Escolar Documentos
Profissional Documentos
Cultura Documentos
Coronal (Frontal) Plane: divides body into anterior (ventral) & posterior (dorsal)
Axial Plane: divides body into superior (cephalad) & inferior (caudad)
Sagittal (Median) Plane: divides body into right & left (medial/lateral)
Proximal: closer to torso or beginning of a system
Distal: farther from torso or beginning of system
Superficial: closer to surface of body or body part or organ
Deep: farther from surface of body or body part or origin
Intermediate: somewhere between superficial & deep
Fascia: visibly organized, sheet-like connective tissue of varying thickness & composition
Superficial Fascia: substrate of skin; contains varying amounts of adipose tissue
Axial Skeleton: Skull, spinal column, ribs & sternum, hyoid bone
Appendicular Skeleton: pectoral girdle (scapula & clavicle), pelvic girdle (hip bones),
free limbs
Sesamoid Bones: Bones that develop in tendons over high stress regions of a joint; part
facing joint cavity is covered with articular hyaline cartilage; often acts as a moveable
pulley, reducing friction, modifying pressure, & altering a tendons direction of pull for best
mechanical advantage. IE: patella of knee, thumb, great toe, fabella
Articulations:
o Condyle: rounded articulated knob
o Facet: smooth, flat, concave/convex articulating surface
o Head: prominent expanded end of a long bone
Extensions & Projections:
o Crest: narrow ridge
o Epicondyle: projection superior to condyle
o Line: slightly raised elongated ridge
o Process: any bony prominence
o Protuberance: outgrowth or protruding part of bone
o Spine: sharp, slender, narrow process
o Trochanter: massive process unique to femur
o Tubercle: small rounded process
o Tuberosity: large tubercle, usually roughened surface
Depressions:
o Alveolus: pit or socket (tooth socket)
o Fossa: (ditch) a shallow basin of variable size
o Foveola: tiny pit
o Sulcus/Groove: groove for tendon, nerve, or blood vessel
Passages:
o Canal: tubular passage or tunnel in a bone
o Fissure: slit through a bone
o Foramen: rounded hole of short length in a bone
o Meatus: opening or passage, usually air-filled
Red Marrow: hematopoietic; mainly in axial skeleton, ilium, some in head & metaphysis
of humerus; glenoid (scapula); neck & metaphysis of femur
Yellow Marrow: mainly fat; in rest of skeleton
Synarthrosis: solid joint with limited or no movement
o Fibrous joint: non-osseous bonding material is collagenous
Suture: bone-collagenous sutural element- bone (cranium)
Syndesmosis: bone-interosseous membrane or ligament bone (radius &
ulna)
Paralysis: complete loss of muscle cell contraction as a result of lesion of a somatic motor
neuron
Paresis: profound weakness in a mytome as a result of injury to a particular spinal nerve
or its ventral ramus
Rami Levels of Motor Innervation
o C5: shoulder abduction
o C6,C7: shoulder adduction, elbow flexion/extension, wrist flexion/extension
o C6, C7, C8: pronation/supination
o C7: finger extension
o C7, C8: finger flexion
o C8: deep extension & thumb (pollicis) abduction, deep flexion
o T1: intrinsics of the hand
ANS: part of the PNS responsible for monitoring & regulating visceral functions; carries
signals to & from visceral structures such as internal organs, glands, & blood vessels via
visceral motor (efferent) & visceral sensory (afferent) neurons
o Sympathetic Division: primarily responsible for motor innervation of smooth
muscle lining blood vessels, cardiac muscle & sweat glands, & sensory innervation
of viscera
o Parasympathetic Division: primarily response for motor innervation of smooth
muscle lining digestive tract, cardiac muscle, & salivary glands & sensory
innervation of viscera
Somatic Motor Neurons: innervate skeletal muscle; have single neuronal pathway from
CNS to skeletal muscle. Cell bodies are multipolar 7 located in the ventral horn of the
spinal cord; axons are myelinated & directly innervate somatic peripheral effectors
(skeletal muscles)
Visceral Motor Neurons: innervate smooth muscle, modified cardiac muscle, & glands;
have a 2-motor-neuron-pathway with a preganglionic neuron (1 st multipolar neuron in
lateral horn of spinal cord with myelinated axon) which synapses with a postganglionic
neuron (cell body in a ganglion with unmyelinated axon which innervates visceral
peripheral effector)
Sudomotor: eccrine sweat glands
Pilomotor: piloerector muscles
Vasomotor: vasoconstriction & vasodilation in skeletal muscle
Lateral Horn: has preganglionic cell bodies found from T1-L2 spinal cord segments
Ventral Root: has preganglionic axons to spinal nerves T1-L2 (& somatic motor axon)
Spinal Nerve: carry somatic motor axons, somatic sensory fibers & postganglionic
sympathetic axons. T1-L2 also have visceral sensory fibbers & preganglionic motor axons
White Ramus Communicans: connects spinal nerves T1-L2 anatomically to ventral rami
with sympathetic trunk ganglion. Carries preganglionic motor axons & visceral sensory
fibers
Gray Ramus Communicans: connects all spinal nerves (anatomically to ventral rami)
with sympathetic trunk ganglion. Carries postganglionic motor axons to spinal nerve.
