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Block 2 > Week 3: CAI > Flashcards

Week 3: CAI Flashcards

1
Q

What is the Mediastinum

A
  • Broad Central region that separates the two laterally placed pleural cavities
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2
Q

Where is the Mediastinum found?

A
  • Extends from Sternum to bodies of verterbra A-P axis

- From Superior Thoracic Aperture to the Diaphragm S-I axis

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3
Q

What Vertebral Level does the Sternal Place Sit?

A
  • T4/T5 intervertebral disc
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4
Q

How are the Mediastinum regions divided?

A
  • Sternal plane (T4/T5 IV disc), divides Superior and Inferior
  • Inferior region further subdivided: Anterior, Middle, Posterior Regions by the Pericardial sac
  • Middle Mediastinum - Where the heart sits
  • Anterior Mediastinum is very narrow
  • Posterior Mediastinum extends inferiorly to 12th Thoracic vertebra –> to Costodiaphragmatic recess
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5
Q

What Structures come off the Aorta at the Aortic Arch

A
  • Right side - Brachiocephalic trunk

- Left side - Left common carotid artery

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6
Q

What structures form the Superior Vena Cava?

A
  • Left and Right Brachiocephalic veins
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7
Q

Where do the Mediastinal Veins sit relative to the arteries

A
  • Veins sit anterior to arteries
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8
Q

Where are the Left and Right Brachiocephalic Veins formed?

A
  • Immediately posterior to the sternal clavicular joint

- Where Subclavian vein + Internal jugular vein meet

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9
Q

Where is the Superior Vena Cava formed?

A
  • Behind right costal cartilage of rib 2
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10
Q

What are the Arteries coming off of the Aortic Arch in order as it passes posteriorly and laterally?

A
  1. Brachiocephalic trunk - Branches into R. Common Carotid a. (right head & neck) and R. Subclavian a. (right upper limb)
  2. Left Common Carotid a. (left head and neck)
  3. Left Subclavian a. (left upper limb)
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11
Q

What is Ligamentum Arteriosum

A
  • In embryonic circulation - Ductus Arteriosus, Connected pulmonary trunk to arch of aorta, Allowed blood to bypass lungs during development.
  • Closes soon after birth to become a ligamentous connection
  • If fails to close, have mixing of low oxygenated blood from pulmonary trunk into highly oxygenated within aorta, Decreasing O2 content of blood to systemic circulation
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12
Q

What structures can be found in the Superior Mediastinum?

A
  • Arch of aorta, great vessels, trachea, oesophagus, thoracic duct, phrenic & vagus nerves
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13
Q

What structures can be found within the Anterior Inferior Mediastinum?

A
  • Internal thoracic vessels
  • Fat
  • Connective tissue
  • Part of Thymus gland
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14
Q

Where is the Anterior portion of the Inferior Mediastinum found?

A
  • Between sternum and anterior pericardial sac down to diaphragm
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15
Q

Describe CABG Procedure and its relevance to the Internal Thoracic arteries

A
  • Coronary Arterial Bypass Graft procedure
  • Can harvest part of an internal thoracic artery to replace/support coronary vessels in the heart which have become blocked/damaged beyond repair
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16
Q

Describe the Internal Thoracic Arteries, where they arise and their connections

A
  • Arise from R + L Subclavian Arteries
  • Pass Veins posteriorly and then pass anteriorly to anterior mediastinum region
  • Give off some segmental anterior intercostal arteries that course within intercostal grooves to anastomose with posterior intercostal arteries that come off aorta.
  • Resists atherosclerotic plaque build up better than any other artery
  • Great anastomotic connections - CABG Procedure
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17
Q

What happens to the thymus with age?

A
  • Involved in early development of immune system

- As age, atrophies after puberty into leftover fatty tissue

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18
Q

Where is the Thymus gland found?

A
  • Located in superior & sometimes anterior mediastinum
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19
Q

What can be seen in the anterior mediastinum of children on CXR?

A
  • Thymus is relatively large in children

- Can lead to thymic sail sign on CXR on right side of chest - Normal

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20
Q

What structures can be found in the posterior Inferior Mediastinum region?

A
  • Oesophagus, Vagus nerves and Plexus, Descending aorta, Thoracic duct, Sympathetic Autonomic chain, Azygous venous system
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21
Q

What is the Function of the Azygous Venous System?

A
  • Drain thoracic wall + overlying tissues
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22
Q

Where do the Oesophagus and Trachea sit in the Mediastinum?

