Netter's Correlative Imaging- Cardiothoracic Anatomy

Cardiothoracic Anatomy, the third title in the brand-new Netters Correlative Imaging series, provides exceptional visual

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Netter's Correlative Imaging- Cardiothoracic Anatomy

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NETTER’S

Correlative Imaging: Cardiothoracic Anatomy Volume Editor

MICHAEL B. GOTWAY, MD Department of Radiology Mayo Clinic Scottsdale, Arizona; Clinical Associate Professor, Diagnostic Radiology/Biomedical Imaging and Pulmonary/Critical Care Medicine Department of Radiology University of California, San Francisco San Francisco, California; Clinical Professor, University of Arizona College of Medicine Adjunct Professor, Department of Biomedical Informatics Arizona State University Phoenix, Arizona

Series Editor

NANCY M. MAJOR, MD Director of Diagnostic Imaging Orthopaedic Associates of Allentown Allentown, Pennsylvania

Illustrations by

Frank H. Netter, MD Contributing Illustrators

Kristen Wienandt Marzejon, MS, MFA Carlos A.G. Machado, MD

1600 John F. Kennedy Blvd. Ste 1800 Philadelphia, PA 19103-2899

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY Copyright © 2013 by Saunders, an imprint of Elsevier Inc.

ISBN: 978-1-4377-0440-2

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the Publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). Permissions for Netter Art figures may be sought directly from Elsevier’s Health Science Licensing Â�Department in Philadelphia, PA, USA: phone 1-800-523-1640, ext. 3276, or (215) 239-3276; or email [email protected].

Notices Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods, they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.

Library of Congress Cataloging-in-Publication Data Gotway, Michael B. Netter’s correlative imaging: cardiothoracic anatomy / Michael B. Gotway; illustrations by Frank H. Netter; contributing illustrators, Kristen Wienandt Marzejon, Carlos A.G. Machado. â•…â•… p. ; cm. Correlative imaging: cardiothoracic anatomy Includes bibliographical references and index. ISBN 978-1-4377-0440-2 (hardcover: alk. paper) I. Netter, Frank H. (Frank Henry), 1906-1991. II. Title. III. Title: Correlative imaging: cardiothoracic anatomy. â•…â•… [DNLM: 1. Lung--anatomy & histology--Atlases. 2. Thorax--anatomy & histology--Atlases. 3. Diagnostic Imaging--Atlases. 4. Heart--anatomy & histology--Atlases. WF 17] 612.2’4--dc23 2011047534 Senior Content Strategist: Elyse O’Grady Content Development Manager: Marybeth Thiel Publishing Services Manager: Anne Altepeter Project Managers: Cheryl Abbott and Jessica Becher Design Direction: Louis Forgione Printed in China Last digit is the print number:â•… 9â•… 8â•… 7â•… 6â•… 5â•… 4â•… 3â•… 2â•… 1

About the Artists FRANK H. NETTER, MD Frank H. Netter was born in 1906 in New York City. He studied art at the Art Student’s League and the National Academy of Design before entering medical school at New York University, where he received his MD degree in 1931. During his student years, Dr. Netter’s notebook sketches attracted the attention of the medical faculty and other physicians, allowing him to augment his income by illustrating articles and textbooks. He continued illustrating as a sideline after establishing a surgical practice in 1933, but he ultimately opted to give up his practice in favor of a full-time commitment to art. After service in the U.S. Army during World War II, Dr. Netter began his long collaboration with the CIBA Pharmaceutical Company (now Novartis Pharmaceuticals). This 45-year partnership resulted in the production of the extraordinary collection of medical art so familiar to physicians and other medical professionals worldwide. In 2005 Elsevier, Inc., purchased the Netter Collection and all publications from Icon Learning Systems. There are now more than 50 publications featuring the art of Dr. Netter available through Elsevier, Inc. (in the United States: www.us.elsevierhealth.com/Netter and outside the United States: www.elsevierhealth.com) Dr. Netter’s works are among the finest examples of the use of illustration in the teaching of medical concepts. The 13-book Netter Collection of Medical Illustrations, which includes the greater part of the more than 20,000 paintings created by Dr. Netter, became and remains one of the most famous medical works ever published. The Netter Atlas of Human Anatomy, first published in 1989, presents the anatomical paintings from the Netter Collection. Now translated into 16 languages, it is the anatomy atlas of choice among medical and health professions students the world over. The Netter illustrations are appreciated not only for their aesthetic qualities but, more important, for their intellectual content. As Dr. Netter wrote in 1949, “... clarification of a subject is the aim and goal of illustration. No matter how beautifully painted or how delicately and subtly rendered a subject may be, it is of little value as a medical illustration if it does not serve to make clear some medical point.” Dr. Netter’s planning, conception, point of view, and approach are what inform his paintings and what makes them so intellectually valuable. Frank H. Netter, MD, physician and artist, died in 1991. Learn more about the physician-artist whose work has inspired the Netter Reference collection: http://www.netterimages.com/artist/netter.htm CARLOS MACHADO, MD Carlos Machado was chosen by Novartis to be Dr. Netter’s successor. He continues to be the main artist who contributes to the Netter collection of medical illustrations. Self-taught in medical illustration, cardiologist Carlos Machado has contributed meticulous updates to some of Dr. Netter’s original plates and has created many paintings of his own in the style of Netter as an extension of the Netter collection. Dr. Machado’s photorealistic expertise and his keen insight into the physician/patient relationship inform his vivid and unforgettable visual style. His dedication to researching each topic and subject he paints places him among the premier medical illustrators at work today. Learn more about his background and see more of his art at: http://www.netterimages.com/artist/machado.htm KRISTEN WIENANDT MARZEJON, MS, MFA Kristen Wienandt Marzejon is a certified medical illustrator with an MS degree from the Â�University of Illinois at Chicago’s Biomedical Visualization graduate program. Her passion for both art and science from an early age makes her perfectly suited to this gratifying profession. She started her career as a staff illustrator at Rush University Medical Center in Chicago and then committed to self-employed status in 2001. She offers medical illustration and graphic design services to a variety of clients in the medical arena. The work of Frank Netter has been a valuable part of Kristen’s medical library throughout her 20-year career. That said, she is honored to continue the Netter tradition by producing work authentic to his distinctive style.

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About the Author Michael B. Gotway, MD, is a cardiopulmonary radiologist at the Mayo Clinic in Scottsdale, Arizona. Dr. Gotway completed his medical school training at the University of Illinois at �Chicago, after which he performed his diagnostic radiology residency training at the �University of California, San Francisco (UCSF), where he was presented with the Elmer Ng, MD award as outstanding diagnostic radiology resident. Dr. Gotway subsequently performed his cardiopulmonary imaging fellowship at UCSF, after which he joined the faculty at UCSF in cardiopulmonary imaging, based at San Francisco General Hospital (SFGH). Dr. Gotway was presented with the Outstanding Teacher Award by the Department of Medicine, section of Pulmonary and Critical Care Medicine, in 1999 and the Hideyo Minagi Outstanding Teacher Award by the UCSF Diagnostic Radiology Residency Program in 2002. Dr. Gotway held the position of Radiology Residency Program Director at UCSF from 2001 to 2005, as well as the Body Imaging Fellowship Director at SFGH from 2002 to 2004. From 2004 to 2005, Dr. Gotway was acting Vice-Chair for the Department of Radiology at UCSF, as well as the acting Chief of Radiology at SFGH. Before joining the Mayo Clinic, Dr. Gotway was a radiologist partner at Scottsdale Medical Imaging, Ltd, an affiliate of Southwest Diagnostic Imaging, from 2005 to 2012.

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Preface Thoracic computed tomography (CT) is a commonly performed procedure and an integral part of modern medical practice. Like most CT imaging, thoracic CT is performed and interpreted in the transverse plane. The transverse plane, or as more commonly referred to in daily practice, the axial plane, is perpendicular to the long axis of the body, dividing the body into cranial and caudal portions. When viewing axial supine CT sections, by convention, the patient’s right side is on the viewer’s left, with anterior structures at the “top” of the image. With multislice CT, serial, contiguous axial sections are acquired as a volume and can be displayed at various slice thicknesses, depending on the desired spatial resolution. The image data are commonly presented as a cephalocaudad “stack” of images that the user can actively scroll through. This display convention has been adopted in this volume. In clinical practice, anatomy is often tracked from image to image when scrolling in a cephalocaudad direction, allowing the reader to develop a three-dimensional impression of the structure of interest. The user is encouraged to adopt this approach when reviewing the thoracic and cardiac images to foster a three-dimensional understanding of cardiothoracic anatomy. The thoracic CT images in this volume are displayed in both “soft tissue” and “lung” windows. The term “windowing” refers to manipulation of the display parameters (window width and window level) whereby the user changes the grayscale of an image to facilitate visualization of various anatomical structures. In the thoracic CT section of this volume, at each level, two images are shown: one displayed using a lung window, the other displayed using a soft-tissue window. These displays are created from the same source image; the display is merely changed to a lung window to optimize visualization of lung anatomy and to a soft tissue window to highlight mediastinal anatomy. In practice, several different window width and level settings are employed during review of CT images, each tailored to show the anatomy of interest to advantage. Cardiac computed tomographic angiography (CTA) is a relatively recent development in the continual improvement of CT technology. Cardiac CTA is performed during the bolus administration of intravenous contrast material and during a breath hold, and the scan is performed in conjunction with electrocardiographic (ECG) gating to control for cardiac motion. CTA examinations performed using retrospective ECG gating allow for the reconstruction of CT data at various time points during the cardiac cycle. Because CT is sensitive to motion, and even minimal motion may compromise the quality of a cardiac CTA examination, ECG gating is an integral part of the performance of cardiac CTA. Images obtained when heart motion is relatively minimized, typically during diastole when the heart is undergoing isovolumic relaxation, provide relatively motion-free images for interpretation. A typical cardiac CTA examination is performed in the axial plane and contains hundreds of images. The interpreter reviews these images and actively interacts with the data, creating various images that highlight particular aspects of cardiac anatomy or pathology. For cardiac imaging, the axial plane is not the only imaging plane, or even the primary imaging plane, used for interpretation. Rather, other imaging planes are created with reference to the axis of the heart: 2-chamber views (vertical long axis), 4-chamber views (horizontal long axis), and short axis views of the heart are commonly employed. These planes are easily constructed from the axial data, and several examples of these imaging planes are presented at the end of the cardiac CTA section and in the cardiac MRI section. The axial plane is used for anatomical illustration in the cardiac CTA plates because it is the plane in which the data are acquired and an appreciation of non-axial cardiac anatomy is facilitated by first gaining an understanding of cardiovascular anatomy in the axial plane. After axial anatomy is understood, using a dedicated workstation to actively manipulate the data and visualize cardiac anatomy in various projections is the best method to gain a firm understanding of cardiovascular anatomy. Note that right ventricular anatomy is not particularly well illustrated in the cardiac CTA study shown in these plates. This is because cardiac CTA examinations are often performed with injection of saline following the injection of iodinated intravenous contrast media, effectively “washing contrast” from the right cardiac chambers. This is done because dense intravenous

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Preface contrast within the right heart chambers may create artifacts that impair visualization of important cardiovascular structures, particularly the right coronary artery. The reader is referred to the magnetic resonance imaging plates for details regarding right atrial and ventricular anatomy. The number of images acquired in a typical cardiac CTA examination can be large. Because of space limitations, all the images acquired in the examination used for these plates cannot be shown, but relevant sections (roughly every sixth image from the actual examination) are presented to illustrate normal cardiovascular anatomy. The information displayed in the cardiac anatomy plates is primarily geared toward cardiovascular anatomy. Some non–cardiovascular structures are illustrated because they are well seen during cardiac CTA examinations and those interpreting these studies must possess a detailed knowledge of non–cardiovascular thoracic anatomy because pathological conditions affecting non–cardiovascular structures are commonly encountered at cardiac CTA examinations. The reader is referred to the thoracic anatomy plates for a more detailed review of non–cardiovascular anatomy, particularly pulmonary anatomy. Magnetic resonance imaging (MRI, or MR) is a technology that also produces cross-sectional images of thoracic and cardiovascular structures but operates using a completely different physical basis than CT imaging—MRI does not employ ionizing radiation to generate image data. MR can provide exquisite visualization of mediastinal anatomy, but the MR images in this volume are restricted to cardiac anatomy because of space limitations. MR imaging can be performed using a wide variety of techniques, each of which has specific benefits and limitations. In this volume, basic “black-blood” and “white-blood” imaging sequences are shown side by side. Although the anatomy shown in image sequence pairs coincides very closely, unlike the process of windowing with CT images, creation of these images does require separate scans, so very slight differences in the anatomical details of these image pairs may be evident to the astute observer. Although white-blood imaging depicts flowing blood as bright, this imaging sequence does not require the use of intravenous contrast. MR imaging can be acquired in any plane. As with cardiac CTA, axial data are often obtained, but the cardiac imaging planes constitute the primary imaging planes used for clinical interpretation. The MRI plates in this volume are obtained in the axial plane and supplemented with cardiac imaging planes similar to the cardiac CTA plates. Finally, several plates illustrating minor anatomical variations are shown. These variations include often incidentally detected tracheobronchial, fissure, and venous anomalies. In addition, the axial data chosen for the MRI plates show a minor vascular aberrancy—the aberrant right subclavian artery. The anatomical variations displayed in this volume generally carry little clinical significance. However, it is anticipated that the display of such variations will enhance the appreciation of the “normal” anatomy shown in the other plates while highlighting the power of imaging to demonstrate human anatomy. Michael B. Gotway, MD

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Contents PART 1 THORACIC ANATOMY 1

OVERVIEW OF THORACIC ANATOMY����������������������������� 3-10

2

THORACIC SOFT TISSUE AND LUNG��������������������������������� 11 Axial,  12-91 Coronal,  92-157

3

PULMONARY ANATOMY AND VARIANTS������������������������� 159 Axial,  160-165 Coronal,  166-167

4

THORACIC LYMPH NODES������������������������������������������������� 169 Axial,  170-187

5

CISTERNA CHYLI AND THORACIC DUCT������������������������ 189 Axial,  190-199 Coronal,  200-217

6

VENOUS ANATOMY AND VARIANTS��������������������������������� 219 Axial,  220-223 Coronal,  224-225 Sagittal,  226-229

PART 2 CARDIAC ANATOMY 7

OVERVIEW OF CARDIAC ANATOMY �������������������������������� 233

8

CARDIAC ANATOMY USING CT ���������������������������������������� 239 Axial,  240-363 2-Chamber,  364-365 3-Chamber,  366-367 4-Chamber,  368-369 Short Axis,  370-371

9

CARDIAC ANATOMY USING MR ��������������������������������������� 373 Axial,  374-411 2-Chamber,  412-413 3-Chamber,  414-415 4-Chamber,  416-417 Short Axis,  418-419

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PART

1

THORACIC ANATOMY

CHAPTER 1â•…OVERVIEW OF THORACIC ANATOMYâ•… 3 CHAPTER 2â•…THORACIC SOFT TISSUE AND LUNGâ•… 11 CHAPTER 3â•…PULMONARY ANATOMY AND VARIANTSâ•… 159 CHAPTER 4â•…THORACIC LYMPH NODESâ•… 169 CHAPTER 5â•…CISTERNA CHYLI AND THORACIC DUCTâ•… 189 CHAPTER 6â•…VENOUS ANATOMY AND VARIANTSâ•… 219

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

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Chapter

1

OVERVIEW OF THORACIC ANATOMY

ANTERIOR THORACIC WALL╅ 4 THORACIC CAGE╅ 5 GREAT VESSELS OF SUPERIOR �MEDIASTINUM╅ 6 LYMPH VESSELS AND NODES OF LUNG╅ 7 LYMPH VESSELS AND NODES OF ESOPHAGUS╅ 8 VEINS OF ESOPHAGUS╅ 9 THORAX: FOUR CHAMBERS OF HEART╅ 10

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

3

Anterior Thoracic Wall

Sternothyroid muscle Sternohyoid muscle Omohyoid muscle

Sternocleidomastoid muscle Posterior triangle of neck Trapezius muscle

Invested by cervical fascia

Clavicle

Perforating branches of internal thoracic artery and anterior cutaneous branches of intercostal nerves

Subclavius muscle invested by clavipectoral fascia Thoracoacromial artery (pectoral branch) and lateral pectoral nerve

Pectoralis major muscle Cephalic vein

Coracoid process

Acromion Medial pectoral nerve

1 2 3 4 5 Long thoracic nerve and lateral thoracic artery Pectoralis minor muscle invested by Clavipectoral fascia

6 Latissimus dorsi muscle 7 Digitations of serratus anterior muscle

8

Lateral cutaneous branches of intercostal nerves and posterior intercostal arteries

External intercostal membranes anterior to internal intercostal muscles

9 10

External oblique muscle

External intercostal muscles Body and xiphoid process of sternum

Anterior layer of rectus sheath

Internal oblique muscle

Sternalis muscle (inconstant) Linea alba

4

Digitations of serratus anterior muscle

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Rectus abdominis muscle Cutaneous branches of thoracoabdominal (abdominal portions of intercostal) nerves and superior epigastric artery

Thoracic Cage

Inferior thyroid veins

Trachea

Thymus

Left common carotid artery

Brachiocephalic trunk

Left brachiocephalic vein

Right brachiocephalic vein

Internal jugular vein

Phrenic nerve

Vagus nerve (X) Thoracic duct

Anterior scalene muscle

Arch of aorta

Brachial plexus External jugular vein

Left recurrent laryngeal nerve

Subclavian artery and vein

Internal thoracic artery Phrenic nerve and pericardiacophrenic artery and vein

Superior vena cava 1st rib Phrenic nerve and pericardiacophrenic artery and vein

Mediastinal part of parietal pleura

Right lung Left lung

Pericardium Diaphragm

Mediastinal Diaphragmatic Costal

Parts of parietal pleura

Line of fusion of fibrous pericardium to diaphragm

Internal thoracic artery Superior epigastric artery

Musculophrenic artery

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

5

Great Vessels of Superior Mediastinum

Cricoid cartilage

Thyroid cartilage

Thyroid gland

Trachea

Right common carotid artery

Left common carotid artery

Right vagus nerve (X)

Left vagus nerve (X)

Anterior scalene muscle

Anterior scalene muscle

Phrenic nerve

Phrenic nerve (cut)

Right internal jugular vein

Thoracic duct

External jugular vein

Brachial plexus

Brachial plexus

Left subclavian artery and vein

Right subclavian artery and vein

Left brachiocephalic vein

Brachiocephalic trunk

Internal thoracic artery

Right brachiocephalic vein

Arch of aorta

Phrenic nerve and pericardiacophrenic artery and vein (cut)

Vagus nerve (X)

Superior vena cava

Left recurrent laryngeal nerve

Right superior lobar (eparterial) bronchus

Ligamentum arteriosum

Right pulmonary artery

Left pulmonary artery

Pulmonary trunk

Left pulmonary veins

Right pulmonary veins

Mediastinal part of parietal pleura (cut edge)

Mediastinal part of parietal pleura (cut edge)

Costal part of parietal pleura (cut edge)

Costal part of parietal pleura (cut edge)

Phrenic nerve (cut)

Diaphragmatic part of parietal pleura

Diaphragmatic part of parietal pleura and cut edge

Right intermediate bronchus Left main bronchus

Phrenic nerve (cut)

Pericardium (cut edge)

Azygos vein Thoracic duct Inferior vena cava

6

Diaphragm Esophagus and esophageal plexus

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Lymph Vessels and Nodes of Lung

Right paratracheal nodes

Left paratracheal nodes

Right superior tracheobronchial nodes

Bronchomediastinal lymphatic trunk

Bronchomediastinal lymphatic trunk

Brachiocephalic vein

Brachiocephalic vein

Inferior deep cervical (scalene) node

Inferior deep cervical (scalene) node

Thoracic duct

Internal jugular vein and jugular lymphatic trunk

Left superior tracheobronchial nodes (Aortic arch) node of ligamentum arteriosum

Right lymphatic duct Subclavian vein and subclavian lymphatic trunk

Bronchopulmonary (hilar) nodes Pulmonary (intrapulmonary) nodes

Bronchopulmonary (hilar) nodes

Subpleural lymphatic plexus

Subpleural lymphatic plexus

Interlobular lymph vessels

Interlobular lymph vessels Pulmonary (intrapulmonary) nodes

Inferior tracheobronchial (carinal) nodes

Drainage follows bronchi, arteries, and veins

Pulmonary ligaments

Drainage follows bronchi, arteries, and veins

Routes to mediastinum

Drainage routes Right lung: All lobes drain to pulmonary and bronchopulmonary (hilar) nodes, then to inferior tracheobronchial (carinal) nodes, right superior tracheobronchial nodes, and right paratracheal nodes on the way to the brachiocephalic vein via the bronchomediastinal lymphatic trunk and/ or inferior deep cervical (scalene) node.

Left lung: The superior lobe drains to pulmonary and bronchopulmonary (hilar) nodes, inferior tracheobronchial (carinal) nodes, left superior tracheobronchial nodes, left paratracheal nodes and/or (aortic arch) node of ligamentum arteriosum, then to the brachiocephalic vein via the left bronchomediastinal trunk and thoracic duct. The left inferior lobe also drains to the pulmonary and bronchopulmonary (hilar) nodes and to inferior tracheobronchial (carinal) nodes, but then mostly to right superior tracheobronchial nodes, where it follows the same route as lymph from the right lung.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

7

Lymph Vessels and Nodes of Esophagus

Inferior deep cervical (internal jugular) nodes

Thoracic duct

Paratracheal nodes Posterior mediastinal nodes Superior and inferior tracheobronchial nodes

Intercostal nodes

Posterior parietal nodes

Superior phrenic nodes

Left gastric nodes (cardiac nodes of stomach)

Juxtaesophageal and superior phrenic nodes

Celiac nodes

8

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Veins

Inferior thyroid vein Internal jugular vein

of

Esophagus

Inferior thyroid vein Internal jugular vein

External jugular vein Subclavian vein Vertebral vein

Right brachiocephalic vein Superior vena cava Right superior intercostal vein Esophagus

Subclavian vein Thoracic duct Left brachiocephalic vein Left superior intercostal vein Esophageal veins (plexus) Accessory hemiazygos vein

6th right posterior intercostal vein Azygos vein Junction of accessory hemiazygos and azygos veins Inferior vena cava (cut)

Submucosal venous plexus Hemiazygos vein Left inferior phrenic vein Short gastric veins

Diaphragm Liver

Hepatic veins

Inferior vena cava Splenic vein Hepatic portal vein

Left suprarenal vein Right renal vein Left gastric vein Right gastric vein

Esophageal branches of left gastric vein

Left renal vein

Omental (epiploic) veins Left gastro-omental (gastroepiploic) vein

Superior mesenteric vein Inferior mesenteric vein Right gastro-omental (gastroepiploic) vein

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

9

Thorax: Four Chambers of Heart

Transverse Section: Level of T7, 3rd Interchondral Space Plane of section

T7

Orifice of tricuspid valve Internal thoracic artery and vein Left atrium Right atrium

Sternum (body) Right ventricle Interventricular septum Left ventricle Anterior interventricular sulcus

Interatrial septum

Pectoralis major muscle Apex of heart

Superior vena cava

Papillary muscle

Right inferior pulmonary vein

Leaflet of mitral valve

Esophagus

Coronary sinus

Azygos vein

Oblique pericardial sinus

Serratus anterior muscle

Descending aorta

Thoracic duct

Latissimus dorsi muscle

Inferior angle of scapula

Latissimus dorsi muscle

Triangle of auscultation

Triangle of auscultation

Neck of 7th rib Zygapophyseal (facet) joint

10

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Head of 7th rib Body of T7 vertebra Trapezius muscle

Chapter

2

THORACIC SOFT TISSUE AND LUNG 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39

AXIALâ•… 12

1 2 4 6

3 5

8 10 12 14 16 18 20 22 24 26

7 9 11 13 15 17 19 21 23 25 27

28 29 30 31 32 33

CORONALâ•… 92

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

11

Soft Tissue and Lung Axial 1

Sternocleidomastoid mm. Right common carotid a.

Thyroid gland

Right internal jugular v.

Left common carotid a.

Anterior scalene m.

Left internal jugular v.

Right subclavian a. Pectoralis major m.

Left clavicle

Left subclavian a. Humerus (head)

Scapula (glenoid)

Scapula (corocoid process)

Rib Left vertebral a.

Trapezius m. Right vertebral a. Erector spinae m.

12

Levator scapulae m. Vertebral body

Esophagus

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Trachea

Soft Tissue and Lung Axial 1

Right common carotid a.

Sternocleidomastoid mm.

Thyroid gland

Right internal jugular v.

Left internal jugular v.

Anterior scalene m.

Left clavicle Pectoralis major m.

Left common carotid a.

Right subclavian a.

Left subclavian a. Humerus (head)

Scapula (glenoid)

Scapula (corocoid process)

Right vertebral a.

Trachea

Rib

Left vertebral a.

Erector spinae m.

Esophagus Trapezius m.

Right common carotid a.

Vertebral body

Levator scapulae m.

Sternocleidomastoid mm.

Thyroid gland

Right internal jugular v.

Left clavicle Pectoralis major m.

Right subclavian a. Humerus (head) Scapula (glenoid)

Trachea

Erector spinae m.

Esophagus Trapezius m.

Vertebral body

Trapezius m.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

13

Soft Tissue and Lung Axial 2

Sternocleidomastoid mm.

Thyroid gland

Left common carotid a. Left internal jugular v. Left clavicle Left vertebral a. Left subclavian a.

Right common carotid a. Right internal jugular v. Right subclavian a. Pectoralis major m.

Subscapularis m.

Pectoralis minor m.

Scapula

Scapula Scapula (spine)

Levator scapulae m. Rib Trapezius m. Right lung apex (right upper lobe, apical segment)

14

Trachea Right vertebral a. Vertebral body

Esophagus Erector spinae m.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Left lung apex (left upper lobe, apical-posterior segment)

Soft Tissue and Lung Axial 2

Right common carotid a.

Sternocleidomastoid mm.

Thyroid gland

Left common carotid a.

Left internal jugular v. Left clavicle Left vertebral a.

Right internal jugular v. Pectoralis major m.

Left subclavian a.

Pectoralis minor m. Subscapularis m. Right subclavian a.

Left lung apex (left upper lobe, apical-posterior segment)

Scapula Right lung apex (right upper lobe, apical segment)

Scapula

Rib Scapula (spine)

Levator scapulae m.

Trapezius m. Right vertebral a.

Vertebral body

Esophagus Erector Trachea spinae m.

Thyroid gland

Left common carotid a.

Right common carotid a. Right internal jugular v. Pectoralis major m.

Left subclavian a.

Right subclavian a. Left lung apex (left upper lobe, apical-posterior segment)

Right lung apex (right upper lobe, apical segment)

Trapezius m. Vertebral body

Esophagus Trapezius m.

Trachea

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

15

Soft Tissue and Lung Axial 3

Sternothyroid & sternohyoid m. Sternocleidomastoid mm. Right common carotid a. Right subclavian a. Right internal jugular v. Right internal mammary a. Right subclavian v. (enhanced)

Left common carotid a. Left internal jugular v. Left clavicle Left vertebral a. Left internal mammary a. Left subclavian a. Left subclavian v. (unenhanced) Subscapularis m.

Pectoralis major m. Pectoralis minor m.

Scapula Scapula (spine) Right lung apex (right upper lobe, apical segment)



Rib Trachea Rib

Vertebral body

Trapezius mm.

Esophagus

Erector spinae m.

Infraspinatus m. Scapula Supraspinatus m.

