IMCT 2014

SGD 12: The Middle Mediastinum

1.

Discuss the pericardium as to its layers (with illustrations), neurovascular supply,

sinuses and attachments.
The pericardium is a fibrouserous sac that encloses heart and roots of great vessels.
Functions:
to restrict excessive movements of the heart as a whole;
to serve as lubricated container in which the different parts of the heart can
contract.
Location: Middle mediastinum
Borders:
Anteriorly, body of the sternum and the 2nd to the 6th costal cartilages
Posteriorly, fifth to the 8th thoracic vertebrae
Layers
Fibrous Pericardium
Strong fibrous part of the sac.
Firmly attached below the central tendon of the diaphragm.
Fuses with outer coats of the great blood vessels passing through it ( aorta, pulmonary
trunk, superior & inferior venae cavae, pulmonary veins).
Attached in front to the sternum by the sternopericardial ligaments.
Serous Pericardium
a. Parietal layer
lines the fibrous pericardium
reflected around the roots of the great vessels to become continuous with the visceral
layer of the serous pericardium
b. Visceral layer
closely applied to the heart
often called epicardium
Pericardial cavity - slit-like space between the parietal and visceral layers; contains a
small amount of tissue fluid (pericardial fluid) that acts as lubricant to facilitate
movements of the heart.
Nerve supply ( Ph-F; V-Va) [Netter]
Fibrous pericardium and parietal layer of serous pericardium - supplied by phrenic
nerves.
Visceral layer of the serous pericardium - supplied by branches of sympathetic trunks
and the vagus nerves
Pericardial Sinuses (both located at posterior surface of the heart)
Oblique sinus - reflection of serous pericardium around large veins forms a recess
(Snell); bounded laterally by the entrances of the pulmonary veins and inferiorly by the
orifice of the inferior vena cava (Netter).
Transverse sinus - short passage that lies between the reflection of serous pericardium
around the aorta and pulmonary trunk and the reflection around the large veins (Snell);
runs transversely in the pericardial sac between origins of great vessels + posterior to
the ascending aorta and pulmonary trunk and anterior to the superior vena cava (Netter).
Pericardial sinus form as consequence of heart bends during development.
Has no clinical significance.
Vascular Supply
Mainly from the pericardiacophrenic vessels from the internal
thoracic and veins.

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IMCT 2014

2.

SGD 12: The Middle Mediastinum

Discuss with illustration the topography of the heart:

Apex
o directed downward, forward, to the left
o lies at the level of 5th left intercostal space, 3.5 (9cm) from the midline
o This region can usually be seen and palpated in living patient
Sternocostal (Anterior)
o Formed mainly by right atrium and right ventricle; separated by the vertical
atrioventricular groove
o Right border formed by right atrium
o Left border formed by left ventricle and part of left auricle
o Right ventricle separated from left by anterior interventricular groove.
Diaphragmatic (Inferior)
o Formed mainly by right and left ventricles separated by the posterior
interventricular groove
o Inferior surface of the right atrium, where the inferior vena cava opens, forms part
of the surface
Base (Posterior)
o Formed mainly by the left atrium, which open the four pulmonary veins
o Lies opposite the apex

Compiled by: AMSA-UST

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IMCT 2014

3.

