aortic-valve-regurgitation-symptoms.php
AUSCULTATORY AREAS OF THE VALVES & HEART SOUNDS
On listening to the heart with a stethoscope, one can hear two sounds. The first sound is produced by the
STIMULATING, CONDUCTING, AND REGULATING
contraction of the ventricles and the closure of the tricuspid and mitral valves. The second sound is produced by
SYSTEMS
HEART
the sharp closure of the aortic and pulmonary
valves. ItOF
is important
for a physician to know where to place the
stethoscope on the chest wall so that he or she will be able to hear sounds produced at each valve with the
STIMULATING, CONDUCTING, AND REGULATING
minimum of distraction or interference.
The tricuspid valve is best heard SYSTEMS
over the right halfOF
of theHEART
lower end of the body of the sternum.
The mitral valve is best heard over the apex beat, that is, at the level of the fifth left intercostal space, 9 cm
from the midline.
The pulmonary valve is heard with least interference over the medial end of the second left intercostal
space.
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The aortic valve is best heard over the medial end of the second right intercostal space.
Figure 18. Heart sounds (You can listen to the heart songs on line from the link below)
http://www.med.umich.edu/lrc/coursepages/m1/anatomy2010/html/surface/thorax/hsounds.html
2.16. PERICARDIUM
The pericardium is a fibroserous membrane that covers the heart and the beginning of its great vessels. The
pericardium is a closed sac composed of two layers.
The pericardium is a closed sac composed of two layers:
1) Fibrous pericardium (external)
continuous with the central tendon of the diaphragm
2) Serous pericardium (internal)
Parietal layer
Visceral layer (epicardium)
The pericardial cavity is the potential space between opposing layers of the parietal and visceral layers of serous
pericardium. It normally contains a thin film of fluid that enables the heart to move and beat in a frictionless
environment.
Figure 13. Pericardium
http://www.physioweb.org/circulation/heart_structure.html
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3. VESSELS IN THE BODY
3.1. GREAT VESSELS
The right and left brachiocephalic veins are formed by the union of the internal jugular and subclavian
veins. The brachiocephalic veins unite to form the superior vena cava (SVC). The superior vena cava (SVC) returns
blood from all structures superior to the diaphragm, except the lungs and heart. It ends by entering the right
atrium of the heart. The ascending aorta begins at the aortic orifice. Its only branches are the coronary arteries,
arising from the aortic sinuses. The arch of the aorta (aortic arch) is the curved continuation of the ascending
aorta. The usual branches of the arch are the brachiocephalic trunk, left common carotid artery, and left
subclavian artery.The ligamentum arteriosum, the remnant of the fetal ductus arteriosus, passes from the root of
the left pulmonary artery to the inferior surface of the arch of the aorta.
Figure 14. The great vessels (arteries)
http://genericlook.com/anatomy/Aortic-Arch
3.2. ARTERIES IN THE BODY
What happens to descending aorta (thoracic aorta) which is the continuation of the arch of aorta is that
after passing through the diaphragm, it becomes the abdominal aorta which finally terminates as common iliac
arteries which will then bifurcate into the external and internal iliac arteries.
The external iliac arteries, after passing below the inguinal ligament, will become femoral arteries. The
femoral arteries will supply the lower limbs. On both sides, these arteries will continue as popliteal arteries back
in the “popliteal fossa” which then will branch into anterior and posterior tibial arteries. The anterior tibial artery
becomes the dorsal pedis artery (dorsal artery of the foot) while passing over the ankle joint.
The subclavian artery will continue as axillary artery, and later brachial artey on both arms. The brachial
artery will divide into ulnar and radial arteries at the elbow. Distally, the ulnar artery swings laterally across the
palm, forming the superficial palmar arch. The deep palmar arch is basically formed as the continuation of the
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radial artery. Both the brachial artery (in the arm), and femoral artery (in the thigh) have a deep branch as the
most important/largest branch [deep artery of the arm (profunda brachii artery), deep artery of thigh (profunda
femoris artery)].
The common carotid artery will divide into external carotid artery and internal carotid artery (Şah
damarı). The external carotid artery basically supplies blood to the face and neck, and the internal one to the
brain. The external carotid artery has important branches such as lingual artery, facial artery.
At the bifurcation, the common carotid artery and the beginning of the internal carotid artery are dilated.
This dilation is the carotid sinus and contains receptors that monitor changes in blood pressure and are
innervated by a branch of the glossopharyngeal nerve [IX]. Another accumulation of receptors in the area of the
bifurcation is responsible for detecting changes in blood chemistry, primarily oxygen content. This is the carotid
body and is innervated by branches from both the glossopharyngeal [IX] and vagus [X] nerves.
The other artery of the brain is the vertebral artery which is a thick branch of the subclavian artery.
Figure 15. Arteries in the body
http://mlkshk.com/r/CU70
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3.3. VEINS IN THE BODY
Although arteries are generally located in deep, well-protected body areas, many veins are more
superficial and some are easily seen and palpated on the body surface. Most deep veins follow the course of the
major arteries, and with a few exceptions, the naming of these veins is identical to that of their companion
arteries. While major systemic arteries branch off the aorta, the veins converge on the vena cava.
Figure 16. Veins in the body
http://www.nakedscience.org/mrg/Anatomy%20Lecture%20Notes%20Unit%207%20Circulatory%20System%20-%20The%20Blood%20Vessels.htm
Blood returns to the right atrium of the heart
through the vena cava. Veins draining the
head and arms empty into the superior vena
cava and those draining the lower body empty
into the inferior vena cava.
The veins listed below begin distally and move
proximally to the heart.
Veins Draining into the Superior Vena Cava:

Radial and ulnar veins are deep veins
draining the forearm. They unite to
form the brachial vein, which drains
the arm and empties into
the axillary vein.

Cephalic vein provides superficial
drainage of the lateral aspect of the
arm and empties into the axillary vein.

Basilic vein provides superficial drainage of the medial aspect of the arm into the brachial vein.
The basilic and cephalic veins are joined at the anterior aspect of the elbow by the median cubital vein. (This
vein is often the site for blood removal for the purpose of blood testing.) The dorsal venous arch of the hand is
drained into the basilica medially and cephalic veins laterally.

Subclavian vein receives blood from the arm through the axillary vein and from the skin and muscles of the
head through the external jugular vein.

Left & right brachiocephalic veins drain the subclavian, vertebral, and internal jugular veins on their
respective sides. The brachiocephalic veins join to form the superior vena cava, which enters the heart.
Veins Draining into the Inferior Vena Cava:
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The inferior vena cava, which is much longer than the superior vena cava, returns blood to the heart from all
body regions below the diaphragm.

Anterior and posterior tibial veins and the peroneal vein drain the calf and foot. The posterior tibial vein
becomes the popliteal vein at the knee and then the femoral vein in the thigh. The femoral vein becomes the
external iliac vein as it enters the pelvis.

Great saphenous veins are the longest veins in the body. They receive the superficial drainage of the leg. They
are on the medial side of the leg and thigh and drain into the femoral vein.
Each left and right common iliac vein is formed by the union of the external iliac vein and the internal iliac vein
(which drains the pelvis) on its own side. The common iliac veins join to form the inferior vena cava, which then
ascends superiorly in the abdominal cavity.
3.4. LYMPHATIC SYSTEM
Lymphatic vessels form an extensive and complex interconnected network of channels, which begin as
"porous" blind-ended lymphatic capillaries in tissues of the body and converge to form a number of larger
vessels, which ultimately connect with large veins in the root of the neck.
Lymphatic vessels mainly collect fluid lost from vascular capillary beds during nutrient exchange processes
and deliver it back to the venous side of the vascular system. Also included in this interstitial fluid that drains into
the lymphatic capillaries are pathogens, cells of the lymphocytic system, cell products (such as hormones), and
cell debris.
The fluid in most lymphatic vessels is clear and colorless and is known as lymph. There are lymphatic
vessels in most areas of the body except the brain, bone marrow, and avascular tissues such as epithelia and
cartilage.
The movement of lymph through the lymphatic vessels is generated mainly by the indirect action of
adjacent structures, particularly by contraction of skeletal muscles and pulses in arteries. Unidirectional flow is
maintained by the presence of valves in the vessels.
Lymph nodes are small (0.1-2.5 cm long) encapsulated structures that interrupt the course of lymphatic
vessels and contain elements of the body's defense system, such as clusters of lymphocytes and macrophages.
All lymphatic vessels coalesce to form larger trunks or ducts, which drain into the venous system at sites in the
neck where the internal jugular veins join the subclavian veins to form the brachiocephalic veins (venous angle).
he major lymphatic trunks (right lymphatic duct and thoracic duct) enter the venous angles formed by the
convergence of these veins
 Lymph from the right side of the head and neck, the right upper limb, right side of the thorax, and right side of
the upper and more superficial region of the abdominal wall is carried by lymphatic vessels that connect with
veins on the right side of the neck (right lymphatic trunk)
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 lymph from all other regions of the body is carried by lymphatic vessels that drain into veins on the left side of
the neck (thoracic duct)
The thoracic duct is a major lymphatic channel that begins in the abdomen, passes superiorly through the thorax,
and ends in the venous channels in the neck.
Figure 17. Thoracic duct and right lymphatic trunk
http://cnx.org/content/m46563/latest/2203_Lymphatic_Trunks_and_Ducts_System.jpg
Figure 18. Lymphatic drainage of the body by the two main lymphatic trunks
http://classconnection.s3.amazonaws.com/987/flashcards/2509987/jpg/lymphanat21361666182624.jpg
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