A
  • Sit in Superior & Posterior Mediastinum
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23
Q

What is the Innervation of the oesophagus

A
  • Motor and Sensory - Vagus nerve
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24
Q

How can you visualise the left atrium of the heart via Ultrasound?

A
  • Due to close relation of oesophagus to heart

- Can pass US probe down oesophagus + visualise left atrium of heart

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25
Q

What structures are found within the Middle Inferior Mediastinum?

A
  • Heart
  • Pericardium
  • Origins of the great vessels: Superior Vena Cava, Pulmonary Trunk, Ascending Aorta
  • Phrenic nerves - Passing very close to pericardium on either side of mediastinum. Contain fibres from C3,4,5 spinal nerves. Innervate diaphragm but also bring sensory innervation to fibrous pericardium
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26
Q

What is the connection of the Fibrous Pericardium to the Diaphragm?

A
  • Binds to the central Diaphragmatic tendon

- So does not change shape that much with respiration, provides support

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27
Q

What can occur if there is compression or blockage of the SVC?

A
  • Extrinsic compression by tumour/metastasis to mediastinal lymph nodes
  • Block of venous return from areas draining into SVC
  • Can see congestion of venous blood unable to drain (purple discolouration of pt in severe case)
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28
Q

What structure does the left recurrent laryngeal nerve swing immediately underneath as it heads back up towards the larynx

A
  • Under the Aortic Arch
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29
Q

Where do the Vagus Nerves pass structures in the chest?

A
  • Passes Posterior to hilum of the lungs
  • But, Runs Anterior to the Subclavian Vessels & descends through mediastinum
  • Right side, Recurs under the Right Subclavian artery posteriorly by apex of lung into Right Recurrent Laryngeal n. into Internal Larynx
  • Left side, Recurs between pulmonary a. and aortic arch into Left Recurrent Laryngeal n.
  • Rest of Vagal n. (R+L) continue down forming plexuses around trachea and inferior oesophagus
  • Into diaphragm and abdominal cavity
  • Vagal / Parasympathetic Autonomic Nerve Supply to gut viscera
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30
Q

What is the Aorto-Pulmonary Window

A
  • Clinical Region between Pulmonary a. and Aortic Arch

- Where Vagus nerve recurs into left Recurrent Laryngeal n.

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31
Q

On what side would a hilar lymph node enlargement cause a hoarse voice?

A
  • Left side

- L RLN recurs close to this region and may be compressed

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32
Q

Describe the Cardiac Plexus

A
  • Cardiac plexus is a mix of BOTH Cardiac branches of vagus nerve (Parasympathetic) and Sympathetic Chain Fibres froom T1-T4 levels (Sympathetic system)
  • Located Behind heart, between trachea and aorta
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33
Q

Describe the Parasympathetic and Sympathetic Nerve Supplies to the Heart

A
  • Parasympathetic - Left & Right Vagus Nerves

- Sympathetic - Sympathetic Chain T1-T4 level fibres, mainly left side.

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34
Q

Describe the Sensory nerve supply to the heart

A
  • Cardiac Visceral sensory fibres travel back to CNS along with sympathetic nerves
  • Sense Stretch, Inflammation, Hypoxia
  • Referred Cardiac Pain occurs in the T1-T4 dermatomes mainly on left
  • E.g. left arm and left jaw as well as chest pain
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35
Q

Why might a myocardial infarction cause pain which is perceived as being in your left arm or jaw?

A
  • Due to the Visceral sensory nerve supply to the heart being derived from T1-T4 dermatomes which also supply the arm and jaw. Stimulation of one may cause perceived stimulation of another.
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36
Q

Describe the Base of the Heart

A
  • True posterior surface of the heart
  • Sits against oesophagus
  • Composed primarily of left atrium
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37
Q

Explain the Orientation of the heart

A
  • Heart is a midline structure that rotates to the left during development
  • Means right-sides structures sit anteriorly while left-sided structures sit posteriorly
  • Heart is also encased by fibrous pericardium
38
Q

What completely encases the heart?

A
  • Pericardium
  • Fibrous pericardium: Outer
  • Serous pericardium: Parietal & Visceral (Epicardium)
  • Pericardial cavity between Serous pericardium layers, containing pericardial fluid
39
Q

Describe the Fibrous Pericardium

A
  • Tough outer connective tissue layer
  • Does not allow sudden fast changes in heart size/volume within pericardial cavity
  • Relatively inflexible, thus, inflammation or changes in fluid surrounding the heart can have large consequences
40
Q

What is the function of Pericardial Fluid?