Accepts visceral sensory fibers from spinal nerves C1-C8, & L3-Co1
Sympathetic Trunk (paravertebral) Ganglion: contains postganglionic cell bodies
Splanchnic nerve: connects sympathetic trunk ganglia with prevertebral ganglia. Carries
preganglionic motor axons & visceral sensory fibers
Prevertebral Ganglion: contains postganglionic cell bodies whose axons are distributed
to abdominopelvic viscera by coursing in the adventition of the arteries supplying those
viscera
Spinal Nerve Innervation Distribution:
o T1-L2: trunk
o C1-C4: neck
o C5-C8: upper limb
o L3-S4: lower limb
Autonomic Sensory Innervation:
o Somatic Sensory Neurons: innervate skin, muscle, joints. Convey pain,
temperature, touch, proprioception. Cell bodies located in dorsal root ganglia of
spinal nerves C2-Co1. Pathway same as motor, up to spinal nerve, through dorsal
root to dorsal horn.
o Visceral Sensory Neurons: innervate viscera, glands, blood vessels. Convey
distension, nausea, hunger. Cell bodies located in dorsal root ganglia of spinal
nerves T1-L2 & S2-S4. Pathway same as motor, up to spinal nerve, through dorsal
root & to dorsal horn.
Viscerosomatic Referred Pain: pain from a visceral organ that is interpreted by the
brain as coming from a somatic region of the body having the same spinal cord segmental
innervation
Raynauds Phenomenon: the condition when it is associated with a pre-existing disease
state such as diabetic neuropathy
Raynauds Disease: used to describe the condition when it is idiopathic
Raynauds Characteristics: abnormal, episodic vasospasm of the digits in response to
cold exposure. Upon warming, the affected digits undergo reactive hyperemia, becoming
engorged with blood. Characteristic biphasic or triphasic color response of affected digits,
from pallor to cyanosis. & upon rewarming, rubor. During rubor phase there is considerable
pain & throbbing
Complex Regional Pain Syndrome:
o Type I (Reflex Sympathetic Dystrophy): abnormal sympathetic response to soft
tissue injury marked by pain & swelling of a distal extremity accompanied by
vasomotor instability, trophic skin changes & rapid development of bone
demineralization
Phase I: period of sympathetic hypoactivity; allodynia, hyperesthesia &
hyperrpathia (hyperalgesia); anhidrosis, edema, pain, throbbing, tender joints
Phase II: period of sympathetic hyperactivity; intense vasoconstriction,
pallor, cyanosis, skin mottling, cold intolerance
Phase III: persistent sympathetic hyperactivity causing gradual atrophy of
skin & subcutaneous tissue with flexion contracture & osteopenia
o Type II (Causalgia): characterized by persistent pain in limb after injury to a
peripheral nerve or major nerve trunk; a complication of brachial plexus surgery or
decompression; persistent pain is said to be in the form of burning & throbbing. Also
focal vasomotor & sudomotor abnormalities, with localized sweating & edema of
affected limb. Does not appear to progress to atrophy as CRPS Type I.
Dysautonomia: autonomic dysfunction associated with disease states
o Idiopathic:
Shy-Drager Syndrome: cases of multiple system atrophy in which
autonomic failure predominates
o Autoimmune:
Acute Pandysautonomic Neuropathy: autonomic failure due to ganglionic
anti-nicotinic acetylcholine receptor antibodies (postsynaptic Ach receptor
destruction)
Guillain-Barre Syndrome: autoimmune acute polyneuropathy; 2/3rds of
patients have some degree of autonomic failure
Trophoblast layer: outer layer of cells next to zona pellucida; supplies embryo
with nutrition. Differentiates into placenta
o Embryoblast: inner mass that contains cell that will form the embryo; as few as 10
cells go on to develop into individual
o Poles: embryonic pole trophoblasts digest zona pellucida; blastocyst hatches from
zona pellucida at day 4.5-5. Embryonic pole undergoes implantation into uterine
wall (day 6)
o Ovum Transport: if fertilization occurs, zygote is transported through uterine tube;
transport is timed to maximize fertilization within 20 hours of ovulation; implanation
at day 6. Secondary oocyte delayed in ampulla for 1 day to prepare for fertilization
(physiological amullary isthmic junction block for 1-2 days). Enters uterine cavity at
day 4 as advanced morula (rise in progesterone helps b break through block).
