Heart and great vessels

Right recurrent laryngeal nerve Trachea Oesophagus

Right common Brachiocephalic trunk
carotid artery
Left recurrent laryngeal nerve
Ansa subclavia Left common carotid artery

Right vagus nerve Superior cervical cardiac nerve (passing to

superficial part of cardiac plexus)
Right phrenic nerve
Left vagus nerve
Right subclavian artery
Ansa subclavia

Right and left

brachiocephalic veins Left subclavian artery

Internal thoracic artery Left phrenic nerve

Internal thoracic artery

Pericardiacophrenic artery

Fibrous pericardium
Pericardiacophrenic artery
Superior vena cava
Inferior cardiac nerve; branch
of vagus nerve (passing
Pulmonary trunk to superficial part of
cardiac plexus)
Ascending aorta
Ductus arteriosus

Pulmonary plexus
Right pulmonary
artery and veins

Left pulmonary artery

Pulmonary plexus and veins
Hilum of right lung

Conus arteriosus Hilum of left lung

Right auricle
Left auricle
Right coronary artery
(in coronary sulcus)
Great cardiac vein

Anterior cardiac veins Left coronary

nerve plexus

Left ventricle
Oblique fissure
of right lung
Oblique fissure
Marginal arterial and of left lung
venous branches

59
Anterior interventricular

CHAPTER
(descending) branch of
left coronary artery

Visceral layer of serous Right coronary Parietal layer of serous pericardium lining fibrous
pericardium (epicardium) plexus pericardium that is fused to diaphragm
Fig. 59.18 Anterior view of heart and great vessels in a full-term neonate. The lungs have been displaced to expose the heart and the epicardium
dissected off the heart and roots of the great vessels. Note that, after birth, blood flow reverses through the ductus arteriosus prior to its closure. (After
Crelin ES 1969 Anatomy of the Newborn. Philadelphia: Lea and Febiger.)

E2, I2 and F2a, which inhibit the ability of the ductus to contract in
response to oxygen.
Closure of the ductus arteriosus
The ductus arteriosus starts to close immediately after birth, although
blood probably continues to flow intermittently through it for a week
or so. The flow is reversed relative to that occurring in the fetal circula-
tion, reflecting the increased systemic vascular resistance which follows
exclusion of the placental circulation, and the decreased pulmonary
resistance which follows expansion of the lungs. Initial constriction at
birth has been attributed to increased oxygen tension. A neural factor
may also be involved: the muscular wall has afferent and efferent nerve
endings and responds to adrenaline and noradrenaline.
The first stage of ductal closure is completed within 10–15 hours
and the second stage takes 2–3 weeks. The first stage consists of contrac-
tion of the smooth muscle cells and development of subendothelial
oedema. Destruction of the endothelium and proliferation of the
intima subsequently occurs, and leads to permanent closure. Diverse
factors which may promote ductal closure have been identified. They
include: increased oxygen tension; increased plasma catecholamine
concentrations; suppression of prostaglandin I2 production; switching
off prostaglandin E receptors; a synergistic role of prostaglandin F2a and
oxygen concentrations; a decrease in plasma adenosine concentration.
After birth, these interrelated events result in the closure of the ductus
arteriosus. It has been proposed that the high oxygen tension of the
reversed blood flow through the ductus initiates the synthesis of a 1029
 HEART AND GREAT VESSELS

Thymic vein
Trachea
Left recurrent laryngeal verve
Inferior thyroid vein Left brachiocephalic vein

Vagus nerve Left common carotid artery

Left subclavian artery
Right brachiocephalic
vein Aortic arch

Phrenic nerve
Internal thoracic vein
Pericardiacophrenic
artery and vein
Brachiocephalic trunk Left lung
Thoracic aortic plexus
Superior vena cava

Parietal pleura, Vagus nerve

mediastinal part
Left recurrent laryngeal nerve

Right lung Left pulmonary

artery
Bifurcation
Transverse
of pulmonary
pericardial sinus Right pulmonary trunk
artery

Postcaval recess

Right superior
pulmonary vein

Right inferior
pulmonary vein Left superior
pulmonary vein

Left inferior
pulmonary vein
Fatty folds

Parietal pleura, Oblique pericardial

diaphragmatic part sinus

Inferior vena cava

Fibrous pericardium
Serous pericardium,
parietal layer

Fig. 56.1 Interior of the serosal pericardial sac after section of the large vessels at their cardiac origin and removal of the heart (seen from the front). See
text for additional named recesses of the general serosal pericardial cavity and its transverse sinus. (From Sobotta 2006.)