A
  • Found between Visceral Serous Pericardium and Parietal Serous Pericardium
  • Roughly 50cc Normally
  • Reduces friction between heart epicardium + surrounding layers
41
Q

Describe Pericarditis

A
  • Inflammation + Swelling of the coverings of the heart
  • Can be very painful due to phrenic nerve sensory innervation of the fibrous pericardium
  • Can have purulent pericarditis, Pus in the pericardial space
42
Q

What is Haemopericardium

A

Blood seeping into pericardial space

43
Q

How might a Haemopericardium lead to a cardiac tamponade?

A
  • Rapid increase in pressure within pericardial space due to blood entering
  • Can compress ventricle spaces
  • = Restricted cardiac filling
  • Can lead to cardiac tamponade
44
Q

What is Pericardial Effusion?

A
  • Under certain conditions pericardial cavity may become distended by accumulations of Serous fluid
45
Q

What innervates the fibrous pericardium

A

Phrenic nerve - Sensory innervation

46
Q

what is inflammation of the pericardium called

A

Pericarditis

47
Q

What are possible causes of pericardial effusion?

A
  • Congestive heart failure
  • Blunt chest trauma
  • Malignancy
  • Ruptured MI
  • Aortic Dissection
  • Mediastinal Lymphatic Obstruction
48
Q

Compare Chronic Pericardial Effusion with Acute Pericardial Effusion

A
  • Chronic - Slowly accumulating fluid within pericardial sac, pericardium has time to dilate, permits effusion to become large without interfering with cardiac function. Pt w/ less 500cc Chronic effusion only clinical significance is characteristic enlargement of heart shadow on chest radiograph
  • Acute - Rapidly accumulating fluid within pericardial sac, pericardium has no time to expand to accommodate, 2-300cc over short amount of time can have clinically devastating consequences (cardiac tamponade), and pain due to rapid pressure increase
49
Q

Describe the development of sinuses in the Pericardium

A
  • During development the heart start as a tube
  • This tube becomes surrounded by pericardial sac with reflections at the great vessels
  • Folding of heart tube creates a passageway between arterial outflows & venous input (Transverse pericardial sinus)
  • Reflection of serous layer creates blind ended sac posterior to heart (Oblique Pericardial sinus)
50
Q

What is the Clinical Significance of the Transverse Pericardial Sinus

A
  • Can be used in surgery to clamp arterial outflow
  • Finger can go through sinus and clamp put on
  • Followed by putting heart on bypass machine
  • E.g. Used if repairing via CABG procedure
51
Q

What venous drainage does the right atrium receive?

A
  • Venous from upper body - SVC
  • Venous from lower body - IVC
  • Venous from Heart walls - Coronary sinus
52
Q

Describe the valve that sits between right atrium and right ventricle

A
  • Tricuspid valve
  • Faces forward and medially
  • Closed during ventricular systole/contraction
  • Stops blood flowing back up into right atrium
53
Q

Describe the division of the right atrium

A
  • Inferior of RA divided into 2 continuous spaces
  • Externally indicated - Sulcus terminalis - from R. side SVC opening to R. side IVC opening
  • Internally indicated - Crista terminalis
  • Posterior to Crista terminalis = Openings of IVC & SVC, V. smooth and thin walls
  • Anterior to Crista terminalis = Opening of Coronary sinus, walls covered in pectinate muscles, Atrial appendage, Tricuspid valve in right ventricle
54
Q

Describe the Atrial Appendage and Explain its clinical relevance

A
  • Ear-like muscular pouch that externally overlap the ascending aorta, covered in pectinate muscles
  • Potential space for blood clots to form especially in irregular heartbeats
  • Blood may get caught there if taking longer to contract + clot may form in dead-ended space.
55
Q

Describe the Inter-atrial septum

A
  • Separating RA from LA
  • Faces forward and right - Medial wall of RA
  • Depression in inter-atrial septum = Fossa ovalis
56
Q

What is the Fossa ovalis

A
  • Depression in inter-atrial septum
  • Marks location of embryonic foramen ovale which allowed oxygenated blood entering RA through IVC to pass directly into LA so as to bypass lungs
57
Q

Where are the SAN and AVN located in the heart?

A
  • Embedded within Superior Atrium

- Part of heart conduction system

58
Q

What might form in the atrial appendages, especially in cases of atrial fibrillation?