Implantation completed by 12 days after fertilization
Blastocyst Stages:
o Day 8: human chorionic gonadotropic maintains corpus luteum of pregnancy for
progesterone production (6-8 wks). Firsts detected 6-8 days after pregnancy.
Doubles in concentration in maternal blood every 2-3 days, reaching peak at 60-90
days of pregnancy. Falls to plateau concentration 20 wks to term
o Day 9: embryo is almost completely implanted into uterine wall; extraembryonic
endoderm (hypoblast cells line cytotrophoblast container) goes onto develop into
gut & derivatives; lacunae developing in syncitiotrophoblast & will fill with maternal
blood
o Day 12: complete implantation; eroded maternal blood vessels/dilated sinusoids
have connected with trophoblastic lacunae; cell to cell transferring of substance
between embryo & maternal blood
o Day 13: extraembryonic endoderm pinches off from exocoelomic cavity to form
definitive yolk sac.. extraembryonic mesoderm reinforces chorionic cavity as
chorionic plate, reinforces definitive yolk sac & amniotic cavity, & forms body stalk;
lacunae replete with maternal blood; cytotrophoblast villi formation
Extraembryonic Mesoderm: provides CT support for amnion & definitive yolk sac, forms
chorionic plate & body stalk, forms support for placental villi (those closes to embryo
expand, branch & grow forming chorion frondosum), serves as center for vasculogenesis
(de novo blood vessel development), angiogenesis (sprouting of new blood vessels from
existing ones), & hematopoiesis (blood cell development)
Hemangioma: most common tumors of infancy; abnormally dense collections of capillary
blood vessels. Often associated with facial structures.
Sites of Ectopic Pregnancy
o Tubal: cause rupture & hemorrhage
o Placenta Previa: close to internal os (opening) of uterus; too close to cervical
opening. Can bridge the opening as they grow & tear away from wall causing
bleeding & spontaneous abortion. Placenta presents ahead of fetus
Chorion Maturation Steps:
o Primary villus: projection of cytotrophoblast covered by syncytiotrophoblast
o Secondary villus: layers around central extraembryonic mesoderm core from
chorionic plate
o Tertiary villus: development of fetal capillaries & sinusoids within mesodermal
core
Amniocentesis: performed at 15-20 wks pregnancy; prenatal screening
Chorionic Villi Sampling: performed at 11 wks. Prenatal screening
o
Cell Lineages
o Zygote
Cleavage
Trophoblast
Epiblast
Inner Cell Mass
Hypoblast
Cytotrophoblast
Syncytiotrophoblast
Embryonic Endoderm:
Neural ectoderm, neural
crest, surface ectoderm
Amnion
Gastrulation
Extraembryoni
Primordial Germ Cellsc Mesoderm:
Prechordal,
notochordal,
&
Extraembryonic
intraembryoni
Endoderm
c mesoderm
(definitive yolk sac)
Extraembryonic
Mesoderm
(chorionic plate,
chorionic villi, body
stalk, support for
amnion & definitive
yolk sac,
Neurulation (20-23 day embryo)
extraembryonic
o Neural tube: closes first in middle then cranially & caudally
angiogenesis)
o Cranial Neuropore: closes at 25 days
Embryonic
Endoderm
Extraembryoni
c Mesoderm
Lower 5 intercostal nerves & subcostal nerve: supply anterolateral abdominal wall
muscle, skin & parietal peritoneum
Thoracotomy: cutting into thorax
Thoracostomy: inserting a tube into the thorax
Hemothorax: blood in the thorax
Pneumothorax: air in the pleural cavity
Thoracentesis: pleurocentesis; inserting a needle to reduce the abnormal situation in the
pleural cavity
To anesthetize an intercostal space for these procedures: anesthetize the main
branch of the intercostal nerve of the superjacent rib, & the collateral of the same nerve to
the subjacent rib. Posteriorly, you can anesthetize the nerve before it gives off the
collateral but hard to do because of back muscles
Lymphatic Drainage of Thorax:
o Deep fascia & deeper: infection/metastasis follows arteries deeply; drains to
internal thoracic lymph nodes (internal mammary lymph nodes) & along sides of
descending thoracic aorta (para-aortic nodes)
o Superficial Fascia (dermis & skin): direction of drainage is determined by line
encircling umbilicus
Above the line posteriorly: drains to posterior axillary lymph nodes
Above the line anteriorly: drains to anterior axillary lymph nodes
Below the line: drains to superficial inguinal lymph nodes
Septum Transversum: visceral mesoderm near the heart that segregates caudally where
