Operative Anatomy of the Heart

Bearbeitet vonDenis Berdajs, Marko Turina

1st Edition. 2010. Buch. xv, 543 S. HardcoverISBN 978 3 540 69227 0

Format (B x L): 21 x 27,7 cmGewicht: 1597 g

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Superior lobe of right lung

Right brachio-

cephalic vein

Internal thoracic

artery

Right superior pulmonary vein

Phrenicnerve

Pulmonarytrunk

Superior vena cava

Rightauricle

Ascendingaorta

Superior lobeof left lung

Leftpulmonary artery

Phrenic nerve

Internal thoracic artery

Right brachioce-phalic vein

Left sub-clavian artery

Left internaljugular vein Left vagal nerve

Left subclavian artery

Brachiocephalictrunk

Right commoncarotid artery

Right subclavian artery

Trachea

Left superiorpulmonary vein

Vagalnerve

Right internaljugular vein

11.1 The Aortic Arch11.1.1 General Anatomy of the Ascending Aorta

and the Aortic Arch

Surgery of the aorta is one of the most challenging areasof cardiac and vascular surgery, from the managementof emergency situations to the treatment of degenera-tive diseases. To achieve an optimal surgical result, it isessential not only to have an exhaustive knowledge ofthe pathological mechanisms involved, but also to befamiliar with the anatomy of the aorta. Hence, we arededicating an entire chapter to this great vessel of thehuman body.

In this chapter, we will focus on the anatomy of theaorta, but not including the aortic root. In the past, theaortic root (also known as the bulb of the aorta) wasconsidered to be an integral part of the ascending aorta.However, since the introduction of reconstructive pro-cedures of the aortic root, this part of the ascendingaorta is now regarded as an independent morphologicaland functional unit. The detailed morphology of theaortic root has been discussed elsewhere (Chap. 5), andso only the segments of the aorta positioned superior to

the aortic root are discussed herein. A morphologicaldescription of the ascending aorta, aortic arch, thoracicaorta, and supraceliac part of the aorta will be provided.A discussion of the abdominal part of the aorta is out-side the scope of this book.

The human aorta commences at the upper part of theaortic root at the level of the sinotubular junction,where it is about 3 cm in diameter, and after ascendingfor a short distance, it arches backward and to the leftside, over the root of the left lung. It then descends with-in the thorax on the left side of the vertebral column,passes into the abdominal cavity through the aortic hia-tus in the diaphragm, and ends by dividing into theright and left common iliac arteries. Thus, the aorta canbe described as having several portions: the ascendingpart, the arch, and the descending part, the latter ofwhich is again divided into the thoracic and abdominalaortae.

Fig. 11.1. Supracardiac mediastinum, with exposure of the great vessels

456 11 Surgical Anatomy of the Aorta

Right subclavian artery

Right internal jugular vein

Right brachiocephalic vein

Internal thoracic artery

Trachea

Superior lobeof right lung

Right superiorpulmonary vein

Phrenic nerveSuperiorvena cava

Right auricle

Ascending aorta

Left superiorpulmonary

vein

Superior lobeof left lung

Pulmonary artery

Pericardiacophrenicvein

Internal thoracic arteryLeft brachiocephalic vein

Left subclavian arteryVagal nerve

Left internal jugular vein

Left common carotid artery

Right common carotid artery

Vagal nerve

Brachiocephalic trunk

Fig. 11.2. Supracardiac mediastinum, with exposure of the great vessels, schematic drawing

The direction and the topographical positions of the as-cending aorta are presented on the dry-dissected speci-men of the superior mediastinum in Fig. 11.1 and thecorresponding drawing (Fig. 11.2), wherein the ascend-ing aorta is viewed from the anterior aspect. The anteri-or chest wall has been removed and the pericardiumopened to secure adequate exposure of the anterior sur-face of the heart. In the presented case, the entire anteri-or sheath of the pericardium has been removed, sparingthe left and right phrenic nerves on the lateral surfacesof the pericardium. The superior lobes of the right andleft lungs have been retracted. The initial part of the as-cending aorta is positioned behind the infundibulum(Figs. 11.1 and 11.2). This initial part is viewed from theposterior aspect and is surrounded by the left and rightatria. Here, the ascending aorta causes a furrow on thesurfaces of both atria. The incisure on the right medialwall of the right atrium is particularly prominent and isseen clearly on the cross section of the mediastinumpresented in Fig. 11.3 and the corresponding drawing(Fig. 11.4). Note here that the ascending aorta is inspect-ed from the superior aspect. The same situation is seenon Figs. 12.4 and 12.5, wherein the ascending aorta isseen from an inferior view.