Left lung apex (left upper lobe, apical-posterior segment)

DIAGNOSTIC CONSIDERATION Thoracic CT scans may be performed with or without the intravenous injection of iodinated contrast. Contrast-enhanced thoracic CT scanning is usually performed following injection into an upper extremity vein, with imaging started at 30 to 40 seconds after the injection is begun, depending on the specific application. In this patient, contrast was injected via the right upper extremity, resulting in dense enhancement of the right subclavian vein (and the right brachiocephalic vein on Axial 5 and subsequent images); the left subclavian vein (and left brachiocephalic vein on Axial 5 and subsequent images) remains unenhanced in this patient because imaging was begun before injected contrast had sufficient time to circulate throughout the body and reach the left subclavian vein.

16

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Soft Tissue and Lung Axial 3

Right internal jugular v.

Right common carotid a.

Sternothyroid & sternohyoid m.

Sternocleidomastoid mm.

Left clavicle Left internal jugular v.

Right internal mammary a.

Left common carotid a.

Pectoralis major m.

Left internal mammary a.

Pectoralis minor m. Right subclavian v. (enhanced)

Left subclavian v. (unenhanced)

Right subclavian a.

Left subclavian a.

Right lung apex (right upper lobe, apical segment) Scapula

Subscapularis m. Infraspinatus m.

Vertebral body

Scapula

Scapula (spine)

Rib Supraspinatus m.

Rib Trapezius m.

Erector spinae m.

Esophagus Trachea

Sternothyroid & sternohyoid m.

Left vertebral a.

Left lung apex (left upper lobe, apical-posterior segment)

Left clavicle

Left common carotid a.

Right common carotid a. Pectoralis major m. Pectoralis minor m. Right subclavian a.

Left subclavian a.

Right lung apex (right upper lobe, apical segment) Scapula

Vertebral body

Trapezius mm.

Esophagus Trachea

Left lung apex (left upper lobe, apical-posterior segment)

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

17

Soft Tissue and Lung Axial 4

Sternothyroid & sternohyoid m. Sternocleidomastoid mm. Left common carotid a. Right common carotid a. Left clavicle (medial head) Right subclavian a. Right internal mammary a. Right subclavian v. (enhanced) Pectoralis major m. Pectoralis minor m.

Left internal jugular v. Left subclavian a. Left internal mammary a. Left lung apex (left upper lobe, apical-posterior segment)

Subscapularis m.

Left subclavian v. (unenhanced)

Scapula Peripheral pulmonary a. Erector spinae m.

Trapezius mm.

Vertebral body

Infraspinatus m. Scapula Rib Supraspinatus m. Trachea Peripheral pulmonary a. Esophagus

18

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Soft Tissue and Lung Axial 4

Right common carotid a.

Sternocleidomastoid Sternothyroid & mm. sternohyoid m.

Left common carotid a.

Left clavicle (medial head)

Right subclavian v. (enhanced)

Left internal jugular v. Left internal mammary a. Left subclavian a.

Pectoralis major m.

Left subclavian v. (unenhanced)

Pectoralis minor m.

Left lung apex (left upper lobe, apicalposterior segment)

Right internal mammary a.

Rib

Right subclavian a.

Infraspinatus m.

Subscapularis m. Scapula

Scapula

Erector spinae m. Supraspinatus m. Trapezius mm.

Vertebral body

Sternocleidomastoid mm.

Esophagus Trachea

Left common carotid a.

Left clavicle (medial head)

Left subclavian a. Pectoralis major m. Left lung apex (left upper lobe, apicalposterior segment)

Pectoralis minor m.

Right subclavian a.

Rib

Peripheral pulmonary a.

Peripheral pulmonary a.

Subscapularis m. Scapula

Infraspinatus m.

Supraspinatus m. Trapezius mm.

Vertebral body

Esophagus Trachea

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

19

Soft Tissue and Lung Axial 5

Right common carotid a.

Clavicle heads

Right subclavian a. Right brachiocephalic v. (enhanced) Right internal mammary a. Pectoralis major m.

Left common carotid a. Left subclavian a. Left brachiocephalic v. Left internal mammary a. Pulmonary vv. Left upper lobe Rib Serratus anterior m.

Pectoralis minor m.

Subscapularis m. Scapula Right upper lobe Pulmonary a.

20

Trapezius mm.

Infraspinatus m. Scapula Supraspinatus m. Pulmonary aa. Vertebral body Esophagus Trachea

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Soft Tissue and Lung Axial 5

Right subclavian a.

Right common carotid a.

Clavicle heads

Trachea

Left common carotid a. Left brachiocephalic v.

Right brachiocephalic v. (enhanced)

Left internal mammary a. Left subclavian a.

Pectoralis major m.

Rib

Pectoralis minor m. Serratus anterior m. Right internal mammary a. Left upper lobe

Subscapularis m.

Infraspinatus m.

Scapula

Scapula

Right upper lobe

Supraspinatus m.

Trapezius m. Vertebral body

Right subclavian a.

Right common carotid a.

Esophagus

Trachea Clavicle (medial head)

Right brachiocephalic v.

Left common carotid a. Left subclavian a.

Pectoralis major m. Pectoralis minor m.

Pulmonary vv.

Supraspinatus m.

Left upper lobe

Scapula

Pulmonary aa.

Pulmonary a. Right upper lobe

Trapezius mm.

Vertebral body

Esophagus

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

21

Soft Tissue and Lung Axial 6

Right brachiocephalic a.

Sternum (manubrium) Left common carotid a. Left brachiocephalic v. Left internal mammary a. Left subclavian a. Pulmonary v. Rib Serratus anterior m.

Clavicle (medial heads)

Right brachiocephalic v. (enhanced) Right internal mammary a. Pectoralis major m. Pectoralis minor m. Subscapularis m.

Infraspinatus m. Scapula Supraspinatus m. Pulmonary a.

22

Scapula (body)

Trapezius m.

Vertebral body

Erector spinae m.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Esophagus

Trachea

Pulmonary aa.

Soft Tissue and Lung Axial 6

Clavicle (medial heads)

Sternum (manubrium)

Left common carotid a.

Left brachiocephalic v.

Right brachiocephalic a.

Pectoralis major m.

Left internal mammary a.

Pectoralis minor m.

Rib Left subclavian a.

Right internal mammary a.

Serratus anterior m.

Right brachiocephalic v. (enhanced) Infraspinatus m.

Scapula (body)

Scapula Subscapularis m. Supraspinatus m. Vertebral body

Trapezius m.

Erector Esophagus spinae m.

Left common carotid a.

Trachea

Left brachiocephalic v.

Right brachiocephalic a.

Pectoralis major m. Pectoralis minor m. Left subclavian a.

Right brachiocephalic v.

Pulmonary v.

Pulmonary a.

Pulmonary aa.

Vertebral body

Trapezius mm.

Esophagus

Trachea

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

23

Soft Tissue and Lung Axial 7

Right brachiocephalic a. Right internal mammary a. Right brachiocephalic v. (enhanced)

Sternum (manubrium)

Pectoralis major m. Pectoralis minor m.

Left brachiocephalic v. Left common carotid a. Left internal mammary a. Left subclavian a. Pulmonary v. Serratus anterior m.

Subscapularis m.

Rib

Scapula

Infraspinatus m.

Pulmonary a.

Scapula Right upper lobe apical subsegmental bronchus

Trachea

Pulmonary a. Trapezius m.

24

Vertebral body

Esophagus

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Erector spinae m.

Left upper lobe apical-posterior subsegmental bronchus Rhomboid major m.

Soft Tissue and Lung Axial 7

Right internal mammary a.

Sternum Right brachiocephalic a. (manubrium)

Left brachiocephalic v. Left internal mammary a.

Pectoralis major m.

Left common carotid a.

Pectoralis minor m.

Trachea

Right brachiocephalic v. (enhanced)

Left subclavian a. Serratus anterior m. Rib

Subscapularis m.

Scapula

Infraspinatus m. Scapula Rhomboid major m. Vertebral body Trapezius m.

Erector spinae m.

Right Sternum brachiocephalic a. (manubrium)

Esophagus

Left brachiocephalic v.

Left common carotid a.

Pectoralis major m. Pectoralis minor m. Right brachiocephalic v.

Left subclavian a. Pulmonary v.

Right upper lobe apical subsegmental bronchus

Pulmonary a.

Pulmonary a. Left upper lobe apical-posterior subsegmental bronchus

Vertebral body Trapezius mm.

Trachea

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

25

Soft Tissue and Lung Axial 8

Right brachiocephalic a. Right internal mammary a. & v.

Sternum (manubrium)

Right brachiocephalic v. (enhanced) Pulmonary a. Pectoralis major m. Pectoralis minor m.

Left brachiocephalic v. Left internal mammary a. Left common carotid a. Left subclavian a. Pulmonary vv. Rib Serratus anterior m.

Subscapularis m.

Axilla

Infraspinatus m. Scapula Pulmonary vv. Pulmonary a. Trapezius m.

26

Spinal cord

Scapula (body) Pulmonary a. Left upper lobe apical-posterior subsegmental bronchus Esophagus Trachea Rhomboid major m. Vertebral body

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Soft Tissue and Lung Axial 8

Sternum Right brachiocephalic a. (manubrium)

Left internal mammary a.

Pectoralis major m.

Left brachiocephalic v.

Right internal mammary a. & v. Pectoralis minor m.

Left common carotid a. Trachea Left subclavian a.

Right brachiocephalic v. (enhanced)

Axilla Serratus anterior m. Rib

Infraspinatus m. Subscapularis m.

Scapula (body)

Scapula

Trapezius m.

Spinal cord

Vertebral body

Esophagus

Rhomboid major m.

Right Sternum brachiocephalic a. (manubrium) Left brachiocephalic v.

Pectoralis major m.

Left common carotid a. Trachea Pectoralis minor m.

Left subclavian a.

Right brachiocephalic v. (enhanced) Pulmonary a.

Pulmonary vv.

Pulmonary vv. Pulmonary v. Pulmonary a. Left upper lobe apicalposterior subsegmental bronchus

Pulmonary v.

Pulmonary a.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

27

Soft Tissue and Lung Axial 9

Right brachiocephalic a. Right internal mammary a. Right brachiocephalic v. Pulmonary a. Pulmonary vv. Pectoralis major m. Pectoralis minor m.

Sternum (manubrium)

Subscapularis m.

Left brachiocephalic v. Left internal mammary a. Left common carotid a. Left subclavian a. Pulmonary vv. Rib Axilla Serratus anterior m.

Scapula (body)

Infraspinatus m. Scapula

Pulmonary a.

Rhomboid major m. Pulmonary a.

Esophagus Trapezius m.

28

Spinal cord

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Vertebral body

Trachea

Soft Tissue and Lung Axial 9

Right brachiocephalic a.

Sternum (manubrium)

Left internal mammary a.

Right internal mammary a.

Left brachiocephalic v. Left common carotid a.

Pectoralis major m.

Left subclavian a.

Pectoralis minor m.

Axilla

Right brachiocephalic v.

Rib Subscapularis m.

Serratus anterior m.

Infraspinatus m.

Scapula (body)

Scapula

Rhomboid major m.

Trapezius m. Spinal cord

Right brachiocephalic a.

Vertebral body

Esophagus

Trachea

Sternum (manubrium)

Left common carotid a.

Pectoralis major m.

Left subclavian a.

Pectoralis minor m. Right brachiocephalic v. Pulmonary a.

Pulmonary v. Pulmonary v.

Pulmonary vv.

Pulmonary a.

Pulmonary a.

Vertebral body

Trachea

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

29

Soft Tissue and Lung Axial 10

Right paratracheal lymph node Right internal mammary a. Superior vena cava

Sternum (joint between manubrium & body) Anterior mediastinum (residual thymus) Left internal mammary a. Aortic arch

Right upper lobe apical subsegmental bronchus Pectoralis major m. Pectoralis minor m.

Pulmonary v. Rib Axilla

Subscapularis m.

Serratus anterior m.

Latissimus dorsi m.

Infraspinatus m. Scapula Pulmonary vv. Rhomboid major m. Right oblique (major) fissure Pulmonary a. Trapezius m. Vertebral lamina



Scapula (body)

Trachea Esophagus

Left upper lobe apical-posterior subsegmental bronchus Pulmonary a. Left oblique (major) fissure

Erector spinae m. Spinal cord Vertebral body

DIAGNOSTIC CONSIDERATION At this level, in lung windows, a small apical-posterior segment left upper lobe bronchus and artery are visible adjacent to one another. This relationship aids in the identification of small, peripheral pulmonary vessels—arteries course adjacent to bronchi, whereas pulmonary veins course separately. Note this relationship on subsequent images and in the peripheral aspects of the lower lobes.

30

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Soft Tissue and Lung Axial 10

Right internal mammary a.

Sternum (joint between Right paratracheal manubrium & body) lymph node

Left internal mammary a.

Anterior mediastinum (residual thymus)

Pectoralis major m. Pectoralis minor m.

Aortic arch Axilla

Superior vena cava

Rib Trachea Serratus anterior m. Pulmonary v.

Latissimus dorsi m. Subscapularis m.

Infraspinatus m. Scapula (body) Scapula

Esophagus

Rhomboid Trapezius m. Vertebral major m. lamina

Spinal Erector cord spinae m.

Vertebral body

Pectoralis major m. Aortic arch Superior vena cava Right upper lobe apical subsegmental bronchus

Trachea Pulmonary v. Left upper lobe apicalposterior subsegmental bronchus

Pulmonary v.

Pulmonary a. Left oblique (major) fissure

Pulmonary a. Right oblique (major) fissure

Vertebral body

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

31

Soft Tissue and Lung Axial 11

Right internal mammary a. Superior vena cava Pulmonary v.

Sternum (body)

Right upper lobe apical subsegmental bronchi

Left internal mammary a. Aortic arch Left upper lobe apical-posterior subsegmental bronchus Pulmonary v.

Pectoralis major m.

Rib

Pectoralis minor m.

Serratus anterior m.

Subscapularis m.

Axilla

Latissimus dorsi m.

Infraspinatus m. Scapula (body)

Scapula Right oblique (major) fissure

Left upper lobe apical-posterior subsegmental bronchi Left oblique (major) fissure

Rhomboid major m. Right upper lobe apical subsegmental pulmonary aa.

Esophagus

Trapezius m. Vertebral lamina

32

Spinal cord

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Vertebral body

Pulmonary a. Trachea

Soft Tissue and Lung Axial 11

Superior Right internal Sternum Aortic vena cava mammary a. (body) arch

Right upper lobe apical subsegmental pulmonary aa.

Left internal mammary a. Pulmonary v.

Pectoralis major m. Pectoralis minor m.

Axilla Serratus anterior m.

Latissimus dorsi m. Subscapularis m.

Rib Pulmonary a.

Scapula

Scapula (body)

Infraspinatus m.

Trachea Pulmonary v.

Rhomboid major m.

Pulmonary v.

Trapezius m.

Superior vena cava

Vertebral lamina

Spinal cord

Vertebral body

Sternum Aortic (body) arch

Esophagus

Pulmonary v.

Pectoralis major m.

Right upper lobe apical subsegmental bronchi

Left upper lobe apicalposterior subsegmental bronchi Pulmonary a.

Right upper lobe apical subsegmental pulmonary aa. Right oblique (major) fissure

Trachea Vertebral body

Left oblique (major) fissure

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

33

Soft Tissue and Lung Axial 12

Right internal mammary a. & v. Superior vena cava Azygos v.

Ascending aorta Left internal mammary v. & a.

Sternum (body)

Aortic arch Left upper lobe apical-posterior subsegmental pulmonary aa.

Right upper lobe apical subsegmental bronchi Pectoralis major m. Pectoralis minor m.

Intercostal m. Serratus anterior m.

Subscapularis m. Latissimus dorsi m.

Scapula Infraspinatus m. Scapula Rib Right oblique (major) fissure Right upper lobe apical segment pulmonary a. Pulmonary v. Trapezius m.

34

Trachea Esophagus Erector spinae m. Vertebral body

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Left upper lobe apicalposterior subsegmental bronchi Pulmonary a. Left oblique (major) fissure Pulmonary v. Rhomboid major m. Descending thoracic aorta

Soft Tissue and Lung Axial 12

Superior vena cava

Right internal mammary a. & v.

Sternum (body)

Ascending aorta

Left internal mammary v. & a. Trachea Aortic arch

Pectoralis major m. Pectoralis minor m.

Left upper lobe apicalposterior subsegmental pulmonary aa.

Azygos v.

Intercostal m. Serratus anterior m.

Latissimus dorsi m.

Descending thoracic aorta

Subscapularis m.

Scapula

Infraspinatus m. Scapula

Pulmonary a. Right upper lobe apical segment pulmonary a.

Pulmonary v. Rib

Superior vena cava

Trapezius m.

Erector spinae m.

Sternum (body)

Vertebral body

Ascending aorta

Esophagus

Rhomboid major m.

Left internal mammary v. & a. Trachea Aortic arch

Pectoralis major m.

Azygos v. Right upper lobe apical subsegmental bronchi Left upper lobe apical-posterior subsegmental bronchi

Pulmonary a.

Right upper lobe apical subsegmental pulmonary artery Right oblique (major) fissure

Pulmonary v. Pulmonary v.

Vertebral body

Left oblique (major) fissure

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

35

Soft Tissue and Lung Axial 13

Right internal mammary a. & v. Superior vena cava

Sternum (body)

Azygos v. Right upper lobe apical subsegmental bronchi

Right paratracheal lymph node Left internal mammary v. & a. Ascending aorta Left upper lobe apical-posterior segment pulmonary a. Left upper lobe apicalposterior subsegmental bronchi

Pectoralis major m.

Intercostal m.

Subscapularis m.

Serratus anterior m.

Latissimus dorsi m.

Infraspinatus m.

Scapula Pulmonary v.

Scapula

Pulmonary a. Left oblique (major) fissure Rhomboid major m. Descending thoracic aorta Trachea

Rib Right oblique (major) fissure Right upper lobe apical segment pulmonary a. Pulmonary v. Trapezius m.

36

Erector spinae m.

Vertebral body

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Esophagus

Soft Tissue and Lung Axial 13

Superior vena cava

Right internal mammary a. & v.

Sternum (body)

Ascending aorta

Left internal Right paratracheal mammary v. & a. lymph node

Azygos v.

Trachea Descending thoracic aorta Left upper lobe apicalposterior segment pulmonary a. Intercostal m. Serratus anterior m.

Pectoralis major m.

Latissimus dorsi m. Subscapularis m. Rib Scapula

Scapula Infraspinatus m. Right upper lobe apical segment pulmonary a.

Pulmonary v. Pulmonary v. Trapezius m. Erector Vertebral Esophagus Rhomboid spinae m. body major m.

Superior vena cava

Sternum (body)

Ascending aorta

Pulmonary a.

Left internal mammary v. & a. Trachea

Azygos v.

Descending thoracic aorta Pectoralis major m.

Right upper lobe apical subsegmental bronchi

Right upper lobe apical segment pulmonary a.

Left upper lobe apicalposterior subsegmental bronchi

Pulmonary v. Right oblique (major) fissure

Pulmonary v. Vertebral body

Left oblique (major) fissure

Pulmonary a.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

37

Soft Tissue and Lung Axial 14

Ascending aorta Right internal mammary a. & v. Sternum (body) Superior vena cava Left internal mammary v. & a. Right paratracheal lymph node Right upper lobe apical subsegmental bronchi Main pulmonary a. Right upper lobe posterior segment pulmonary a.

Left upper lobe apicalposterior segment pulmonary a.

Pectoralis major m.

Pulmonary v.

Subscapularis m.

Serratus anterior m.

Latissimus dorsi m.

Scapula Infraspinatus m. Scapula Rib Right oblique (major) fissure Right upper lobe apical segment pulmonary a. Pulmonary v. Trapezius m. Azygos v.

38

Esophagus Erector spinae m. Vertebral body

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Left upper lobe apicalposterior subsegmental bronchi Left oblique (major) fissure Rhomboid major m. Pulmonary a. Descending thoracic aorta Trachea (carina)

Soft Tissue and Lung Axial 14

Superior vena cava

Right internal mammary a. & v.

Sternum (body)

Right Ascending paratracheal aorta lymph node

Left internal mammary v. & a.

Trachea (carina)

Main pulmonary a.

Pectoralis major m. Left upper lobe apicalposterior segment pulmonary a.

Right upper lobe posterior segment pulmonary a.

Serratus anterior m.

Latissimus dorsi m. Pulmonary v.

Subscapularis m. Scapula

Scapula

Infraspinatus m. Pulmonary a. Rib

Rhomboid major m. Pulmonary v. Azygos v. Erector Vertebral Trapezius m. spinae m. body

Superior vena cava

Sternum (body)

Ascending aorta

Esophagus

Descending thoracic aorta

Left internal mammary v. & a.

Trachea (carina)

Main pulmonary a.

Pectoralis major m. Pulmonary v.

Right upper lobe apical segment pulmonary a. Right upper lobe apical subsegmental bronchi

Left upper lobe apicalposterior subsegmental bronchi

Right upper lobe posterior segment pulmonary a.

Right oblique (major) fissure

Pulmonary a. Pulmonary v.

Azygos v.

Vertebral body

Descending thoracic aorta

Left oblique (major) fissure

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

39

Soft Tissue and Lung Axial 15

Ascending aorta Right internal mammary a. & v. Superior vena cava

Sternum (body)

Right upper lobe pulmonary a. (truncus anterior)

Anterior mediastinum (residual thymus) Left internal mammary v. & a. Main pulmonary a. Left pulmonary a. Pulmonary v. Left upper lobe apical-posterior segment pulmonary a. Serratus anterior m.

Pectoralis major m. Subscapularis m. Latissimus dorsi m.

Scapula Infraspinatus m. Scapula Right oblique (major) fissure Right upper lobe apical segment bronchus (B1)

Rib

Trapezius m. Esophagus Right mainstem bronchus Erector spinae m. Azygos v. Vertebral body



Left upper lobe apicalposterior subsegmental bronchi Left oblique (major) fissure Rhomboid major m. Pulmonary a. Descending thoracic aorta Left mainstem bronchus

DIAGNOSTIC CONSIDERATION The composition of the anterior mediastinum varies substantially with age. In younger patients (particularly infants and children), abundant soft tissue, representing thymus residing within anterior mediastinal fat, is often readily visible on thoracic CT. As individuals age, the thymus normally involutes and becomes more fatty replaced, and progressively less soft tissue is visible within the anterior mediastinal fat. The pace at which thymic involution occurs is variable, and a fairly wide variation in the appearance of “normal thymus” at various ages is recognized.

40

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Soft Tissue and Lung Axial 15

Right internal Left internal Anterior Ascending mammary Sternum mediastinum Main mammary aorta (body) (residual thymus) pulmonary a. a. & v. v. & a. Superior vena cava

Left pulmonary a.

Pectoralis major m. Pulmonary vv.

Right upper lobe pulmonary a. (truncus anterior)

Left upper lobe apicalposterior segment pulmonary a.

Right upper lobe apical segment bronchus (B1)

Serratus anterior m.

Latissimus dorsi m. Subscapularis m. Right mainstem bronchi

Scapula

Infraspinatus m. Scapula

Pulmonary a. Left mainstem bronchi

Rhomboid Azygos v. Rib Trapezius m. Erector Vertebral Esophagus Descending thoracic aorta major m. spinae m. body

Ascending aorta

Left internal Main mammary pulmonary a. v. & a.

Sternum (body)

Superior vena cava

Pulmonary vv.

Pectoralis major m. Right upper lobe pulmonary a. (truncus anterior) Right upper lobe apical segment bronchus (B1)

Left upper lobe apicalposterior subsegmental bronchi

Right mainstem bronchus

Pulmonary a. Left mainstem bronchus Right oblique (major) fissure

Left oblique (major) fissure Azygos v.

Vertebral body

Esophagus

Descending thoracic aorta

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

41

Soft Tissue and Lung Axial 16 Right internal mammary a. Superior vena cava Right upper lobe pulmonary a. (truncus anterior)

Sternum (body)

Ascending aorta Left internal mammary v. & a. Main pulmonary a. Pulmonary vv. Left upper lobe apical-posterior segment pulmonary a.

Pectoralis major m. Right upper lobe anterior segment bronchus (B3)

Serratus anterior m.

Subscapularis m. Latissimus dorsi m.

Scapula Rhomboid major m.

Infraspinatus m. Scapula Right oblique (major) fissure Right upper lobe posterior segment bronchus (B2) Right upper lobe bronchus Rib Trapezius m. Esophagus Right mainstem bronchus Erector spinae m. Azygos v. Vertebral body



Left upper lobe apicalposterior subsegmental bronchi Left oblique (major) fissure Pulmonary a. Left pulmonary a. Descending thoracic aorta Left mainstem bronchus

NORMAL ANATOMY At this level, the segmental bronchi within the right upper lobe are now visible. Segmental bronchi are commonly named for the anatomic segment they supply (e.g., apical segment right upper lobe bronchus). Another nomenclature system for segmental bronchi may occasionally be encountered, as described by the Federative Committee on Anatomical Terminology in Terminologia Anatomica. This terminology identifies the segmental bronchi according to numbers (e.g., B1 = apical segment right upper lobe bronchus, B1+2 = apical-posterior segment left upper lobe bronchus; see Axial 19). Both nomenclature systems are illustrated in this text.



NORMAL VARIANT A number of variations in the branching pattern of the pulmonary arteries are recognized. In particular, variations in the branching pattern of the left upper lobe pulmonary artery are commonly encountered in clinical practice. In the most common pattern, the left upper lobe pulmonary artery gives rise to apical-posterior and anterior segmental branches in a manner analogous to the bronchial branching pattern. Less commonly, as in this patient, a posterior left upper lobe subsegmental artery arises directly from the left pulmonary artery. The left upper lobe pulmo� nary artery can be seen originating from the left pulmonary artery on Axials 17 and 18.

42

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Soft Tissue and Lung Axial 16

Superior Right internal Sternum Ascending Left internal vena cava mammary a. & v. (body) aorta mammary a.

Left mainstem bronchus Left pulmonary a.

Pectoralis major m.

Pulmonary vv.

Right upper lobe pulmonary a. (truncus anterior)

Left upper lobe apicalposterior segment pulmonary a.

Right upper lobe bronchus

Serratus anterior m. Latissimus dorsi m. Subscapularis m. Scapula

Scapula

Infraspinatus m.

Pulmonary a.

Right mainstem bronchus

Rhomboid major m. Rib

Azygos v. Trapezius m. Erector Vertebral Esophagus Descending spinae m. body thoracic aorta

Superior vena cava

Sternum Ascending Left internal Main (body) aorta mammary v. & a. pulmonary a.

Pectoralis major m.

Left pulmonary a.

Right upper lobe pulmonary a. (truncus anterior) Right upper lobe anterior segment bronchus (B3)

Pulmonary vv.

Right upper lobe posterior segment bronchus (B2) Left upper lobe apicalposterior subsegmental bronchi

Right upper lobe apical segment bronchus (B1) Left mainstem bronchus Right oblique (major) fissure Right mainstem bronchus

Left oblique (major) fissure Azygos v.

Vertebral Esophagus Descending body thoracic aorta

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

43

Soft Tissue and Lung Axial 17

Right internal mammary a. Superior vena cava Right upper lobe pulmonary a. (truncus anterior) Right upper lobe anterior segment pulmonary a. Pectoralis major m. Right upper lobe anterior segment bronchus (B3) Subscapularis m.

Sternum (body) Ascending aorta Left internal mammary v. & a. Main pulmonary a. Pulmonary v. Left upper lobe pulmonary a. Lymph node Left upper lobe apical-posterior subsegmental bronchi Serratus anterior m.

