Thorax

1. Thorax Marilyn Rose

2. Bony thorax • Thoracic vertebrae (12) • Posterior boundary • Sternum • Anterior boundary • Manubrium-superior- articulate w/first two ribs and clavicles (sternoclavicular joints) • Also jugular notch- @ T2-T3 • Body- articulate w/ cartilage of 3rd-7th ribs • Xiphoid- inferior- muscle attachment

3. Bony Thorax Contd. • Ribs (12 pair) • First 7 pairs- true ribs- articulate with sternum @ costal cartilage • Lower 5 pairs- false ribs- do not attach to sternum • 11th and 12th are floating- attach only to vertebrae • (no neck or tubercle) • Head , neck, tubercle, body • Facets of head articulate with vertebral bodies • @ costovertebral joints • Facets of tubercles articulate with transverse processes • @ costrotransverse joints • Costal cartilage • 1st- 7th @ sternum • 8th, 9th, 10th rib attach to costal cartilage of ….7th rib

4. Sternum retrosternal goiter

5. Ribs on X-ray scapula coracoid process clavicle trachea (TR) aortic arch (AA) left auricle (LAu) left primary bronchus (LPB) right border of the heart (RB). Remember that the right atrium forms this border. pulmonary vessels (PV) descending aorta (DA) left border of the heart (LB) formed by the left ventricle (LV) right diaphragm (RD) Usually slightly higher that the left diaphragm (LD) vertebral spine (VS) 12th rib lower border of the breast in the female (BR) gas bubble in the stomach (usually gives a clue to where the stomach is

6.  Pulmonary necrosis in a 48-year-old man after postoperative radiation therapy (60 Gy) for upper right bronchogenic carcinoma. (a, b) Chest radiograph (a) and computed tomographic (CT) scan (b) obtained 1 year after radiation therapy show fibrotic changes in the apex of the right lung. (c, d) Chest radiograph (c) and CT scan (d) obtained 2 years after radiation therapy show a large cavity with a sequestrum. Surgical exploration and histologic examination revealed changes due to radiation necrosis. Neither a bronchial fistula nor an associated infection was identified. Ribs on CT Pulmonary necrosis in a 48-year-old man after postoperative radiation therapy (60 Gy) for upper right bronchogenic carcinoma. (a, b) Chest radiograph (a) and computed tomographic (CT) scan (b) obtained 1 year after radiation therapy show fibrotic changes in the apex of the right lung. (c, d) Chest radiograph (c) and CT scan (d) obtained 2 years after radiation therapy show a large cavity with a sequestrum. Surgical exploration and histologic examination revealed changes due to radiation necrosis. Neither a bronchial fistula nor an associated infection was identified.

7. Thoracic Apertures trachea is displaced to the right at the thoracic inlet Chest radiograph and CT scan showing a thoracic inlet neurofibroma Pancoast tumor invasion of the subclavian artery • Thoracic inlet • Superior • First thoracic vertebra, first pair of ribs, costal cartilage and manubrium • Allows for passage of nerves, vessels and neck viscera

8. Thoracic Apertures Thoracic outlet syndrome is a combination of pain in the neck and shoulder, numbness and tingling of the fingers, and a weak grip. The thoracic outlet is the area between the rib cage and collar bone. • Thoracic outlet • Inferior • Larger than the superior inlet • 12th thoracic vertebra, 12th pair of ribs, costal margins and xiphoid

9. Lungs • Apex- superior to 1st rib • Base- dome of diaphragm • Divided into lobes by fissures • Rt lung= 3 lobes-sup, (horizontal fissure, mid, (oblique fissure) inf • Lt lung= 2 lobes-sup, (oblique fissure) inf • Lt lung has a cardiac notch which is on the medial surface of the sup lobe • Each lobe has a hilum- passage for mainstem bronchi, blood, lymph vessels and nerves.

10. Lungs Wegener's Granulomatosis Lung carcinoma: Spiral CT detection

11. Cystic Disease of the lungs…

12. Pleural Cavities • Parietal pleura • Outer layer, continuous with thoracic wall and diaphragm • Visceral pleura • Inner layer, closely covers the outer surface of the lung and continues into the fissures to enclose each lobe. • Both membranes secrete fluid to lubricate during breathing

13. Bronchi • Trachea bifurcates-LT/RT mainstem bronchi @ T5….Carina • Rt is wider, shorter and more vertical than LT • Hilum- mainstem bronchi divides into secondary bronchi- corresponding with 3 on the Rt and 2 on the Lt • Secondary bronchi further divide into tertiary bronchi • Extending into each segment of the lobes- 10 segments per lung • Bronchial tree continues to divide into bronchi and bronchioles • Finally they terminate into the alveoli • Functional unit of the respiratory system • Gaseous exchange occurs here..remember?

