The Heart

Introduction
• The heart is a muscular double pump with two
functions
– Its right side receives oxygen poor blood from the
body tissues and then pumps it to the lungs
– Its left side receives oxygenated blood from the
lungs and then pumps it to the body
• The cardiovascular system provides the
transport system of the body

2
 Pathway of Blood
• Pulmonary circulation
– The blood vessels that carry blood to and from the
lungs form the pulmonary circulation
– The right side of the heart is part of the pulmonary
circulation
– Blood returning from the body enters the right atrium
through superior and inferior vena cava and passes
into the right ventricle which pumps the blood to the
lungs via the pulmonary trunk
– Oxygenated blood is carried to the heart by the
pulmonary veins
– The pulmonary circulation, served by the right 3
ventricle, is a low pressure circulation
• Systemic circulation
– The vessels that carry blood to and from all the
body tissues form the systemic circulation
– The left side of the heart is the systemic pump
– Oxygenated blood enters the left atrium and passes
into the left ventricle
– The left ventricle pumps blood into the aorta and
from there into many distributing arteries and to
capillaries
– Blood then returns to the right atrium of the heart
via systemic veins and the cycle continues
– The systemic circulation, served by the left
ventricle, circulates through the entire body and
encounters about five times as much resistance to 4
5
 Size, location and position of heart
• The heart is about the size of a fist
• It weighs between 250 - 350 grams
• Located in the medial cavity of the thorax, the
mediastinum, anterior to the vertebral column &
posterior to the sternum
• It extends from the 2nd rib to 5th intercostal space
• Two thirds of the heart lies to the left of the mid-
sternal line

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 Heart Chambers
• The heart has four chambers
– two atria Atria
– two ventricles
• The atria lie above and behind
ventricles
• Upper part of each atrium has
an appendage called auricle
• The longitudinal wall
separating the chambers is
called septum
– Interatrial septum
• between atria Ventricles Septum
– Interventricular septum
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Grooves
• indicate the boundaries of its
Coronary
four chambers and carry Sulcus
coronary vessels
– Atrioventricular groove or
coronary sulcus
• encircles the junction of
the atria and ventricle
– Anterior and posterior inter-
ventricular sulcus
• separates the right and left
ventricles Anterior
Interventricular
Sulcus
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Shape
• 3 sided pyramid with apex, base and 4 borders and 4
surfaces
• The apex
• points downwards, forwards and to the left
• lies in left 5th intercostal space just medial to
midclavicular line
• formed by left ventricle
• The base
• directs to right shoulder
• at vertebral levels of T6 –T9
• between bifurcation of pulmonary trunk and coronary
groove
• forms the posterior surface
• formed mainly by left atrium and small part of right
atrium 11
Borders
• Right – vertical, formed by
right atrium; in line with
SVC and IVC
• Left – oblique and curved;
formed mainly by left
ventricle and partly by left
auricle
• Inferior – horizontal,
formed mainly by right
ventricle; left ventricle near
the apex
• Superior – slightly oblique,
formed by two atria

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Surfaces
 Diaphragmatic (inferior) surface
• Rests on central tendon of diaphragm
• Directed downwards and slightly backwards
• Formed by left ventricle (left 2/3) and right ventricle (right
1/3)
 Sternocostal (anterior) surface
• Faces anteriorly, superiorly and to the left
• Formed mainly by right atrium and right ventricle; and
partly by left ventricle and left auricle
 Left pulmonary surface
• Formed by left ventricle
 Right pulmonary surface
• Formed by right atrium

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 Surface marking of the heart

• Upper border – a line joining a point at 2nd left costal

cartilage 1.2 cm from sternal edge to a point at 3rd right
costal cartilage 1.2 cm from sternal edge

• Lower border – a line joining a point at 6th right costal

cartilage 1.2 cm from the sternal edge to a point at apex in
5th intercostal space 9 cm from the midline

• Right and Left borders – slightly convex lines joining

upper and lower borders

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 Right atrium Atria
SVC

• Receives venous blood from the

body through SVC, IVC and
coronary sinus and pumps it to
right ventricle through right AV
orifice
• Forms the- right border Auricles
- the sternocostal surface
-base of heart
IVC