Latissimus dorsi m.

Infraspinatus m. Scapula Right oblique (major) fissure Right lower lobe superior segment Right upper lobe posterior segment bronchus (B2) Rib Right upper lobe bronchus Trapezius m. Right mainstem bronchus Erector spinae m.



Scapula Rhomboid major m. Left oblique (major) fissure Left pulmonary a. Left lower lobe superior segment Esophagus Azygos v.

Left mainstem bronchus Descending thoracic aorta

Vertebral body

DIAGNOSTIC CONSIDERATION The artery supplying the right upper lobe is visible. This vessel is usually simply referred to as “the right upper lobe pulmonary artery”; however, the term truncus anterior is occasionally used as well and is equivalent in meaning.

44

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Soft Tissue and Lung Axial 17

Pectoralis major m.

Superior Right vena internal Sternum Ascending Left internal aorta mammary a. cava mammary a. (body) Left mainstem bronchus

Right upper lobe anterior segment pulmonary a.

Pulmonary v.

Right upper lobe pulmonary a. (truncus anterior)

Left upper lobe pulmonary a. Lymph node Serratus anterior m.

Latissimus dorsi m. Subscapularis m.

Left pulmonary a.

Right upper lobe bronchus

Descending thoracic aorta

Scapula Infraspinatus m.

Scapula

Right mainstem bronchus Rib

Azygos v. Trapezius m.

Pectoralis major m.

Superior vena cava

Erector Vertebral Esophagus spinae m. body

Sternum Ascending Left internal (body) aorta mammary v. & a.

Right upper lobe anterior segment pulmonary a.

Rhomboid major m.

Main pulmonary a. Left mainstem bronchus Pulmonary v.

Right upper lobe pulmonary a. (truncus anterior) Right upper lobe anterior segment bronchus (B3)

Left upper lobe apicalposterior subsegmental bronchi

Right upper lobe posterior segment bronchus (B2)

Right upper lobe bronchus

Left pulmonary a. Descending thoracic aorta

Right oblique (major) fissure

RIght lower lobe superior segment

Left oblique (major) fissure

Azygos v.

Vertebral body

Esophagus

Left lower lobe superior segment

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

45

Soft Tissue and Lung Axial 18

Right internal mammary a. & v. Superior vena cava Right upper lobe anterior segment pulmonary a. Right upper lobe pulmonary a. (truncus anterior)

Sternum (body)

Ascending aorta Left internal mammary v. & a. Main pulmonary a. Pulmonary v. Left upper lobe pulmonary a.

Pectoralis major m. Right upper lobe anterior segment bronchus (B3)

Lymph node

Subscapularis m.

Serratus anterior m.

Latissimus dorsi m.

Scapula

Infraspinatus m. Right oblique (major) fissure Right hilar lymph node Right upper lobe bronchus Right mainstem bronchus Rib Right pulmonary a. Trapezius m. Erector spinae m.

46

Rhomboid major m.

Esophagus Azygos v.

Vertebral body

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Left upper lobe apicalposterior subsegmental bronchi Left oblique (major) fissure Left pulmonary a. Left mainstem bronchus Descending thoracic aorta

Soft Tissue and Lung Axial 18

Pectoralis major m.

Superior Right Sternum vena internal cava mammary a. (body)

Ascending aorta

Left internal mammary a.

Main pulmonary a. Pulmonary vein

Left upper lobe pulmonary a. Right upper lobe pulmonary a. (truncus anterior)

Serratus anterior m.

Latissimus dorsi m. Right hilar lymph node Subscapularis m.

Scapula

Infraspinatus m. Left interlobar pulmonary artery Right upper lobe bronchus

Left mainstem bronchus

Right mainstem bronchus

Rhomboid major m. Rib

Pectoralis major m.

Azygos v. Trapezius m. Erector Vertebral spinae m. body

Superior vena cava

Sternum (body)

Ascending aorta

Esophagus Descending thoracic aorta

Left internal mammary v. & a.

Main pulmonary a. Pulmonary v.

Right upper lobe anterior segmental pulmonary a. Right upper lobe anterior segment bronchus (B3) Right upper lobe pulmonary a. (truncus anterior) Left upper lobe apicalposterior subsegmental bronchi Right oblique (major) fissure

Left pulmonary a.

Left mainstem bronchus Left oblique (major) fissure

Right pulmonary a. Azygos v.

Vertebral body

Esophagus Descending thoracic aorta

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

47

Soft Tissue and Lung Axial 19

Right internal mammary a. & v. Superior vena cava

Sternum (body)

Nipple Pectoralis major m. Right upper lobe anterior subsegmental pulmonary a.

Ascending aorta Left internal mammary v. & a. Main pulmonary a. Pulmonary v. Left upper lobe anterior segment pulmonary a. Left upper lobe pulmonary a.

Subscapularis m.

Serratus anterior m.

Latissimus dorsi m.

Scapula Infraspinatus m. Right oblique (major) fissure

Rhomboid major m. Left upper lobe apicalposterior segment bronchus (B12) Left oblique (major) fissure

Rib

Lymph node Bronchus intermedius Right pulmonary a. Trapezius m. Erector spinae m.

48

Esophagus Azygos v.

Vertebral body

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Left interlobar pulmonary a. Left mainstem bronchus Descending thoracic aorta

Soft Tissue and Lung Axial 19

Nipple

Right internal mammary a.

Sternum (body)

Ascending aorta

Left internal mammary a.

Main pulmonary a.

Pectoralis major m.

Pulmonary v. Left upper lobe pulmonary a.

Superior vena cava Serratus anterior m.

Lymph node Latissimus dorsi m. Subscapularis m.

Scapula

Right pulmonary a.

Left interlobar pulmonary artery

Infraspinatus m.

Rhomboid major m. Bronchus intermedius

Left mainstem bronchus Rib

Trapezius m.

Erector Azygos v. Vertebral body spinae m.

Sternum (body)

Ascending aorta

Esophagus

Left internal mammary v. & a.

Descending thoracic aorta

Main pulmonary a.

Pectoralis major m.

Pulmonary v.

Left upper lobe anterior segment pulmonary a.

Superior vena cava

Left upper lobe apicalposterior segment bronchus (B12)

Right pulmonary artery

Left interlobar pulmonary a. Left oblique (major) fissure

Right oblique (major) fissure Bronchus intermedius

Left mainstem bronchus Azygos v.

Vertebral body

Esophagus

Descending thoracic aorta

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

49

Soft Tissue and Lung Axial 20

Right internal mammary a. & v.

Sternum (body)

Right atrial appendage Pectoralis major m. Superior vena cava Right pulmonary a.

Ascending aorta Left internal mammary v. & a. Main pulmonary a. Left atrial appendage Pulmonary v. Left upper lobe anterior segment bronchus (B3) Left upper lobe anterior segment pulmonary a.

Pulmonary vv. Subscapularis m.

Serratus anterior m.

Latissimus dorsi m.

Scapula Infraspinatus m. Right oblique (major) fissure

Rhomboid major m. Left oblique (major) fissure

Rib

Lymph node Bronchus intermedius Subcarinal lymph node Trapezius m. Erector spinae m. Azygos v.



Left upper lobe apical-posterior segment bronchus (B12) Left interlobar pulmonary a. Esophagus Left mainstem bronchus Descending thoracic aorta Vertebral body

NORMAL ANATOMY On this and a number of cranially and caudally located images displayed in lung windows, the oblique fissures are visible as thin, hypovascular planes extending transversely across the lungs bilaterally. The oblique fissures sweep anteriorly from the posterior toward the anterior chest wall. The oblique fissures are also often commonly referred to as the major fissures.

50

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Soft Tissue and Lung Axial 20

Pectoralis major m.

Right internal mammary Sternum Ascending (body) aorta a. & v.

Left internal mammary v. & a.

Main pulmonary a. Left atrial appendage

Right atrial appendage Superior vena cava Right pulmonary a.

Left upper lobe anterior segment pulmonary a. Serratus anterior m.

Latissimus dorsi m.

Pulmonary v.

Subscapularis m. Lymph node

Scapula

Infraspinatus m.

Left interlobar pulmonary artery

Bronchus intermedius

Rhomboid major m.

Rib

Left mainstem bronchus Subcarinal lymph node

Pectoralis major m.

Trapezius m. Erector Azygos v. Vertebral Esophagus Descending body thoracic aorta spinae m.

Sternum (body)

Ascending aorta

Left internal mammary v. & a.

Main pulmonary a.

Right atrial appendage

Left upper lobe anterior segment bronchus (B3)

Superior vena cava Right pulmonary artery

Left upper lobe anterior segment pulmonary a.

Pulmonary vv. Pulmonary v. Left upper lobe apicalposterior segment bronchus (B12) Left interlobar pulmonary a. Left oblique (major) fissure Bronchus intermedius Left mainstem bronchus Azygos v.

Vertebral body

Esophagus Descending thoracic aorta

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

51

Soft Tissue and Lung Axial 21

Ascending aorta Right internal mammary a. & v. Right atrial appendage

Sternum (body)

Superior vena cava Pulmonary vv. Pectoralis major m.

Left internal mammary v. & a. Main pulmonary a. Left atrial appendage Left superior pulmonary v. Left upper lobe bronchus Left upper lobe anterior segment bronchus (B3)

Right horizontal (minor) fissure

Serratus anterior m. Latissimus dorsi m.

Scapula

Right oblique (major) fissure

Rhomboid major m.

Right interlobar pulmonary a.

Left oblique (major) fissure

Bronchus intermedius Subcarinal lymph node

Left interlobar pulmonary a. Descending thoracic aorta

Rib

Right pulmonary a.

Esophagus

Trapezius m. Erector spinae m.



Azygos v.

Intercostal a. Vertebral body

NORMAL ANATOMY In lung windows, the horizontal fissure is visible on the right as a hypovascular area anteriorly. The horizontal fissure separates the right upper and middle lobes, and is also commonly referred to as the minor fissure.

52

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Soft Tissue and Lung Axial 21

Left internal Pectoralis Right atrial Right internal Sternum Ascending mammary Main v. & a. major m. appendage mammary a. (body) aorta pulmonary a. Superior vena cava

Left atrial appendage

Pulmonary vv. Left superior pulmonary v. Left upper lobe bronchus Serratus anterior m. Latissimus dorsi m.

Left interlobar pulmonary a.

Right interlobar pulmonary a.

Scapula

Rhomboid major m.

Bronchus intermedius

Subcarinal lymph node

Esophagus Rib

Trapezius m. Erector Azygos v. Vertebral Intercostal a. Descending thoracic aorta spinae m. body

Pectoralis Right atrial major m. appendage

Left internal Sternum Ascending mammary Main v. & a. (body) aorta pulmonary a.

Superior vena cava

Left atrial appendage Left upper lobe anterior segment bronchus (B3)

Pulmonary v.

Left superior pulmonary v. Right horizontal (minor) fissure

Left upper lobe bronchus

Right interlobar pulmonary a.

Left interlobar pulmonary a.

Right oblique (major) fissure

Left oblique (major) fissure

Bronchus intermedius

Esophagus Azygos v.

Vertebral body

Descending thoracic aorta

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

53

Soft Tissue and Lung Axial 22

Right atrial appendage

Sternum (body)

Right internal mammary a. & v. Superior vena cava Pulmonary vv. Pectoralis major m. Right horizontal (minor) fissure

Ascending aorta Left internal mammary v. & a. Main pulmonary a. Left main coronary a. Left atrial appendage Left superior pulmonary v. Left upper lobe bronchus Left upper lobe anterior segment bronchus (B3)

Serratus anterior m.

Latissimus dorsi m.

Scapula

Scapula Right oblique (major) fissure

Rhomboid major m.

Bronchus intermedius Right interlobar pulmonary a.

Left oblique (major) fissure Rib

Azygoesophageal recess lymph node Trapezius m. Esophagus Erector spinae m. Azygos v. Spinal cord Vertebral body

54

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Left interlobar pulmonary a. Left lower lobe superior segment pulmonary a. Descending thoracic aorta Intercostal a.

Soft Tissue and Lung Axial 22

Right atrial appendage

Right internal Sternum Ascending Left internal mammary a. (body) mammary a. aorta

Main pulmonary a.

Pectoralis major m.

Left main coronary a.

Superior vena cava

Left atrial appendage Left superior pulmonary v.

Pulmonary v. Left upper lobe bronchus

Right interlobar pulmonary a. Latissimus dorsi m.

Serratus anterior m. Left interlobar pulmonary a. Scapula

Scapula Bronchus intermedius

Left lower lobe superior segment pulmonary a.

Azygoesophageal recess lymph node

Rhomboid major m. Azygos v.

Esophagus Rib

Right atrial appendage

Trapezius m. Erector Spinal Vertebral Intercostal a. Descending spinae m. cord thoracic aorta body

Sternum Ascending Left internal (body) mammary a. aorta

Main pulmonary a.

Pectoralis major m.

Left atrial appendage Left superior pulmonary v.

Superior vena cava

Left upper lobe anterior segment bronchus (B3)

Pulmonary v. Right horizontal (minor) fissure Right interlobar pulmonary a.

Left upper lobe bronchus

Left interlobar pulmonary a. Right oblique (major) fissure Left oblique (major) fissure

Bronchus intermedius

Left lower lobe superior segment pulmonary a.

Azygos v. Vertebral body

Descending thoracic aorta

Esophagus

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

55

Soft Tissue and Lung Axial 23

Right atrial appendage Sternum (body) Right internal mammary a. & v. Superior vena cava Right superior pulmonary v.

Aortic root: left sinus of Valsalva Left internal mammary v. & a. Right ventricular outflow tract

Right interlobar pulmonary a. Right middle lobe pulmonary a.

Left circumflex coronary a. Left anterior descending coronary a. Left atrial appendage Left superior pulmonary v.

Pectoralis major m.

Pulmonary v.

Right lower lobe pulmonary a.

Serratus anterior m.

Latissimus dorsi m.

Scapula Scapula Right oblique (major) fissure

Rhomboid major m. Left oblique (major) fissure

Rib

Lymph node

Right lower lobe superior segment pulmonary aa. (branches) Bronchus intermedius Trapezius m. Erector spinae m. Azygos v. Spinal cord



Lingular bronchus Left interlobar pulmonary a. Esophagus

Left lower lobe bronchus Descending thoracic aorta

Vertebral body

DIAGNOSTIC CONSIDERATION At this level, the sinuses of Valsalva are now visible. The sinuses of Valsalva are three areas of mild dilation of the aortic root located between the aortic valve annulus and sinotubular junction. Each sinus of Valsalva is associated with its corresponding aortic valve cusp. Occasionally abnormal enlargement of one of the sinuses of Valsalva may be encountered, representing a sinus of Valsalva aneurysm. Aneurysms of the sinus of Valsalva require attention because they may result in rupture—a potentially catastrophic event.

56

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Soft Tissue and Lung Axial 23

Aortic root: Superior Right atrial Right internal Sternum left sinus Left internal Right ventricular vena cava appendage mammary a. (body) of Valsalva mammary a. outflow tract Left anterior descending coronary a.

Pectoralis major m. Right superior pulmonary v.

Left circumflex coronary a. Left atrial appendage

Right middle lobe pulmonary a.

Left superior pulmonary v.

Right interlobar pulmonary a.

Lingular bronchus Serratus anterior m.

Right lower lobe pulmonary a.

Lymph node

Bronchus intermedius Scapula Left lower lobe bronchus Left interlobar pulmonary a.

Right lower lobe superior segment pulmonary a.

Rhomboid major m. Rib Trapezius m. Erector Azygos v. Spinal Vertebral Descending Esophagus cord body thoracic aorta spinae m.

Superior Right atrial vena cava appendage

Sternum Ascending Left internal Right ventricular aorta (body) mammary a. outflow tract

Pectoralis major m. Right superior pulmonary v. Left atrial appendage Left superior pulmonary v. Pulmonary v. Lingular bronchus

Bronchus intermedius

Right oblique (major) fissure

Left oblique (major) fissure Left lower lobe bronchus Left interlobar pulmonary a.

Right lower lobe superior segment pulmonary a. Azygos v.

Vertebral body

Descending Esophagus thoracic aorta

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

57

Soft Tissue and Lung Axial 24 Right coronary a. Right internal mammary a. & v. Right atrial appendage Superior vena cava Right superior pulmonary v. Right middle lobe bronchus Pectoralis major m. Right middle lobe pulmonary a.

Aortic root: non-coronary & left sinuses of Valsalva Left internal mammary v. & a. Right ventricular outflow tract Sternum (body) Left atrium Left circumflex coronary a. Left superior pulmonary v. Left anterior descending coronary a. Anterior interventricular v. Left atrial appendage Pulmonary v. Lingular bronchus Serratus anterior m.

Latissimus dorsi m.

Scapula

Scapula Right oblique (major) fissure Rib Right lower lobe basal trunk pulmonary a. Right lower lobe superior segment bronchus (B6) Right lower lobe bronchus Trapezius m. Azygoesophageal recess

Rhomboid major m. Left oblique (major) fissure Lingular pulmonary a. Lower lobe pulmonary aa. Left lower lobe bronchus Esophagus

Erector spinae m.

Left lower lobe superior segment bronchus (B6) Descending thoracic aorta

Azygos v. Spinal cord Vertebral body



DIAGNOSTIC CONSIDERATION The azygoesophageal recess is the region of the retocardiac mediastinum outlined by the right lower lobe, extending from the arch of the azygos vein to the diaphragm. This space is an important area because various types of pathology, including mediastinal masses and lymphadenopathy, may occur in this area.



NORMAL ANATOMY The undivided lower lobe bronchi are short structures giving rise to the superior segment bronchi (B6) of the lower lobes; these airways are readily visible in lung windows. Inferior to the superior segmental bronchi, the lower lobe airways continue as lower lobe bronchial trunks but are also sometimes referred to as truncus basalis. Bilaterally, the basal bronchial trunks give rise to the basal segmental bronchi.

58

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Soft Tissue and Lung Axial 24

Right atrial Right appendage coronary a.

Right Left Right Aortic root: internal non-coronary internal ventricular mammary Sternum & left sinuses mammary outflow Left a. a. (body) tract of Valsalva atrium

Pectoralis major m. Superior vena cava

Left anterior descending coronary a. Anterior interventricular v.

Right superior pulmonary v.

Left circumflex coronary a. Left atrial appendage

Right middle lobe pulmonary a.

Left superior pulmonary v.

Right middle & lower lobe bronchi Right lower lobe basal trunk pulmonary a.

Serratus anterior m.

Latissimus dorsi m.

Lingular pulmonary a. Scapula Left lower pulmonary aa. Rhomboid major m. Left lower lobe bronchus

Azygoesophageal recess Rib

Right atrial appendage

Azygos v. Trapezius m. Erector Spinal Vertebral Descending spinae m. cord body thoracic aorta

Sternum (body)

Left internal Ascending mammary a. aorta

Esophagus

Right ventricular outflow Left tract atrium

Pectoralis major m. Superior vena cava Right superior pulmonary v.

Pulmonary v.

Right middle lobe pulmonary a.

Left superior pulmonary v. Lingular bronchus

Right lower lobe basal trunk pulmonary a.

Lingular pulmonary a. Left lower lobe pulmonary a.

Right oblique (major) fissure Right middle lobe bronchus

Left oblique (major) fissure

Right lower lobe bronchus

Left lower lobe bronchus Right lower lobe superior segment bronchus (B6) Azygos v.

Vertebral body

Descending Esophagus thoracic aorta

Left lower lobe superior segment bronchus (B6)

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

59

Soft Tissue and Lung Axial 25 Right coronary a. Right internal mammary a. & v. Sternum (body) Right atrial appendage Superior vena cava Right superior pulmonary v. Right middle lobe bronchus Right middle lobe pulmonary a. Right middle lobe lateral & medial segment bronchi (B45) Pectoralis major m.

Aortic root: non-coronary & right sinuses of Valsalva Left internal mammary v. & a. Right ventricular outflow tract Left atrium Left circumflex coronary a. Left anterior descending coronary a. Anterior interventricular v. Pulmonary v. Lingular bronchus Lingular pulmonary a., superior segment Serratus anterior m.

Latissimus dorsi m.

Scapula Scapula Right oblique Rhomboid major m. (major) fissure Rib Left oblique (major) fissure Right lower lobe basal trunk pulmonary a. Lingular pulmonary a., inferior segment Right lower lobe bronchus Lower lobe anteromedial basal Right lower lobe superior segment pulmonary a. segment bronchus (B6) Lower lobe posterior basal segment pulmonary a. Azygoesophageal recess Left lower basal bronchial trunk Esophagus Trapezius m. Superior segment left lower lobe bronchus (B6) Erector spinae m. Descending thoracic aorta Azygos v. Spinal cord Vertebral body



NORMAL VARIANTS This level marks the origin of the left lower lobe segmental pulmonary arteries. Typically the left basal arterial trunk, inferior to the superior segmental left lower lobe pulmonary artery, branches into the anteromedial basal, lateral basal, and posterior basal segmental pulmonary arteries. In this patient, two, instead of three, basal segmental left lower lobe pulmonary arteries are visible. These vessels can be sequentially followed through Axial 29. On Axial 30, the lateral basal segmental lower lobe pulmonary artery is seen originating from the anteromedial basal segmental vessel. Although this pattern of segmental pulmonary arterial branching is uncommon, variations in the branching patterns of the pulmonary arteries are frequently encountered and usually of no clinical importance.

60

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Soft Tissue and Lung Axial 25

Right atrial appendage

Right Aortic root: Left Right internal non-coronary internal ventricular Left anterior Right mammary Sternum & right sinuses mammary outflow Left descending coronary a. a. (body) of Valsalva a. tract atrium coronary a.

Pectoralis major m. Superior vena cava Right superior pulmonary v.

Anterior interventricular v. Left circumflex coronary a.

Right middle lobe pulmonary a. Serratus anterior m. Right middle bronchus

Lingular pulmonary aa., superior & inferior segments

Latissimus dorsi m.

Lower lobe anteromedial basal segment pulmonary a.

Scapula Right lower lobe basal trunk pulmonary a.

Left lower lobe posterior basal segment pulmonary a.

Right lower lobe bronchus

Left lower basal bronchial trunk

Azygoesophageal recess Rib

Right atrial appendage

Azygos v. Trapezius m. Erector Spinal Vertebral Descending Esophagus spinae m. cord body thoracic aorta

Right coronary a.

Sternum (body)

Left internal Ascending mammary aorta a.

Right ventricular outflow Left tract atrium

Pectoralis major m. Superior vena cava Right superior pulmonary v.

Pulmonary v.

Right middle lobe pulmonary a. Right middle lobe lateral & medial segment bronchi (B45)

Lingular bronchus

Right middle lobe bronchus

Lingular pulmonary aa.

Lower lobe anteromedial basal segment pulmonary a. Left lower lobe bronchus

Right lower lobe basal trunk pulmonary a. Right lower lobe bronchus Right lower lobe superior segment bronchus (B6)

Left lower lobe posterior basal segment pulmonary a. Azygos v.

Vertebral body

Descending Esophagus thoracic aorta

Left lower lobe superior segment bronchus (B6)

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

61

Soft Tissue and Lung Axial 26

Pericardium Right coronary a. Sternum (body) Right internal mammary a. & v. Right atrium Crista terminalis Right superior pulmonary v. Pectoralis major m. Right middle lobe pulmonary a., lateral & medial segments Right middle lobe lateral & medial segment bronchi (B45)

Aortic root: right & non-coronary sinuses of Valsalva Left internal mammary v. & a. Right ventricular outflow tract Left circumflex & obtuse marginal coronary aa. Left anterior descending coronary a. Diagonal coronary a. Lingular bronchus Lingular pulmonary a., inferior segment Lingular pulmonary a., superior segment Serratus anterior m.

Latissimus dorsi m.

Scapula

Scapula Right oblique (major) fissure Rib Right lower lobe medial basal segment pulmonary a. Right lower lobe basal trunk pulmonary a. Right lower lobe basal trunk bronchus

Left oblique (major) fissure Lower lobe anteromedial basal segment pulmonary a. Lower lobe posterior basal segment pulmonary a. Left lower lobe basal trunk bronchus Spinal cord

Right lower lobe medial basal segment bronchus (B7) Trapezius m. Erector spinae m. Azygos v.

62

Esophagus Vertebral body

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Pulmonary v. Left atrium Descending thoracic aorta

Soft Tissue and Lung Axial 26

Left Right Right internal Right internal coronary Sternum mammary atrium mammary a. a. a. (body) Pericardium

Crista terminalis

Right ventricular outflow tract

Aortic root: non-coronary & right sinuses of Valsalva Left anterior descending coronary a. Diagonal coronary a.

Right middle lobe pulmonary a., lateral & medial segments

Left circumflex & obtuse marginal coronary aa. Lingular pulmonary aa., inferior and superior segments

Right superior pulmonary v.

Latissimus dorsi m. Right lower lobe medial basal segment pulmonary a.

Left lower lobe anteromedial basal segment pulmonary a.

Scapula

Left lower basal bronchial trunk Left lower lobe posterior basal segment pulmonary a. Rib

Left inferior pulmonary v. Azygos v. Trapezius m.

Pectoralis major m.

Right atrium

Erector Spinal spinae m. cord

Right Sternum coronary a. (body)

Esophagus

Pulmonary v. Descending Left thoracic aorta atrium Left internal mammary a.

Right ventricular outflow Ascending tract aorta

Right middle lobe lateral & medial segment pulmonary aa. Right middle lobe lateral & medial segment bronchi (B45)

Lingular bronchus

Right oblique (major) fissure

Lingular pulmonary a. Left oblique (major) fissure Left lower lobe anteromedial basal segment pulmonary a.

Right superior pulmonary v. Right lower lobe basal trunk pulmonary a.

Left lower lobe basal trunk bronchus

Right lower lobe basal trunk bronchus

Right lower lobe medial basal segment bronchus (B7)

Left lower lobe posterior basal segment pulmonary a. Azygos v.

Vertebral Esophagus Descending Left thoracic aorta atrium body NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

63

Soft Tissue and Lung Axial 27 Right coronary a. Pectoralis major m. Sternum (body) Right ventricle Right internal mammary a. Left internal mammary a. Right atrium Moderator band Crista terminalis Left circumflex & obtuse Right middle lobe medial marginal coronary aa. segment bronchus (B4) Left anterior descending coronary a. Right middle lobe Diagonal coronary a. pulmonary a., Lingular v. lateral & medial segments Lingular Right oblique pulmonary a. (major) fissure Serratus Latissimus anterior m. dorsi m.

Rib Left oblique (major) fissure

Right middle lobe lateral segment bronchus (B5)

Left lower lobe anteromedial basal segment pulmonary a. Left lower lobe posterior basal segment pulmonary a. Left lower lobe basal trunk bronchus Left inferior pulmonary v. Esophagus Left atrium Descending thoracic aorta

Right lower lobe anterior basal segment pulmonary a. Right lower lobe posterolateral basal trunk pulmonary a. Right lower lobe medial basal segment pulmonary a. Azygos v. Right lower lobe medial basal segment bronchus (B7) Spinal cord Erector spinae m. Vertebral body Trapezius m.



NORMAL VARIANTS As previously noted, pulmonary artery branching variations are common. In the right lower lobe, the right lower lobe basal arterial trunk usually gives rise first to the medial basal segmental right lower lobe pulmonary artery, followed by a trifurcation into anterior, lateral, and posterior basal segmental arteries. In this patient, however, the medial basal segmental vessel originates first, followed by the anterior basal segmental artery; the lateral and posterior basal segmental vessels remain briefly combined in a posterolateral basal pulmonary arterial trunk. The right lower lobe posterolateral basal trunk pulmonary artery subsequently bifurcates into lateral and posterior basal segmental pulmonary arteries. This variant branching pattern is probably the most commonly encountered variant arterial branching pattern affecting the lower lobe pulmonary arteries, and is of no clinical significance.