14. Bronchi

15. Mediastinum • Midline thoracic cavity • Between pleural cavities of lungs • Superior-thoracic inlet • Inferior- diaphragm • Anterior- sternum • Posterior- thoracic vertebrae • Superior compartment • Inferior compartment- anterior, middle and posterior • Structures= thymus gland, trachea, esophagus, lymph nodes, thoracic duct, heart, great vessels and nerves

16. Thymus Gland • Bi-lobed gland of lymph tissue • Superior mediastinum posterior to manubrium • Primary lymphatic organ for development of cellular immunity- T Lymphocytes • Thymus reaches max size at puberty and decreases in size as an adult • Secrete thymosin- develop/ maturation of T lymphocytes

17. Thymus gland Thymoma is the most common neoplasm of the anterior mediastinum which originates within the cells of the thymus

18. Trachea and Esophagus • Trachea • runs anterior to esophagus • Cross section- round air-filled bifurcating @ carina • Esophagus • Cross section-oval • Descend to stomach at gastroesophageal junction

19. Trachea and Esophagus Bronchiectasis with slight mediastinal shift and pleural thickening, and adhesions tenting the left side of the diaphragm. The destroyed lung which results from primary (nonimmune) tuberculosis almost always affects only one lung. The other lung remains normal apart from over-expansion.

20. Lymphatic System • Lymph nodes in mediastinum are clustered around- great vessels, esophagus, bronchi, and carina. • Nodal stations-lung cancer staging. • Lymph vessels- interstitial fluid into venous circulation • Thoracic duct- drains tissue below diaphragm • Begins inferior to diaphragm @ L2 and ascends into diaphragm between azygous vein /descending AO- empties into LT subclavian. • Smaller Rt lymphatic duct collects lymph from Rt upper side and extremities into Rt subclavian.

21. Mediastinal Nodes Mediastinal tuberculous adenopathy. Axial contrast-enhanced CT scan demonstrates multiple enlarged mediastinal lymph nodes with central areas of low attenuation and peripheral enhancement

22. Heart 4 chambered muscular organ Oblique and fist sized Base- most superior and posterior- formed by the atria Apex- points inferiorly, anteriorly and to the LEFT -at the level of the 5th intercostal space. Formed by the LT ventricle…

23. Pericardium pericardial effusion and enhancing pericardium • The heart is enclosed in a pericardial sac • Double layered serous membrane • Parietal- lines inner surface • Visceral (epicardium)-cover the outer surface • Pericardial cavity- potential space between the two layers with serous fluid • Between the pericardium and the heart wall is epicardial fat

24. Heart • Heart wall • Epicardium- thin outer layer • Myocardium- thick middle layer • Endocardium- thin endothelial lining • 2 atria- divided by interatrial septum • Embryonic development- foramen ovale • Blood flowed between the atria during lung development, and at birth it closes • 2 ventricles- divided by interventricular septum

25. Chambers of the Heart • Rt atrium- rt border- DO blood from S/IVC,coronary sinus, cardiac veins • Rt vent- on the diaphragm, anterior heart- DO blood from RA and sends it to the pulmonary trunk- lungs (vent walls- papillary muscles • Lt atrium- most posterior surface, O2 blood comes directly from lungs via 4 pulmonary veins • Lt Vent- forms the apex, left border, morst inferior surface- O2 blood from Lt atrium and pumps into the AO (myocardium is 3X thicker in the LT vent)

26. Heart Chambers

27. Cardiac Ultrasound(echo) RVOT Rt vent- Pulm art LVOT Lt vent- Aorta arch 4 chamber heart

28. Cardiac Valves • Four valves • One-way directional blood flow • Atrioventricular • 2- one at each entrance to the vents • Attached to papillary by chordae tendineae • Rt has 3 leaflets- tricuspid • Lt has 2 leaflets- bicuspid (Mitral) • Semilunar • Junction of vents and great vessels • Pulmonary semilunar- at RV and pulm art • AO semilunar is btw LV and Ascending AO

29. TOF? “Blue Baby” • The classic form- Tetralogy of Fallot includes 4 defects within the heart structures: • Ventricular septal defect • (hole between the right and left ventricles) • Narrowing of the pulmonary outflow tract • (tube that connects the heart with the lungs) • An aorta that grows from both ventricles, rather than exclusively from the left ventricle • A thickened muscular wall of the right ventricle (right ventricular hypertrophy)