A
  • Blood clots
59
Q

Describe the Right Ventricular walls

A
  • RA opening where tricuspid valve located
  • Numerous muscular irregular structures = Trabeculae Carnae
  • Attached to ventricular walls throughout length/form bridges across and between ventricular wall
  • Trabeculae Carnae muscles with one end attached to ventricular surface and other attachment point for tendon-like fibrous cords = Chordae tendinae
  • Papillary muscles - Chordae tendinae - Connect to free edges of cusps of tricuspid valve
  • Superior portion of ventricle with opening into pulmonary trunk via pulmonary semilunar valve = Conus Arteriosus (Infundibulum)
60
Q

What is the Infundibulum

A
  • Conus Arteriosus
  • Superior right ventricle smooth surface
  • Pulmonary semilunar valve here
61
Q

What are the Trabeculae carnae

A
  • Numerous irregular muscular structures in the wall of the right ventricle
  • Attached to ventricular walls throughout length of right ventricle. Form small bridges/ridges across ventricular wall
  • Few = Papillary Muscles - One end attached to ventricular wall, other attachment = tendon-like fibrous cord (Chordae tendinae) which attaches to free edges of cusp of tricuspid valve
62
Q

Describe the structure of the left atrium

A
  • Anterior portion, smooth thin walls, openings of all 4 pulmonary veins.
  • Inter-atrial septum - Fossa ovalis
  • Anterior portion, pectinate muscles, continuous with left atrial appendage.
  • Blood passes through Mitral (bicuspid) valve into left ventricle
63
Q

How does the Ventricular wall reflect its function?

A
  • Wall is 3x THICKER than right ventricular wall –> Reflects function
64
Q

Describe the Left Ventricle

A
  • Lies anterior to LA
  • Forms apex of heart
  • Blood enters through mitral valve and exits superiorly through aortic semilunar valve
  • Trabeculae carnae present with
  • some papillary muscles extending off trabeculae carnae to anchor bottom of Chordae tendinae to secure bottom of mitral valve cusps
65
Q

Describe the Papillary muscles of the Heart Ventricles

A
  • Papillary muscles are extensions of ventricular wall
  • Attach to Chordae Tendinae which attach to bottom of a Cusp of the Tricuspid/Bicuspid Valve
  • Contract to prevent cusps from being blown back into Atria during Ventricular Systole
  • Cusps open passively
66
Q

Describe the Atrioventricular valves

A
  • Lie between atria and ventricles and allow for unidirectional flow of blood
  • Valves formed by flap-like cusps that are anchored to the ventricle wall by tendons
  • Tricuspid - Between RA + RV
  • Bicuspid/Mitral - Between LA + LV
67
Q

What might happen after a MI with damage to the papillary muscle?

A
  • May necrotise
  • Have AV valve incompetence/regurgitation
  • No longer able to contract during ventricular sytole
  • Can develop cardiac murmur
68
Q

What is the Dense Fibrous Cardiac Skeleton?

A
  • Dense fibrous connective tissue of the heart
69
Q

What is the Function of the Fibrous Skeleton of the Heart

A
  • Provides ANCHOR point for cardiac muscle and heart valve cusps
  • Mechanical stability
  • Electrical insulation, Prevents ‘free’ conduction of electrical signal from atria to ventricles
  • AV node found embedded within it
70
Q

Describe how the Aortic and Pulmonary Valves Function

A
  • Found in outflow tracts of the aorta & pulmonary trunk
  • Are semilunar & each have 3x cusps
  • Pocket like spaces (sinuses are located behind each valve cusp
  • During Ventricular systole - Ventricles contract, value cusps pushed toward vessel walls and OPEN up
  • During Ventricular diastole - Ventricles relax, reverse-flowing blood catches in the pockets of aortic and pulmonary valves, and CLOSES the valve.
71
Q

State the Aortic Semi-lumar Valve Nomenclature

A
  • New names reflect position relative to the coronary arteries
  • Right Coronary leaflet - Right Coronary a. opens behind
  • Left Coronary leaflet - Left Coronary a. opens behind
  • Non-adjacent leaflet
72
Q

State the Pulmonary Semilumar Valve Nomenclature

A
  • New names reflect position relative to coronary arteries
  • Right-adjacent leaflet
  • Left-adjacent leaflet
  • Non-adjacent leaflet
73
Q

What is Stenosis in regards to the Heart valves?

A
  • Valvular Heart disease
  • Failure of valve to open fully
  • Slows blood from leaving a chamber
74
Q

What is Valvular Insufficiency?