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NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Soft Tissue and Lung Axial 27

Right atrium

Right internal mammary a.

Sternum Left internal Pectoralis Right major m. coronary a. (body) mammary a.

Right Moderator ventricle band

Crista terminalis

Left anterior descending coronary a. Diagonal coronary a.

Right middle lobe lateral & medial segment pulmonary aa.

Left circumflex & obtuse marginal coronary aa.

Serratus anterior m.

Latissimus dorsi m. Right lower lobe medial basal segment pulmonary a.

Left lower lobe anteromedial basal segment pulmonary a.

Right lower lobe anterior basal segment pulmonary a.

Left lower lobe basal trunk bronchus Left lower lobe posterior basal segment pulmonary a.

Rib

Left inferior pulmonary v. Right lower lobe posterolateral basal trunk pulmonary a.

Right atrium

Azygos v. Erector Trapezius m. spinae m.

Pectoralis major m.

Spinal cord

Descending thoracic aorta

Esophagus

Left atrium

Right Sternum Left internal Right coronary a. (body) mammary a. ventricle

Right middle lobe medial segment bronchus (B4) Right middle lobe lateral & medial segment pulmonary aa.

Lingular v.

Right middle lobe lateral segment bronchus (B5)

Lingular pulmonary a.

Right oblique (major) fissure Left oblique (major) fissure

Right lower lobe medial basal segment pulmonary a.

Left lower lobe anteromedial basal segment pulmonary a.

Right lower lobe anterior basal segment pulmonary a.

Left lower lobe basal trunk bronchus

Right lower lobe medial basal segment bronchus (B7)

Left lower lobe posterior basal segment pulmonary a. Left inferior pulmonary v.

Right lower lobe lateral & posterior basal segment pulmonary aa.

Azygos v.

Vertebral Descending thoracic aorta body

Esophagus

Left atrium

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65

Soft Tissue and Lung Axial 28

Right atrium Right internal mammary a. Pectoralis major m. Crista terminalis Right lower lobe medial basal segment pulmonary a. Right middle lobe subsegmental bronchi Right middle lobe pulmonary a., lateral & medial segments

Right coronary a. Right ventricle Sternum (body)

Right oblique (major) fissure

Latissimus dorsi m.

Left internal mammary a. Moderator band Coronary aa. Left anterior descending coronary a. Lingular pulmonary a. Lingular v. Left oblique (major) fissure Serratus anterior m.

Left lower lobe anteromedial basal segment Right lower lobe anterior pulmonary a. basal segment pulmonary a. Left lower lobe anteromedial & bronchus (B8) (B7+8), lateral (B9), & posterior Right lower lobe lateral & posterior (B10) basal segment bronchi basal segment pulmonary aa. Left lower lobe posterior basal Right lower lobe posterolateral segment pulmonary a. basal bronchial trunk Left inferior pulmonary v. Right lower lobe medial basal Great cardiac v. Trapezius m. Esophagus segment bronchus (B7) Left atrium Erector spinae m. Spinal cord Azygos v. Descending thoracic aorta Right inferior pulmonary v. Vertebral body

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NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Soft Tissue and Lung Axial 28

Left Right Left anterior Right internal internal Moderator descending Crista Right coronary mammary Pectoralis Sternum mammary Right coronary a. a. a. major m. (body) ventricle band terminalis atrium a. Coronary aa. Right middle lobe medial & lateral segment pulmonary aa.

Great cardiac v.

Right lower lobe medial basal segment pulmonary a.

Left inferior pulmonary v. Serratus anterior m.

Right lower lobe anterior basal segment pulmonary a.

Left lower lobe anteromedial basal segment pulmonary a.

Latissimus dorsi m.

Right lower lobe lateral & posterior basal segment pulmonary aa.

Left lower lobe posterior basal segment pulmonary a. Right inferior Erector Trapezius Spinal Vertebral Azygos Descending Esophagus Left atrium cord pulmonary v. spinae m. m. v. thoracic body aorta

Right atrium

Right coronary a.

Right middle lobe lateral & medial segment pulmonary aa.

Sternum (body)

Left internal mammary a.

Right ventricle Lingular v. Lingular pulmonary a.

Right middle lobe subsegmental bronchi Right oblique (major) fissure Right lower lobe medial basal segment pulmonary a.

Left inferior pulmonary v. Left oblique (major) fissure

Right lower lobe anterior basal segment pulmonary a. & bronchus (B8)

Left lower lobe anteromedial basal segment pulmonary a. Left lower lobe anteromedial (B7+8), lateral (B9), & posterior (B10) basal segment bronchi

Right lower lobe lateral & posterior basal segment pulmonary aa.

Left lower lobe posterior basal segment pulmonary a. Right lower lobe posterolateral basal bronchial trunk

Vertebral Azygos v. Descending Esophagus Left atrium body thoracic aorta NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

67

Soft Tissue and Lung Axial 29

Pericardium Right internal mammary a. Pectoralis major m. Right atrium Crista terminalis Right middle lobe subsegmental bronchus Right lower lobe medial basal segment pulmonary a. Right middle lobe subsegmental pulmonary aa. Right lower lobe anterior basal subsegmental pulmonary a. & segment bronchus (B8)

Right coronary a. Sternum (body) Right ventricle Left internal mammary a. Mitral valve (anterior leaflet) Left ventricle Left anterior descending coronary a. Left inferior pulmonary v. Lingular v. Lingular pulmonary a.

Right oblique (major) fissure

Latissimus dorsi m.

Left oblique (major) fissure

Serratus anterior m.

Left lower lobe Right lower lobe anteromedial basal lateral basal segment segment pulmonary a. pulmonary a. Left lower lobe anteromedial Right lower lobe lateral (B7+ 8), lateral (B9), & posterior basal segment bronchus (B9) (B10) basal segment bronchi Right lower lobe posterior Left lower lobe posterior basal basal segment pulmonary a. subsegmental pulmonary aa. Right lower lobe posterior Coronary aa. basal segment bronchus (B10) Great cardiac v. Azygos v. Esophagus Right lower lobe medial basal segment bronchus (B7) Left atrium Spinal cord Erector spinae m. Vertebral body Descending thoracic aorta Right inferior pulmonary v. Trapezius m.

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NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Soft Tissue and Lung Axial 29

Pericardium Right Right internal Sternum Crista Right Pectoralis mammary coronary (body) terminalis atrium major m. a. a.

Left internal mammary a.

Right ventricle

Left anterior descending coronary a. Mitral valve (anterior leaflet) Left ventricle Left atrium

Right inferior pulmonary v.

Coronary aa.

Right lower lobe medial basal segment pulmonary a.

Great cardiac v.

Right lower lobe anterior basal segment pulmonary a.

Left inferior pulmonary v. Serratus anterior m.

Left lower lobe anteromedial basal segment pulmonary a.

Latissimus dorsi m.

Left lower lobe posterior basal subsegmental pulmonary aa. Right lower lobe lateral & posterior basal segment pulmonary aa.

Azygos Erector Trapezius Spinal Vertebral Descending Esophagus cord v. spinae m. thoracic body m. aorta

Right Sternum Right middle lobe Right coronary a. (body) Right middle lobe sub- subsegmental bronchus atrium segmental pulmonary aa. Right inferior pulmonary v. Right lower lobe medial basal segment pulmonary a. Right oblique (major) fissure

Left internal Right mammary a. ventricle Left atrium Lingular v. Lingular pulmonary a.

Right lower lobe medial basal segment bronchus (B7) Right lower lobe anterior basal subsegmental pulmonary a. & segment bronchus (B8)

Left inferior pulmonary v.

Left oblique (major) fissure

Right lower lobe lateral basal segment bronchus (B9)

Left lower lobe anteromedial basal segment pulmonary a.

Right lower lobe lateral basal segment pulmonary a.

Left lower lobe anteromedial (B7+8), lateral (B9), & posterior (B10) basal segment bronchi

Right lower lobe posterior basal segment bronchus (B10) Right lower lobe posterior basal segment pulmonary a.

Azygos v.

Vertebral body

Descending Esophagus thoracic aorta

Left lower lobe posterior basal subsegmental pulmonary aa.

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Soft Tissue and Lung Axial 30

Left internal mammary a. Mitral valve (posterior leaflet) Mitral valve (anterior leaflet) Left ventricle Great cardiac v. Right internal mammary a. Coronary aa. Papillary m. Acute marginal coronary a. Right ventricle Left anterior descending coronary a. Right coronary a. Pulmonary vv. Right atrium Sternum Left lower lobe medial & Crista terminalis (body) anterior basal subsegmental Right lower lobe medial basal bronchi subsegmental pulmonary aa. Left lower lobe medial basal Right middle lobe subsubsegmental pulmonary a. segmental pulmonary aa. Lingular v. Lingular Right lower lobe anterior pulmonary a. basal subsegmental Left lower lobe pulmonary a. & segment anterior basal bronchus (B8) subsegmental Right pulmonary aa. oblique Serratus (major) anterior m. fissure

Latissimus dorsi m.

Left oblique (major) fissure

Right lower lobe lateral basal subsegmental pulmonary a. Right lower lobe lateral basal segment bronchus (B9) Right lower lobe posterior basal subsegmental pulmonary a. Right lower lobe posterior basal segment bronchus (B10) Right lower lobe medial basal subsegmental bronchus Right inferior pulmonary v.

Left lower lobe lateral basal segment pulmonary a. Left lower lobe lateral basal segment bronchus (B9) Left lower lobe posterior basal segment bronchus (B10) Left lower lobe posterior basal subsegmental pulmonary aa. Intercostal a. Left atrium Esophagus Descending thoracic aorta Azygos & hemiazygos vv.

Erector spinae m. Trapezius m.

70

Spinal cord

Vertebral body

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Soft Tissue and Lung Axial 30

Left Right Mitral Acute Mitral Left anterior Right marginal internal valve internal valve descending Right coronary coronary mammary (anterior Sternum Right mammary (posterior coronary Left atrium ventricle a. a. leaflet) (body) ventricle a. a. leaflet) artery Papillary muscle

Crista terminalis

Coronary aa.

Right lower lobe medial basal subsegmental pulmonary aa.

Pulmonary vv. Left lower lobe anterior & medial basal subsegmental pulmonary aa.

Right lower lobe anterior basal segment pulmonary a. Pulmonary vein

Serratus anterior m.

Left lower lobe lateral basal segment pulmonary a.

Latissimus dorsi m. Right lower lobe lateral & posterior basal segment pulmonary aa.

Left lower lobe posterior basal subsegmental pulmonary aa.

Left Azygos & Erector Trapezius Spinal Descending Esophagus m. cord thoracic atrium hemiazygos spinae m. aorta vv. Right atrium Right middle lobe subsegmental pulmonary aa. Right lower lobe medial basal subsegmental pulmonary a. Right oblique (major) fissure

Right coronary a.

Sternum Right (body) ventricle

Intercostal artery

Left internal mammary a. Pulmonary v. Lingular v. Lingular pulmonary a. Left lower lobe anterior & medial basal subsegmental bronchi

Right lower lobe medial basal subsegmental bronchus Right lower lobe anterior basal subsegmental pulmonary a. & segment bronchus (B8) Right inferior pulmonary v. Right lower lobe lateral basal subsegmental pulmonary a. Right lower lobe lateral basal segment bronchus (B9) Right lower lobe posterior basal segment bronchus (B10) Right lower lobe posterior basal segment pulmonary a.

Coronary sinus

Left oblique (major) fissure Left lower lobe anteromedial basal subsegmental pulmonary aa. Left lower lobe lateral basal segment pulmonary a. Left lower lobe lateral basal segment bronchus (B9) Left lower lobe posterior basal segment bronchus (B10) Left lower lobe posterior basal segment pulmonary a. Left atrium

Azygos v.

Descending Esophagus thoracic aorta

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Soft Tissue and Lung Axial 31

Acute marginal coronary a. Right internal mammary a. Right coronary a. Right atrium Crista terminalis Right lower lobe medial basal subsegmental pulmonary aa. Right middle lobe subsegmental pulmonary a. Right lower lobe medial basal subsegmental bronchus Right middle lobe Right oblique (major) fissure

Mitral valve (anterior leaflet) Right ventricle Coronary sinus Left internal mammary a. Coronary a. Mitral valve (posterior leaflet) Interventricular septum Left ventricle Pulmonary v. Left anterior descending coronary a. Papillary m. Left lower lobe medial & anterior basal subsegmental bronchi Lingular v. Lingular pulmonary a. Left oblique (major) fissure

Serratus anterior m. Latissimus dorsi m.

Left lower lobe medial & anterior basal subsegmental pulmonary aa. Left lower lobe lateral basal segment pulmonary a. Left lower lobe lateral basal segment bronchus (B9) Left lower lobe posterior basal subsegmental pulmonary a. Esophagus Left lower lobe posterior basal subsegmental bronchi Descending thoracic aorta Intercostal a. Azygos & hemiazygos vv.

Right lower lobe anterior basal subsegmental pulmonary a. & bronchus Right lower lobe lateral basal subsegmental pulmonary a . Right lower lobe lateral basal segment bronchus (B9) Pulmonary vv. Right lower lobe posterior basal subsegmental pulmonary aa. Right lower lobe posterior basal subsegmental bronchus Erector spinae m. Trapezius m.

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Spinal cord

Vertebral body

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Soft Tissue and Lung Axial 31

Coronary a.

Right atrium

Right Acute Right internal marginal coronary a. mammary a. coronary a.

Mitral valve (anterior Right Left internal leaflet) ventricle mammary a.

Left anterior descending coronary a.

Left ventricle

Crista terminalis

Papillary m.

Right lower lobe medial basal subsegmental pulmonary aa.

Mitral valve (posterior leaflet) Pulmonary v.

Right lower lobe anterior basal segment pulmonary a.

Serratus anterior m.

Pulmonary vv.

Left lower lobe anteromedial basal subsegmental pulmonary aa.

Latissimus dorsi m.

Left lower lobe lateral basal segment pulmonary a.

Right lower lobe lateral & posterior basal segment pulmonary aa. Esophagus

Right middle lobe subsegmental pulmonary a.

Left lower lobe posterior basal subsegmental pulmonary aa. Azygos & Erector Spinal InterDescending hemiazygos vv. spinae m. cord costal a. thoracic aorta

Right atrium Right coronary a. Right ventricle

Coronary sinus

Left internal mammary a. Lingular v.

Right middle lobe

Pulmonary a.

Right oblique (major) fissure Right lower lobe medial basal subsegmental pulmonary aa.

Left lower lobe anterior & medial basal subsegmental bronchi Left oblique (major) fissure

Right lower lobe anterior basal subsegmental pulmonary a. & bronchus Right lower lobe medial basal subsegmental bronchus Right lower lobe lateral basal subsegmental pulmonary a. Right lower lobe lateral basal segment bronchus (B9) Right lower lobe posterior basal subsegmental bronchus Right lower lobe posterior basal subsegmental pulmonary aa.

Interventricular septum

Left lower lobe anterior basal subsegmental pulmonary a. Left lower lobe lateral basal segment pulmonary a. Left lower lobe lateral basal segment bronchus (B9)

Pulmonary v.

Azygos v.

Descending thoracic aorta

Esophagus

Pulmonary v. Left lower lobe posterior basal segment pulmonary a. Left lower lobe posterior basal subsegmental bronchus

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Soft Tissue and Lung Axial 32

Right internal mammary a. Right coronary a. Right atrium Inferior vena cava Right middle lobe subsegmental pulmonary a. Right lower lobe medial basal subsegmental pulmonary a. Pulmonary vv. Right lower lobe anterior basal subsegmental pulmonary a. & bronchus Right oblique (major) fissure

Coronary sinus Right ventricle Left internal mammary a. Interventricular septum Left ventricle Left anterior descending coronary a. Sternum Papillary m. (Xiphoid) Left lower lobe medial basal subsegmental bronchus Left lower lobe medial & anterior basal subsegmental pulmonary aa. Lingular v. Lingular pulmonary a. Left oblique (major) fissure

Serratus anterior m.

Latissimus dorsi m. Right lower lobe lateral basal subsegmental pulmonary a. Right lower lobe lateral basal subsegmental bronchus Right lower lobe posterior basal subsegmental pulmonary a. Right lower lobe posterior basal subsegmental bronchi Trapezius m. Right lower lobe posterior basal subsegmental pulmonary a. Erector spinae m. Spinal cord

Esophagus

Left lower lobe lateral basal segment pulmonary a. Left lower lobe lateral basal segment bronchus (B9) Left lower lobe posterior basal subsegmental bronchus Left lower lobe posterior basal subsegmental pulmonary a. Pulmonary v. Left lower lobe posterior basal subsegmental bronchus Left lower lobe posterior basal subsegmental pulmonary a.

Descending thoracic aorta Vertebral body Azygos & hemiazygos vv.

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NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Soft Tissue and Lung Axial 32

Right Right coronary atrium a.

Right internal mammary a.

Left internal Sternum mammary Right (Xiphoid) ventricle a.

Interventricular septum

Left ventricle Papillary m.

Inferior vena cava Right lower lobe medial basal subsegmental pulmonary a. Right lower lobe anterior basal segment pulmonary a. Pulmonary vv.

Coronary sinus Serratus anterior m. Left lower lobe anterior & medial basal subsegmental pulmonary aa.

Left lower lobe lateral basal segment pulmonary a.

Latissimus dorsi m.

Right lower lobe lateral & posterior basal segment pulmonary aa.

Pulmonary v.

Azygos & hemiazygos vv.

Right middle lobe subsegmental pulmonary a.

Left anterior descending coronary a.

Erector Trapezius m. spinae m.

Right coronary a.

Spinal cord

Descending Esophagus thoracic aorta

Left lower lobe posterior basal subsegmental pulmonary aa.

Left Right & internal Coronary Sternum (Xiphoid) mammary a. left ventricles sinus

Right lower lobe medial basal subsegmental pulmonary a. Right lower lobe anterior basal subsegmental pulmonary a. & bronchus Pulmonary v.

Lingular v. Lingular pulmonary a.

Right lower lobe lateral basal subsegmental bronchus

Left oblique (major) fissure Left lower lobe medial basal subsegmental bronchus Left lower lobe anterior & medial basal subsegmental pulmonary aa.

Right lower lobe lateral basal subsegmental pulmonary a.

Left lower lobe lateral basal segment pulmonary a.

Right lower lobe posterior basal subsegmental bronchi Right lower lobe posterior basal subsegmental pulmonary aa.

Azygos v.

Descending Esophagus thoracic aorta

Left lower lobe lateral basal segment bronchus (B9) Left lower lobe posterior basal subsegmental pulmonary a. Left lower lobe posterior basal subsegmental bronchi

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Soft Tissue and Lung Axial 33

Posterior interventricular v. (middle cardiac v.) Coronary sinus Right superior epigastric a. Right musculophrenic a. Right coronary a. Right atrium Right middle lobe subsegmental pulmonary a. Inferior vena cava

Pericardium Right ventricle Left internal mammary a. Interventricular septum Papillary m. Left anterior descending coronary a. Left ventricle Left lower lobe medial basal subsegmental bronchus Pulmonary v. Lingular v. Lingular pulmonary a.

Sternum (Xiphoid)

Right oblique (major) fissure Right lower lobe anterior basal subsegmental pulmonary aa.

Left oblique (major) fissure Serratus anterior m.

Latissimus dorsi m. Right lower lobe lateral basal subsegmental pulmonary a. Pulmonary vv. Right lower lobe posterior basal subsegmental pulmonary aa. Right lower lobe posterior basal subsegmental bronchus Right lower lobe medial basal subsegmental pulmonary aa. Erector spinae m.

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Vertebral body

Left lower lobe medial & anterior basal subsegmental pulmonary aa. Left lower lobe lateral basal subsegmental pulmonary a. Left lower lobe lateral basal subsegmental bronchus Left lower lobe posterior basal subsegmental bronchus Esophagus Left lower lobe posterior basal subsegmental pulmonary a. Descending thoracic aorta Azygos & hemiazygos vv.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Soft Tissue and Lung Axial 33

Right atrium

Right Left anterior Right Left internal Right musculo- Sternum descending coronary a. phrenic a. (Xiphoid) Pericardium mammary a. ventricle coronary a.

Coronary sinus Posterior interventricular v. (middle cardiac v.) Inferior vena cava

Interventricular septum Left ventricle Papillary m. Pulmonary v.

Right lower lobe anterior basal subsegmental pulmonary aa. Serratus anterior m.

Right lower lobe medial basal subsegmental pulmonary a. Latissimus dorsi m.

Left lower lobe anterior & medial basal subsegmental pulmonary aa.

Pulmonary v.

Left lower lobe lateral basal subsegmental pulmonary a. Right lower lobe lateral & posterior basal segment pulmonary aa.

Erector Vertebral Descending Esophagus Azygos & thoracic hemiazygos vv. spinae m. body aorta Right coronary a.

Sternum (Xiphoid)

Left lower lobe posterior basal subsegmental pulmonary aa. Left & right ventricle

Coronary sinus Lingular v. Lingular pulmonary a.

Right oblique (major) fisssure Inferior vena cava

Left oblique (major) fissure

Right lower lobe anterior basal subsegmental pulmonary aa. Right lower lobe medial basal subsegmental pulmonary a. Right lower lobe lateral basal subsegmental pulmonary aa. Pulmonary vv.

Left lower lobe anterior & medial basal subsegmental pulmonary aa. Left lower lobe lateral basal subsegmental bronchus Left lower lobe lateral basal subsegmental pulmonary a.

Right lower lobe posterior basal subsegmental bronchus

Right lower lobe posterior basal subsegmental pulmonary aa.

Esophagus

Azygos & hemiazygos vv.

Descending thoracic aorta

Left lower lobe medial basal subsegmental bronchus Left lower lobe posterior basal subsegmental bronchus Left lower lobe posterior basal subsegmental pulmonary a.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

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Soft Tissue and Lung Axial 34

Posterior descending coronary a. Posterior interventricular v. (middle cardiac v.) Right superior epigastric a. Right musculophrenic a. Right coronary a. Inferior vena cava Right middle lobe subsegmental pulmonary a. Right lower lobe medial basal subsegmental pulmonary a.

Pericardium Sternum (Xiphoid)

Right oblique (major) fissure Pulmonary v.

Left superior epigastric a. Right ventricle Left musculophrenic a. Interventricular septum Papillary m. Left ventricle Pulmonary v. Left lower lobe anterior basal subsegmental bronchus Lingular v. Lingular pulmonary a. Left oblique (major) fissure Serratus anterior m.

Latissimus dorsi m. Right lower lobe anterior basal subsegmental pulmonary a. Right lower lobe lateral basal subsegmental pulmonary a. Right lower lobe posterior basal subsegmental pulmonary aa. Right lower lobe posterior basal subsegmental bronchus Erector spinae m.

78

Left lower lobe lateral basal subsegmental bronchus Left lower lobe lateral basal subsegmental pulmonary a. Left lower lobe medial & anterior Vertebral body Esophagus basal subsegmental pulmonary aa. Left lower lobe posterior basal subsegmental bronchus Left lower lobe posterior basal subsegmental pulmonary aa. Descending thoracic aorta Azygos & hemiazygos vv.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Soft Tissue and Lung Axial 34

Right coronary a.

Right Left superior Posterior superior Peri- epigastric descending epigastric Sternum a. (Xiphoid) cardium a. coronary a.

Right ventricle Interventricular septum

Posterior interventricular v. (middle cardiac v.)

Left ventricle Papillary m.

Inferior vena cava

Serratus anterior m.

Pulmonary vv.

Left lower lobe anterior basal subsegmental pulmonary a. Pulmonary v. Latissimus dorsi m. Left lower lobe lateral basal subsegmental pulmonary a. Right lower lobe lateral Esophagus Azygos & Erector Vertebral & posterior basal subhemiazygos vv. spinae m. body segmental pulmonary aa.

Right coronary a.

Right middle lobe subsegmental pulmonary a.

Sternum (Xiphoid)

Descending thoracic aorta Left superior epigastric a.

Left lower lobe posterior basal subsegmental pulmonary aa.

Right & left ventricle

Right oblique (major) fissure Lingular v. Lingular pulmonary a.

Inferior vena cava Right lower lobe medial basal subsegmental pulmonary a. Right lower lobe anterior basal subsegmental pulmonary a.

Left oblique (major) fissure Left lower lobe medial & anterior basal subsegmental pulmonary aa.

Pulmonary vv.

Left lower lobe anterior basal subsegmental bronchus

Right lower lobe lateral basal subsegmental pulmonary a. Right lower lobe posterior basal subsegmental bronchus

Right lower lobe posterior basal subsegmental pulmonary aa.

Left lower lobe lateral basal subsegmental pulmonary a. Left lower lobe posterior basal subsegmental bronchus Esophagus

Azygos & hemiazygos vv.

Descending thoracic aorta

Left lower lobe posterior basal subsegmental pulmonary aa.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

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Soft Tissue and Lung Axial 35 Posterior descending coronary a. Posterior interventricular v. (middle cardiac v.) Right superior epigastric a. Right musculophrenic a. Right coronary a. Intercostal aa. Inferior vena cava Right middle lobe subsegmental pulmonary a.

Pericardium Left superior epigastric a. Right ventricle Left musculophrenic a. Pulmonary ligament Interventricular septum Papillary m. Left ventricle Left anterior descending coronary a. Pulmonary v. Lingular v. Left lower lobe anterior basal subsegmental bronchus Lingular pulmonary a. & bronchus Left oblique (major) fissure Serratus anterior m.

Sternum (Xiphoid)

Right lower lobe medial basal subsegmental pulmonary a. Right oblique (major) fissure Pulmonary vv.

Latissimus dorsi m. Right lower lobe anterior basal subsegmental pulmonary a.

Left lower lobe medial & anterior basal subsegmental pulmonary aa.

Right lower lobe lateral basal subsegmental pulmonary a. Right lower lobe posterior basal subsegmental pulmonary aa.

Vertebral body

Erector spinae m. Azygos & hemiazygos vv.



Left lower lobe lateral basal subsegmental bronchus Left lower lobe lateral basal Esophagus subsegmental pulmonary a. Left lower lobe posterior basal subsegmental bronchus Left lower lobe posterior basal subsegmental pulmonary aa. Descending thoracic aorta

NORMAL ANATOMY The pulmonary ligament is formed by the visceral pleura lining the medial lower lobes reflecting over the mediastinal pleural surface. The pulmonary ligaments extend inferiorly from the hila toward the diaphragm; occasionally the ligaments may contain systemic vessels supplying the lungs. On thoracic CT, the pulmonary ligaments are often visible as linear or triangular, narrow, short structures extending laterally from the esophagus, caudal to the inferior pulmonary veins.

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NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Soft Tissue and Lung Axial 35

Right coronary a.

Right superior epigastic a.

Sternum Left superior (Xiphoid) epigastric a.

Right ventricle Pericardium Left anterior descending coronary a.

Posterior interventricular v. (middle cardiac v.)

Interventricular septum

Inferior vena cava

Left ventricle

Esophagus

Papillary m.

Pulmonary v.

Posterior descending coronary a.

Intercostal aa. Right lower lobe lateral & posterior basal subsegmental pulmonary aa.

Serratus anterior m. Left lower lobe anterior basal subsegmental pulmonary a.

Latissimus dorsi m.

Pulmonary v. Left lower lobe lateral basal subsegmental pulmonary a. Erector spinae m.