it is invaded by the liver parenchyma; forms a large part of the thoracoabdominal
diaphragm & contributes to the formation of the liver sinusoids
Development of the Thoracic Cavity (pleural cavities & midline pericardial
cavity):
o Cranial part of intraembrynoic body cavity occupied by developing heart future
pericardial cavity
o Lung buds bulge into future pericardial cavity
o Pleuropericardial folds divide future pericardial cavity into definitive pericardial
cavity & more dorsal pleural cavity; pleuropericardial folds contain veins (right
becomes inferior vena cava) & phrenic nerves
o Pleuropericardial folds fuse & separate 2 pleural cavities from pericardial cavity
o Lungs grow & push & enlarge pleural cavities ventrolaterally to almost completely
surround midline pericardial cavity
o Parenchymal portion = mesothelium that secretes & absorbes serous fluid
Costodiaphragmatic Recess: inferior pouch of the pleural cavity; lungs never
completely fill this recess
Costophrenic angles: limits of the lung tissue form these
Sibsons Fascia: a thickened fascia that protects the cervical pleura & apex of the lung
Innervation of Visceral & Parietal Pleurae: visceral pleura & lung are insensitive to
pain; parietal pleurae are heavily innervated with pain fibers
Chilaiditis Syndrome: constant swallowing of air & sputum from pneumonia produces
gas in the GI tract; the distended loop of the bowel insinuates itself between the stomach
& diaphragm or diaphragm & liver
Relationship between pleural cavity, lungs & rib cage
o Anteriorly: ribs 2-4 pleural cavities are in contact behind the sternum (anterior
junction line)
o Anteriorly: ribs 4-6 right parietal pleura stays midline, left parietal pleura deviates
leftward
o Midclavicular line: lung inferior limit is rib 6, parietal pleura inferior limit is rib 8
o Mixaxillary Line: lung inferior limit is rib 8, parietal pleura inferior limit is rib 10
o Scapular Line: lung inferior limit is rib 10, parietal pleura inferior limit is rib 12
Becks Triad: hallmark feature of cardiac tamponade; rising central venous pressure
manifesting as jugular venous distension & distension of other head, neck & upper limb
veins, diminished heart sounds, diminished arterial & pulse pressures; pericardiocentesis
is performed to relieve pressure of cardiac tamponade
o Trendelenberg Position: head elevated 15-30 degrees with respect to feet &
supine; position used to perform pericardiocentesis; insert needle 45 degree angle
to body into left xiphi-costal angle (Larreys Point) aimed at left shoulder
Cardiothoracic Ratio: normal-sized heart silhouette in PA CXR should fit in width of 1
lung field or of chest cavity
Sniff Test: check for hemidiaphragm paralysis; paralyzed hemidiaphragm moves
paradoxically upward
Pleural Effusion: tend to collect in costodiaphragmatic recess & eventually blunt
normally sharp costophrenic angle
Pneumothorax: air in the pleural space; causes partial collapse of the lung
Pneumoconiosis: lung disease caused by inhalation of aerosolized particulates; chronic
irritation leads to chronic pleuritic & pleural adhesions
Bulla: air-filled space of the lung greater than 1 cm in diameter; usually seen in
emphysema
Bleb: air-filled alveolar dilatation in the lung less than 1 cm in diameter
Open Pneumothorax: pneumothorax retaining communication with atmospheric air;
caused by wounding of parietal pleura but sometimes by a spontaneous variety retaining a
communication with pulmonary air; has danger of converting to tension pneumothorax
Tension Pneumothorax: air comes into the cavity with inspiration, but has a check-valve
closed effect with expiration; pressure continues to rise in the pleural space as a result
Apical Bullous Lung Disease: of unknown etiology; occurs in the pediatric population,
generally in asthenic males. Prone to recurring pneumothoraces.
Carinal Cartilage: last tracheal ring; surrounds the beginning of the main bronchi
Tracheomalacia: disease states can put long-term pressure on the trachea causing
chondromalacia of the tracheal rings; leads to segmental collapse with inspiration
Traumatic/Iatrogenic Tracheoesophageal fistula: a rare complication of endoscopy of
the trachea or esophagus in which the unsupported wall of the trachea abutting the
esophageal wall provides opportunity for fistula formation.