A
  • Regurgitation or failure of valve to close completely

- Results in Backflow

75
Q

What are the most commonly affected Valves in Valvular Heart Disease (Stenosis or Insufficiency)

A
  • Mitral and Aortic Valve
  • Commonly
  • Mitral Valve Prolapse - Most common type of congenital heart disease in adults
  • Aortic Stenosis - Most frequent valve abnormality, often result of degenerative calcification
76
Q

Describe Mitral Valve Prolapse

A
  • One of both leaflets are enlarger, redundant, or FLOPPY
  • Most common type of congenital heart disease in adults
  • Results in leaflets extending back into LA during systole
  • Blood regurgitates into LA, when LV contracts = Late systolic murmur
  • Clinically:
  • LV Hypertrophy
  • LA dilation
  • Increased pulmonary pressure + Pulmonary Oedema
  • Shortness of breath
  • Right sided heart failure
77
Q

Describe Aortic Stenosis

A
  • Often result of Degenerative calcification
  • Valve cannot open fully, blood cannot enter aorta easily
  • Results in LV hypertrophy (thickness & enlargement of left ventricle trying to compensate for reduced blood supply to body)
  • Pt may experience dizziness, syncope, episodes of fainting, angina chest pain
78
Q

Where does the myocardium get its blood supply from?

A
  • Coronary arteries which arise from the coronary sinus above the cusps of aortic values
79
Q

When does the heart receive its blood supply?

A
  • Main inflow is during Ventricular diastole
  • Blood backflow closes semilunar valves + opens coronary arteries
  • During systole, valves opened and pressed against openings of arteries
80
Q

What is a Right Coronary Artery Dominant heart?

A
  • When a heart is RCA dominant it gives rise to the Inferior Interventricular Artery
  • Can also give rise to Sinuatrial Nodal Artery
  • Also a number of Anterior Ventricular arteries
  • Artery along its margin = Right Marginal Artery
81
Q

What does the Right Coronary Artery Supply?

A
  • Right atrium & Right Ventricles
  • SA node & AV node
  • Conduction system up to AV bundles
  • Posterior 1/3rd of IV septum
82
Q

What can occur in a MI in the right coronary artery

A

Can affect the conduction of signal propagation across heart’s tissues, SA/AV node knock out

83
Q

What determines the Coronary Artery Dominance of the heart?

A

Which artery gives rise to the inferior interventricular artery

84
Q

What is a Left Coronary Artery Dominant Heart?

A
  • Left coronary artery gives rise to the inferior interventricular artery
  • Will arise off termination of the Circumflex artery
85
Q

What arteries arise off of the LCA of the heart?

A
  • If LCA dominant - Inferior Interventricular artery
  • Sometimes Sinuatrial Nodal artery
  • Branches into
  • Circumflex artery
  • And Anterior Interventricular artery
  • Marginal artery
86
Q

What does the LCA normally supply?

A
  • Left atrium & Left Ventricle
  • Anterior 2/3rds of IV septum
  • AV bundle
  • Right & Left Bundle Branches
87
Q

What can occur in a MI in the LCA

A
  • If Supply of AV bundle +/ Right & Left bundle branches compromised
  • Can cease to have electrical signal propagation of heart in these areas
88
Q

Describe the Cardiac Veins

A
  • Great, Middle & Small Cardiac veins
  • Drain blood from myocardium of the heart
  • Majority of venous blood drains into the Right Atrium via the Coronary sinus
89
Q

Describe the Surface anatomy of the heart

A
  1. 3rd Rib Costal Cartilage - Right Lateral to Sternum. Junction of SVC & RA
  2. 6th Rib Costal Cartilage - Right Lateral to Sternum. Junction of RA & IVC
  3. 2nd Rib Costal Cartilage - Left Lateral to Sternum. Site of Left Atrial Appendage meets Pulmonary trunk
  4. 5th ICS - Left mid-clavicular line. Site of Apex of lung & LV
90
Q

Describe the Auscultation points of the Heart

A
  • Heart sounds results from valves closing and pathologies affecting heart, sounds tend to travel in direction of flow
    1. Aortic Valve - 2nd R ICS lateral to sternum
    1. Pulmoary Valve - 2nd L ICS lateral to sternum
    1. Tricuspid Valve - 5th L ICS lateral to sternum
    1. Mitral Valve - 5th L ICS MCL
91
Q

Describe the Conduction system of the heart

A
  • Allows rapid coordinated delivery of cardiac impulse to atrial & ventricular muscles
  • Impulse originates in SA node (Pacemaker)
  • Propagates to AV node - Cardiac skeleton helps electrically insulate atria from ventricles.
  • Electrical signal can only travel to ventricles via AV node and bundle
  • Splits into R + L bundle branches
  • Course down either side of interventricular septum
  • Along ventricular floors via Purkinje fibres

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