Right middle lobe subsegmental pulmonary a.

Vertebral body (spinous process)

Azygos & Descending Left lower lobe posterior hemiazygos vv. thoracic aorta basal subsegmental pulmonary aa.

Right coronary a.

Sternum (Xiphoid)

Right & left ventricle

Lingular v. Lingular pulmonary a. & bronchus

Inferior vena cava

Left oblique (major) fissure

Right lower lobe anterior basal subsegmental pulmonary a.

Left lower lobe anterior basal subsegmental bronchus

Pulmonary vv.

Left lower lobe anterior & medial basal subsegmental pulmonary aa.

Right lower lobe lateral basal subsegmental pulmonary a.

Left lower lobe lateral basal subsegmental bronchus Left lower lobe lateral basal subsegmental pulmonary a.

Pulmonary vv. Right lower lobe posterior basal subsegmental pulmonary aa.

Pulmonary ligament

Descending Azygos & hemiazygos vv. thoracic aorta

Left lower lobe posterior basal subsegmental Left lower lobe posterior bronchus basal subsegmental pulmonary aa.

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81

Soft Tissue and Lung Axial 36 Posterior descending coronary a. Posterior interventricular v. (middle cardiac v.) Right posterolateral coronary a. Right musculophrenic a. Inferior vena cava

Pericardium Sternum (Xiphoid)

Liver Right middle lobe Right oblique (major) fissure Pulmonary vv.

Latissimus dorsi m.

Left superior epigastric a. Right ventricle Pulmonary ligament Left musculophrenic a. Interventricular septum Left anterior descending coronary a. Left ventricle Lingular v. Pulmonary v. Lingular pulmonary a. Left oblique (major) fissure Serratus anterior m.

Left lower lobe anterior basal subsegmental pulmonary aa.

Right lower lobe anterior basal subsegmental pulmonary a.

Left lower lobe lateral basal subsegmental pulmonary aa. Left lower lobe lateral basal subsegmental bronchus Right lower lobe posterior Left lower lobe posterior basal Esophagus basal subsegmental pulmonary aa. subsegmental bronchus Right lower lobe posterior basal Intercostal v. Left lower lobe posterior subsegmental bronchus basal subsegmental pulmonary a. Erector spinae m. Descending thoracic aorta Vertebral body (transverse process) Azygos & hemiazygos vv.

Right lower lobe lateral basal subsegmental pulmonary a.



NORMAL ANATOMY The phrenic nerves are occasionally seen reflecting over the diaphragm, anterior to the inferior pulmonary ligament.

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NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Soft Tissue and Lung Axial 36

Right superior epigastic a.

Sternum (Xiphoid)

Left superior epigastic a.

Right ventricle Pericardium

Right posterolateral coronary a.

Left anterior descending coronary a.

Posterior interventricular v. (middle cardiac v.)

Interventricular septum Left ventricle

Liver Inferior vena cava

Serratus anterior m.

Esophagus

Pulmonary v.

Right lower lobe lateral & posterior basal subsegmental pulmonary aa.

Left lower lobe lateral basal subsegmental pulmonary aa.

Intercostal v.

Left lower lobe posterior basal subsegmental pulmonary a.

Latissimus dorsi m. Vertebral body (transverse process)

Erector spinae m. Liver

Inferior vena cava

Azygos & hemiazygos vv. Sternum (Xiphoid)

Descending thoracic aorta

Esophagus Right & left ventricle Lingular v.

Right oblique (major) fissure

Lingular pulmonary a.

Pulmonary a.

Left oblique (major) fissure Left lower lobe anterior & medial basal subsegmental pulmonary aa.

Right lower lobe anterior basal subsegmental pulmonary a.

Left lower lobe lateral basal subsegmental bronchus

Pulmonary vv. Right lower lobe lateral basal subsegmental pulmonary a.

Left lower lobe lateral basal subsegmental pulmonary aa.

Pulmonary vv.

Left lower lobe posterior basal subsegmental bronchus

Right lower lobe posterior basal subsegmental pulmonary aa. Right lower lobe posterior basal subsegmental bronchus

Left lower lobe posterior basal subsegmental pulmonary a. Azygos & hemiazygos vv.

Descending thoracic aorta

Pulmonary ligament

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

83

Soft Tissue and Lung Axial 37

Diaphragm Inferior vena cava Right musculophrenic a. Liver Pulmonary vv.

Right superior epigastric a. Diaphragm

Right middle lobe Right oblique (major) fissure

Sternum (Xiphoid)

Pulmonary ligament Intersublobar septum Left superior epigastric a. Posterior interventricular v. (middle cardiac v.) Pericardium Right ventricle Left musculophrenic a. Posterior descending coronary a. Left anterior descending coronary a. Left ventricle Lingular v. Lingular pulmonary a. Left oblique (major) fissure

Right lower lobe anterior basal subsegmental pulmonary a.

Serratus anterior m.

Rib

Latissimus dorsi m.

Left lower lobe anterior basal subsegmental pulmonary a. Left lower lobe lateral basal subsegmental pulmonary aa. Pulmonary v.

Right lower lobe lateral basal subsegmental pulmonary a. Right lower lobe posterior basal subsegmental pulmonary aa. Intercostal a. Erector spinae m.

84

Vertebral body

Left lower lobe posterior basal subsegmental pulmonary a. Pulmonary vv. Descending thoracic aorta Hemiazygos v.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Esophagus

Soft Tissue and Lung Axial 37

Right superior Sternum epigastric a. (Xiphoid)

Left superior epigastric a. Pericardium

Diaphragm

Left anterior descending coronary a.

Posterior interventricular v. (middle cardiac v.)

Right ventricle

Liver

Serratus anterior m.

Inferior vena cava

Left ventricle

Esophagus

Rib

Vertebral body

Latissimus dorsi m. Pulmonary vv. Intercostal a. Right middle lobe

Erector Hemiazygos v. spinae m.

Descending thoracic aorta Right & left ventricle

Liver

Lingular v. Lingular pulmonary a.

Right oblique (major) fissure

Left oblique (major) fissure

Pulmonary v. Left lower lobe anterior basal subsegmental pulmonary a.

Right lower lobe anterior basal subsegmental pulmonary a.

Pulmonary ligament

Pulmonary vv.

Left lower lobe posterior basal subsegmental pulmonary a.

Right lower lobe lateral basal subsegmental pulmonary a.

Left lower lobe lateral basal subsegmental pulmonary aa.

Pulmonary vv.

Pulmonary vv. Right lower lobe posterior basal subsegmental pulmonary aa.

Inferior Esophagus vena cava

Hemiazygos v. Descending thoracic aorta

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

85

Soft Tissue and Lung Axial 38

Inferior vena cava Right middle lobe Right oblique (major) fissure

Right ventricle Left anterior descending coronary a. Pericardium Left superior epigastric a. Phrenic n. Diaphragm Pulmonary vv. Esophagus

Lingular v. Lingular pulmonary a. Left lower lobe anterior basal subsegmental pulmonary a.

Liver

Pulmonary v. Right lower lobe anterior basal subsegmental pulmonary aa.

Left oblique (major) fissure Serratus anterior m.

Rib

Latissimus dorsi m. Right lower lobe lateral basal subsegmental pulmonary aa. Right lower lobe posterior basal subsegmental pulmonary aa. Intercostal a. Pulmonary vv.

86

Left lower lobe lateral basal subsegmental pulmonary aa. Left lower lobe posterior basal subsegmental pulmonary a. Spinal cord Erector spinae m.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Descending thoracic aorta

Soft Tissue and Lung Axial 38

Left superior epigastric a.

Diaphragm

Right ventricle

Liver Pericardium Left anterior descending coronary a. Serratus anterior m. Inferior vena cava

Rib Latissimus dorsi m.

Intercostal a.

Right middle lobe

Erector spinae m.

Liver

Spinal cord

Inferior vena cava

Descending thoracic aorta

Esophagus

Lingular v.

Right oblique (major) fissure

Lingular pulmonary a. Left oblique (major) fissure

Pulmonary v.

Left lower lobe anterior basal subsegmental pulmonary a.

Right lower lobe anterior basal subsegmental pulmonary aa. Pulmonary v.

Phrenic n.

Right lower lobe lateral basal subsegmental pulmonary aa.

Pulmonary v. Left lower lobe lateral basal subsegmental pulmonary aa.

Pulmonary vv.

Pulmonary v.

Right lower lobe posterior basal subsegmental pulmonary aa.

Esophagus

Descending Hemiazygos v. thoracic aorta

Pulmonary vv.

Left lower lobe posterior basal subsegmental pulmonary a.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

87

Soft Tissue and Lung Axial 39

Costochondral junction Right oblique (major) fissure

Liver

Diaphragm

Inferior vena cava

Right lower lobe anterior basal subsegmental pulmonary aa.

Stomach

Diaphragm

Lingular v. Lingular pulmonary a. Left oblique (major) fissure Pulmonary v. Serratus anterior m.

Pulmonary v.

Rib

Intercostal mm. Latissimus dorsi m. Right lower lobe lateral basal subsegmental pulmonary aa. Right lower lobe posterior basal subsegmental pulmonary aa. Pulmonary vv.

Left lower lobe anterior basal subsegmental pulmonary a. Left lower lobe lateral basal subsegmental pulmonary aa. Spinal cord Spleen Pulmonary v. Left lower lobe posterior basal Vertebral body Pulmonary vv. subsegmental pulmonary a. Descending thoracic aorta

Erector spinae m.

88

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Soft Tissue and Lung Axial 39

Costochondral junction

Diaphragm

Liver Serratus anterior m. Inferior vena cava Stomach Diaphragm

Rib Spleen Intercostal mm.

Latissimus dorsi m.

Erector spinae m. Right oblique (major) fissure

Spinal cord

Descending thoracic aorta

Lingular v.

Liver

Lingular pulmonary a. Left oblique (major) fissure

Right lower lobe anterior basal subsegmental pulmonary aa.

Stomach Pulmonary v. Left lower lobe anterior basal subsegmental pulmonary a.

Right lower lobe lateral basal subsegmental pulmonary aa.

Pulmonary v. Descending thoracic aorta

Inferior vena cava

Left lower lobe lateral basal subsegmental pulmonary aa.

Pulmonary vv.

Right lower lobe posterior basal subsegmental pulmonary aa.

Pulmonary v.

Vertebral body

Pulmonary vv.

Left lower lobe posterior basal subsegmental pulmonary a.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

89

Soft Tissue and Lung Axial 40

Costochondral junction Diaphragm

Inferior vena cava Stomach

Costochondral junction Liver Diaphragm (crus)

Spleen Lingular pulmonary a. Left oblique (major) fissure Left lower lobe anterior basal subsegmental pulmonary a. Serratus anterior m.

Kidney

Rib

Pulmonary v. Intercostal mm.

Latissimus dorsi m. Right lower lobe posterior basal subsegmental pulmonary a.

Left lower lobe lateral basal subsegmental pulmonary aa. Pulmonary v.

Spinal cord Pulmonary vv.

Erector spinae m.

Diaphragm

Vertebral body Descending thoracic aorta

90

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Left lower lobe posterior basal subsegmental pulmonary a. Pulmonary v.

Soft Tissue and Lung Axial 40

Costochondral junction

Costochondral junction

Diaphragm

Liver

Stomach

Inferior vena cava

Serratus anterior m. Rib

Diaphragm

Kidney

Spleen

Latissimus dorsi m.

Intercostal mm. Spinal cord

Erector spinae m.

Descending Diaphragm thoracic aorta Stomach

Left oblique Lingular pulmonary a. (major) fissure

Left lower lobe anterior basal subsegmental pulmonary a.

Liver

Inferior vena cava Pulmonary v.

Diaphragm (crus) Pulmonary vv.

Left lower lobe lateral basal subsegmental pulmonary aa. Pulmonary v.

Right lower lobe posterior basal subsegmental pulmonary aa. Vertebral body

Descending Pulmonary v. thoracic aorta

Left lower lobe posterior basal subsegmental pulmonary a.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

91

Soft Tissue and Lung Coronal 1

Sternum Pectoralis major m.

Costochondral junction

Costochondral junction

Left internal mammary a. (left internal thoracic a.)

Rib Right lung

Left lung Serratus anterior m.

Musculophrenic a.

Superior epigastric aa.

92

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Soft Tissue and Lung Coronal 1

Pectoralis major m.

Sternum

Costochondral junction

Costochondral junction Left internal mammary a. (left internal thoracic a.) Rib Left lung

Right lung

Serratus anterior m.

Musculophrenic a.

Superior epigastric aa. Pectoralis major m.

Sternum Costochondral junction

Costochondral junction

Rib

Right lung

Left internal mammary a. (left internal thoracic a.) Left lung

Serratus anterior m.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

93

Soft Tissue and Lung Coronal 2

Anterior junction line

Sternum (body)

Left internal mammary v. & a.

Pectoralis major m.

Costochondral junction Costochondral junction Right horizontal (minor) fissure

Left upper lobe anterior subsegmental pulmonary a.

Rib

Left anterior descending coronary a.

Right middle lobe medial subsegmental pulmonary aa.

Serratus anterior m.

Diaphragm

Diaphragm

Liver

Right ventricular outflow tract (infundibulum)



Stomach

NORMAL ANATOMY The anterior junction line is a linear region of contact between the anterior aspects of the right and left lungs, just posterior to the sternum. The anterior junction line consists of 4 layers of pleura with a variable amount of mediastinal fat interposed between the layers of pleura. The anterior junction line may become widened when pathological processes occur within the anterior �mediastinum.

94

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Soft Tissue and Lung Coronal 2

Sternum (body)

Pectoralis major m.

Left internal mammary v. & a.

Costochondral junction

Costochondral junction

Right ventricular outflow tract (infundibulum)

Rib

Left anterior descending coronary a.

Liver Diaphragm Stomach Sternum (body)

Pectoralis major m.

Diaphragm Left internal mammary v. & a.

Costochondral junction Costochondral junction Anterior junction line Left upper lobe anterior subsegmental pulmonary a.

Right horizontal (minor) fissure

Right ventricular outflow tract (infundibulum) Rib Serratus anterior m. Right middle lobe medial subsegmental pulmonary aa. Left anterior descending coronary a. Diaphragm

Liver

Stomach

Diaphragm

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

95

Soft Tissue and Lung Coronal 3

Sternum (manubrium)

Sternal-manubrial junction

Sternum (body)

Anterior junction line Left internal mammary v. & a.

Pectoralis major m.

Right horizontal (minor) fissure Left upper lobe anterior subsegmental pulmonary aa. Rib

Left anterior descending coronary a.

Right upper lobe anterior subsegmental pulmonary a. Right middle lobe lateral & medial subsegmental pulmonary aa.

Serratus anterior m.

Diaphragm Diaphragm

Liver

Right ventricular outflow tract (infundibulum)



Stomach

Colon

NORMAL ANATOMY The diaphragm is a curved, muscular structure. Because the portion of the diaphragm located centrally between the inferior pleural space and upper abdomen is very thin and primarily oriented in the axial plane, it is difficult to visualize in the axial plane on CT. However, coronal imaging is very effective in demonstrating the curved surface of the diaphragm, as can be appreciated on this and subsequent images.

96

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Soft Tissue and Lung Coronal 3

Sternal-manubrial Sternum junction (manubrium)

Left internal mammary v. & a.

Pectoralis major m. Sternum (body)

Right ventricular outflow tract (infundibulum) Left anterior descending coronary a.

Rib

Serratus anterior m. Diaphragm

Diaphragm

Liver Sternum (manubrium)

Stomach Colon Sternal-manubrial junction

Pectoralis major m.

Left internal mammary v. & a.

Sternum (body) Anterior junction line

Left upper lobe anterior subsegmental pulmonary aa.

Right horizontal (minor) fissure

Right ventricular outflow tract (infundibulum)

Right upper lobe anterior subsegmental pulmonary a. Rib

Left anterior descending coronary a. Serratus anterior m.

Right middle lobe lateral & medial subsegmental pulmonary aa. Diaphragm

Diaphragm

Liver

Stomach Colon

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

97

Soft Tissue and Lung Coronal 4

Anterior mediastinum Right atrial appendage Left internal mammary v. & a. Sternum (manubrium)

Left upper lobe apical-posterior subsegmental pulmonary a.

Pectoralis major m. Right upper lobe anterior subsegmental pulmonary a.

Left upper lobe anterior subsegmental pulmonary aa.

Right horizontal (minor) fissure

Left upper lobe anterior subsegmental bronchus

Rib

Serratus anterior m.

Right middle lobe

Left anterior descending coronary a.

Right middle lobe lateral & medial subsegmental pulmonary aa.

Intercostal m.

Right oblique (major) fissure

Lingular superior subsegmental pulmonary a.

Diaphragm

Lingular inferior subsegmental pulmonary a.

Liver

Diaphragm

Right ventricular outflow tract (infundibulum)

Stomach

Colon Left ventricle

98

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Soft Tissue and Lung Coronal 4

Pectoralis major m.

Sternum (manubrium)

Left internal mammary v. & a.

Right internal mammary a. & v. Right ventricular outflow tract (infundibulum)

Right upper lobe anterior subsegmental pulmonary a.

Right atrial appendage

Left anterior descending coronary a.

Rib

Intercostal m. Serratus anterior m. Left ventricle Diaphragm Diaphragm

Liver Right internal mammary a. & v.

Sternum (manubrium)

Stomach Anterior mediastinum

Colon

Left upper lobe apical-posterior subsegmental pulmonary a.

Pectoralis major m.

Right ventricular outflow tract (infundibulum) Right atrial appendage

Left upper lobe anterior subsegmental pulmonary aa.

Right upper lobe anterior subsegmental pulmonary a. Right horizontal (minor) fissure

Left upper lobe anterior subsegmental bronchus

Right middle lobe

Left anterior descending coronary a. Lingular superior subsegmental pulmonary a.

Right middle lobe lateral & medial subsegmental pulmonary aa.

Left ventricle Right oblique (major fissure) Lingular inferior subsegmental pulmonary a.

Diaphragm

Diaphragm Liver

Stomach

Colon

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

99

Soft Tissue and Lung Coronal 5

Anterior mediastinum Right atrial appendage Left internal mammary v. & a. Sternum (manubrium)

Left upper lobe apical-posterior subsegmental pulmonary a.

Pectoralis major m. Right upper lobe anterior subsegmental pulmonary a.

Right ventricular outflow tract (infundibulum)

Right horizontal (minor) fissure

Left upper lobe anterior subsegmental pulmonary aa.

Right coronary a. Rib

Serratus anterior m. Left anterior descending coronary a.

Right middle lobe Right middle lobe lateral & medial subsegmental pulmonary aa.

Intercostal m. Lingular superior subsegmental pulmonary a.

Right oblique (major) fissure Pulmonary vv.

Lingular inferior subsegmental pulmonary a.

Diaphragm

Diaphragm

Liver

Right ventricle

Stomach

Colon Left ventricle

100

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Soft Tissue and Lung Coronal 5

Right internal mammary a. & v.

Sternum (manubrium)

Left internal mammary v. & a. Anterior mediastinum

Pectoralis major m. Right upper lobe anterior subsegmental pulmonary a.

Right ventricular outflow tract (infundibulum)

Right atrial appendage Left anterior descending coronary a.

Rib

Intercostal m.

Right coronary a.

Serratus anterior m. Right middle lobe lateral & medial subsegmental pulmonary aa.

Left ventricle

Diaphragm

Diaphragm Liver Right internal mammary a. & v.

Right Stomach ventricle Sternum Anterior (manubrium) mediastinum

Colon

Left upper lobe apical-posterior subsegmental pulmonary a.

Pectoralis major m. Right atrial appendage

Right ventricular outflow tract (infundibulum)

Right upper lobe anterior subsegmental pulmonary a. Right horizontal (minor) fissure

Left upper lobe anterior subsegmental pulmonary aa.

Right coronary a.

Left anterior descending coronary a.

Rib Right middle lobe lateral & medial subsegmental pulmonary aa.

Lingular superior subsegmental pulmonary a.

Pulmonary vv.

Left ventricle

Right oblique (major fissure) Lingular inferior subsegmental pulmonary a.

Diaphragm

Diaphragm Liver

Right Stomach ventricle

Colon

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

101

Soft Tissue and Lung Coronal 6

Sternum (manubrium) Anterior mediastinum Right internal mammary a. Right atrial appendage

Sternocleidomastoid mm.

Pectoralis major m.

Left upper lobe apical-posterior subsegmental pulmonary a.

Right upper lobe anterior subsegmental pulmonary a.

Right ventricular outflow tract (infundibulum)

Right horizontal (minor) fissure

Left upper lobe anterior subsegmental pulmonary aa.

Right coronary a. Rib

Left anterior descending coronary a.

Right middle lobe lateral & medial subsegmental pulmonary aa. Right oblique (major) fissure

Intercostal m. Lingular superior subsegmental pulmonary a. Lingular inferior subsegmental pulmonary a. Left oblique (major) fissure

Pulmonary vv.

Diaphragm

Liver Right ventricle

102

Stomach

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Colon Left ventricle

Soft Tissue and Lung Coronal 6

Pectoralis major m.

Sternocleidomastoid mm.

Sternum (manubrium) Anterior mediastinum

Right internal mammary a.

Left upper lobe apical-posterior subsegmental pulmonary a.

Right upper lobe anterior subsegmental pulmonary a.

Right ventricular outflow tract (infundibulum) Left upper lobe anterior subsegmental pulmonary aa.

Rib Right atrial appendage

Left anterior descending coronary a.

Right coronary a.

Intercostal m.

Right middle lobe lateral & medial subsegmental pulmonary aa.

Serratus anterior m.

Left ventricle Diaphragm

Pulmonary vv. Liver Pectoralis major m.

Right ventricle

Stomach

Sternocleidomastoid m.

Colon Sternum (manubrium) Anterior mediastinum

Right internal mammary a.

Left upper lobe apical-posterior subsegmental pulmonary a.

Right atrial appendage

Right ventricular outflow tract (infundibulum)

Right upper lobe anterior subsegmental pulmonary a. Right horizontal (minor) fissure

Left upper lobe anterior subsegmental pulmonary aa.

Right coronary a.

Left anterior descending coronary a.

Right middle lobe lateral & medial subsegmental pulmonary aa.

Lingular superior subsegmental pulmonary a.

Pulmonary vv.

Left ventricle Right oblique (major fissure)

Lingular inferior subsegmental pulmonary a. Left oblique (major) fissure Liver

Right ventricle

Stomach Colon

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

103

Soft Tissue and Lung Coronal 7

Sternum (manubrium) Anterior mediastinum Right internal mammary a. Right atrial appendage

Sternocleidomastoid mm. Left upper lobe apical-posterior subsegmental pulmonary a.

Pectoralis major m.

Right ventricular outflow tract (infundibulum)

Right upper lobe anterior subsegmental pulmonary a. Right horizontal (minor) fissure

Left upper lobe anterior subsegmental pulmonary aa.

Right coronary a. Rib

Left anterior descending coronary a.

Right middle lobe lateral & medial subsegmental pulmonary aa. Serratus anterior m.

Intercostal m.

Lingular inferior subsegmental pulmonary a.

Right oblique (major) fissure

Left oblique (major) fissure

Pulmonary vv.

Diaphragm

Liver

Right atrium

Right ventricle

Stomach

Right coronary a.

104

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Colon Left ventricle

Soft Tissue and Lung Coronal 7

Pectoralis major m.

Sternum (manubrium)

Sternocleidomastoid mm.

Left upper lobe apical-posterior subsegmental pulmonary a.

Right internal mammary a.

Right ventricular outflow tract (infundibulum)

Anterior mediastinum Right upper lobe anterior subsegmental pulmonary a.

Left upper lobe anterior subsegmental pulmonary aa.

Right atrial appendage Left anterior descending coronary a.

Rib Right middle lobe lateral & medial subsegmental pulmonary aa.

Right coronary a. Intercostal m.

Pulmonary vv. Left ventricle

Serratus anterior m.

Right ventricle

Right atrium

Diaphragm Liver Pectoralis major m.

Stomach

Sternocleidomastoid mm.

Colon

Sternum (manubrium) Left upper lobe apical-posterior subsegmental pulmonary a.

Right internal mammary a. Anterior mediastinum Right atrial appendage

Right ventricular outflow tract (infundibulum)

Right upper lobe anterior subsegmental pulmonary a.

Left upper lobe anterior subsegmental pulmonary aa.

Right horizontal (minor) fissure Right coronary a. Right middle lobe subsegmental pulmonary aa.

Left anterior descending coronary a.

Right middle lobe lateral & medial subsegmental pulmonary aa.

Left ventricle Lingular inferior subsegmental pulmonary a.

Pulmonary vv. Right oblique (major fissure)

Left oblique (major) fissure Right ventricle Diaphragm Liver

Stomach

Colon

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

105

Soft Tissue and Lung Coronal 8

Sternum (manubrium) Anterior mediastinum (residual thymus) Right internal mammary a.

Sternocleidomastoid mm.

Right atrial appendage

Left upper lobe apical-posterior subsegmental pulmonary a.

Pectoralis major m.

Main pulmonary a. Right ventricular outflow tract (infundibulum)

Right upper lobe anterior subsegmental pulmonary a. & bronchus

Left upper lobe anterior subsegmental pulmonary aa.

Right horizontal (minor) fissure Right coronary a.

Left anterior descending coronary a. Diagonal coronary a.

Right middle lobe subsegmental pulmonary aa.

Intercostal m.

Rib Right middle lobe lateral & medial subsegmental pulmonary aa.

Serratus anterior m.

Lingular inferior subsegmental pulmonary a.

Right oblique (major) fissure

Left oblique (major) fissure

Right lower lobe

Left lower lobe

Right atrium Liver

Diaphragm Right coronary a. Right ventricle



Stomach

Colon Left ventricle

NORMAL ANATOMY The tissue composition of the anterior mediastinum varies with age. In younger patients (particularly infants and children), abundant soft tissue, representing thymic tissue, is found residing within anterior mediastinal fat. As individuals age, the thymus normally involutes and becomes more fatty replaced, and progressively less soft tissue is visible within the anterior mediastinal fat. The pace at which thymic involution occurs is variable, and a fairly wide variation in the appearance of “normal thymus” at various ages is recognized. In young adults, such as this patient, residual thymus is often visualized as small nodular areas of soft tissue interspersed within lowerattenuation anterior mediastinal fat.

106

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Soft Tissue and Lung Coronal 8

Pectoralis major m.

Sternocleidomastoid mm.

Sternum (manubrium) Anterior mediastinum (residual thymus) Left upper lobe apical-posterior subsegmental pulmonary a. Main pulmonary a. Right ventricular outflow tract (infundibulum)

Right internal mammary a. Pectoralis minor m. Right atrial appendage

Left upper lobe anterior subsegmental pulmonary aa.

Right atrium

Left anterior descending coronary a.

Rib

Diagonal coronary a.

Right middle lobe lateral & medial subsegmental pulmonary aa.

Intercostal m. Left ventricle

Right middle lobe pulmonary v. Right ventricle Right coronary a. Diaphragm Stomach

Liver Pectoralis major m.

Sternocleidomastoid mm.

Colon Sternum (manubrium) Anterior mediastinum (residual thymus) Left upper lobe apical-posterior subsegmental pulmonary a. Main pulmonary a. Right ventricular outflow tract (infundibulum)

Right internal mammary a. Right atrial appendage Right upper lobe anterior subsegmental pulmonary a. Right horizontal (minor) fissure Right middle lobe subsegmental pulmonary aa.

Left upper lobe anterior subsegmental pulmonary aa. Left anterior descending coronary a.