CARDIAC TAMPONADE interposed in series at different points in the double circulation. Despite
7

this functional disposition in series, the two pumps are usually described
SECTION

Cardiac tamponade is external compression of the heart usually caused
by accumulation of fluid in the pericardial space. This causes compres-
sion of the right atrium and reduces venous return, which reduces
cardiac output. It may occur after trauma, proximal extension from a
dissecting aortic aneurysm or cardiac surgery. Patients develop hypoten-
sion and circulatory collapse. Emergency treatment involves first reliev-
ing the tamponade by percutaneous pericardial aspiration, followed by
surgery to address the underlying cause. Echocardiography can be useful
in assessing tamponade and is also useful in guiding percutaneous
pericardial aspiration. Surgery is via a subxiphoid incision or a left
anterior thoracotomy.
HEART
The microstructure of cardiac muscle is described in detail in Chapter
6.
GENERAL ORGANIZATION
The heart is a pair of valved muscular pumps combined in a single
organ (Fig. 56.2A–D). Although the fibromuscular framework and con-
duction tissues of these pumps are structurally interwoven, each pump
960 (the so-called ‘right’ and ‘left’ hearts) is physiologically separate, and is
topographically in parallel.
Of the four cardiac chambers, the two atria receive venous blood as
weakly contractile reservoirs for final filling of the two ventricles, which
then provide the powerful expulsive contraction that forces blood into
the main arterial trunks.
The right heart starts at the right atrium, and receives the superior
and inferior venae cavae together with the main venous inflow from
the heart itself via the coronary sinus. This systemic venous blood tra-
verses the right atrioventricular orifice, guarded by the tricuspid valve,
to enter the inlet component of the right ventricle. Contraction of the
ventricle, particularly its apical trabecular component, closes the tri-
cuspid valve and, with increasing pressure, ejects the blood through the
muscular right ventricular outflow tract into the pulmonary trunk. The
blood then flows through the pulmonary vascular bed, which has a
relatively low resistance. Changes in pressure, time relations and valvu-
lar events are described below. Many structural features of the ‘right
heart’, including its overall geometry, myocardial architecture and the
construction and the relative strengths of the tricuspid and pulmonary
valves, accord with this low resistance, being associated with compara-
tively low changes in pressure.
The left heart starts at the left atrium, which receives all the pulmo-
nary inflow of oxygenated blood and some coronary venous inflow. It
contracts to fill the left ventricle through the left atrioventricular orifice
guarded by its mitral valve. The valve is the entry to the inlet of the left
ventricle. Ventricular contraction rapidly increases the pressure in the
apical trabecular component, closing the mitral valve and opening the
 Heart

A Left common carotid artery

Brachiocephalic trunk
Left subclavian artery

Aortic arch

Superior vena cava Ligamentum arteriosum

Pulmonary trunk
Right pulmonary artery
Serous pericardium, Serous pericardium,
parietal layer parietal layer
C
Left auricle
Right auricle Great cardiac vein
Infundibulum Left coronary artery,
(conus arteriosus) circumflex branch
Left coronary
Right atrium artery, anterior
interventricular branch
Anterior
Middle cardiac vein interventricular vein
Left ventricle
Right coronary artery

Right ventricle

Serous pericardium,
visceral layer (epicardium)

Serous pericardium, parietal layer

B
Vertebral vein
Left subclavian artery
Right brachiocephalic vein
Left common carotid artery
Left brachiocephalic vein
Aortic arch
Brachiocephalic trunk
Posterior intercostal arteries
Azygos vein
Descending aorta
Ascending aorta
Ligamentum arteriosum
Superior vena cava