The part of the ascending aorta positioned inferior tothe pulmonary artery is covered by the epicardial fat tis-sue. The presence of this condensation of fat is charac-teristic and is found in every heart, independent of the

habitus. At this level, the ascending aorta is joined onthe right to the superior vena cava and on the left to thepulmonary trunk. Anteriorly, the ascending aorta iscovered by the appendage of the right atrium, from theleft by the pulmonary trunk, and from the right by thesuperior vena cave. The aforementioned fat-tissue con-densation elevates the epicardium from the anteriorwall of the aorta, forming a semicircular plica, as seenclearly on Fig. 11.1. The fold of the transition betweenthe pericardium and the epicardium may be found onthe superior part of the ascending aorta, just before thejunction with the aortic arch. Note that the ascendingaorta is contained within the pericardium and is en-closed in a tube of serous pericardium, which it shareswith the pulmonary artery. On the presented specimen,this is seen as oblique line running along the anteriorwall of the ascending aorta, from right to left, from infe-rior to the brachiocephalic artery, inferior toward thepulmonary trunk (Figs. 11.1 and 11.2).

11.1 The Aortic Arch 457

Superior lobe

Inferior lobe

Left superior pulmonary

vein

Superior lobar artery

Left superior lobar bronchi

Descending aorta

EsophagusHemi-azygos vein

Spinal cord, dura mater, epidural space

Thoracic duct

Azygos vein

Superior lobe

Right superior lobar bronchi

Superior lobar artery

Superior lobe

Right superior pulmonary vein

Pectoralismajor

Superior vena cava

Sternocostaljoint

Right auricleSternum

Internal thoracic artery/vein

Left auricle

APS

LPS

RPS

Left auricle

Right auricle

Sternum

Internal thoracic artery and vein

Sternocostal joint

Superior vena cava

Pectoralis major

Right superiorpulmonary veinLeft superior

pulmonary vein

Superior lobeSuperior lobe

Inferior lobe

Superior lobar artery

Superior lobar artery

Left superior lobar bronchi

Esophagus

Thoracic duct

Azygos veinHemi-azygos veinDescending

aortaSpinal cord, dura mater,

epidural spaceInferior lobe

Right superior lobar bronchi

Fig. 11.3. Horizontal cross section of the thorax at the level of the sinotubular junction, superior view

Fig. 11.4. Horizontal cross section of the thorax at the level of the sinotubular junction, superior view, schematic drawing

458 11 Surgical Anatomy of the Aorta

Brachioce-phalic trunk

Ascending aorta

Aortic arch

Right auricle

Great cardiac vein

Diagonal branch

Circumflex branch

Ligamentum arteriosum

Left auricle

Superior vena cava

Pulmonaryroot

Left main trunk

Rightventricle

Anterior interventri-

cular branch

Phrenic nerve, pericardiaco-phrenic vein

Left pulmo-nary artery

Recurrent laryngeal nerve

Left vagal nerve

Brachiocephalic trunk

Superior vena cava

Ascending aorta

Right brachiocephalic vein

Pulmonary trunk

Left subclavian arteryCommon carotid artery

Right auricle

Right phrenic nerve

Right ventricle

Transverse pericardial sinus

Fig. 11.5. Ascending aorta, left anterior view. Arrows indicate the pericardial transition

Fig. 11.6. Ascending aorta, anterior view, schematic drawing

In the next specimens, the ascend-ing aorta will be viewed from theleft aspect in order to establish thedetailed topography and its rela-tionship to the other anatomicalstructures (Figs. 11.5 and 11.6). Onthe dry-dissected specimen in Fig.11.5 and the corresponding sche-matic drawing in Fig. 11.6, theascending aorta and the aortic rootare seen from the left anterolateralview. The pulmonary trunk hasbeen dissected so that the superiordissection line is positioned infe-rior to its bifurcation into the leftand right main pulmonary arteries.The inferior dissection line is posi-tioned in the pulmonary root. Thesinuses of the pulmonary bulb havebeen removed, leaving only thethree intervalvular triangles andthe commissures in situ. Thus, thespace behind the pulmonary trunkmay be investigated. This is effec-tively the space of the transversepericardial sinus, which is in-spected from the anterior direction(Fig. 11.6). Note that the left mainstem and the bifurcation have alsobeen brought into the view usingthis exposure. The appendage ofthe left atrium has been retracted.In this specimen, it is clear that thepulmonary root and the infundibu-lum are positioned in front of theaortic root and the conjoined partof the ascending aorta. Here, theascending aorta is a direct continu-ation of the aortic root and the axisof the left ventricle. From here on,the course of the ascending aortadescribes a slight curve, which isdirected upward, forward, and tothe right (Fig. 11.5). At the level ofthe junction between the superiorvena cava and the right atrium, theascending aorta reaches the mostextreme right position, from whichpoint the aorta travels in the frontalplane upward and to the left, towardthe aortic arch. The mentioned

11.1 The Aortic Arch 459