Right middle lobe lateral & medial subsegmental pulmonary aa.

Right ventricle Left ventricle

Right atrium

Lingular inferior subsegmental pulmonary a.

Right oblique (major fissure)

Right lower lobe

Left oblique (major) fissure

Right coronary a.

Diaphragm Liver

Stomach

Colon

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

107

Soft Tissue and Lung Coronal 9

Sternum (manubrium) Anterior mediastinum (residual thymus) Right internal mammary a. Clavicle Ascending aorta

Sternocleidomastoid mm. Pericardial fluid (normal)

Left upper lobe apical-posterior subsegmental pulmonary a. & bronchus

Pectoralis major m. Pectoralis minor m. Right upper lobe anterior subsegmental pulmonary a. & bronchi

Main pulmonary a. Left upper lobe anterior subsegmental pulmonary aa. & bronchus Left anterior descending coronary a. Lingular superior subsegmental pulmonary a.

Right horizontal (minor) fissure Rib Right middle lobe lateral subsegmental pulmonary aa. Right middle lobe pulmonary v. Right middle lobe medial subsegmental pulmonary a. & bronchus

Intercostal m. Serratus anterior m. Lingular inferior subsegmental pulmonary a. Left oblique (major) fissure

Right oblique (major) fissure

Left lower lobe

Right lower lobe Diaphragm

Liver Right atrium Right ventricle Stomach Right coronary a.



Colon Left ventricle

NORMAL ANATOMY A small amount of low-attenuation fluid is visualized between the ascending aorta and main pulmonary artery; this fluid represents pericardial fluid. A small amount of pericardial fluid is commonly visualized in various pericardial recesses on thoracic CT studies.

108

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Soft Tissue and Lung Coronal 9

Pectoralis Sternum major m. (manubrium) Sternocleidomastoid mm. Anterior mediastinum (residual thymus)

Clavicle Right internal mammary a.

Pericardial fluid (normal)

Pectoralis minor m. Ascending aorta

Main pulmonary a.

Rib

Left anterior descending coronary a.

Right middle lobe lateral & medial subsegmental pulmonary aa.

Intercostal m.

Right middle lobe pulmonary v.

Serratus anterior m. Left ventricle Diaphragm

Right atrium Liver Pectoralis major m.

Right coronary a.

Sternocleidomastoid m.

Stomach

Colon

Sternum (manubrium) Right internal mammary a. Anterior mediastinum (residual thymus) Left upper lobe apical-posterior subsegmental pulmonary a. & bronchus Main pulmonary a.

Clavicle Pectoralis minor m. Ascending aorta Right upper lobe anterior subsegmental pulmonary a. & bronchi

Left upper lobe anterior subsegmental pulmonary aa. & bronchus Left anterior descending coronary a. Lingular superior subsegmental pulmonary a. Left ventricle Lingular inferior subsegmental pulmonary a. Right coronary a.

Right middle lobe lateral subsegmental pulmonary aa. Right middle lobe medial subsegmental pulmonary a. & bronchus Right oblique (major) fissure

Right lower lobe

Left oblique (major) fissure Diaphragm

Right atrium Liver

Stomach

Colon

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

109

Soft Tissue and Lung Coronal 10

Clavicle Right internal mammary a.

Trachea

Anterior mediastinum (residual thymus)

Ascending aorta

Left upper lobe apical-posterior subsegmental pulmonary a. & bronchus Main pulmonary a.

Pectoralis major m. Pectoralis minor m. Right upper lobe anterior subsegmental pulmonary aa. & bronchus

Left upper lobe anterior subsegmental pulmonary a. & bronchus Left anterior descending coronary a. Lingular superior subsegmental pulmonary a.

Right horizontal (minor) fissure Rib Right middle lobe lateral subsegmental pulmonary aa.

Serratus anterior m. Lingular v.

Right middle lobe pulmonary v.

Lingular inferior subsegmental pulmonary a.

Right oblique (major) fissure

Left oblique (major) fissure

Right middle lobe medial subsegmental pulmonary a. & bronchus Right lower lobe

Left lower lobe

Pulmonary v. Liver

Diaphragm Right atrium

Aortic valve Right coronary a.

Stomach

Posterior interventricular v. (middle cardiac v.)

110

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Colon Papillary m. Left ventricle

Soft Tissue and Lung Coronal 10

Pectoralis major m.

Clavicle

Trachea Anterior mediastinum (residual thymus)

Pectoralis minor m. Main pulmonary a. Right internal mammary a. Left anterior descending coronary a.

Ascending aorta Aortic valve Rib

Papillary m.

Right middle lobe lateral & medial subsegmental pulmonary aa. Serratus anterior m.

Right middle lobe pulmonary v.

Right atrium

Left ventricle Diaphragm

Right coronary a. Posterior interventricular v. (middle cardiac v.) Pectoralis major m.

Stomach

Colon

Clavicle Trachea Anterior mediastinum (residual thymus)

Pectoralis minor m.

Left upper lobe apical-posterior subsegmental pulmonary a. & bronchus

Right internal mammary a. Ascending aorta Right upper lobe anterior subsegmental pulmonary a. & bronchi

Main pulmonary a. Left upper lobe anterior subsegmental pulmonary a. & bronchus

Right horizontal (minor) fissure Right middle lobe medial subsegmental pulmonary a. & bronchus

Left anterior descending coronary a. Lingular superior subsegmental pulmonary a.

Right middle lobe lateral subsegmental pulmonary aa.

Lingular v.

Right oblique (major fissure)

Lingular inferior subsegmental pulmonary a.

Right atrium

Left ventricle

Pulmonary a. Right lower lobe

Left oblique (major) fissure Diaphragm

Right coronary a. Liver

Stomach

Colon

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

111

Soft Tissue and Lung Coronal 11

Sternothyroid & sternohyoid mm. Clavicle Right internal mammary a. Ascending aorta

Left brachiocephalic v.

Trachea

Anterior mediastinum

Pectoralis major m.

Left upper lobe apical-posterior subsegmental pulmonary a. & bronchus Main pulmonary a.

Pectoralis minor m. Right upper lobe anterior subsegmental pulmonary a. & bronchus

Left upper lobe anterior subsegmental pulmonary a. & bronchus Left anterior descending coronary a. Diagonal coronary a. Lingular superior subsegmental pulmonary a. Serratus anterior m.

Right horizontal (minor) fissure Rib Right middle lobe lateral subsegmental pulmonary aa. & bronchus Right middle lobe medial subsegmental pulmonary a. & bronchi

Lingular v. Lingular inferior subsegmental pulmonary a.

Right oblique (major) fissure

Left oblique (major) fissure

Right lower lobe

Left lower lobe

Pulmonary v.

Diaphragm

Liver Right atrium Aortic valve Right coronary a. Posterior interventricular v. (middle cardiac v.)

112

Stomach Left ventricle

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Colon

Papillary mm.

Soft Tissue and Lung Coronal 11

Pectoralis major m.

Trachea

Sternothyroid & sternohyoid mm. Left brachiocephalic v. Anterior mediastinum

Clavicle

Left upper lobe apical-posterior subsegmental pulmonary a.

Pectoralis minor m.

Main pulmonary a. Right internal mammary a.

Left anterior descending coronary a.

Ascending aorta

Diagonal coronary a.

Rib

Aortic valve

Right middle lobe lateral & medial subsegmental pulmonary aa.

Serratus anterior m. Papillary m. Left ventricle

Right atrium

Papillary m.

Right coronary a. Posterior interventricular v. (middle cardiac v.)

Diaphragm Liver

Stomach Clavicle

Trachea

Colon Main pulmonary a.

Right upper lobe apical subsegmental pulmonary a. & bronchus

Left upper lobe apical-posterior subsegmental pulmonary a. & bronchus

Pulmonary v. Pulmonary v. Left upper lobe anterior subsegmental pulmonary a. & bronchus Left anterior descending coronary a. Lingular superior subsegmental pulmonary a.

Right upper lobe anterior subsegmental pulmonary a. & bronchus Right horizontal (minor) fissure Right middle lobe lateral subsegmental pulmonary aa.

Lingular v. Lingular inferior subsegmental pulmonary a.

Right oblique (major) fissure Pulmonary v.

Left oblique (major) fissure

Right lower lobe

Right coronary a.

Right middle lobe medial subsegmental pulmonary a. & bronchi

Left lower lobe Liver

Stomach

Colon

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

113

Soft Tissue and Lung Coronal 12

Sternothyroid & sternohyoid mm. Right brachiocephalic v. Clavicle Right internal mammary a.

Left brachiocephalic v. Anterior mediastinum

Trachea

Ascending aorta

Left upper lobe apical-posterior subsegmental pulmonary a. & bronchus

Pectoralis major m. Pectoralis minor m.

Main pulmonary a. Left atrial appendage

Right upper lobe anterior subsegmental pulmonary a. & bronchus Right horizontal (minor) fissure Rib

Left upper lobe anterior subsegmental pulmonary a. & bronchus Left anterior descending coronary a.

Right middle lobe lateral subsegmental pulmonary a. Right middle lobe medial subsegmental pulmonary a. & bronchi Right oblique (major) fissure

Lingular superior subsegmental pulmonary a. Lingular v. Lingular inferior subsegmental pulmonary a. Left oblique (major) fissure

Right lower lobe

Left lower lobe

Pulmonary v.

Diaphragm

Liver

Right atrium Right coronary a.

Aortic valve

Pancreas

Stomach

Posterior interventricular v. (middle cardiac v.) Left ventricle

114

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Colon Papillary mm.

Soft Tissue and Lung Coronal 12

Pectoralis major m.

Clavicle

Trachea

Sternothyroid & sternohyoid mm. Left brachiocephalic v.

Pectoralis minor m.

Anterior mediastinum Right internal mammary a.

Main pulmonary a. Left atrial appendage

Right brachiocephalic v. (enhanced)

Left anterior descending coronary a.

Ascending aorta

Aortic valve

Right middle lobe lateral & medial subsegmental pulmonary aa.

Papillary m. Left ventricle

Right atrium Right coronary a.

Papillary m. Diaphragm

Posterior interventricular v. (middle cardiac v.)

Stomach Liver

Pancreas

Colon

Clavicle Trachea Left upper lobe apical-posterior subsegmental pulmonary a. & bronchus Main pulmonary a.

Right upper lobe apical subsegmental pulmonary a. & bronchus Pulmonary v.

Pulmonary v. Left upper lobe anterior subsegmental pulmonary a. & bronchus

Right upper lobe anterior subsegmental pulmonary a. & bronchus

Left anterior descending coronary a.

Right horizontal (minor) fissure

Lingular superior subsegmental pulmonary a.

Right middle lobe lateral subsegmental pulmonary a.

Lingular v. Lingular inferior subsegmental pulmonary a. Left ventricle

Right oblique (major) fissure Pulmonary v.

Left oblique (major) fissure

Right lower lobe

Right coronary a. Right middle lobe medial subsegmental pulmonary a. & bronchi

Left lower lobe Liver

Stomach

Colon

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

115

Soft Tissue and Lung Coronal 13

Thyroid gland Trachea Right brachiocephalic v. Clavicle Right internal mammary a. Right subclavian v.

Right brachiocephalic a. Left brachiocephalic v. Anterior mediastinum Pericardial fluid

Ascending aorta Right upper lobe apical subsegmental pulmonary a. & bronchus Superior vena cava Pulmonary v.

Left upper lobe apical-posterior subsegmental pulmonary a. & bronchus Main pulmonary a.

Right upper lobe anterior segment pulmonary a. & subsegmental bronchus Right horizontal (minor) fissure Right middle lobe lateral & medial segment pulmonary aa. Right middle lobe lateral (B4) & medial (B5) segment bronchi Right oblique (major) fissure Right lower lobe

Pulmonary v. Left atrial appendage Left upper lobe anterior subsegmental pulmonary a. & bronchi Left main coronary a. Lingular superior subsegmental pulmonary a. & bronchus Lingular v. Lingular inferior subsegmental pulmonary a. & bronchus

Right lower lobe anterior basal subsegmental pulmonary aa.

Left oblique (major) fissure Left lower lobe

Pulmonary v. Liver

Diaphragm

Right atrium Stomach Pancreas Aortic valve Inferior vena cava Left ventricle Right coronary a. Posterior interventricular v. (middle cardiac v.)



Colon Papillary mm.

NORMAL ANATOMY The oblique (major) and horizontal (minor) fissures are visible. The fissures appear as thin, hypovascular planes on thoracic CT. The horizontal (minor) fissure in particular is often more readily visualized on coronal imaging. Note that the right middle lobe—the region of lung inferior to the horizontal (minor) fissure and cranial to the right oblique (major) fissure—is well visualized on coronal CT imaging.

Soft Tissue and Lung Coronal 13

Right subclavian v. Clavicle (enhanced)

Thyroid gland Trachea Right brachiocephalic a.

Right internal mammary a.

Left brachiocephalic v. Anterior mediastinum

Right brachiocephalic v. (enhanced) Superior vena cava

Pericardial fluid (normal) Main pulmonary a.

Right upper lobe anterior subsegmental pulmonary a.

Left atrial appendage

Ascending aorta Right middle lobe lateral & medial segment pulmonary aa.

Left main coronary a. Papillary m.

Aortic valve Right atrium

Left ventricle

Inferior vena cava

Papillary m.

Right coronary a.

Diaphragm

Posterior interventricular v. (middle cardiac v.)

Stomach Pancreas

Liver Right brachiocephalic v.

Colon

Trachea

Right upper lobe apical subsegmental pulmonary a. & bronchus

Left upper lobe apical-posterior subsegmental pulmonary a. & bronchus Main pulmonary a.

Pulmonary v.

Pulmonary v. Right upper lobe anterior segment pulmonary a. & subsegmental bronchus

Left upper lobe anterior subsegmental pulmonary a. & bronchus

Right horizontal (minor) fissure

Lingular superior subsegmental pulmonary a. & bronchus

Right middle lobe

Lingular v.

Right oblique (major) fissure

Lingular inferior subsegmental pulmonary a. & bronchus

Right middle lobe lateral & medial segment pulmonary aa. & bronchi (B45) Pulmonary v.

Left oblique (major) fissure Posterior interventricular v. (middle cardiac v.)

Right lower lobe anterior basal subsegmental pulmonary aa.

Left lower lobe Right lower lobe

Stomach

Colon

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

117

Soft Tissue and Lung Coronal 14

Right common carotid a. Trachea Right brachiocephalic a. Right internal jugular v. Right brachiocephalic v. Thyroid gland Right internal mammary a. Aortic arch Left subclavian v. Right subclavian v. Right upper lobe apical subsegmental pulmonary a. & bronchus

Main pulmonary a. Pulmonary v.

Right upper lobe anterior segment pulmonary a. & subsegmental bronchus

Left circumflex coronary a. Left atrial appendage Left upper lobe anterior subsegmental pulmonary a. & bronchus Lingular superior subsegmental pulmonary a. & bronchus Lingular v. Lingular inferior subsegmental pulmonary a. & bronchus

Superior vena cava Pulmonary v. Right horizontal (minor) fissure Right middle lobe pulmonary a. Serratus anterior m. Right middle lobe lateral (B4) & medial (B5) segment bronchi Right oblique (major) fissure

Left oblique (major) fissure Left lower lobe anterior basal subsegmental pulmonary a.

Right lower lobe Right lower lobe anterior basal subsegmental pulmonary aa.

Left lower lobe Diaphragm

Pulmonary v. Liver Inferior vena cava Ascending aorta Coronary sinus

Pancreas

Stomach

Left ventricle

118

Left upper lobe apical-posterior subsegmental pulmonary a. & bronchus

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Colon Papillary mm.

Soft Tissue and Lung Coronal 14

Right internal jugular v.

Trachea

Thyroid gland

Right common carotid a.

Left subclavian v.

Right subclavian v. (enhanced) Right brachiocephalic a.

Right internal mammary a. Right brachiocephalic v. (enhanced) Superior vena cava

Aortic arch Main pulmonary a.

Right upper lobe anterior segment pulmonary a.

Left atrial appendage

Pulmonary v. Left circumflex coronary a.

Right middle lobe pulmonary a.

Papillary m.

Serratus anterior m.

Left ventricle Ascending aorta

Papillary m.

Coronary sinus

Diaphragm Stomach

Inferior vena cava Liver Right brachiocephalic v.

Pancreas

Colon

Trachea Left upper lobe apical-posterior subsegmental pulmonary a. & bronchus

Right upper lobe apical subsegmental pulmonary a. & bronchus

Main pulmonary a.

Right upper lobe anterior segment pulmonary a. & subsegmental bronchus

Pulmonary v. Left upper lobe anterior subsegmental pulmonary a. & bronchus

Right horizontal (minor) fissure

Pulmonary v.

Right middle lobe

Lingular superior subsegmental pulmonary a. & bronchus

Right middle lobe pulmonary a.

Lingular v.

Right oblique (major) fissure

Left oblique (major) fissure

Right lower lobe anterior basal subsegmental pulmonary aa.

Left lower lobe

Pulmonary v.

Left lower lobe anterior basal subsegmental pulmonary a.

Right lower lobe Right middle lobe lateral (B4) & medial (B5) segment bronchi

Stomach

Colon

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

119

Soft Tissue and Lung Coronal 15

Right common carotid a. Right subclavian a. Right paratracheal space Right internal mammary a. Right subclavian v. Right upper lobe apical subsegmental pulmonary a. & bronchus

Thyroid gland Trachea

Left common carotid a. Aortic arch Left subclavian v. Left upper lobe apical-posterior subsegmental pulmonary a. & bronchus

Right upper lobe anterior segment pulmonary a. & subsegmental bronchus

Main pulmonary a. Pulmonary v. Left circumflex coronary a. Left atrial appendage

Superior vena cava

Left upper lobe anterior segment pulmonary a. & subsegmental bronchus

Right superior pulmonary v. Right horizontal (minor) fissure

Lingular superior subsegmental pulmonary aa.

Right middle lobe pulmonary a. Right middle lobe lateral (B4) & medial (B5) segment bronchi

Lingular v. Lingular inferior subsegmental pulmonary a.

Right oblique (major) fissure

Left oblique (major) fissure

Right lower lobe

Left lower lobe anterior basal subsegmental pulmonary a.

Right lower lobe anterior basal subsegmental pulmonary a.

Left lower lobe

Pulmonary v.

Diaphragm

Liver

Spleen Inferior vena cava Ascending aorta

120

Coronary sinus

Stomach Pancreas Left ventricle

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Soft Tissue and Lung Coronal 15

Clavicle

Trachea

Thyroid gland Left subclavian v.

Right common carotid a.

Right subclavian a.

Right subclavian v. (enhanced) Right internal mammary a.

Left common carotid a. Right paratracheal space

Aortic arch

Superior vena cava

Main pulmonary a.

Right upper lobe anterior segment pulmonary a. Right pulmonary a.

Left atrial appendage

Right middle lobe pulmonary a. Left circumflex coronary a.

Right superior pulmonary v. Ascending aorta

Left ventricle

Coronary sinus

Diaphragm Stomach

Inferior vena cava Spleen

Pancreas

Liver Superior vena cava

Trachea

Main pulmonary a.

Right upper lobe apical subsegmental pulmonary a. & bronchus

Left upper lobe apical-posterior subsegmental pulmonary a. & bronchus

Right upper lobe anterior segment pulmonary a. & subsegmental bronchus

Pulmonary v.

Left upper lobe anterior subsegmental bronchus & segment pulmonary a. Pulmonary v. Right middle lobe Right middle lobe pulmonary a.

Lingular superior subsegmental pulmonary aa. Lingular v. Lingular inferior subsegmental pulmonary a.

Right oblique (major) fissure Right middle lobe lateral (B4) & medial (B5) segment bronchi

Left oblique (major) fissure Left lower lobe

Right lower lobe anterior basal subsegmental pulmonary a.

Left lower lobe anterior basal subsegmental pulmonary a.

Pulmonary v. Right lower lobe

Coronary sinus

Stomach

Colon

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

121

Soft Tissue and Lung Coronal 16

Right common carotid a. Right subclavian a. Right paratracheal space Right internal mammary a. Trachea Clavicle Right subclavian v.

Esophagus

Left common carotid a. Aortic arch Left subclavian v. Left subclavian a.

Superior vena cava

Main pulmonary a.

Right upper lobe apical subsegmental pulmonary a. & bronchus Right upper lobe anterior segment pulmonary a. & bronchus (B3)

Left upper lobe apical-posterior subsegmental pulmonary a. & bronchus Pulmonary v. Left atrial appendage Left upper lobe anterior segment pulmonary a. & subsegmental bronchus

Right pulmonary a. Pulmonary v. Right horizontal (minor) fissure

Left circumflex coronary a.

Right middle lobe Right oblique (major) fissure

Lingular v. Lingular superior subsegmental pulmonary a.

Right middle lobe pulmonary a.

Lingular inferior subsegmental pulmonary a.

Right middle lobe bronchus

Left oblique (major) fissure

Right lower lobe anterior basal subsegmental pulmonary a. & bronchus

Left lower lobe Left lower lobe anterior basal subsegmental pulmonary a.

Right lower lobe Pulmonary v. Liver

Diaphragm Spleen

Right superior pulmonary v. Inferior vena cava

122

Left atrium Coronary sinus

Mitral valve Pancreas

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Stomach Left ventricle

Soft Tissue and Lung Coronal 16

Clavicle

Right common Trachea Esophagus carotid a.

Right subclavian v. (enhanced)

Left subclavian a. Left subclavian v.

Right internal mammary a.

Right subclavian a.

Right paratracheal space

Left common carotid a. Superior vena cava

Aortic arch Main pulmonary a.

Right upper lobe anterior segment pulmonary a.

Left atrial appendage

Right pulmonary a.

Left circumflex coronary a.

Right interlobar pulmonary a.

Left atrium Mitral valve

Right middle lobe pulmonary a.

Left ventricle

Right superior pulmonary v. Diaphragm Coronary sinus

Stomach

Inferior vena cava Liver

Spleen

Pancreas

Superior vena cava

Trachea

Main pulmonary a.

Right upper lobe apical subsegmental pulmonary a. & bronchus

Left upper lobe apical-posterior subsegmental pulmonary a. & bronchus

Right upper lobe anterior segment pulmonary a. and bronchus (B3)

Pulmonary v. Left upper lobe anterior subsegmental bronchus & segment pulmonary a.

Pulmonary v. Right horizontal (minor) fissure

Lingular superior subsegmental pulmonary a.

Right middle lobe pulmonary a. Right middle lobe

Lingular v.

Right oblique (major) fissure

Lingular inferior subsegmental pulmonary a.

Right middle lobe bronchus Right lower lobe anterior basal subsegmental pulmonary a. & bronchus

Left oblique (major) fissure Left lower lobe

Left lower lobe anterior basal subsegmental pulmonary a.

Pulmonary v. Right lower lobe

Coronary sinus

Stomach

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

123

Soft Tissue and Lung Coronal 17

Right subclavian a. Right paratracheal space Lymph node Trachea Esophagus Left common carotid a. Anterior scalene m. Right internal mammary a. Right upper lobe pulmonary a. Azygos v. (truncus anterior) Right subclavian a.

Aortic arch Aortopulmonary window Main pulmonary a.

Clavicle

Left subclavian a.

Right upper lobe apical segment pulmonary a. & subsegmental bronchus Right upper lobe anterior segment pulmonary a.

Left upper lobe apical-posterior subsegmental pulmonary a. & bronchus Pulmonary v. Left atrial appendage Left upper lobe anterior segment pulmonary a. & subsegmental bronchus

Right upper lobe anterior segment bronchus (B3) Pulmonary v.

Left circumflex & obtuse marginal coronary aa. Lingular v.

Right horizontal (minor) fissure Right middle lobe Right interlobar pulmonary a.

Lingular superior segment bronchus

Right oblique (major) fissure

Lingular superior & inferior segment pulmonary aa.

Right middle lobe bronchus Right lower lobe anterior basal subsegmental pulmonary a. & bronchus

Left oblique (major) fissure Left lower lobe Left lower lobe anterior basal subsegmental pulmonary a.

Right lower lobe Pulmonary v.

Diaphragm

Liver

Spleen Stomach Left ventricle Inferior vena cava Pancreas Right pulmonary a. Mitral valve Coronary sinus Left atrium

Right superior pulmonary v.

124

Left subclavian v.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Soft Tissue and Lung Coronal 17

Clavicle

Left common Anterior scalene carotid a. Esophagus m.

Trachea

Left subclavian a.

Right subclavian a.

Left subclavian v. Right subclavian a.

Right internal mammary a.

Aortic arch Aortopulmonary window Main pulmonary a. Left upper lobe anterior segment pulmonary a.

Right paratracheal space Lymph node Right upper lobe pulmonary a. (truncus anterior)

Left atrial appendage

Right pulmonary a.

Left circumflex & obtuse marginal coronary aa.

Serratus anterior m.

Left atrium Mitral valve

Right interlobar pulmonary a. Right superior pulmonary v.

Left ventricle Diaphragm

Coronary sinus

Stomach

Inferior vena cava Liver

Spleen

Pancreas Trachea

Aortic arch

Right upper lobe apical segment pulmonary a. & subsegmental bronchus

Left upper lobe apical-posterior subsegmental pulmonary a. & bronchus Pulmonary v.

Right upper lobe pulmonary a.

Left upper lobe anterior subsegmental bronchus & segment pulmonary a.

Right upper lobe anterior segment bronchus (B3) Pulmonary v. Right horizontal (minor) fissure

Lingular v.

Right interlobar pulmonary a.

Lingular superior & inferior subsegmental pulmonary aa.

Right middle lobe

Left oblique (major) fissure

Right oblique (major) fissure Right middle lobe bronchus Right lower lobe anterior basal subsegmental pulmonary a. & bronchus

Left lower lobe anterior basal subsegmental pulmonary a. Left lower lobe Right lower lobe Pulmonary v. Coronary sinus

Lingular superior segment bronchus

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

125

Soft Tissue and Lung Coronal 18

Right vertebral a. Azygos v. Trachea Anterior scalene m. Right mainstem bronchus Right subclavian a. Right pulmonary a. Clavicle

Esophagus Left subclavian a. Aortic arch Aortopulmonary window Left pulmonary a.

Right upper lobe apical segment pulmonary a. & bronchus (B1)

Left upper lobe apical-posterior segment pulmonary a. & subsegmental bronchus Pulmonary v.

Right upper lobe anterior segment bronchus (B3) Right upper lobe bronchus Pulmonary v. Lymph node

Left superior pulmonary v. Left upper lobe anterior segment pulmonary a. & subsegmental bronchus

Right horizontal (minor) fissure Serratus anterior m.

Pulmonary v. Lingular superior & inferior segment pulmonary aa. Lingular bronchus

Right middle lobe Right oblique (major) fissure Right lower lobe pulmonary a. Right middle lobe bronchus Right lower lobe anterior basal subsegmental pulmonary aa. & segment bronchus (B8) Right lower lobe

Left circumflex and obtuse marginal coronary aa. Left oblique (major) fissure Left lower lobe Left lower lobe anterior & medial basal subsegmental pulmonary aa. & bronchus

Pulmonary v. Liver

Diaphragm Spleen Inferior vena cava

Left atrium Coronary sinus

126

Pancreas Left ventricle Mitral valve Stomach

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Soft Tissue and Lung Coronal 18

Anterior

Right scalene Clavicle vertebral a. Esophagus muscle Right subclavian a.

Left subclavian a.

Trachea

Aortic arch

Azygos v.

Aortopulmonary window Right upper lobe apical segment pulmonary a.

Left pulmonary a. Left upper lobe anterior segment pulmonary a.