30. Great Vessels-arterial • AO • Largest artery • Ascending, arch, descending • Base of LV- sternal angle, curves superiorly and posteriorly as the arch- top of arch (T3)- descending AO anterior and LT of vertebral column • Pulm Arteries • Pulm trunk- within pericardial sac • Attached to AO by ligamentum arteriosum= renmant fetal blood vessel- ductus arteriousis linking pulmonary/systemic circuit • Arises from RV and bifurcates at (T4) into Rt and LT pulm art. • Rt -lateral, post to AO/cava, ant to esophagus, and enters hilum of Rt lung- divides into two branches • Lt – shorter, smaller and most superior of pulm vessels-enters Lt lung hilum superior to mainstem bronchus

31. Great Vessels- Venous • Pulmonary Veins • Anterior and Inferior to pulm arteries • Two each sup/inf extends from each lung to the LT atrium of the heart- continuous with capillaries of the pulm arteries. • Rt/Lt sup pulm vein and Rt/Lt inf pulm vein • Superior VenaeCavae • Junction of brachiocephalic- blood from thorax, up limbs, head and neck- post and lat to ascd AO • Enters upper portion of RA • Inferior VenaeCavae • Juction of common iliac veins in pelvis • RT of abd AO and anterior to vertebral column- enters inferior Rt Atrium

32. Great vessels of the heart Left image shows contrast in the right ventricle (RV) being pumped into the pulmonary trunk (PT). The image on the right shows contrast distribution to the right pulmonary artery (yellow arrow) and left pulmonary artery (green arrow). The right pulmonary artery runs just posterior to the ascending aorta and in front of the tracheal bifurcation. The left pulmonary artery is shorter and smaller and runs anteroinferior to the descending aorta

33. Great vessels contd.

34. Aortic Arch • 3 branches: • Brachiocephalic (innominate) trunk • 1st and largest branch, divides into: • Rt common carotid- lat to trachea at C4-Int/Ext carotid art • Rt subclavian arteries- post to clavicle into axilla • LT common carotid artery • 2nd- lt of trachea @ C4 where it too – Int/Ext carotid art • Lt subclavian artery • Post to LC carotid, arches laterally toward axilla

35. AO Arch 20-days old male presented with heart failure. The arch is interrupted between left CCA and SCA. The pulmonary artery is markedly dilated and connected to descending aorta via large PDA giving the appearance of a low aortic arch. The PA is much larger than ascending aorta. Other associated anomalies in this case included VSD and large sinus venosus ASD

36. AO arch Thoracic aortic dissection is commonly divided according to the Stanford classification into type A (involving the ascending aorta or aortic arch) and type B (involving the descending thoracic aorta only). The main causes of dissection are hypertension, atherosclerosis, Marfan’s syndrome, Ehlers-Danlos syndrome, vasculitis, pregnancy and iatrogenic (aortic catheterisation).

37. SVC • SVC receives blood from head/neck via internal/ external jugular veins and from the upper ext via the subclavian. • Subclavians arise from axillary – receive blood from external jugular before joining the internal jugular continue as brachiocephalic vein • Lt brachio- runs anterior to AO and unites with Rt brachio- post to costal cartilage of 1st rib • Union of the Lt/Rt brachio= Superior Vena Cava- which empties into RA of heart

38. SVC Superior vena cava syndrome hypoattenuating thrombus that fills the superior vena cava- use anticoagulants. Multiple serpentine vessels are visualized in the left anterior and posterior chest walls. Contrast is also visualized within the azygos vein, there is also dilatation of the azygos vein. There is no contrast visualized in the superior vena cava and there appears to be a hypodense abnormality within the lumen. This most likely represents thrombus

39. Coronary Circulation • Heart requires continuous O2 blood • Coronary circulation supplies blood to the heart • Coronary arteries- 1st branch of AO • Rt coronary • rt marginal branch to apex • posterior interventricular branch (post descending) • Lt coronary • circumflex (branches to Lt marginal) • left anterior interventricular (ant descending)- LAD • LAD= “widow maker”

40. Coronary arteries left circumflex coronary artery

41. Cardiac Veins • Coronary sinus • Posterior • Main vein of the heart • Great • Small • middle

42. Cardiac Veins

43. Azygos Venous System • Collateral circulation • Between the inferior and superior venaecavae • Divided into two: • Azyogs-ascends along Rt vert column • Hemiazygos vein- ascends along Lt vert column • Hemiazygos crosses behind the AO and joins the azygos (T7-9) and emties into the posterior SVC.

44. Azygos Veins

45. Muscles • Intercostal • Serrtus posterior sup/inf • Diaphragm • Crura of diaphragm- tendons that attach to lumbar spine • Aortic hiatus, caval hiatus and esophageal hiatus • Pectoralis major/minor • Subclavius • Serratus anterior

46. HLHS

47. Berlin Heart First step: is a Norwood then A Glenn and a Fontan… Perhaps a Berlin Heart and finally A Heart Transplant is needed as The final fix to the condition

48. What is it? LAD! Mesothelioma Rt lung Name the valves…