Left pulmonary artery

Bifurcation of D

56
Pericardium pulmonary trunk

Right pulmonary artery

CHAPTER
Pulmonary trunk

Left pulmonary veins Right pulmonary veins

Left auricle

Great cardiac vein

Left atrium
Left coronary artery,
circumflex branch
Sinus of venae cavae
Posterior veins Serous pericardium,
of left ventricle parietal layer
Serous pericardium,
visceral layer Left atrial veins
(epicardium)
Right atrium
Sulcus terminalis cordis
Left ventricle
Inferior vena cava

Coronary sinus
Coronary sulcus
Right coronary artery, posterior
interventricular branch
Middle cardiac vein Right ventricle

Fig. 56.2 The heart and great vessels: A, Anterior and B, posterior views with corresponding three-dimensional reconstructions from multislice CT
scanning (C, D). (Main figures from Sobotta 2006.)

961
 Heart

A Pulmonary trunk Fig. 56.4 A, The interior of the heart,

Ascending aorta
Left coronary artery (orifice)
Superior vena cava Sinus of pulmonary trunk
Pulmonary valve,
Opening of superior vena cava left semilunar cusp
Aortic sinus
Right atrium Aortic valve, left semilunar cusp,
left coronary cusp
Sinoatrial nodes
Opening of coronary sinus
revealed by incising it along its right
and part of the lower surface. The
rest of the heart has been turned
over to the left. B, The triangle of
Koch, which is defined by the
tendon of Todaro, orifice of the
coronary sinus and the septal cusp
of the tricuspid valve. (A from
Sobotta 2006.)

Supraventricular crest
Opening of inferior
vena cava
Right bundle

Atrioventricular bundle
Valve of inferior vena cava
Atrioventricular node
Valve of coronary sinus

Anterior papillary muscle

Right ventricle
Tricuspid valve,
anterior cusp

B Triangle of Koch Atrioventricular bundle

Tendon of Todaro

Orifice of coronary sinus

Septal cusp of tricuspid valve

Aortic valve, left semilunar cusp Fig. 56.5 A dissection opening the
ventricles, viewed from the front.
Aortic valve, posterior semilunar cusp (From Sobotta 2006.)

56
Left atrium
[noncoronary cusp]

CHAPTER
Ascending aorta
Anterior cusp
Mitral valve
Aortic sinus Posterior cusp

Right auricle

Right coronary artery

Interventricular septum, Pericardium

membranous part

Posterior papillary muscle

Tricuspid valve,
posterior cusp

Tricuspid valve,
Anterior papillary muscle
septal cusp

Pericardium

Anterior papillary muscle

Posterior papillary muscle

Interventricular septum, muscular part 965

 HEART AND GREAT VESSELS

Ligamentum arteriosum Fig. 56.8 The anterior or sternocostal surface of the

Aortic arch heart. (From Sobotta 2006.)

Serous pericardium, parietal layer

Superior vena cava

Serous pericardium, Left pulmonary artery

parietal layer
Pulmonary trunk
Right pulmonary artery

Ascending aorta
Left coronary artery
Transverse Left atrium, left auricle
pericardial sinus
Great cardiac vein
Right coronary artery
Left coronary artery,
circumflex branch
Right auricle
Infundibulum (conus
Right atrium arteriosus)
Left coronary artery,
anterior interventricular branch
Right ventricular veins

Atrial branch
Anterior interventricular
vein

Right marginal branch

Apex of heart
Notch of cardiac apex

Pulmonary trunk Fig. 56.9 The base of the ventricles, after

removal of the atria and the pericardium.
Anterior semilunar Left semilunar cusp
Coronary arteries and cardiac veins can be seen.
cusp Contrast the planes and positions of the aortic
Pulmonary valve Right semilunar Right semilunar cusp Aortic valve and pulmonary valves. Contrast with Fig. 56.10.
cusp
Left semilunar
(From Sobotta 2006.)
cusp Posterior semilunar cusp
Anterior interventricular branch
Right coronary artery
Left coronary artery