18
 Right atrium: external features
• Elongated vertically, receiving SVC at upper
end and IVC at lower end
• Upper end is prolonged to left to form right
auricles
– ear like appendages, increase the atrial capacity
slightly
– represent primordial atrium

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• Sulcus terminalis
– shallow groove along right border run from SVC to
IVC vertically
– produced by internal muscular elevation (cristae
terminalis)
– upper end is land mark of SA node
• The right atrioventricular groove separate it
from right ventricle
– vertical
– lodges right coronary artery and small cardiac vein

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Anterior aspect of heart

21
 Right atrium: internal features
• The interior has 2 parts
• The smooth posterior part (sinus venarum)
– Derived from embryonic sinus venosus
– SVC (upper end) & IVC (lower end) opens into it
– Coronary sinus opens between IVC orifice and right
AV orifice
• The rough anterior part (pectinate part)
– Present a series of transverse muscular ridges,
pectinate muscles
• Arise from crista terminalis and run towards AV
orifice
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• Inlets of the right atrium
– Major
• SVC
• IVC
• Coronary sinus
– Smaller
• Anterior cardiac veins
• Venae cordis minimi
• Right marginal vein (sometimes)

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• Interatrial septum
– Separate the atria
– Presents a shallow depression, fossa ovalis
• Remnant of the opening, foramen ovale,
existed in the fetal heart
• Limbus fossa ovalis: a prominent margin
of fossa ovalis; valve of foramen ovale

25
 Right ventricle
• The right ventricle forms
most of the anterior surface
Papillary
of the heart, a small part of muscles
diaphragmatic surface and
entire inferior border
• Receive blood from right
atrium and pump into
pulmonary trunk
Trabeculae
• Superiorly tapers into a carneae
cone, conus arteriosus
(infundibulum) 26
• Internal structure
– Outflow part – smooth, pulmonary trunk arise,
separated from inflow part by supraventricular crest
– Inflow part – rough due to muscular ridges called
trabeculae carneae
• Papillary muscles
– Conical projections arise from ventricular wall
whose free ends are for chordae tendineae
– Three: anterior, posterior & septal
– Contract before contraction of ventricle, tightening
tendinous cords and drawing cusps together

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• Interventricular septum
– Partition between ventricles
– Composed of membranous and muscular parts
– Membranous – superoposterior, thin, continuous with
fibrous skeleton
– Muscular part – thick, bulges to the right
• Septomarginal trabecula (moderator band)
– Muscular bundle runs from interventricular septum to base
of anterior papillary muscle
– Carries part of the right bundle of the AV bundle of
conducting system
– Facilitate conduction time allowing contraction of the
papillary muscle before contraction of ventricle wall
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Right ventricle: internal structures

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 Left atrium
• Forms most of the base
• Blood enters the left Right
Pulmonary
atrium via four veins Left veins
– 2 Right and 2 left pulmonary
veins
pulmonary veins
• Thicker than right
• Interior
– large smooth part and small
muscular part
– pectinate muscles are found
in the auricle
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Posterior aspect of heart

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 Left Ventricle
• Forms the apex of the
heart, most of
diaphragmatic surface
and left border
• Receive blood from left
atrium & pumps into the
aorta
• The walls of the left
ventricle are 2-3 times
thicker than that of the
right ventricle
– Due to the work load
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• Internal structure
– The cavity is circular and longer than the
right
– Smooth upper part and rough lower part
– Trabeculae carneae are finer and more
numerous than the right
– Papillary muscles: two; anterior and
posterior
– Smooth walled posterosuperior part – aortic
vestibule, leads to aortic orifice
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Left Ventricle: Internal structure

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 Contraction and relaxation of the heart
• The two atria contract together, followed by the
simultaneous contraction of the two ventricles

• The synchronous pumping action of the heart two pumps

constitute cardiac cycle

• The cycle begins with ventricular elongation (relaxing) and

filling with blood termed as diastole and ends with a period
of ventricular shortening (contraction) and emptying called
a systole