Right mainstem bronchus

Left superior pulmonary v.

Right upper lobe bronchus Lymph node

Left circumflex & obtuse marginal coronary aa.

Right pulmonary a. Right lower lobe pulmonary a.

Left atrium

Serratus anterior m.

Mitral valve

Coronary sinus

Left ventricle

Esophagus

Diaphragm Stomach

Inferior vena cava Liver

Pancreas

Right mainstem Azygos v. bronchus

Trachea

Spleen

Aortic arch & left pulmonary a.

Right upper lobe apical segment pulmonary a. & bronchus (B1)

Left upper lobe apical-posterior segment pulmonary a. & subsegmental bronchus

Right upper lobe bronchus Left upper lobe anterior subsegmental bronchus & segment pulmonary a.

Pulmonary v.

Lingular bronchus

Right upper lobe anterior segment bronchus (B3) Right horizontal (minor) fissure

Lingular superior & inferior segment pulmonary aa.

Right middle lobe Right oblique (major) fissure

Left oblique (major) fissure

Right lower lobe anterior basal subsegmental pulmonary aa. & segment bronchus (B8)

Right middle lobe bronchus Left lower lobe anterior & medial basal subsegmental pulmonary aa. & bronchus

Pulmonary v. Right lower lobe Liver

Coronary sinus

Left lower lobe

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

127

Soft Tissue and Lung Coronal 19

Right vertebral a. Trachea Azygos v. Right mainstem bronchus Esophagus Right subclavian a. Anterior scalene m. Right upper lobe bronchus Clavicle

Left vertebral a. Left subclavian a. Aortic arch Aortopulmonary window

Right upper lobe apical segment pulmonary a. & bronchus (B1) Right upper lobe posterior segment bronchus (B2) and pulmonary a. Pulmonary v. Lymph node Right lower lobe pulmonary a. Right horizontal (minor) fissure Right middle lobe Right oblique (major) fissure Bronchus intermedius Right lower lobe anterior basal subsegmental pulmonary aa. & segment bronchus (B8) Right lower lobe Pulmonary v. Liver Pancreas Right inferior pulmonary v. Inferior vena cava Stomach Left ventricle Left atrium Coronary sinus Esophagus

128

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Left pulmonary a. Left upper lobe apical-posterior segment pulmonary a. and subsegmental bronchus

Left upper lobe anterior segment pulmonary a. Left upper lobe anterior segment bronchus (B3) Left superior pulmonary v. Lingular bronchus Lingular superior & inferior segment pulmonary aa. Left oblique (major) fissure Left circumflex and obtuse marginal coronary aa. Left lower lobe Left lower lobe anterior & medial basal subsegmental pulmonary aa. & bronchi Diaphragm Spleen

Soft Tissue and Lung Coronal 19

Clavicle

Right vertebral a.

Left Esophagus vertebral a.

Anterior scalene muscle

Right subclavian a.

Left subclavian a.

Trachea

Aortic arch

Azygos v.

Aortopulmonary window

Right upper lobe apical segment pulmonary a.

Left upper lobe apical-posterior segment pulmonary Left pulmonary a.

Right upper lobe posterior segment pulmonary a. Right mainstem bronchus

Left upper lobe anterior segment pulmonary a.

Right upper lobe bronchus

Left superior pulmonary v.

Lymph node

Left circumflex & obtuse marginal coronary aa.

Right lower lobe pulmonary a. Bronchus intermedius

Left atrium

Right inferior pulmonary v.

Left ventricle

Coronary sinus

Diaphragm Stomach

Esophagus Liver

Inferior vena cava

Right mainstem bronchus Azygos v.

Trachea

Pancreas

Spleen

Aortic arch & left pulmonary a. Left upper lobe apical-posterior segment pulmonary a. & subsegmental bronchus

Right upper lobe apical segment pulmonary a. & bronchus (B1) Pulmonary v.

Left superior pulmonary v.

Right upper lobe posterior segment bronchus (B2) & pulmonary a.

Left upper lobe anterior segment bronchus (B3) Lingular bronchus

Right horizontal (minor) fissure Right middle lobe

Lingular superior & inferior segment pulmonary aa.

Right oblique (major) fissure

Left oblique (major) fissure

Right lower lobe anterior basal subsegmental pulmonary aa. & segment bronchus (B8) Left lower lobe anterior & medial basal subsegmental pulmonary aa. & bronchus

Pulmonary v. Right lower lobe Liver

Right upper lobe bronchus

Bronchus Coronary intermedius sinus

Left lower lobe

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

129

Soft Tissue and Lung Coronal 20

Right upper lobe apical segment bronchus (B1) & subsegmental pulmonary a.

Subcarinal space Trachea Left vertebral a. Left subclavian a. Azygos v. Descending thoracic aorta Right mainstem bronchus Left mainstem bronchus Pulmonary v. Clavicle Aortopulmonary window

Right upper lobe posterior segment bronchus (B2) and pulmonary a. Pulmonary v. Right upper lobe bronchus Lymph node

Left upper lobe apical-posterior segment pulmonary a. & bronchus (B1+2) Left interlobar pulmonary a.

Right lower lobe basal trunk pulmonary a. Right horizontal (minor) fissure Right middle lobe

Left superior pulmonary v. Left upper lobe anterior segment bronchus (B3) Lingular bronchus

Right oblique (major) fissure

Lingular superior & inferior segment pulmonary aa.

Bronchus intermedius

Left circumflex and obtuse marginal coronary aa.

Right lower lobe anterior basal segment pulmonary a. & bronchus (B8)

Left oblique (major) fissure Left lower lobe Left lower lobe anterior & medial basal subsegmental pulmonary aa. & bronchi

Right lower lobe Pulmonary v.

Diaphragm

Liver

Spleen

Right inferior pulmonary v.

Left atrium Esophagus

Pancreas

Stomach

Coronary sinus



NORMAL ANATOMY The subcarinal space is illustrated on this and subsequent images. The subcarinal space is the region of the mediastinum just inferior to the carina, and often contains lymph nodes. The subcarinal space is occasionally involved with a number of pathological processes, notably lymphadenopathy.

130

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Soft Tissue and Lung Coronal 20

Clavicle

Trachea

Left Left vertebral a. subclavian a.

Pulmonary v.

Descending thoracic aorta

Right upper lobe apical segment pulmonary a.

Aortopulmonary window

Azygos v. Right upper lobe posterior segment pulmonary a.

Left interlobar pulmonary a. Left mainstem bronchus

Right mainstem bronchus Lymph node

Subcarinal space

Right lower lobe basal trunk pulmonary a.

Left superior pulmonary v.

Bronchus intermedius Right inferior pulmonary v. Serratus anterior m.

Left circumflex & obtuse marginal coronary aa.

Left atrium

Diaphragm

Coronary sinus

Stomach

Esophagus Pancreas

Liver Right mainstem bronchus Azygos v.

Spleen

Descending thoracic aorta & Trachea left pulmonary a.

Right upper lobe apical subsegmental pulmonary a. & segment bronchus (B1)

Left upper lobe apical-posterior segment pulmonary a. & bronchus (B12)

Pulmonary v.

Left upper lobe anterior segment bronchus (B3)

Right upper lobe posterior segment bronchus (B2) & pulmonary a.

Lingular bronchus

Right horizontal (minor) fissure

Lingular superior & inferior segment pulmonary aa.

Right middle lobe Right oblique (major) fissure

Left atrium

Right lower lobe basal trunk pulmonary a. Left oblique (major) fissure

Right lower lobe anterior basal segment pulmonary a. & bronchus (B8)

Left lower lobe anterior & medial basal subsegmental pulmonary aa. & bronchi

Pulmonary v. Right lower Right upper lobe lobe bronchus

Bronchus intermedius

Left circumflex coronary a.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

131

Soft Tissue and Lung Coronal 21

Azygos v. Right mainstem bronchus Pulmonary v. Clavicle

Trachea Carina

Subcarinal space Descending thoracic aorta Left mainstem bronchus

Right upper lobe apical subsegmental pulmonary a. & bronchus Right upper lobe posterior segment pulmonary a. & bronchus

Pulmonary v.

Bronchus intermedius

Left interlobar pulmonary a.

Right lower lobe bronchus

Lymph node

Right horizontal (minor) fissure Right middle lobe Right oblique (major) fissure

Left upper lobe bronchus Lingular pulmonary a.

Right lower lobe basal trunk pulmonary a. Right lower lobe anterior basal subsegmental pulmonary a. & bronchus Right lower lobe medial basal segment bronchus (B7) Right lower lobe

Left oblique (major) fissure

Left lower lobe anterior & medial basal subsegmental pulmonary aa. & bronchi Diaphragm Spleen

Pulmonary v. Liver Right inferior pulmonary v.

Left atrium

Esophagus Coronary sinus

132

Stomach Pancreas Great cardiac v.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Soft Tissue and Lung Coronal 21

Corocoid process (scapula)

Clavicle Pulmonary v. Trachea

Descending thoracic aorta Azygos v. Pulmonary v. Right upper lobe posterior subsegmental pulmonary a.

Subcarinal space Left interlobar pulmonary a.

Right mainstem bronchus

Lymph node Left mainstem bronchus

Bronchus intermedius Right lower lobe superior segment pulmonary a. Right lower lobe basal trunk pulmonary a. Right lower lobe bronchus

Left upper lobe bronchus Lingular pulmonary a.

Serratus anterior muscle

Great cardiac v.

Pulmonary v. Right inferior pulmonary v.

Diaphragm

Left atrium

Stomach

Coronary sinus Esophagus

Liver Azygos v.

Pancreas

Spleen

Descending thoracic aorta & left pulmonary a.

Trachea

Pulmonary v

Right upper lobe apical subsegmental pulmonary a. & bronchus

Left mainstem bronchus Right mainstem bronchus Right upper lobe posterior subsegmental pulmonary a. & bronchus

Left upper lobe bronchus

Right lower lobe bronchus Lingular pulmonary a. Right middle lobe Right lower lobe basal trunk pulmonary a. Right lower lobe anterior basal subsegmental pulmonary a. & bronchus

Carina

Left lower lobe anterior & medial basal subsegmental pulmonary aa. & bronchi

Pulmonary v. Right lower lobe Right lower lobe medial basal segment bronchus (B7)

Right inferior pulmonary v.

Bronchus intermedius

Left Great atrium cardiac v.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

133

Soft Tissue and Lung Coronal 22

Vertebral body Subcarinal space Right mainstem bronchus Azygos v. Humerus

Clavicle

Carina Esophagus Trachea

Descending thoracic aorta Left mainstem bronchus Corocoid process (scapula)

Right upper lobe apical subsegmental pulmonary a. & bronchus Right upper lobe posterior subsegmental pulmonary a. & bronchi

Pulmonary v. Left interlobar pulmonary a.

Pulmonary v. Bronchus intermedius Right oblique (major) fissure Right lower lobe superior segment pulmonary a. Right lower lobe bronchus Right lower lobe posterolateral basal trunk pulmonary a. Right lower lobe

Lymph node

Right lower lobe anterior basal subsegmental pulmonary a. & bronchus Right lower lobe basal bronchial trunk Pulmonary v. Liver

Left lower lobe anterior & medial basal subsegmental pulmonary aa. & bronchi

Left upper lobe bronchus

Lymph node Lingular pulmonary a. Left oblique (major) fissure Left inferior pulmonary v. Great cardiac v.

Diaphragm Spleen Pulmonary vv.

134

Esophagus

Left atrium

Pancreas Stomach

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Soft Tissue and Lung Coronal 22

Vertebral Clavicle Azygos v. body Esophagus

Humerus

Corocoid process (scapula)

Trachea Descending thoracic aorta

Right upper lobe posterior subsegmental pulmonary aa.

Pulmonary v. Left interlobar pulmonary a. Lymph node

Right mainstem bronchus

Left upper lobe bronchus

Bronchus intermedius Right lower lobe superior segment pulmonary a.

Lymph node Left mainstem bronchus Subcarinal space Left inferior pulmonary v.

Right lower lobe posterolateral basal trunk pulmonary a.

Left atrium

Great cardiac v. Pulmonary vv.

Diaphragm Liver Azygos v.

Esophagus Trachea

Stomach

Pancreas

Spleen

Descending thoracic aorta & left interlobar pulmonary a.

Right upper lobe apical subsegmental pulmonary a. & bronchus Right mainstem bronchus

Pulmonary v. Left mainstem bronchus

Pulmonary v. Left upper lobe bronchus

Right upper lobe posterior subsegmental pulmonary a. & bronchus

Lingular pulmonary a.

Right lower lobe bronchus

Left oblique (major) fissure

Right lower lobe superior segment pulmonary a. Right lower lobe basal bronchial trunk

Carina Left inferior pulmonary v.

Right lower lobe anterior basal subsegmental pulmonary a. & bronchus

Left lower lobe anterior & medial basal subsegmental pulmonary aa. & bronchi

Pulmonary vv. Liver

Right lower lobe Esophagus

Left atrium

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

135

Soft Tissue and Lung Coronal 23

Humerus

Pulmonary v. Right upper lobe apical subsegmental pulmonary a. & bronchus Pulmonary v.

Clavicle

Esophagus Vertebral body Azygos v.

Esophagus Descending thoracic aorta Left mainstem bronchus Corocoid process (scapula)

Pulmonary v.

Right upper lobe posterior subsegmental pulmonary a. & subsegmental bronchus Right lower lobe superior subsegmental pulmonary a. & segment bronchus (B6) Right oblique (major) fissure Serratus anterior m. Right lower lobe basal trunk pulmonary a. and bronchus Right lower lobe lateral basal segment pulmonary a.

Left upper lobe apical-posterior subsegmental bronchi Left interlobar pulmonary a. Lingular pulmonary a. Lymph node Left oblique (major) fissure Left lower lobe bronchus Left lower lobe anterior & medial basal subsegmental pulmonary aa. & bronchi

Right lower lobe Pulmonary vv.

Diaphragm Spleen

Liver Left inferior pulmonary v.

136

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Pancreas Stomach

Soft Tissue and Lung Coronal 23

Humerus

Clavicle

Vertebral Esophagus body

Corocoid process Pulmonary v. (scapula)

Azygos v.

Descending thoracic aorta Right upper lobe posterior subsegmental pulmonary aa.

Left interlobar pulmonary a.

Serratus anterior m.

Left mainstem bronchus

Right lower lobe superior subsegmental pulmonary a. Lymph node

Right lower lobe posterolateral basal trunk pulmonary a.

Left inferior pulmonary v. Diaphragm

Pulmonary vv. Liver Pulmonary v.

Azygos v.

Esophagus Esophagus

Stomach Pancreas

Spleen

Descending thoracic aorta & left interlobar pulmonary a.

Right upper lobe apical subsegmental pulmonary a. & bronchus

Pulmonary v.

Left upper lobe apicalposterior subsegmental bronchi

Pulmonary vv. Right upper lobe posterior subsegmental pulmonary a. & bronchus

Left mainstem bronchus Lingular pulmonary a.

Right oblique (major) fissure

Left oblique (major) fissure

Right lower lobe superior subsegmental pulmonary a. & segment bronchus (B6)

Left lower lobe bronchus

Right lower lobe basal trunk bronchus & pulmonary a.

Left inferior pulmonary v.

Right lower lobe lateral basal segment pulmonary a.

Left lower lobe anterior & medial basal subsegmental pulmonary aa. & bronchi

Pulmonary v. Liver Right lower lobe

Left lower lobe

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

137

Soft Tissue and Lung Coronal 24

Vertebral body Right upper lobe apical subsegmental pulmonary aa. & bronchus Humerus

Clavicle Pulmonary v.

Esophagus

Azygos v.

Descending thoracic aorta

Pulmonary v.

Corocoid process (scapula)

Right upper lobe posterior subsegmental pulmonary a. & bronchi

Pulmonary a.

Right lower lobe superior segment bronchus (B6) & subsegmental pulmonary aa.

Left upper lobe apical-posterior subsegmental bronchi Left interlobar pulmonary a. Lingular pulmonary a.

Right oblique (major) fissure Serratus anterior m.

Left lower lobe bronchus & pulmonary a. Left oblique (major) fissure

Right lower lobe posterior basal segment pulmonary a. Right lower lobe lateral basal segment pulmonary a. & bronchus (B9)

Left lower lobe anteromedial basal segment pulmonary a. & bronchus (B7+8) Left lower lobe anterior & medial basal subsegmental bronchi Left lower lobe medial basal subsegmental pulmonary a.

Right lower lobe

Pulmonary vv. Diaphragm Liver

Spleen Left inferior pulmonary v.

138

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Pancreas Stomach

Soft Tissue and Lung Coronal 24

Humerus Clavicle

Azygos v. Esophagus

Vertebral body

Corocoid process (scapula) Descending thoracic aorta

Right upper lobe posterior subsegmental pulmonary aa. Esophagus

Left interlobar pulmonary a.

Serratus anterior m. Lingular pulmonary a. Right lower lobe superior subsegmental pulmonary aa.

Left inferior pulmonary v.

Right lower lobe posterior basal segment pulmonary a. Left lower lobe medial basal subsegmental pulmonary a.

Right lower lobe lateral basal segment pulmonary a.

Diaphragm

Pulmonary vv. Liver

Stomach Pancreas

Descending Pulmonary v. Azygos v. thoracic aorta

Spleen

Pulmonary vv. Pulmonary a.

Right upper lobe apical subsegmental pulmonary aa. & bronchus

Left upper lobe apicalposterior subsegmental bronchi

Pulmonary v. Left interlobar pulmonary a.

Right upper lobe posterior segment pulmonary a. & subegmental bronchi

Lingular pulmonary a.

Right oblique (major) fissure

Left oblique (major) fissure

Right lower lobe superior subsegmental pulmonary aa. & segment bronchus (B6)

Left lower lobe bronchus & pulmonary a. Left lower lobe anteromedial basal segment pulmonary a. & bronchus (B78)

Right lower lobe posterior basal segment pulmonary a. Right lower lobe lateral basal segment pulmonary a. & bronchus (B9)

Left lower lobe medial basal subsegmental pulmonary a. Left lower lobe anterior & medial basal subsegmental bronchi

Right lower lobe Liver Pulmonary vv.

Esophagus

Left inferior Left lower lobe pulmonary v.

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139

Soft Tissue and Lung Coronal 25

Pulmonary v. Right upper lobe apical subsegmental pulmonary a. & bronchus Humerus

Clavicle

Vertebral body Azygos v.

Esophagus Descending thoracic aorta Corocoid process (scapula)

Glenoid (scapula)

Subscapularis m.

Pulmonary v. Right upper lobe posterior subsegmental bronchus and pulmonary aa. Right lower lobe superior segment bronchus (B6) & subsegmental pulmonary aa.

Pulmonary vv. Pulmonary a. Left upper lobe apical-posterior subsegmental bronchi Left interlobar pulmonary a. Left lower lobe bronchus & pulmonary a.

Right oblique (major) fissure Serratus anterior m. Right lower lobe posterior basal segment pulmonary a. & bronchus (B10) Right lower lobe lateral basal segment pulmonary a. & bronchus (B9)

Left oblique (major) fissure Left lower lobe basal trunk bronchus & pulmonary a. Left lower lobe anteromedial basal segment pulmonary a. & bronchus (B7+8)

Right lower lobe

Left lower lobe Pulmonary vv. Diaphragm Liver

Spleen Adrenal gland

Pancreas

Stomach Left inferior pulmonary v.

140

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Soft Tissue and Lung Coronal 25

Humerus

Clavicle Azygos v.

Esophagus

Vertebral body

Corocoid process (scapula)

Descending thoracic aorta Glenoid (scapula) Left interlobar pulmonary a. Right upper lobe posterior subsegmental pulmonary aa. Subscapularis m.

Esophagus

Left lower lobe bronchus

Serratus anterior m.

Right lower lobe superior subsegmental pulmonary aa.

Left lower lobe anteromedial basal segment pulmonary a.

Left inferior pulmonary v. Right lower lobe posterior basal segment pulmonary a.

Diaphragm Liver

Pulmonary vv.

Adrenal Stomach Pancreas Spleen gland

Descending Pulmonary v. Azygos v. thoracic aorta Pulmonary v. Pulmonary a. Right upper lobe apical subsegmental pulmonary a. & bronchus

Left upper lobe apicalposterior subsegmental bronchi

Pulmonary v.

Right upper lobe posterior subsegmental aa. & bronchus

Left interlobar pulmonary a.

Right oblique (major) fissure Left oblique (major) fissure

Right lower lobe superior subsegmental pulmonary aa. & segment bronchus (B6)

Left lower lobe bronchus & pulmonary a.

Right lower lobe posterior basal segment pulmonary a. & bronchus (B10)

Left lower lobe basal trunk bronchus & pulmonary a.

Right lower lobe lateral basal segment pulmonary a. & bronchus (B9)

Pulmonary vv.

Left lower lobe anteromedial basal segment bronchus (B7+8) Liver

Right lower lobe Esophagus Pulmonary vv. Left lower lobe NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

141

Soft Tissue and Lung Coronal 26

Pulmonary vv. Right upper lobe apical subsegmental pulmonary a. Humerus

Vertebral body Azygos v.

Descending thoracic aorta Scapula

Glenoid (scapula)

Pulmonary v.

Pulmonary v.

Pulmonary a.

Right upper lobe posterior subsegmental pulmonary aa. Right lower lobe superior subsegmental bronchus & pulmonary aa.

Subscapularis m. Left upper lobe apical-posterior subsegmental bronchus Rib Left lower lobe superior segment pulmonary a. & bronchus (B6)

Right oblique (major) fissure Serratus anterior m.

Left oblique (major) fissure

Right lower lobe posterior basal segment pulmonary a. & subsegmental bronchus

Left lower lobe posterior basal segment bronchus (B10) Left lower lobe lateral basal segment pulmonary a. & bronchus (B9)

Right lower lobe lateral basal subsegmental pulmonary a. & bronchus Right lower lobe

Left lower lobe

Pulmonary vv.

Diaphragm

Liver

Spleen Kidney

142

Diaphragm

Pulmonary vv. Adrenal gland

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Soft Tissue and Lung Coronal 26

Glenoid Humerus (scapula)

Azygos v.

Vertebral body

Descending thoracic aorta

Scapula

Left lower lobe superior segment pulmonary a. Subscapularis m. Right lower lobe superior subsegmental pulmonary aa. Rib Right lower lobe posterior basal subsegmental pulmonary a.

Pulmonary v. Descending thoracic aorta

Pulmonary vv.

Diaphragm

Liver

Kidney

Pulmonary vv.

Diaphragm

Descending thoracic aorta

Adrenal gland

Spleen

Pulmonary v. Pulmonary a.

Right upper lobe apical subsegmental pulmonary a. Left upper lobe apicalposterior subsegmental bronchus

Pulmonary v. Right upper lobe posterior subsegmental pulmonary aa.

Left lower lobe superior segment pulmonary a. & bronchus (B6)

Right oblique (major) fissure

Left oblique (major) fissure

Right lower lobe superior subsegmental pulmonary aa. & bronchus

Left lower lobe lateral basal segment pulmonary a. & bronchus (B9)

Right lower lobe posterior basal segment pulmonary a. & subsegmental bronchus Right lower lobe lateral basal subsegmental pulmonary a. & bronchus (B9)

Left lower lobe posterior basal segment bronchus (B10) Pulmonary vv. Right lower lobe Pulmonary vv.

Left lower lobe

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

143

Soft Tissue and Lung Coronal 27

Pulmonary vv. Right upper lobe apical subsegmental pulmonary a. Humerus

Vertebral body Azygos v.

Spinal cord Descending thoracic aorta Scapula

Glenoid (scapula)

Subscapularis m.

Pulmonary v.

Pulmonary v.

Right upper lobe posterior subsegmental pulmonary aa.

Pulmonary a.

Right lower lobe superior subsegmental bronchi & pulmonary aa.

Left upper lobe apical-posterior subsegmental bronchus

Rib

Left oblique (major) fissure

Right oblique (major) fissure

Left lower lobe superior segment pulmonary a. & bronchus (B6)

Right lower lobe posterior basal segment pulmonary a. & subsegmental bronchi Right lower lobe lateral basal subsegmental pulmonary a.

Left lower lobe lateral basal subsegmental pulmonary a. & bronchi Left lower lobe posterior basal segment bronchus (B10) & pulmonary a. Left lower lobe lateral basal subsegmental pulmonary a. Diaphragm

Right lower lobe Pulmonary vv. Liver

Spleen Kidney

144

Diaphragm

Adrenal gland Pulmonary vv.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Soft Tissue and Lung Coronal 27

Humerus

Glenoid (scapula) Azygos v.

Spinal cord

Vertebral body

Scapula

Descending thoracic aorta

Subscapularis m. Left lower lobe superior segment pulmonary a. Right lower lobe superior subsegmental pulmonary aa.

Rib

Right lower lobe posterior basal subsegmental pulmonary a.

Pulmonary v.

Pulmonary vv.

Descending thoracic aorta Diaphragm Liver

Kidney Diaphragm

Pulmonary vv.

Adrenal gland

Spleen

Descending thoracic aorta Pulmonary v. Pulmonary a.

Right upper lobe apical subsegmental pulmonary a. Pulmonary v.

Left upper lobe apicalposterior subsegmental bronchus

Right upper lobe posterior subsegmental pulmonary aa.

Left oblique (major) fissure

Right oblique (major) fissure Right lower lobe superior subsegmental pulmonary aa. & bronchi

Left lower lobe superior segment pulmonary a. & bronchus (B6)

Right lower lobe posterior basal segment pulmonary a. & subsegmental bronchi

Left lower lobe lateral basal subsegmental pulmonary aa. & bronchi

Right lower lobe lateral basal subsegmental pulmonary a.

Pulmonary vv. Liver

Right lower lobe

Pulmonary vv. Left lower lobe

Left lower lobe posterior basal segment bronchus (B10) & pulmonary a.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

145

Soft Tissue and Lung Coronal 28

Pulmonary vv. Vertebral body Right upper lobe apical Azygos v. subsegmental pulmonary a. Humerus

Spinal cord Descending thoracic aorta

Scapula

Scapula Subscapularis m. Pulmonary v. Pulmonary a.

Right upper lobe posterior subsegmental pulmonary aa.

Rib Left lower lobe superior subsegmental pulmonary a. & bronchi

Right oblique (major) fissure

Left oblique (major) fissure

Right lower lobe superior subsegmental bronchi & pulmonary aa.

Pulmonary v.

Right lower lobe posterior basal subsegmental pulmonary aa. & bronchi

Left lower lobe lateral basal subsegmental bronchi Left lower lobe posterior basal segment pulmonary a. & subsegmental bronchi

Right lower lobe

Left lower lobe lateral basal subsegmental pulmonary a.

Pulmonary vv.

Diaphragm

Liver

Spleen Kidney Intercostal aa.

146

Diaphragm

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Pulmonary vv.

Soft Tissue and Lung Coronal 28

Spinal cord

Humerus Scapula

Vertebral body

Scapula

Descending thoracic aorta Subscapularis m.

Azygos v.

Left lower lobe superior subsegmental pulmonary a. Intercostal aa. Rib Pulmonary v.

Pulmonary vv.

Descending thoracic aorta Diaphragm Liver

Kidney Diaphragm

Descending Pulmonary vv. thoracic aorta

Spleen Pulmonary v. Pulmonary a.

Right upper lobe apical subsegmental pulmonary a. Right upper lobe posterior subsegmental pulmonary aa. Right oblique (major) fissure

Left oblique (major) fissure

Right lower lobe superior subsegmental pulmonary aa. & bronchi

Left lower lobe superior subsegmental pulmonary a. & bronchi

Right lower lobe posterior basal subsegmental pulmonary aa. & bronchi

Left lower lobe lateral basal subsegmental pulmonary a. & bronchi

Pulmonary vv.