Circumflex branch Right fibrous trigone

Left fibrous trigone Right fibrous ring

Great cardiac vein

Atrioventricular bundle
7

Left fibrous ring

Valve of coronary sinus
SECTION

Right marginal branch

Left marginal branch
Middle cardiac vein
Opening of coronary sinus

Right coronary artery,

Posterior interventricular vein
posterior interventricular branch

of (usually) two pulmonary veins from each lung. It forms the anterior
wall of the oblique pericardial sinus (Fig. 56.1). This surface ends at
the shallow vertical interatrial groove, which descends to the cardiac
crux. The left atrial auricle is constricted at its atrial junction and all the
pectinate muscles of the left atrium are contained within it. It is char-
acteristically longer, narrower and more hooked than the right auricle,
its margins being more deeply indented. It turns forwards to the left of
the pulmonary trunk, overlapping its origin (Fig. 56.8). Interiorly, the
four pulmonary veins open into the upper posterolateral surfaces of the
left atrium, two on each side. Their orifices are smooth and oval, the
left pair frequently opening via a common channel. Some minimal
cardiac veins return blood directly from the myocardium to the cavity
of the left atrium. The left atrial aspect of the septum has a characteristi-
cally rough appearance, bounded by a crescentic ridge, concave upwards,
968 which marks the site of the foramen ovale.
Left ventricle
General and external features
The left ventricle is constructed in accordance with its role as a powerful
pump that sustains pulsatile flow in the high-pressured systemic arter-
ies. Variously described as half-ellipsoid or cone-shaped, it is longer and
narrower than the right ventricle, extending from its base in the plane
of the atrioventricular groove to the cardiac apex. Its long axis descends
forwards and to the left. In transverse section, at right angles to the axis,
its cavity is oval or nearly circular, with walls about three times thicker
(8–12 mm) than those of the right ventricle (Fig. 56.12). It forms part
of the sternocostal, left and inferior (diaphragmatic) cardiac surfaces.
Except where obscured by the aorta and pulmonary trunk, the base of
the ventricular cone is superficially separated from the left atrium and
 Heart

A B

Arch of aorta

Pulmonary trunk

Left coronary artery (main stem)

Superior vena cava
Anterior interventricular
(descending) artery
Sinu-atrial nodal
artery Circumflex artery
Left atrial auricle
Right coronary artery Left atrial rami

Outlines of: Left conus artery

Anterior aortic sinus Circumflex artery Sinu-atrial artery
Right posterior aortic sinus Left (obtuse)
Left posterior aortic sinus marginal artery C
Right conus artery Diagonal artery
Right anterior
ventricular arteries

Atrioventricular
Interventricular
nodal artery
anterior septal branches

Posterior interventricular
(descending) arteries

Right (acute)
marginal artery

D Ascending aorta E

Right posterior
Pulmonary trunk Superior vena cava atrial arteries

Left pulmonary veins

Stem of posterior Right pulmonary veins

atrial arteries

Circumflex artery Region of

crux of heart

56
CHAPTER

Inferior vena cava

Right coronary artery
Anterior interventricular
(descending) artery (termination) Posterior interventricular
(descending) arteries

