TBL reading resource

The mediastinum – Anterior and Middle

The student should be able to;

 list structures found in the Anterior and Middle mediastinum, and briefly be
aware of their spatial relationships.
 describe the arrangement of the chambers of the heart, and its surfaces and
borders (including apex and base and sulci)
 describe the fibrous pericardium and the parietal and visceral layers of the
serous pericardium.

The thorax includes the primary organs of the respiratory and cardiovascular

systems. The thoracic cavity is divided into three major spaces:

 1 central compartment, or mediastinum, houses the conducting structures that

make up the thoracic viscera.

 2 lateral compartments or pulmonary cavities for the lungs.

Thus the majority of the thoracic cavity is occupied by the lungs, which provide for

the exchange of oxygen and carbon dioxide between air and blood, whereas most of

the remainder of the thoracic cavity is occupied with structures involved in

conducting the air and blood to and from the lungs. Nutrients traverse the thoracic

cavity via the esophagus, to the abdomen.

Mediastinum

The mediastinum is the central compartment of the thoracic cavity and contains all

thoracic viscera except the lungs. Occupying structures are hollow (fluid or air filled).

The superior mediastinum (above the transverse thoracic plane) is occupied by the

trachea and upper parts of the great vessels; the middle part of the inferior

mediastinum is occupied by the heart; and most of the posterior mediastinum is

occupied by structures vertically traversing all or much of the thorax.

The mediastinum (Latin. middle septum) is covered on each side by mediastinal

pleura. It extends from the superior thoracic aperture to the diaphragm inferiorly and

from the sternum and costal cartilages anteriorly to the bodies of the thoracic

vertebrae posteriorly.

Unlike the rigid structure observed in the embalmed cadaver, the mediastinum in

living people is a highly mobile region. The looseness of the connective tissue and

the elasticity of the lungs and parietal pleura on each side of the mediastinum enable

it to accommodate movement as well as volume and pressure changes in the

thoracic cavity. The mediastinum is artificially divided into superior and inferior parts

for purposes of description. The superior mediastinum extends inferiorly from the

superior thoracic aperture to the horizontal plane that includes the sternal angle

anteriorly and passes approximately through the junction (IV disc) of the T4 and T5

vertebrae posteriorly. The inferior mediastinum—between this plane and the

diaphragm—is further subdivided by the pericardium into anterior, middle, and

posterior parts. The pericardium and its contents constitute the middle

mediastinum. Some structures, such as the esophagus, pass vertically through the

mediastinum and therefore lie in more than one mediastinal compartment.

Anterior Mediastinum

The anterior mediastinum, the smallest subdivision of the mediastinum, lies

between the body of the sternum and the transverse thoracic muscles anteriorly and

the pericardium posteriorly. It is continuous with the superior mediastinum at the

sternal angle and is limited inferiorly by the diaphragm. The anterior mediastinum

consists of loose connective tissue (sternopericardial ligaments), fat, lymphatic

vessels, a few lymph nodes, and branches of the internal thoracic vessels. In infants

and children, the anterior mediastinum contains the inferior part of the thymus.

Pericardium

The middle mediastinum includes the pericardium, heart, and roots of its great

vessels — ascending aorta, pulmonary trunk, and SVC—passing to and from the

heart. 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 (blends

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. This layer is reflected

onto the heart at the great vessels—aorta, pulmonary trunk and veins, and

superior and inferior venae cavae—as the visceral layer of serous

pericardium. The serous pericardium is composed mainly of mesothelium, a

single layer of flattened cells forming an epithelium that lines both the internal

surface of the fibrous pericardium and the external surface of the heart.

The pericardium is a fibroserous sac, invaginated by the heart and roots of the great

vessels, that encloses the serous cavity surrounding the heart. The pericardial

cavity is the potential space between 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. The fibrous pericardium is inelastic.

Thus it holds the heart in its middle mediastinal position and limits expansion (filling)

of the heart. If fluid or a tumor occupies the pericardial space, the capacity of the

heart is compromised. The parietal layer of the serous pericardium is sensitive. Pain

impulses conducted from it by the somatic phrenic nerves result in referred pain

sensations.
The ascending aorta, begins at the aortic orifice. Its only branches are the coronary

arteries, arising from the aortic sinuses. It end at the level of manubriosternal joint to

become the arch of aorta

Heart and Great Vessels

The heart, slightly larger than a clenched fist, is a double, self-adjusting, suction and

pressure pump. The right side of the heart receives poorly oxygenated (venous)

blood from the body through the SVC and IVC and pumps it through the pulmonary

trunk to the lungs for oxygenation (Fig. 1.39A). The left side of the heart receives

well-oxygenated (arterial) blood from the lungs through the pulmonary veins and

pumps it into the aorta for distribution to the body.

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 synchronous

pumping actions of the heart's two atrioventricular (AV) pumps (right and left

chambers) constitute the cardiac cycle. The heart and roots of the great vessels

within the pericardial sac are related anteriorly to the sternum, costal cartilages, and

anterior ends of the 3rd–5th ribs on the left side. The heart and pericardial sac are

situated obliquely, approximately two thirds to the left and one third to the right of the

median plane. Externally, the atria are demarcated from the ventricles by the

coronary or atrioventricular groove (L. sulcus), and the right and left ventricles are

demarcated from each other by anterior and posterior interventricular (IV)

grooves. The heart is shaped like a pyramid with an apex, a base, and four sides.

The apex of the heart (apex beat) Is formed by 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.

The base of the heart Is the heart's posterior aspect (opposite the apex) is formed

mainly by the left atrium. Faces posteriorly toward the bodies of vertebrae T6–T9

and is separated from them by the pericardium, esophagus, and aorta. It receives

the right and left pulmonary veins and the superior and inferior venae cavae.

The four surfaces of the heart (see figures above) are the:

 Anterior (sternocostal) surface, formed mainly by the right ventricle.

 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.
  Right pulmonary surface, formed mainly by the right atrium.

 Left pulmonary surface, formed mainly by the left ventricle; it forms the

cardiac impression of the left lung.

Its four borders are the:

1. Right border formed by the right atrium and extending between the SVC and

the IVC.

2. Inferior border, formed mainly by the right ventricle and slightly by the left

ventricle.

3. Left border formed mainly by the left ventricle and slightly by the left auricle.

4. Superior border, formed by the right and left atria and auricles in an anterior

view; the ascending aorta and pulmonary trunk emerge from this border and

the SVC enters its right side. The pulmonary trunk and arteries conduct poorly

oxygenated blood to the lungs for oxygenation

The coronary arteries, the first branches of the aorta, supply the myocardium and

epicardium. The right and left coronary arteries (RCA and LCA) arise from the

corresponding aortic sinuses at the proximal part of the ascending aorta.

Typically, the RCA supplies

 The right atrium.

 Most of right ventricle.

 Part of the left ventricle (the diaphragmatic surface).

 Part (usually the posterior third) of the IV septum.

 The SA node (in approximately 60% of people).

 The AV node (in approximately 80% of people).

the LCA supplies

 The left atrium.

 Most of the left ventricle.

 Part of the right ventricle.

 Most of the Interventricular septum (IVS) (usually its anterior two thirds)