Congenital Tracheoesophageal Fistula: if septation & separation fails in some part of
the laryngeotracheal tube, TEF develops; incompatible with postnatal life, except the H
type
Carina: internal keel of the carinal cartilage
Right tracheobronchial angle: 25 degrees
Left tracheobronchial angle: 40 degrees
Hemoptysis: coughing up of blood;
Bronchial veins: superficial veins return to venous system via azygos & hemiazygos
system
Interbronchial angle: almost 90 degrees
Widening/Flatteningo f interbronchial angle: left atrial enlargement, upper lobar
atelectasis, carinal lymphadenopathy
Air Bronchogram: patent airways that become visible out to the tertiary divisions &
beyond
muscle is supplied by the PDA. Smooth walled outflow tract, aortic vestibule, ends with the
aortic (semilunar) valve, having right coronary, left coronary, & posterior non-coronary
cusps.
Cardiac Fibrous Skeleton: gasket of collagenous fibers situated between the atria &
ventricles. supports the orifices & attached valves & prevents their collapse, the
ventricular myocardial syncytial bands directly begin & end on the skeleton, & it serve as
an electron conduction barrier between atria & ventricles
Atrial Myocardium: superficial atrial fibers begin on the fibrous skeleton & wind through
the atrial septum. Superficial fibers wring dimension of the chambers with atrial systole, &
conduct to ensure impulses largely originating in the right atrium are rapidly brought to
the left. Deep atrial fibers are restricted to each atrium. They direct blood toward AV
orifices & form quasi-functional sphincters to minimize retrograde flow of blood into the
veins
Aortic Valve Stenosis: common feature of the aged heart; leads to left ventricular
hypertrophy & eventually left atrial hypertrophy
Right Coronary Arteries: proximal RCA gives off conus artery, SA nodal arteria, right
atrial branches & right anterior ventricular arteries. Acute marginal artery demarcates
beginning of distal RCA, which gives off posterior descending artery. SA node, AV node, &
common AV bundle receive their blood supply from the right coronary artery
Left Coronary Arteries: divide into left anterior descending artery (divided into proximal
LAD & distal LAD). Circumflex artery (divided into 2 obtuse marginal arteries)
Conduction System: SA node (supplied by RCA) innervated by right vagus nerve. AV
node (supplied by RCA) innervated by left vagus nerve. Common AV bundle of His
(supplied by RCA) as is right bundle branch. Left bundle branch is supplied by LCA.
Occlusions of RCA give rise to conduction block.
Postganglionic Sympathetic Fibers:
o Superior cervical sympathetic cardiac nerve derived from superior cervical ganglion
o Middle cervical sympathetic cardiac nerve derived from cervicothoracic (stellate)
ganglion
o Postganglionic fibers from thoracic sympathetic ganglia T2-T5
o Intercostobrachial Nerve (large component of T2) heart nerve
Thebesian Veins: smallest cardiac veins, drain their respective myocardia
Coronary Sinus: 80% of blood draining here comes from left ventricle via great cardiac
vein; site of drainage from posterior vein of left ventricle & oblique vein of left atrium
Small cardiac vein : courses in right part of coronary sulcus; drains distal field of right
coronary artery
Middle cardiac vein: accompanies PDA
Anterior cardiac veins: drains proximal field of right coronary artery
Lymphatics of the Heart:
o Right: follows RCA, right trunk, left brachiocephalic node, left bronchomediastinal
trunk, left lymphovenous portal (thoracic duct)
o Left: follows LCA, left trunk, inferior tracheobronchial node, right superior
tracheobronchial nodes, right bronchomediastinal trunk, right lymphovenous portal
(right lymphatic duct)
Primary Heart Field: cardiac crescent cranial to the oropharyngeal membrane
Cardiac Crescent: forms left ventricle, most of atria, & has a minor contribution to the
outflow tract & right ventricle
Secondary Heart Field: cells from this inner portion of the cardiac crescent form most of
the outflow tract & right ventricle & contribute to the formation of the atria
Proepicardium Cells: form most of the visceral pericardium (epicardium), the coronary
arteries, & the fibroblasts of the heart; eventually form the definitive epicardium, & layer
becomes continuous with parietal mesothelial layer
Cardiac Neural Crest Cells: invade the developing heart & contribute to the walls of the
outflow tract & the conotruncal septum; play a critical role for the formation of the atrial &
membranous ventricular septa
Conotruncal Septum: divide the outflow tract into the pulmonary trunk & the aorta
FROM 18-22 DAYS:
o Myocardial Primordium: develops from the visceral mesoderm of the developing