Fig. 56.18 Anterior views of the coronary arterial system, with the principal variations. The right coronary arterial tree is shown in magenta, the left in full
red. In both cases posterior distribution is shown in a paler shade. A, The most common arrangement. B, A common variation in the origin of the
sinoatrial nodal artery. C, An example of left ‘dominance’ by the left coronary artery, showing also an uncommon origin of the sinu-atrial artery.
Posteroinferior views of the coronary arterial system. The right coronary arterial tree is shown in magenta, the left in full red. D, An example of the more
normal distribution in right ‘dominance’. E, A less common form of left ‘dominance’. In these ‘posterior’ views, the diaphragmatic (inferior) surface of the
ventricular part of the heart has been artificially displaced and foreshortening ignored, to clarify the details of the so-called posterior (inferior) distribution
of the coronary arteries. 979
 HEART AND GREAT VESSELS
Aorta
Pulmonary trunk
Superior vena
cava
Left pulmonary veins
Oblique vein of
Right pulmonary
veins
left atrium
Great cardiac vein
Right atrium
Left marginal vein
Posterior vein of
Coronary sinus
left ventricle
Inferior vena
cava
Small cardiac vein
Middle
cardiac vein Right marginal vein
Fig. 56.19 The principal veins of the heart.
the left atrium to join the coronary sinus near its end. It is continuous
above with the ligament of the left vena cava. The two structures are
remnants of the left common cardinal vein.
Anterior cardiac veins
The anterior cardiac veins drain the anterior part of the right ventricle
(Figs 56.2A,C; 56.8). Usually two or three, sometimes even five, they
ascend in subepicardial tissue to cross the right part of the atrioventricu-
lar groove, passing deep or superficial to the right coronary artery. They
end in the right atrium, near the groove, separately or in variable com-
binations. A subendocardial collecting channel, into which all may
open, has been described. The right marginal vein courses along the
inferior (acute) cardiac margin, draining adjacent parts of the right
ventricle, and usually opens separately into the right atrium. It may join
the anterior cardiac veins or, less often, the coronary sinus. Because it
is commonly independent, it is often grouped with the small cardiac
veins, but it is larger in calibre, being comparable to the anterior cardiac
veins or even wider.
Small cardiac veins
The existence of small cardiac veins, opening into all cardiac cavities,
has been confirmed, but they are more difficult to demonstrate than
larger cardiac vessels. Their numbers and size are highly variable: up to
2 mm in diameter opening into the right atrium and 0.5 mm into the
right ventricle. Numerous small cardiac veins have been identified in
7
the right atrium and ventricle, but they are rare in the left atrium and
SECTION
left ventricle.
Cardiac venous anastomosis
There are widespread anastomoses at all levels of the cardiac venous
circulation, on a scale exceeding that of the arteries and amounting to
a veritable venous plexus. Not only are adjacent veins often connected,
but connections also exist between tributaries of the coronary sinus and
those of the anterior cardiac veins. Abundant anastomoses occur at the
apex and its anterior and posterior aspects. Like coronary arteries,
cardiac veins connect with extracardiac vessels, chiefly the vasa vasorum
of the large vessels continuous with the heart.
Lymphatic drainage of the heart
Cardiac lymphatic vessels form subendocardial, myocardial and sub-
epicardial plexuses, the first two draining into the third. Efferents from
the subepicardial plexuses form the left and right cardiac collecting
trunks. Two or three left trunks ascend the anterior interventricular
groove, receiving vessels from both ventricles. On reaching the atrio-
ventricular groove, they are joined by a large vessel from the diaphrag-
matic surface of the left ventricle, which first ascends in the posterior
interventricular groove and then turns left along the atrioventricular
groove. The vessel formed by this union ascends between the pulmo-
nary artery and the left atrium, and usually ends in an inferior tracheo-
bronchial node. The right trunk receives afferents from the right atrium
982 and the right border and diaphragmatic surface of the right ventricle. It
ascends in the atrioventricular groove, near the right coronary artery,
and then anterior to the ascending aorta to end in a brachiocephalic
node, usually on the left.
INNERVATION