• Systole and diastole refers to the ventricles which are the

dominant heart chambers

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Heart Valves
• Blood flows through the heart and other parts of the
circulatory system in one direction
– Right atrium  right ventricle  pulmonary
arteries  lungs
– Lungs  pulmonary veins  left atrium  left
ventricle  body
• This one way flow of blood is controlled by four
heart valves

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 Heart Valves
• Heart valves are
positioned between
Bicuspid
the atria and the
(mitral)
ventricles and valve
between the
ventricles and the
large arteries that
Aortic
leave the heart valve
• Valves open and
Pulmonary
close in response to
valve
differences in blood
Tricuspid
pressure valve
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 Atrioventricular (AV) Valves
• Located at each atrio-ventricular junction
– Right AV valve (tricuspid) has three flexible
cusps
• anterior, posterior & septal
– Left AV valve (bicuspid) has two flexible cusps
• anterior and posterior
• The cusps are flaps of endocardium reinforced by
connective tissue
• Attached to each of the AV valve flaps are tiny cords
called chordae tendinae
– The cords anchor the cusps to the papillary
39
muscles
40
• Blood flows into the atria
& then through the open
AV valves into the
ventricles
• When the atria contract,
force additional blood into
the ventricles through
open AV valve
• When the ventricles begin
to contract, intra-
ventricular pressure rises
forcing blood superiorly
against the valve flaps
• The chordae tendonae and
the papillary muscles
anchor the flaps in their
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closed position
 Semilunar (SL) Valves
• Found at the bases of the large arteries exiting the
ventricles
– The aortic and pulmonary semilunar valves
• Each semilunar valve is made up of three pocket
like cusps
– anterior/posterior, right & left
– Concave superiorly
– Spaces between dilated wall of the vessel and
each cusp – sinuses (pulmonary & aortic)
– Blood in sinuses prevents cusps from sticking to
wall of the vessel

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 Heart Sounds
• The closing of the heart valves causes vibrations
in the adjacent blood and heart walls that
account for the familiar “lub-dup” sounds of the
heartbeat
• The “lub” is produced by the closing of the AV
valves at the start of ventricular systole
• The “dup” is produced by the closing of the
semilunar valves at the end of ventricular
systole
• Sounds are heard away from the valves in the
direction of the blood flow
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 Surface markings of the valves and auscultation areas
Valve Surface marking auscultation area
(diameter)
Pulmonary Upper border of 3rd left costal cart. sternal end of 2nd right
(2.5 cm) near sternum intercostal space

Aortic Behind left half of sternum at the Sternal end of 2nd right
(2.5 cm) level of medial end of 3rd intercostal space
intercostal space

Mitral Behind the left half of sternum 5th left intercostal space
(3 cm) opposite to 4th costal cartilage (cardiac apex) at
midclavicular line

Tricuspid Behind the right half of sternum 5th right intercostal

(4 cm) opposite to 4th and 5th intercostal space near sternal body
space

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 Layers of the Heart Wall
• The heart wall is composed of three layers (superficial
to deep)
– epicardium
– myocardium
– endocardium
• All three layers are richly supplied with blood vessels
• Epicardium – outer layer
– is the visceral layer of the serous pericardium
– often infiltrated with fat, especially in older people
• Myocardium – middle layer
– Layer of cardiac muscle forming the bulk of the heart
– Elongated, circularly and spirally arranged muscle
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cells squeeze the blood though the heart
48
The endocardium – inner layer
• Is a glistening white sheet of endothelium
(squamous epithelium) resting on a thin layer of
connective tissue
• Located on the inner myocardial surface, it lines the
heart chambers and covers the connective tissue
skeleton of the valves
• The endocardium is continuous with the endothelial
linings of the blood vessels leaving and entering the
heart

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 Conducting System of the heart
• Cardiac muscle cells have an intrinsic ability to generate and
conduct impulses that signal them to contract rhythmically

• These properties are intrinsic to the heart muscle itself and do not
depend on extrinsic nerve impulses

• Even if all nerve connections to the heart are severed, the heart
continues to beat rhythmically

50
 Cont…
• The conducting system of the heart is a series of specialized
cardiac muscle cells that carries impulses throughout the heart
musculature, signaling the heart chambers to contract in proper
sequence