pericardial cavity
o Visceral Mesoderm: gives rise to the endocardial tubes; eventually fuse to form a
single tube
o Pericardial Cavity: with lateral infolding, encircles developing heart
o Visceral Mesothelium: forms the scaffold for the myocardium & the contact
support for the epicardium; is eventually displaced by invading proepicardium cells
o Dorsal Mesocardium: eventually breaks down, leaving developing heart free in
pericardial cavity
o Parietal Mesoderm: forms parietal pericardium
Primordial Heart: formed from fusing of endocardial tubes, with fusion occurring in the
cranial-caudal direction; with cranial infolding, the heart primordium & pericardial cavity
undergo 180 degree roation so they end up on the underside of the embryo
Endocardial Tube: comes to lie in front of part of gut tube which will become future
esophagus
First heart beat: 20-22 days of development
Five Parts of Embryonic Heart & Their Fates
o Sinus Venosus: becomes sinus venarum, coronary sinus, & oblique vein of the left
atrium (Oblique Vein of Marshall)
o Primitive Atrium: becomes rough walled parts of right & left atria & their atrial
appendages (auricles)
Right atrium: distinction between rough & smooth walls is separated by
crista terminalis, with pectinate muscle emanating from crista terminalis
lining anterior aspects of RA
Left atrium: incorporation of 4 pulmonary veins largely displaces most of
the embryonic rough wall, leaving it almost entirely smooth walled with rough
wall restricted to left auricle
o Primitive Left Ventricle: forms trabeculated part of left ventricle
o Bulbus Cordis:
proximal portion becomes primitive right ventricle, which later becomes
trabeculated portion of right ventricle
Conus Cordis: middle portion that becomes conus arteriorsus
(infundibulum) of right ventricle & aortic vestibule of left ventricle (the
smooth outflow regions of each ventricle)
Truncus Arteriosus: distal portion that becomes the pulmonary trunk &
ascending thoracic aorta
o Aortic Sac: becomes aortic arch branches, proximal pulmonary artery branches, &
ductus arteriorsus
Septation of Atria
o Semptum primum grows down from roof of primitive atrium to bottom of primitive
atrium to form left & right atria without completely fusing with floor; gap formed is
ostium primum
Ostium secundum develops by cell death in top part of septum primum before
ostium primum is completely closed by septum primum fusion with floor; maintains
flow while atria are developing
o in region of AV junction, endocardial cushions (mound of cardiac cells) push in
from all sides to separate atria from ventricles & provide anchoring point for
interatrial & interventricular septa; complete AV separation
o septum secundum grow to right of floppy septum primum; free edge of septum
secundum is thickened (crista dividens)
o foramen ovale: gap left in septum secundum; low on right atrium
o right to left shunt maintained by blood pushing against floppy, valve-like septum
primum & flowing over top of valve into left atrium (septum primum = valve of
foramen ovale)
o with first breaths, pulmonary blood flow from left atrium causes pressure in left
atrium to rise greater than right atrium
o valve-like free upper edge of septum primum pushed against rigid septum
secundum & crista dividens, & foramen ovale closes
o Crista dividens becomes limbus fossa ovalis in right atrium
o Free edge of septum primum becomes foramen ovale in left atrium
Muscular part of IV septum: formed by selective cavitation through cell death; as
ventricle grows outwards, relatively solid ventricle is sculpted out by cell death except for
center (forming partition)
Derivatives of Aortic Arches
o 1 & 2- drop out & become small arteries
o 3 becomes common carotid formed by remaining cranial extension of dorsal aorta;
external carotid develops by sprouting out from proximal part of 3 rd arch
o 4 arches of aorta from left common carotid to left subclavian arteries on left;
proximal portion of right subclavian artery on right
o 6- left pulmonary artery & ductus arteriorsus, right pulmonary artery
Left umbilical vein: carries oxygenated blood from placenta to fetus; becomes sole
source of oxygenated blood after right vein degenerates during development
Fetal circulation at the heart
o 50% of oxygenated blood courses through fetal liver & then to IVS via hepatic veins,
where it gets a little desaturated
o Diversion to vena cava by ductus venosus (50%); mixed with desaturated blood in
IVC
o Ductus venosus: has a pressure sensitive sphincter; if pressure in umbilical vein
is too high, sphincter closes & diverts more blood to liver & dissipate pressure that
can damage fetal heart