Initiation of the cardiac cycle is myogenic, originating in the sinu-atrial
node. It is harmonized in rate, force and output by autonomic nerves
which operate on the nodal tissues and their prolongations, on coro-
nary vessels and on the working atrial and ventricular musculature. All
the cardiac branches of the vagus (parasympathetic) and all the sympa-
thetic branches (except the cardiac branch of the superior cervical sym-
pathetic ganglion) contain both afferent and efferent fibres; the cardiac
branch of the superior cervical sympathetic ganglion is entirely efferent.
Sympathetic fibres accelerate the heart and dilate the coronary arteries
when stimulated, whereas vagal fibres slow the heart and cause constric-
tion of the coronary arteries.
Preganglionic cardiac sympathetic axons arise from neurones in the
intermediolateral column of the upper four or five thoracic spinal seg-
ments. Some synapse in the corresponding upper thoracic sympathetic
ganglia, others ascend to synapse in the cervical ganglia; postganglionic
fibres from these ganglia form the sympathetic cardiac nerves.
Preganglionic cardiac parasympathetic axons arise from neurones in
either the dorsal vagal nucleus or near the nucleus ambiguus; they run
in vagal cardiac branches to synapse in the cardiac plexuses and atrial
walls. In man (like most mammals) intrinsic cardiac neurones are
limited to the atria and interatrial septum, and are most numerous in
the subepicardial connective tissue near the sinu-atrial and atrioven-
tricular nodes. There is evidence that these intrinsic ganglia are not
simple nicotinic relays, but may act as sites for integration of extrinsic
nervous inputs and form complex circuits for the local neuronal control
of the heart, and perhaps even local reflexes.
Cardiac plexus
Nearing the heart, the autonomic nerves form a mixed cardiac plexus,
usually described in terms of a superficial component inferior to the
aortic arch lying between it and the pulmonary trunk, and a deep
part between the aortic arch and tracheal bifurcation. The cardiac plexus
is also described by regional names for its coronary, pulmonary, atrial
and aortic extensions (Fig. 56.20). These plexuses contain ganglion
cells. Ganglion cells, confined to the atrial tissues, and with a prepon-
derance adjacent to the sinu-atrial node, are also found in the heart
along the distribution of branches of the plexus. Their axons are con-
sidered to be largely, if not exclusively, postganglionic parasympathetic.
Cholinergic and adrenergic fibres, arising in or passing through the
cardiac plexus, are distributed most profusely to the sinu-atrial and
atrioventricular nodes; the supply to the atrial and ventricular myocar-
dium is much less dense. Adrenergic fibres supply the coronary arteries
and cardiac veins. Rich plexuses of nerves containing cholinesterase,
adrenergic transmitters and other peptides, e.g. neuropeptide Y, are
found in the subendocardial regions of all chambers and in the cusps
of the valves.
Superficial (ventral) part of the cardiac plexus The superficial
(ventral) part of the cardiac plexus lies below the aortic arch and ante-
rior to the right pulmonary artery. It is formed by the cardiac branch
of the left superior cervical sympathetic ganglion and the lower of the
two cervical cardiac branches of the left vagus. A small cardiac ganglion
is usually present in this plexus immediately below the aortic arch, to
the right of the ligamentum arteriosum. This part of the cardiac plexus
connects with the deep part, the right coronary plexus and the left
anterior pulmonary plexus.
Deep (dorsal) part of the cardiac plexus The deep (dorsal) part
of the cardiac plexus is anterior to the tracheal bifurcation, above the
point of division of the pulmonary trunk and posterior to the aortic
arch. It is formed by the cardiac branches of the cervical and upper
thoracic sympathetic ganglia and of the vagus and recurrent laryngeal
nerves. The only cardiac nerves that do not join it are those that join
the superficial part of the plexus.
Branches from the right half of the deep part of the cardiac plexus
pass in front of and behind the right pulmonary artery. Those anterior
to it, the more numerous, supply a few filaments to the right anterior
pulmonary plexus and continue on to form part of the right coronary
plexus. Those behind the pulmonary artery supply a few filaments to
the right atrium and then continue into the left coronary plexus. The
left half of the deep part of the cardiac plexus is connected with the
 Major blood vessels