• The components of the conducting system are:

– Sinoatrial (SA) node
– Internodal fibers
– Atrioventricular (AV) node
– Atrioventricular bundle
– Right and left branches
– Purkinje fibers
SA (Sinoatrial) node
• Crescent shaped mass of muscle cells located anterolaterally
deep to epicardium in the wall of the right atrium, below the
entrance of the SVC near superior end of sulcus terminalis

• Initiates and regulates the impulses for contraction

• The heart’s own pacemaker, sets the basic heart rate by

generating 70-80 impulses per minute

• Impulses from the SA node spread in a wave along the

cardiac muscle fibers of the atria signaling the atria to
contract
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AV (atrioventricular) node

• Collection of nodal tissue located in the posteroinferior

part of the interatrial septum near opening of coronary
sinus

• Some impulses travel along the internodal pathway to

the (AV) node, where they are delayed for a fraction of a
second

• After this delay, the impulses race through the atrio-

ventricular bundle which enters the interventricular
septum and divides into right and left bundle branches

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 Cont…
• The brief delay of the contraction signaling
impulses at the AV node enables the ventricles
to fill completely before they start to contract

• Because the fibrous skeleton between the atria

and ventricles is non conducting, it prevents
impulses in the atrial wall from proceeding
directly on to the ventricular wall

• As a result, only those signals that go through

the AV node can continue on
Atrio-ventricular (AV) bundle

• Is the only bridge of conduction between atrial and

ventricular myocardium

• Passes through fibrous skeleton of heart and along

membranous part of interventricular septum

• At junction of membranous and muscular parts of the

septum it divides into right and left bundle branches

57
 Cont…
• The bundles proceed on each side of muscular septum
and ramify into subendocardial branches called
Purkinje fibers which approach the apex of the heart,
then turn superiorly into the ventricular walls
– This arrangement of conducting structures ensures
that the contraction of the ventricles begins at the
apex of the heart and travels superiorly, so that the
ventricular blood is ejected superiorly into the
great arteries
 Summary of conduction

• SA node initiate impulse

• Conduct to cardiac muscle fibers in atria
causing them to contract
• Impulse reach AV node
• Distribute through AV bundle and branches to
purkinje fibers to papillary muscles and walls
of the ventricles

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 Innervation of the heart
Parasympathetic nerve Sympathetic nerves
supply • from the cervical and
• arise as branches of the upper thoracic chain
Vagus nerve in the neck gangli
and thorax
• Postsynaptic cell bodies • Postsynaptic fibers end in
are located near SA and SA and AV nodes and
AV nodes and along along coronary arteries
coronary arteries
• Parasympathetic • Sympathetic stimulation
stimulation slows the increases the rate and
heart rate, reduces force force of heart
of contraction and contractions and produce
constricts coronary dilation of coronary
arteries arteries
• All nerves serving the heart pass through the cardiac
plexus on the trachea before entering the heart
• They project most heavily to the SA, AV nodes and
the coronary arteries and some to cardiac muscles
• Cardiac centers in the reticular formation of the
medulla of the brain control these fibers
– cardioinhibitory center influences parasympathetic
neurons
– cardioacceleratory center influences sympathetic
neurons
– Cardiac centers are influenced by higher brain
regions; hypothalamus, periaqueductal gray matter,
amygdala, and insular cortex

61
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Parasympathetic innervation

63
Sympathetic innervation

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 Carotid bodies and sinuses
Carotid sinuses
• Baroreceptor, sensor of blood pressure
• located at the distal end of common carotid
arteries
• Sensory innervation from the glossopharyngeal
nerve
Carotid bodies
• chemoreceptor at the bifurcation of carotid
arteries
• Sensory branches from vagus and
glossopharyngeal
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 Coronary Circulation

• The blood supply of the heart

• the shortest circulation in the body
• There are anastomosis between blood vessels
• Consume 1/20 of the whole blood supply to the body
• Course just deep to epicardium, embedded in fat
• The right and left coronary arteries arise from aortic sinuses
at proximal part of ascending aorta