o Blood travels from IVC to RA & is directed through foramen ovale to LA by
Eustachian valve
o Most of SVC blood is prevented from mixing with oxygenated umbilical vein blood;
diverted to right ventricle by cascading over intervenous tubercle
o Lungs dont function in gas exchange; exhibit high pulmonary resistance blood in
pulm. Artery is diverted to aortic arch through ductus arteriosus
o Ductus arteriosus: prevents overload of incompliant lungs & resistance supports
growth of right ventricle for transition into neonatal life
o Umbilical arteries: oxygen saturation 58% by time it reaches this point
Ductus venosus: closes by unknown mechanism; sphincter constricts & shunts umbilical
venous blood to liver, causing pressure in right atrium to fall; becomes ligamentum
o
venosum in left sagittal fissure of liver connecting left branch of hepatic portal vein with
left hepatic vein
Umbilical vein: closes over time but remains patent neonatally, can be used
therapeutically. Occlude to form round ligament of liver from umbilicus in falciform
ligament to left sagittal fissure, then connecting to left branch of hepatic portal vein
DA becomes fibrous connection between left pulmonary artery & aortic arch
ligamentum arteriosum
Distal part of umbilical arteries occlude & become medial umbilical ligaments
Atrial Septal Defect: secundum atrial septal defect; pressure in left atrium is high after
birth, causing oxygenated blood to be shunted to left atrium. Acyanotic. Can cause
enlarged right atrium, right ventricle (causing convexity of normally slightly concave left
auricle),& pulmonary trunk (obliterating distinction between aortic knuckle & pulmonary
trunk)
Ebstein anomaly: some of right ventricle is incorporated into right atrium (atrialization
dysfunction). Distorts normal architecture of tricuspid valve, resulting in severe tricuspid
Valvular dysfunction. Right heart has to work harder. Called box-shaped heart
Perimembranous VSD: involves membranous ventricular septum because of active
growth required to form it. Left heart pressure is higher than right; left to right shunt.
Acyanotic
Tetralogy of Fallot:
o Pulmonary infundibular stenosis
o Right ventricular hypertrophy
o Perimembranous VSD
o Cyanotic (aorta overrides VSD & desaturated blood makes it to systemic circulation)
o Patent ductus arteriosus
o Boot-shaped heart
Persistent Truncus Arteriosus: failure of development of conotruncal septum &
contribution to membranous interventricular septum. Cyanotic. Causes left tracheal
deviation
Patent Ductus Arteriosus: seen in many cyanotic conditions because level of oxygen
desaturation causes ductus to remain patent. Pulmonary stenosis & greater aortic
pressure expands ductus retrograde into pulmonary artery, leading to enlargement of
pulmonary artery. Left to right shunt.
Transposition of Great Arteries: arteries get hooked up to wrong ventricle. Cyanotic.
Egg-on-string appearance.
Tricuspid atresia: right atrioventricular orifice & valve fail to develop; patent foramen
ovale & PDA. Cyanotic.
Common Stenoses of Aorta & Pulmonary Artery & their Valves
o Isolated pulmonary Valvular & arterial stenosis: PDA provides flow to lungs for
oxygenation. Acyanotic
o Aortic Valvular stenosis: acquired stenosis. Enlargement of left ventricle & left
atrium because of resistance of stenotic aortic valve.
o Aortiic Valvular Atresia: no blood can go from left ventricle to aorta. Left ventricle
is hypoplastic. Only outflow is pulmonary artery supplying lungs & systemic
circulation. When it returns to left atrium it is shunted to right atrium & mixing with
venous blood. Cyanotic.
Anomalies of aortic sac
o Vascular Rings, Slings & Compressors: affect trachea, esophagus, or both.
Airway obstruction accompanied by stridor (especially expiratory). If esophagus is
involved, there is dysphagia lusoria (dysphagia caused by act of nature)
If dorsal aorta fails to degenerate: double aortic arch that forms vascular ring
around esophagus & trachea
o Aberrant right subclavian artery: indentation of esophagus, trachea is displaced
& compressed
o Aberrant left pulmonary artery: courses between esophagus & trachea. Indents
esophagus & trachea airway
o Left aortic arch loses connection with descending aorta: double aortic arch
with left one being incomplete. Right gives off left common carotid, right common
carotid, & right subclavian & forms main connection with descending thoracic aorta.
Left arch is broken leaving a stump (Kommerells diverticulum). Horsehoe clamp
around trachea
Displaced innominate artery: may be taught & over trachea such that it compresses
tracheal rings. Can lead to gradual tracheomalacia, tracheal compression, & dyspnea.