SGD 12: The Middle Mediastinum

In an illustration, discuss the

3.1.
blood supply of the heart
Right coronary artery
o Origin: anterior aortic sinus of the ascending aorta
o Commencement: level of the ascending aorta
o Course: descends almost vertically in the right atrioventricular groove, and at the
inferior border of the heart it continues posteriorly along the atrioventricular
groove to anastomose with the left coronary artery in the posterior interventricular
groove.
o Termination: atrioventricular groove
o Branches:
Right conus artery - supplies anterior surface of pulmonary conus
(infundibulum of the right ventricle) and the upper part of the anterior wall
of the right ventricle.
Anterior ventricular branches - two or three in number and supply
the anterior surface of the right ventricle. [Marginal branch
largest and runs along lower margin of costal surface to reach the
apex].
Posterior ventricular branches - two, supply diaphragmatic surface
of the right ventricle.
Posterior interventricular (descending) artery - runs towards apex
in the posterior interventricular groove. Gives off two branches to
right and left ventricles + inferior wall.
Supplies branches to posterior part of ventricular septum but not
to apical part (which receives from atrioventricular node
Atrial branches - supply anterior and lateral surfaces of right
atrium One branch supplies posterior surface of both the right and
left atria.
Artery of the sinoatrial node supplies node from the right and left
atria
Left coronary artery
o Origin: left posterior aortic sinus of the ascending aorta
o Commencement: after the ascending aorta
o Course: passes forward between the pulmonary trunk and left auricles
o Termination: atrioventricular groove
o Branches:
Anterior interventricular (descending) branch - runs downward in the
anterior interventricular groove to the apex of the heart. Passes around
the apex of the heart to enter the posterior interventricular groove and
anastomose with terminal branches of the right coronary artery.
It supplies the right and left ventricles with numerous branches that also
supply the anterior part of the ventricular septum.
Left diagonal artery arise from trunk of left coronary artery
Left conus artery supplies the pulmonary conus
Circumflex artery same size as anteriointerventricular artery; winds
around the left margin of heart in the atrioventricular groove.
Left marginal artery supplies left margin of the left ventricle down
to the apex.
Anterior ventricular & posterior ventricular branches supply left
ventricle
Atrial branches supply left atrium.

Compiled by: AMSA-UST

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IMCT 2014

SGD 12: The Middle Mediastinum

3.2.
venous drainage
Blood drains to right atrium through coronary sinus, which lies in the posterior part of the
atrioventricular groove and is a continuation of the great cardiac vein.
Small and middle cardiac veins tributaries of the coronary sinus.
Remainder of blood is returned to the right atrium by the anterior cardiac vein, and by small
veins that open directly into the heart chambers.
3.3.
cardio-pulmonary plexus
Innervated by sympathetic and parasympathetic fibers of the ANS via cardiac plexus
situated below the arch of the aorta.
Sympathetic supply from cervical and upper thoracic portions of sympathetic trunks.
Parasympatehtic supply from vagus nerves
Postganglionic sympathetic fibers terminate at sinoatrial and atrioventricular nodes, cardiac
muscles, coronary arteries. [Activation results in cardiac acceleration, increased force of
contraction of cardiac muscles, dilatation of the coronary arteries]
Postganglionic parasympathetic fibers terminate on sinoatrial and atrioventricular nodes,
and on coronary arteries. [Activation results in reduction in rate and force of contraction of
heart and constriction of coronary arteries.]

Compiled by: AMSA-UST

Credits to the owner

IMCT 2014

SGD 12: The Middle Mediastinum

Afferent fibers run with sympathetic nerves carry nervous impulses that normally do not
reach consciousness.
Afferent fibers run with vagus nerves take part in cardiovascular reflexes.
4.

Discuss the great vessels of the heart

*Pulmonary Trunk brings deoxygenated blood from right ventricle of heart to lungs.
Commencement: Leaves upper part of right ventricle
Course: runs upward, backward, to the left, about 2in. long
Termination: concavity of the aortic arch by dividing into left and right pulmonary arteries.
Relationship: together with ascending aorta, enclosed in fibrous pericardium and sheath of
serous pericardium.
4.1.
Pulmonary artery
Right pulmonary artery to right behind the ascending aorta and superior vena cava to enter
root of right lung.
Left pulmonary artery to left in front of descending aorta to enter root of left lung.
4.2.
Ascending aorta
Origin: Heart
Commencement: Base of the left ventricle
Course: Runs upward and forward to come to lie behind the right half of the sternum at
the level of the sternal angle
Termination: level of the sternal angle where it becomes the arch of the aorta
Relationships: Lies within fibrous pericardium, enclosed with pulmonary trunk in serous
pericardium. At its root, it has three bulges, the sinuses of the aorta, one behind each
aortic valve cusp.
4.3.
Superior vena cava
Origin: Union of two brachiocephalic veins, contains all venous blood from the head and
neck, and both upper limbs.
Commencement:
Course: Passes downward to end in the right atrium of the heart. Vena azygos joins the
posterior aspect of the superior vena cava
Termination: Pericardium

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