Right sympathetic trunk

Fig. 56.20 The human cardiac
Left sympathetic trunk
plexus: its source from the cervical
parts of the vagus nerves and
Left vagus nerve sympathetic trunks and its
Right vagus nerve extensions, the pulmonary, atrial
and coronary plexuses. Note the
numerous junctions between
Left recurrent laryngeal nerve
Right recurrent sympathetic and parasympathetic
laryngeal nerve (vagal) branches that form the
Trachea Left common carotid artery plexus.

Oesophagus Left subclavian artery

Right recurrent laryngeal nerve Third thoracic sympathetic ganglion

Thoracic cardiac branch

of vagus nerve
Thoracic (sympathetic)
Brachiocephalic trunk cardiac branches

Thoracic cardiac branch

Thoracic (sympathetic) of vagus nerve
cardiac branches
Arch of aorta
Deep cardiac plexus
Superficial cardiac plexus
Left recurrent laryngeal nerve
Ligamentum arteriosum

Left pulmonary artery

Superior vena cava

superficial, and supplies filaments to the left atrium and left anterior
pulmonary plexus. It forms much of the left coronary plexus.
Left coronary plexus The left coronary plexus is larger than the
right, and is formed chiefly by the prolongation of the left half of the
deep part of the cardiac plexus and a few fibres from the right. It accom-
panies the left coronary artery to supply the left atrium and ventricle.
Right coronary plexus The right coronary plexus is formed from
both superficial and deep parts of the cardiac plexus, and accompanies
the right coronary artery to supply the right atrium and ventricle.
Atrial plexuses The atrial plexuses are derivatives of the right and
fetus, at the level of the bifurcation the pulmonary artery is connected
to the aortic arch by the ductus arteriosus, which lies in the same direc-
tion as the pulmonary artery.
Relations The pulmonary artery is entirely within the pericardium,
enclosed with the ascending aorta in a common tube of visceral peri-
cardium. The fibrous pericardium gradually disappears within the
adventitia of the pulmonary arteries. Anteriorly, it is separated from the
sternal end of the left second intercostal space by the pleura, left lung
and pericardium. Posterior are the ascending aorta and left coronary
artery initially, then the left atrium. The ascending aorta ultimately lies
on its right. An auricle and coronary artery lie on each side of its origin.
The superficial cardiac plexus is between the pulmonary bifurcation and

56
left continuations of the cardiac plexus along the coronary arteries. the aortic arch. The tracheal bifurcation, lymph nodes and nerves are
Their fibres are distributed to the corresponding atria, overlapping those above, bilateral and right.

CHAPTER
from the coronary plexuses. During fetal life, when blood pressure is similar in the pulmonary
artery and the aorta, the structure of the vessels is similar. After birth,
the lungs expand and pulmonary arterioles dilate, and so pulmonary
MAJOR BLOOD VESSELS vascular resistance decreases, whereas blood flow increases. The systolic
pressure in the pulmonary artery consequently decreases and this is
The major blood vessels comprise the pulmonary trunk, the thoracic accompanied by a structural remodelling of its wall. The elastic
aorta and its branches, the superior and inferior venae cavae and their material, which originally had a lamellar structure, becomes aggregated
tributaries. into star-shaped units linked to many muscle cells. The amount of
muscular tissue grows extensively after birth and exceeds that found in
the aorta. The thickness of the wall of the aorta is about twice that of
ARTERIES the pulmonary artery.

Pulmonary trunk Right and left pulmonary arteries

The pulmonary trunk, or pulmonary artery, conveys deoxygenated
blood from the right ventricle to the lungs (Fig. 56.2A,C; see Fig. 57.8).
About 5 cm in length and 3 cm in diameter, it is the most anterior of
the cardiac vessels and arises from the base of the right ventricle (from
the pulmonary anulus surmounting the conus arteriosus) above and to
the left of the supraventricular crest. It slopes up and back, at first in
front of the ascending aorta, then to its left. Below the aortic arch it
divides, level with the fifth thoracic vertebra and to the left of the
midline, into right and left pulmonary arteries of almost equal size. The
pulmonary trunk bifurcation lies below, in front and to the left of
the tracheal bifurcation (which is also associated with the inferior tra-
cheobronchial lymph nodes and the deep cardiac nerve plexus). In the
The pulmonary arteries are described on page 996.
Thoracic aorta
Ascending aorta
The ascending aorta is typically 5 cm long and begins at the base of the
left ventricle, level with the lower border of the third left costal cartilage;
it ascends obliquely, curving forwards and to the right, behind the left
half of the sternum to the level of the upper border of the second left
costal cartilage (Figs 56.2A, B, 56.8, 56.18A–C; see Figs 53.2, 57.8). At
its origin, proximal to the aortic anulus, the sectional profile is larger
and not circular because of three almost hemispherical outward bulges 983