Eisenmenger Syndrome: high flow through pulmonary artery persists, resulting in
pulmonary arterial resistance increasing & pulmonary hypertension. Right ventricle begins
to hypertrophy to such a point that shunt from left to right reverses. Body is supplied with
deoxygenated blood. Cyanotic. Previous high pressure through lungs causes damage &
scar tissue in lunges which reduces oxygen transfer & decreased oxygen saturation in
blood. Leads to increased production of RBCs (polycythemia). More immature blood cells
enter vasculature leading to hyperviscosity syndrome & formation of microthromboemboli
in small vessels. Patients have uncontrolled bleeding & random clots
Persistent Hypoxia: cyanosis, clubbing of digits
Manubriosternal joint: sternal angle, angle of Louis, T4/T5 ivd
Inferior vena cava: T8/T9 ivd (+right phrenic nerve)
Xiphisternal junction: T9V
Esophagus: T10 (+ vagal trunks)
Descending aorta: T12 (+ thoracic duct)
Burkells surgical classification:
o anterior & middle mediastina: separated by curvilinear line that passes anterior
to heart shadow & then superiorly passes posteriorly to anterior surface of trachea,
cutting off great vessels. Contains pulmonary artery & branches, superior vena
cava, aortic arch & branches, thymus, anterior lymphatics & fatty areolar tissue
o middle mediastinum: separated from posterior by smooth curvilinear line
posterior to trachea & heart shadow. Contains pericardial cavity & heart proper,
pulmonary veins, inferior vena cava, trachea & bifurcation, main bronchi
o posterior mediastinum: contains osteoligamentous elements, pulmonary sulci,
sympathetic trunk & splanchnic nerves, azygos & hemiazygos venous systems,
esophagus, descending aorta, thoracic duct, paravertebral lymphatics & fatty
areolar tissue
Osteoligamentous layer: thoracic vertebrae & disks, posterior ribs, pulmonary sulci, &
assoc. ligaments (especially anterior longitudinal ligament)
Spinal arcuate lines: smooth imaginary lines drawn along contours of vertebral bodies &
posterior elements of vertebrae
Anterior vertebral line: connects anterior surface of vertebral bodies. There should be
uniformity in this line
Enthesopathies: abnormalities where anterior longitudinal ligament attaches to vertebral
body along anterior spinal line.
Enthesis: attachment point of a ligament or tendon onto a bone
o
Osteophytes: (syndesmophytes) grow into ligaments & severe vertebral lipping of edges
of vertebral bodies occurs
Posterior vertebral line: aligns posterior surface of vertebral bodies
Spinolaminar line: spinolaminar junctions of vertebrae; junction of spinous process with
laminae of vertebral arch; posterior boundary of spinal canal
Neurovascular layer
o Arterial Layer: descending thoracic aorta & posterior intercostal arteries
Thoracic aortic aneurysm: abnormal dilatation of thoracic aorta. Can erode
left anterior surface vertebral bodies distorting anterior spinal line
Aortic aneurysm with dissection: force of blood in true lumen can dissect
along fracturing tunica media, forming a false lumen
Marfans Syndrome: patients prone to aortic dissection
Aortic Isthmus: take-off of left subclavian artery & third pair of posterior
intercostal arteries; marked by ligamentum arteriosum
o Venous Layer: azygos system & posterior intercostal veins
Superior Vena Cava Syndrome: trauma to superior vena cava or
encroachment via metastasis causes this syndrome. Venous pressures in
head & arm veins can approach 200-500 mm Hg. If it involves azygos arch
thus curtains collateral routes, may be more serious & result in fatal cerebral
edema. In pediatric setting SVC syndrome is a medical emergency
Gradual Superior Vena Cava Syndrome: if SVCS is gradual, collateral
chest & abdominal veins can enlarge. Venous return from upper body gets
back to right heart by flowing through femoral system & eventually inferior
vena cava
o Lympathic Layer: thoracic duct
Chylomediastinum: injury to thoracic duct resulting in 1500 ml?day of chyle
extravasating into mediastinum
Chylothorax: chyle seets into pleural space
Chylopericardium: chyle seeps into pericardial space
o Nervous Layer
Sympathetic trunk
Greater splanchnic
Digestive Layer: esophagus & plexues; vagal trunks
o Gastroesophageal venous plexus: in portal hypertension, this plexus can
become varicose posing danger of rupture. Normally smooth luminal contour
demonstrates worm-like, space taking lesions which are the varices into the
projecting lumen
o Sengstaken-Blakemore Tube: tube with 2 inflatable section to tamponade
hemorrhage from ruptured gastroesophageal varicies above & below diaphragm
o Esophagus 4 Constricted Points: upper esophageal constrictor (cricopharyngeus
muscle 70% of obstructions by foreign objects), left of esophagus (aortic arch &
left main bronchus- 15% of obstructions by foreign objects), anterior wall (left
atrium, basis for fistula formation), esophagus through diaphragm (angle leftward to
enter stomach 15% of obstruction by foreign objects)
o Phrenic ampulla: normal manometric pause prior to relaxation of lower
esophageal sphincter
o Schatzkis Ring: constriction at esophageal hiatus; B ring or congenital narrow
mucosal ring that develops at lower end of esophagus