66
Coronary arteries 67
• Right coronary artery supplies
– The whole of right atrium
– Most of the right ventricle
– Part of left ventricle (diaphragmatic surface)
– Part of interventricular septum (posterior third)
– SA node (in 60% of people)
– AV node (in 80% of people)

68
• Left coronary artery supplies
– The left atrium
– Most of the left ventricle
– Part of right ventricle
– Most of interventricular septum (anterior
two third)
– SA node (in 40% of people)

69
 Veins of the heart
• the heart is drained mainly by veins that drain into coronary
sinus which empties into the right atrium
Coronary sinus
• Wide venous channel that lies in the left part of coronary sulcus
• It receives
• Great cardiac vein
• Middle cardiac vein
• Small cardiac vein
• Oblique vein
• Left posterior ventricular vein
• Left marginal vein
Anterior cardiac vein
• from the anterior aspect of right atrium
• empty directly to right atrium
Smallest cardiac veins (venae cordis minimae)
• begin in myocardium and open directly into all chambers 70
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 Lymphatic drainage of heart

• Lymphatic vessels in myocardium and

subendocarial tissue pass to subepicardial
lymphatic plexus
• Vessels from the plexus follow coronary
arteries
• A single vessel ascends between pulmonary
trunk and left atrium and ends in inferior
trachiobronchial lymph nodes

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 Posterior mediastinum
• A space behind the pericardium
and diaphragm
• Boundaries
– Posteriorly – thoracic
vertebrae ( T5- T12)
– Anteriorly
• Above – pericardium
(left atrium), bifurcation
of trachea, pulmonary
vessels
• Inferiorly – posterior
part of diaphragm
• Laterally – mediastinal
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pleura
 Contents
• Esophagus
• Descending thoracic aorta and its branches
• Thoracic duct
• Right lymphatic duct
• Azygos system of veins
• Thoracic sympathetic trunk and splanchnic nerves
• Vagus nerve
• Lymph nodes

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 Clinical importance
• Posterior mediastinum is continuous through
superior mediastinum with neck between the
pretracheal fascia and prevertebral fascia which
includes:
retropharyngeal space
lateral spaces to trachea and esophagus
spaces between the two tubes (esophagus &
trachea) and carotid sheaths
• Infection from these spaces can spread to superior
and posterior mediastina

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 Descending thoracic aorta
• Course
– Begins on the left side of the lower border of the
body of T4
– Descends with inclination to the right
– Terminates at lower border of T12 where it passes
through the aortic hiatus
• Relations
– Anterior: root of left lung, pericardium and heart,
esophagus, diaphragm
– Posterior: vertebral column, hemiazygos vein
– To the right side: esophagus, azygos vein, thoracic
duct, right lung and pleura
– To the left side: left lung and pleura
– The greater splanchnic nerve from the sympathetic
trunk joins the descending aorta and enters the 79
abdomen with it
80
Branches
• two left bronchial arteries
• esophageal arteries – supplying middle 1/3 of
esophagus
• Pericardial branches
• Mediastinal branches
• Right & left posterior intercostal arteries for 3rd -
11th intercostal spaces
• Right and left subcostal
• Right and left superior phrenic
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 The azygos & Hemiazygos venous systems
Azygos vein
– drain the posterior thoracic wall and upper lumbar
region
– connects superior and inferior venae cavae
Formation
• originate in the abdomen by union of lumbar azygos,
right ascending lumbar and right subcostal veins
Course
– enter thoracic cavity through aortic opening or pierce
right crus of diaphragm
– ascends on the right side of the vertebral column and
arches over the right bronchus to enter the posterior
aspect of the superior vena cava at the level of T4 83
Tributaries

1. Right superior intercostal vein

2. Right 4 – 11 intercostal veins
3. Right subcostal vein and right ascending lumbar
4. Right bronchial vein
5. Esophageal, Mediastinal & pericardial veins
6. Hemiazygos vein
7. Accessory hemiazygos azygos vein

84
Hemiazgos vein
• Origin
– in the abdomen by union of left ascending lumbar and
left subcostal or from left renal vein
• Course
– enter thoracic cavity piercing the left crus of
diaphragm  at T9 crosses to the right behind thoracic
aorta, esophagus & thoracic duct  end in azygos vein
• Tributaries
1. 9th – 11th left intercostal
2. Left subcostal
3. Left ascending lumbar
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Accessory hemiazygos vein
 Originate at medial end of 4th and 5th intercostal
space on the left of the vertebral column
 Crosses to the right at T8 behind aorta,
esophagus and join azygos vein
Tributaries
 Left 5th - 8th intercostal veins
 Left bronchial vein

86
87
Remember
The right superior intercostal vein joins the azygos
after draining the 2nd, 3rd, 4th right intercostal
spaces

• The left superior intercostal vein joins the left

brachiocephalic vein by crossing the anterior
aspect of the aortic arch

• The highest posterior intercostal veins drain the

1st intercostal space and join the brachiocephalic
veins

• The anterior intercostal veins drain into the

internal thoracic veins
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89
 Esophagus
• Muscular tube, food passage between pharynx and
stomach
• extends from the level of C6 to the stomach (T11),
below the left dome of the diaphragm (25cm)
• Three parts – cervical, thoracic & abdominal
• pierces the diaphragm at the level of the rib 7 costal
cartilage (T10)
• Constrictions - in 4 regions
– C6 (at beginning)
– T2/3 (crossing of aortic arch)
– T4/5 (crossing of left primary bronchus)
– T10 (diaphragm)
– Obstructions may occur at these levels. These levels
are respectively 15, 22, 27 and 40 cm from the 90
incisor teeth
Sphincters
• superior esophageal sphincter - at junction
with pharynx ;voluntary

• Inferior esophageal sphincter – at junction

with stomach; under the control of vagal
(opener) and sympathetic fibers (closer)

91
92
Arterial supply
1. Cervical part up to arch of aorta – inferior thyroid
arteries
2. Thoracic part – esophageal branches of thoracic aorta
3. Abdominal part – esophageal branches of left gastric
artery

93
 Cont…
Venous drainage
1. Upper part – brachiocephalic veins
2. Middle part – azygos veins( systemic vein)
3. Lower end – left gastric vein (portal drainage)
• Lower end of esophagus is one of the sites of
anastomosis between systemic and portal veins 
porto-systemic anastomosis
• In portal hypertension, dilation of lower
esophageal veins called esophageal varicose 
rapture of these veins result in vomiting of blood
Nerve supply – autonomic
Parasympathetic
Upper ½ - recurrent laryngeal nerve
Lower ½- esophageal plexus (formed by the two vagi)
Function – sensory, motor to muscles and mucus secreting
glands
Sympathetic
upper ½ - middle cervical ganglion
Lower ½- upper 4 thoracic ganglia (esophageal plexus)
Function – vasomotor
Lymphatic drainage
• Cervical – deep cervical lymph nodes
• Thoracic- posterior mediastinal lymph nodes
• Abdominal – left gastric lymph nodes 95
 The thoracic duct
• Largest lymphatic vessel
• begins at the cisterna chyli (L1), posterior to the
abdominal aorta, inferior to the diaphragm
• enters the thorax through aortic opening posterior to the
aorta
• ascends on the right of the vertebral column
• At T5 cross to left side
• In the root of the neck it arches laterally (C7)
• terminate at the junction between the left subclavian and
left internal jugular veins

96
• Tributaries
– Posterior mediastinal nodes
– Intercostal nodes
– Left jugular trunk
– Left subclavian trunk
– Left mediastinal trunk
• It drains all the lymph of the body except for the
right thorax, right upper limb and right side of the
head and neck
• These remaining areas drain into the right lymphatic
duct which joins the junction of the right internal
jugular and right subclavian veins 97
 Right lymphatic duct
Thoracic duct
draining into
brachiocephalic
V

Accessory
Azygos
Intercostal lymph nodes
Thoracic duct
Azygos
Hemiazygos

Cistrena
chyli
98
99
 Lymph nodes

 Pre-aortic lymph node – anterior aorta and drain the

visceral structures of the mediastinum
 Para-aortic – located along the side of aorta draining the
body wall
• Extend in the posterior intercostal space and then
named as posterior intercostal lymph nodes
• Upper members of posterior intercostal lymph nodes
drain into thoracic duct/right lymphatic duct
• Lower members ( intercostal and diaphragmatic)
drain into the descending intercostal trunk to join the
cisterna chyli
100
  The anterior ends of the intercostal space is drained
through anterior intercostal lymph nodes (commonly
involved in cancer of the breast)  brachiocephalic
veins
 Lower group of paraortic lies on the diaphragm
• Middle Mediastinal group – on the doom of diaphragm,
drain extra peritoneal tissue beneath diaphragm & bare
area of the liver

101
 Sympathetic trunk
 Is gaglionated chain one on each side of the thoracic vertebral
column
 Continues
superiorly with cervical sympathetic chain
inferiorly with lumbar chain
 Contain 12 ganglia , but often 10 or 11 due to fusion of adjacent
ganglia
 The first is commonly fused with inferior cervical ganglion to
form cervicothoracic or stellate ganglion
 Lie at levels of corresponding intervertebral discs and intercostal
nerves
 Approaches to midline as descending downwards
Lies on
 the neck of first rib
 Head of the ribs 2nd - 10th
 Bodies of 11th & 12th thoracic vertebra 102
103
Branches – two groups
1. Lateral branches – for limbs & body wall
• Communicate with spinal nerve by two rami
• White ramus – from spinal nerve to the
ganglia (preganglionic fiber)
• Grey ramus - from ganglia to spinal nerves
(postganglionic fibers)
• Function
• Piloerection – arrector pili muscle of skin
• Vasomotor – blood vessels
• Secretomotor – sweat glands
104
2. Medial branches – to thoracic and abdominal viscera
A. Upper five ganglia – supply
A. Heart – cardiac plexus
B. Great vessels – aortic plexus
C. Lung – pulmonary plexus
D. Esophagus – esophageal plexus
B. Lower seven ganglia – from three splachnic nerves
which supply abdominal viscera
A. Greater splanchnic – 5th – 9th; ends in coeliac,
aorticorenal or suprarenal
B. Lesser splanchnic – 10th & 11th; ends in coeliac
ganglion
C. Lowest (least ) splanchnic – 12th; ends in renal
plexus 105
Sympathetic
trunk

106
 Diaphragm

• Dome-shaped musculotendinous partition

between thoracic and abdominal cavities
• Principal muscle of respiration
• Composed of two portions:
• muscular (peripheral part)
• aponeurotic (central part)

107
Muscular part
• Fibers converge radially to central tendon
• 3 parts based on origin
• Sternal – back of xiphoid process
• Costal – inner surface of lower six costal cartilage
• Vertebral – lumbar vertebrae by two crura
• Right – superior 3
• Left – superior 2
• Crura are united superiorly at T12 by narrow arch
called median arcuate ligament
Central tendon
• aponeurotic tendon formed by fibers of different direction
• has three lobes (right, left & median)
Relations of the lobes
• Left – left pleura
• Right – right pleura
• Median – pericardium 108
 Major openings
Aortic – T12 median plane, transmits
descending aorta, thoracic duct, azygos vein

Esophageal – T10 left of the median plane,

transmits esophagus, vagi (anterior &
posterior), esophageal branch of left gastric
artery
Vena caval – T8 right of the median plane with
in the central tendon, transmits IVC, branch of
right phrenic, lymph vessels from liver
109
Other structures passing through diaphragm
1. Superior epigastric vessels – b/n sternal & costal
origins
2. Musculophrenic nerve– pierce at 7 or 8 costal
cartilage
3. Lower five intercostal nerves - b/n two slips of costal
origin
4. Subcostal nerves and vessels - behind lateral arcuate
ligament

110
• Nerve supply
– phrenic (motor and sensory)
– lower six intercostal and subcostal for peripheral
part (sensory)
• Blood supply
– Arteries
• Superior surface
–superior phrenic (thoracic aorta)
–musculophrenic and pericardiacophrenic
(internal thoracic artery)
• Inferior surface: inferior phrenic
– Veins: same
• Lymphatic drainage
– Thoracic surface to phrenic nodes
– Abdominal surface to lateral aortic nodes
– The two surfaces communicate freely 111
112