Liver

Right lower lobe

Pulmonary vv.

Left lower lobe

Left lower lobe posterior basal segment pulmonary a. & subsegmental bronchi

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147

Soft Tissue and Lung Coronal 29

Vertebral body

Spinal cord Supraspinatus m.

Infraspinatus m. Scapula

Pulmonary vv.

Subscapularis m

Right upper lobe posterior subsegmental pulmonary aa. Scapula

Pulmonary v. Pulmonary a. Rib

Right oblique (major) fissure Left oblique (major) fissure

Right lower lobe superior subsegmental bronchi & pulmonary aa.

Left lower lobe superior subsegmental pulmonary a. & bronchi Left lower lobe lateral basal subsegmental pulmonary a. & bronchus Left lower lobe posterior basal subsegmental pulmonary a. & bronchi

Right lower lobe posterior basal subsegmental pulmonary aa. & bronchi Right lower lobe

Left lower lobe lateral basal subsegmental pulmonary a. & bronchus

Pulmonary vv. Diaphragm

Liver

Spleen Kidney

148

Diaphragm

Pulmonary vv. Hemiazygos v.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Soft Tissue and Lung Coronal 29

Spinal cord

Vertebral body

Supraspinatus m.

Scapula Infraspinatus m.

Scapula

Subscapularis m. Rib Left lower lobe superior subsegmental pulmonary a.

Pulmonary v.

Hemiazygos v. Pulmonary vv. Diaphragm Liver

Kidney

Pulmonary vv.

Diaphragm Pulmonary v.

Spleen Pulmonary a.

Right upper lobe posterior subsegmental pulmonary aa. Left oblique (major) fissure

Right oblique (major) fissure Right lower lobe superior subsegmental pulmonary aa. & bronchi

Left lower lobe superior subsegmental pulmonary a. & bronchi

Right lower lobe posterior basal subsegmental pulmonary aa. & bronchus

Left lower lobe lateral basal subsegmental pulmonary aa. & bronchus

Pulmonary vv. Pulmonary vv.

Right lower lobe

Liver

Left lower lobe Left lower lobe posterior basal subsegmental pulmonary a. & bronchi NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

149

Soft Tissue and Lung Coronal 30

Vertebral body

Spinal cord Supraspinatus m.

Infraspinatus m.

Scapula

Right upper lobe posterior subsegmental pulmonary a.

Subscapularis m. Rib

Scapula Pulmonary a. Right oblique (major) fissure Left oblique (major) fissure Right lower lobe superior subsegmental pulmonary aa.

Left lower lobe superior subsegmental pulmonary a. & bronchus

Right lower lobe posterior basal subsegmental pulmonary aa. Latissimus dorsi m.

Left lower lobe lateral basal subsegmental pulmonary a. & bronchus Left lower lobe posterior basal subsegmental pulmonary a. & bronchus

Right lower lobe

Pulmonary vv.

Diaphragm

Liver

Spleen Kidney

150

Diaphragm

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Pulmonary vv. Left lower lobe posterior basal subsegmental pulmonary a.

Soft Tissue and Lung Coronal 30

Spinal cord

Infraspinatus m.

Supraspinatus m.

Scapula

Scapula

Subscapularis m. Rib Left lower lobe superior subsegmental pulmonary a.

Latissimus dorsi m.

Vertebral body

Pulmonary v. Diaphragm Liver

Kidney

Diaphragm

Right upper lobe posterior subsegmental pulmonary a.

Spleen Pulmonary a.

Left oblique (major) fissure Right oblique (major) fissure

Left lower lobe superior subsegmental pulmonary a. & bronchus

Right lower lobe superior subsegmental pulmonary aa.

Pulmonary a. Left lower lobe lateral basal subsegmental pulmonary a. & bronchus

Right lower lobe posterior basal subsegmental pulmonary aa.

Left lower lobe posterior basal subsegmental pulmonary aa. & bronchus

Pulmonary vv.

Liver Right lower lobe

Pulmonary vv.

Left lower lobe

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

151

Soft Tissue and Lung Coronal 31

Vertebral body

Spinal cord Supraspinatus m.

Infraspinatus m.

Scapula Subscapularis m.

Scapula

Rib

Right oblique (major) fissure

Left oblique (major) fissure

Right lower lobe superior subsegmental pulmonary aa.

Left lower lobe superior subsegmental pulmonary a.

Right lower lobe posterior basal subsegmental pulmonary aa.

Left lower lobe lateral basal subsegmental pulmonary aa.

Latissimus dorsi m.

Left lower lobe posterior basal subsegmental pulmonary aa. & bronchus

Right lower lobe

Pulmonary vv. Liver Kidney

152

Diaphragm

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Pulmonary vv.

Soft Tissue and Lung Coronal 31

Spinal cord

Infraspinatus m.

Supraspinatus m.

Scapula

Scapula

Subscapularis m. Rib

Latissimus dorsi m.

Liver

Kidney

Diaphragm

Right oblique (major) fissure

Left oblique (major) fissure Left lower lobe superior subsegmental pulmonary a.

Right lower lobe superior subsegmental pulmonary aa. Right lower lobe posterior basal subsegmental pulmonary aa.

Left lower lobe lateral basal subsegmental pulmonary aa. Left lower lobe posterior basal subsegmental pulmonary aa. & bronchus

Pulmonary vv.

Liver

Right lower lobe

Pulmonary vv.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

153

Soft Tissue and Lung Coronal 32

Vertebral body

Spinal cord

Vertebral spinous processes Levator scapulae m.

Supraspinatus m.

Infraspinatus m.

Scapula Scapula

Subscapularis m. Rib

Right oblique (major) fissure

Left oblique (major) fissure

Right lower lobe superior subsegmental pulmonary aa.

Left lower lobe superior subsegmental pulmonary a.

Right lower lobe posterior basal subsegmental pulmonary aa.

Left lower lobe lateral basal subsegmental pulmonary aa.

Latissimus dorsi m.

Left lower lobe posterior basal subsegmental pulmonary aa. & bronchus

Right lower lobe

Left lower lobe

Pulmonary vv.

Kidney

154

Diaphragm

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Pulmonary v.

Pulmonary v.

Soft Tissue and Lung Coronal 32

Vertebral spinous processes

Infraspinatus m.

Spinal cord

Levator scapulae m. Supraspinatus m. Scapula

Subscapularis m.

Scapula

Rib

Vertebral body

Latissimus dorsi m.

Kidney

Diaphragm

Right oblique (major) fissure

Left oblique (major) fissure

Left lower lobe superior subsegmental pulmonary a.

Right lower lobe superior subsegmental pulmonary aa.

Left lower lobe lateral basal subsegmental pulmonary aa.

Right lower lobe posterior basal subsegmental pulmonary aa.

Left lower lobe Left lower lobe posterior basal subsegmental pulmonary aa.

Pulmonary vv.

Right lower lobe

Pulmonary vv.

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155

Soft Tissue and Lung Coronal 33

Vertebral transverse process

Spinal cord

Scapula Infraspinatus m. Supraspinatus m. Scapula

Rib

Right lower lobe peripheral pulmonary a. Latissimus dorsi m.

Left lower lobe

Right lower lobe

Diaphragm

156

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Soft Tissue and Lung Coronal 33

Infraspinatus m.

Scapula

Supraspinatus m.

Scapula

Vertebral transverse process Rib Rhomboid major m.

Spinal cord Latissimus dorsi m.

Diaphragm

Right lower lobe peripheral pulmonary a. Right lower lobe

Left lower lobe

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

157

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Chapter

3

PULMONARY ANATOMY AND VARIANTS 2 3

1

AXIALâ•… 160

1

CORONALâ•… 166

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159

Pulmonary Axial 1

Inferior vena cava Right oblique (major) fissure

Left oblique (major) fissure

Right lower lobe inferior accessory fissure Right lower lobe posterior basal subsegmental bronchi



Descending thoracic aorta

Left lower lobe posterior basal subsegmental bronchi

NORMAL VARIANTS A thin, well-defined linear structure representing an inferior accessory fissure. An inferior accessory fissure segregates the medial basal segment of either lower lobe from the remaining basal segments. This variation is a common finding in the population and generally of no clinical significance.

160

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Pulmonary Axial 1

Right oblique (major) fissure

Inferior vena cava

Descending thoracic aorta

Left oblique (major) fissure

Right lower lobe inferior accessory fissure

Right lower lobe posterior basal subsegmental bronchi

Left lower lobe posterior basal subsegmental bronchi

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161

Pulmonary Axial 2

Azygos fissure & v.

Azygos lobe

Trachea

Aortic arch

Left oblique (major) fissure



NORMAL VARIANTS A thin, curvilinear structure extends through the medial right upper lobe, representing an azygos fissure—the lung subtended by the azygos fissure is referred to as the azygos lobe. The azygos vein courses through the azygos fissure. This anomaly is formed when the azygos vein extends into the right upper lobe during fetal development. The azygos fissure consists of 4 layers of pleura: 2 of visceral pleura and 2 of parietal pleura. This finding is a usually an incidentally detected anomaly, without clinical significance, and is found in 0.3% to 0.5% of the population.

162

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Pulmonary Axial 2

Azygos lobe

Trachea

Aortic arch

Azygos fissure & v.

Left oblique (major) fissure

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163

Pulmonary Axial 3

Tracheal bronchus

Superior vena cava

Right upper lobe subsegmental bronchi



Trachea

Ascending aorta

Spine

Esophagus

Descending thoracic aorta

Left upper lobe bronchi

Left oblique (major) fissure

NORMAL VARIANTS An anomalous bronchus originating directly from the right lateral trachea wall—this anomaly is known as a tracheal bronchus. A tracheal bronchus supplies all or a portion of the apical segment of the right upper lobe and is found in 0.1% of the population.

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Pulmonary Axial 3

Superior vena cava

Trachea

Ascending aorta

Tracheal bronchus

Esophagus

Right upper lobe subsegmental bronchi

Left upper lobe bronchi

Left oblique (major) fissure

Spine

Descending thoracic aorta

Left lower lobe superior segment

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165

Pulmonary Coronal 1

Right upper lobe bronchus Right upper lobe Right oblique (major) fissure

Bronchus intermedius

Right lower lobe Right lower lobe pulmonary a.



Right mainstem bronchus Tracheal bronchus

Right lower lobe basal segment bronchi

Left mainstem bronchus Aorta

Trachea

Carina Right lower lobe bronchus

Aorta

Pulmonary a.

Left upper lobe & lingular bronchi

Left lower lobe Left lower lobe bronchus Left inferior pulmonary v.

NORMAL VARIANTS The coronal projection of the patient shown in Axial 3. The right upper lobe tracheal bronchus is seen to advantage.

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Pulmonary Coronal 1

Right mainstem bronchus

Tracheal bronchus

Trachea

Aorta

Right upper lobe

Left mainstem bronchus

Right upper lobe bronchus

Pulmonary a.

Bronchus intermedius

Left upper lobe & lingular bronchus

Right oblique (major) fissure

Left lower lobe bronchus

Right lower lobe pulmonary a.

Left inferior pulmonary v.

Right lower lobe basal segment bronchi

Right lower lobe Left lower lobe

Right lower lobe bronchus

Carina

Aorta

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Chapter

4

THORACIC LYMPH NODES

1 3 5 7

1 2 4 6 8

2 3 5 7

4 6

8 9

9

AXIALâ•… 170

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169

Lymph Nodes Axial 1

Left brachiocephalic (innominate) v.

Sternum (manubrium) Right brachiocephalic (innominate) a.

Upper right paratracheal lymph node (station 2R)

Left common carotid a.

Right brachiocephalic (innominate) v.

Prevascular space

Axilla

Scapula Rib

Left subclavian a. Trachea



Vertebral body

Esophagus

DIAGNOSTIC CONSIDERATION Thoracic CT plays a major role in the evaluation of patients with suspected pulmonary malignancy. In particular, one major role for thoracic CT for patients with pulmonary malignancy is the depiction of hilar, mediastinal, and intrapulmonary lymph node enlargement. Correct identification and classification of lymph node locations is critical for accurate staging for lung cancer patients as well as numerous other thoracic diseases. Intrathoracic lymph nodes are commonly referred to in clinical practice using descriptive terms, although a widely accepted lymph node classification system, set forth by the American Joint Committee on Cancer (AJCC) and International Union Against Lung Cancer (UICC), is often used to standardize reporting of lymph node involvement in lung cancer patients. Although an extensive review of thoracic lymph node classifications is beyond the scope of this work, several images illustrating locations of abnormal lymph nodes in a patient with sarcoidosis will be reviewed. In this system, the designation “R” and “L” refers to “right” and “left” of midline, respectively. Enlarged lymph nodes is seen just anterior and to the right of the trachea; this region is often referred to as the “right paratracheal space.” In the AJCC classification system, lymph nodes in this location are referred to as “upper paratracheal lymph nodes” (station 2); these lymph nodes lie inferior to the cranial margin of the left brachiocephalic vein, where this vein crosses anterior to the trachea, and superior to the cranial margin of the aortic arch.

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Lymph Nodes Axial 1

Right brachiocephalic (innominate) v.

Left brachiocephalic (innominate) v.

Sternum (manubrium)

Right brachiocephalic (innominate) a.

Left common carotid a.

Prevascular space

Axilla Upper right paratracheal lymph node (station 2R)

Left subclavian a.

Trachea

Scapula

Rib

Vertebral body

Esophagus

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171

Lymph Nodes Axial 2

Anterior mediastinal (paraaortic) lymph node (station 6) Right internal mammary a. & v.

Sternum (manubrium)

Superior vena cava

Anterior mediastinum Aortic arch

Lower right paratracheal lymph node (station 4R)

Axilla

Scapula Rib Trachea



Vertebral body

Esophagus

DIAGNOSTIC CONSIDERATION A focus of high attenuation is present within the mildly enlarged right paratracheal lymph node; this high-attenuation focus represents calcification, which is a common occurrence in patients with sarcoidosis. In the AJCC lymph node classification, this lymph node is considered a “lower paratracheal lymph node (station 4).” This lymph node lies inferior to the cranial aspect of the aortic arch and cranial to the superior margin of the right upper lobe bronchus.

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Lymph Nodes Axial 2

Right internal mammary a. & v.

Anterior mediastinal (paraaortic) Sternum lymph node (station 6) (manubrium)

Anterior mediastinum

Superior vena cava

Aortic arch

Axilla

Lower right paratracheal lymph node (station 4R)

Rib

Scapula

Trachea

Vertebral body

Esophagus

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Lymph Nodes Axial 3

Lower right paratracheal lymph node (station 4R)

Right internal mammary a. & v.

Sternum

Anterior mediastinum Ascending aorta Lower left paratracheal lymph node (station 4L)

Superior vena cava Rib

Calcified ligamentum arteriosum

Scapula Descending thoracic aorta Right mainstem bronchus

Left mainstem bronchus Azygos v.



Vertebral body

Esophagus

DIAGNOSTIC CONSIDERATION High-attenuation foci are present in both lower paratracheal lymph nodes visible in this section, very faint within the right-sided lymph node. One lower paratracheal lymph node lies to the right of midline, whereas another lymph node lies to the left of midline—station 4R and 4L lymph nodes, respectively, in the AJCC lymph node classification system. Lower paratracheal (station 4) lymph nodes lie inferior to the cranial aspect of the aortic arch and cranial to the superior margin of the right upper lobe bronchus. In this section, the calcified ligamentum arteriosum is visible. This is an important anatomical landmark because paratracheal lymph nodes lie medial to this structure and may be sampled with cervical mediastinoscopy, whereas prevascular, subaortic, and aortopulmonary window lymph nodes lie lateral to the ligamentum arteriosum and are not accessible with standard cervical mediastinoscopy.

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Lymph Nodes Axial 3

Right internal mammary a. & v.

Anterior Ascending Sternum mediastinum aorta

Rib Superior vena cava Lower left paratracheal lymph node (station 4L)

Lower right paratracheal lymph node (station 4R)

Calcified ligamentum arteriosum

Right mainstem bronchus

Left mainstem bronchus Descending thoracic aorta

Scapula

Azygos v.

Vertebral body

Esophagus

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Lymph Nodes Axial 4

Right internal mammary a. & v.

Sternum

Ascending aorta

Lower right paratracheal lymph node (station 4R)

Anterior mediastinum Lower left paratracheal lymph node (station 4L)

Superior vena cava Rib

Scapula

Left mainstem bronchus Right mainstem bronchus



Azygos v.

Descending thoracic aorta Vertebral body

Esophagus

DIAGNOSTIC CONSIDERATION High-attenuation foci, representing calcification, are readily visible within the right and left lower paratracheal lymph nodes. These nodes are accessible with cervical mediastinoscopy.

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Lymph Nodes Axial 4

Right internal mammary a. & v.

Sternum

Anterior mediastinum

Rib

Superior vena cava Ascending aorta Lower right paratracheal lymph node (station 4R)

Lower left paratracheal lymph node (station 4L)

Right mainstem bronchus

Left mainstem bronchus

Descending thoracic aorta

Scapula

Azygos v.

Vertebral body

Esophagus

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Lymph Nodes Axial 5

Right internal mammary a.

Sternum

Superior vena cava

Ascending aorta

Anterior mediastinum Main pulmonary a. Subaortic lymph node (station 5)

Rib Right pulmonary a.

Left pulmonary a.

Right hilar lymph node (station 10R)

Scapula Left mainstem bronchus

Right mainstem bronchus Esophagus

Subcarinal lymph node (station 7) Azygos v.



Vertebral body

Descending thoracic aorta

DIAGNOSTIC CONSIDERATION Right hilar lymph nodes, station 10R in the AJCC lymph node classification system, are visible. Hilar lymph nodes are located caudal to the cranial portion of the right upper lobe bronchus and lie adjacent to the right mainstem bronchus and proximal bronchus intermedius. Hilar lymph nodes are located distal to the mediastinal pleural reflection. In other words, hilar lymph nodes, station 10 lymph nodes, as well as station 11-14 lymph nodes lie within the lung. In contrast, lymph nodes located in stations 1-9 in the AJCC lymph node classification system reside within the mediastinum. In patients with lung carcinoma, mediastinal lymph node involvement confers a worse prognosis compared with involved lymph nodes that reside within the lung. In this image, a subaortic lymph node (station 5) is also visible. These lymph nodes lie lateral to the ligamentum arteriosum and medial to the origin of the first branch of the left pulmonary artery.

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Lymph Nodes Axial 5

Right internal mammary a.

Sternum

Ascending aorta

Anterior mediastinum

Superior vena cava

Rib Main pulmonary a.

Right pulmonary a. Right hilar lymph node (station 10R)

Subaortic lymph node (station 5) Left pulmonary a.

Right mainstem bronchus

Left mainstem bronchus

Subcarinal lymph node (station 7)

Esophagus Scapula

Azygos v.

Vertebral body

Descending thoracic aorta

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Lymph Nodes Axial 6

Right internal mammary a.

Sternum

Superior vena cava

Ascending aorta Main pulmonary a.

Rib Right pulmonary a.

Left interlobar pulmonary a.

Right interlobar lymph node (station 11R)

Scapula Bronchus intermedius

Left mainstem bronchus

Subcarinal lymph node (station 7)

Esophagus Azygos v.



Vertebral body

Descending thoracic aorta

DIAGNOSTIC CONSIDERATION With views progressively caudal to the pulmonary hilum, lymph nodes are consistently closely related to the pulmonary arteries. A calcified right interlobar lymph node (station 11R) is visible. The contour abnormality created by right hilar lymphadenopathy on chest radiographs is often caused by a combination of enlarged lymph nodes in the right hilar (station 10) and right interlobar (station 11) regions. Subcarinal lymph nodes (station 7), which reside within the mediastinum, are visible.

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Lymph Nodes Axial 6

Right internal mammary a.

Sternum

Ascending aorta

Rib Superior vena cava Right pulmonary a.

Main pulmonary a.

Right interlobar lymph node (station 11R)

Left interlobar pulmonary a.

Bronchus intermedius Left mainstem bronchus Subcarinal lymph node (station 7)

Esophagus

Scapula

Azygos v.

Vertebral body

Descending thoracic aorta

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Lymph Nodes Axial 7

Right internal mammary a.

Sternum

Ascending aorta

Superior vena cava

Main pulmonary a.

Rib

Left upper lobe bronchus Left interlobar pulmonary a.

Right pulmonary a.

Scapula Bronchus intermedius Subcarinal lymph node (station 7)

Left hilar lymph node (station 10L)

Azygos v.



Vertebral body

Descending thoracic aorta

Esophagus

DIAGNOSTIC CONSIDERATION This view is caudal to the foregoing images (Axial 1-6). Note how lymph nodes are closely associated with the pulmonary arteries. In the lower lobes, lymph nodes are often positioned medial to the adjacent pulmonary arteries and lateral to the bronchi.

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Lymph Nodes Axial 7

Right internal mammary a.

Sternum

Ascending aorta

Rib Main pulmonary a.

Superior vena cava Right pulmonary a.

Left upper lobe bronchus

Bronchus intermedius

Left interlobar pulmonary a. Subcarinal lymph node (station 7) Left hilar lymph node (station 10L)

Azygos v.

Esophagus Scapula

Vertebral body

Descending thoracic aorta

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183

Lymph Nodes Axial 8

Right atrial appendage Right internal mammary a. Right superior pulmonary v.

Sternum

Right middle lobe bronchus, medial and lateral segments

Ascending aorta

Left lower lobe bronchus Left interlobar lymph node (station 11L)

Right segmental lymph node (station 13R)

Left lower lobe pulmonary a.

Right lower lobe bronchus

Esophagus

Right lobar lymph node (station 12R) Paraesophageal lymph node (station 8)



Descending thoracic aorta Azygos v.

Vertebral body

Hemiazygos v.

DIAGNOSTIC CONSIDERATION At this level, segmental lymph nodes (station 13R) are seen just lateral to the lateral segmental right middle lobe bronchus, and lobar lymph nodes (station 12R) are seen adjacent to the right lower lobe bronchus. On the left, calcified interlobar lymph nodes (station 11L) are seen. Interlobar lymph nodes are typically found adjacent to and between proximal lobar bronchi. On the left, typically between the lingular and superior segmental bronchi.

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Lymph Nodes Axial 8

Right superior pulmonary v.

Right internal mammary a.

Right atrial appendage

Sternum

Ascending aorta

Left lower lobe bronchus

Right middle lobe bronchus, medial and lateral segments Right segmental lymph node (station 13R)

Left interlobar lymph node (station 11L)

Right lower lobe bronchus

Left lower lobe pulmonary a.

Right lobar lymph node (station 12R)

Esophagus Descending thoracic aorta

Paraesophageal lymph node (station 8)

Azygos v.

Vertebral body

Hemiazygos v.

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185

Lymph Nodes Axial 9

Right internal mammary a.

Sternum

Right ventricle

Right atrium

Left pulmonary ligament lymph node (station 9L) Pulmonary v.

Left atrium

Segmental pulmonary aa.

Rib

Scapula

Paraesophageal lymph node (station 8L) Esophagus Azygos v.



Vertebral body

Hemiazygos v.

Descending thoracic aorta

DIAGNOSTIC CONSIDERATION Left inferior pulmonary ligament lymph nodes are visible. A small area of high attenuation, representing calcification, is visible within the lymph node. Inferior pulmonary ligament lymph nodes, also often referred to as pulmonary ligament lymph nodes, are usually found slightly medial and inferior to the inferior pulmonary veins.

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Lymph Nodes Axial 9

Right internal mammary a.

Sternum

Right ventricle

Left pulmonary ligament lymph node (station 9L)

Right atrium

Rib Pulmonary v. Left atrium

Esophagus Segmental pulmonary aa.

Scapula Paraesophageal lymph node (station 8L) Azygos v.

Vertebral Hemiazygos v. body

Descending thoracic aorta

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Chapter

5

CISTERNA CHYLI AND THORACIC DUCT 5 4 3

2

1

AXIALâ•… 190

9

8 6 4 2

7 5 3 1

CORONALâ•… 200

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189

Cisterna Chyli/Thoracic Duct Axial 1

Diaphragm

Stomach

Liver

Rib

Diaphragm

Spleen Diaphragm crus

Gastroesophageal junction

Intercostal v. entering azygos v. Cisterna chyli



Diaphragm crus Erector spinae m.

Descending thoracic aorta Vertebral body

NORMAL ANATOMY A normal structure is shown—the cisterna chyli—which is inconsistently seen on clinical thoracic CT scans. The cisterna chyli is typically located between the distal thoracic or upper abdominal aorta and azygos vein in the right posterior mediastinum or retrocrural space, posterior to the right diaphragmatic crus. The cisterna chyli receives lymph from the right and left lumbar lymphatic trunks, the intestinal lymphatic trunk, and the inferior intercostal lymph nodes. The cisterna chyli gives rise to the thoracic duct, whose course will be shown on subsequent images.

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Cisterna Chyli/Thoracic Duct Axial 1

Diaphragm

Stomach

Liver

Rib Diaphragm crus Diaphragm

Spleen

Cisterna chyli

Gastroesophageal junction Diaphragm crus

Intercostal v. entering azygos v.

Erector spinae m.

Vertebral body

Descending thoracic aorta

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191

Cisterna Chyli/Thoracic Duct Axial 2

Right internal mammary a. & v. Right atrial appendage Right ventricle Left atrial appendage

Ascending aorta Superior vena cava Right superior pulmonary v.

Sternum

Left anterior descending coronary a.

Right middle lobe medial & lateral segment pulmonary aa.

Left inferior pulmonary v.

Pectoralis major m.

Descending thoracic aorta

Right lower lobe basal trunk pulmonary a.

Thoracic duct Vertebral body



Erector spinae m.

Azygos v.

Esophagus

NORMAL ANATOMY The thoracic duct is not always visible on thoracic CT scans, but is well seen in this patient. The thoracic duct originates from the cisterna chyli and ascends within the posterior mediastinum. The thoracic duct is well visualized adjacent to the azygos vein, posterior to the esophagus. Caudally, it usually ascends on the right side, often crossing to the left of midline at approximately the level of the 5th thoracic vertebral body. In this patient, the thoracic duct crossed midline at a more inferior level than is typically seen.

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Cisterna Chyli/Thoracic Duct Axial 2

Pectoralis major m.

Right atrial appendage

Right internal mammary a. & v.

Sternum

Right ventricle

Left anterior descending coronary a.

Ascending aorta Superior vena cava Right superior pulmonary v.

Right middle lobe medial & lateral segment pulmonary aa.

Left atrial appendage Left inferior pulmonary v.

Right lower lobe basal trunk pulmonary a.

Esophagus Thoracic duct

Vertebral body

Erector spinae m.

Azygos v.

Descending thoracic aorta

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193

Cisterna Chyli/Thoracic Duct Axial 3

Ascending aorta Superior vena cava Right upper lobe anterior segment pulmonary a.

Main pulmonary a. Left internal mammary a. Left mainstem bronchus

Sternum

Left superior pulmonary v.

Pectoralis major m.

Left pulmonary a.

Right mainstem & upper lobe bronchi Azygos v.

Descending thoracic aorta

Trapezius m. Vertebral body



Esophagus Erector spinae m.

Intercostal v.

Thoracic duct

NORMAL ANATOMY The thoracic duct is again seen coursing within the posterior mediastinum adjacent to the �azygos vein and descending thoracic aorta and posterior to the esophagus.

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Cisterna Chyli/Thoracic Duct Axial 3

Pectoralis major m.

Ascending aorta

Main Sternum pulmonary a.

Left internal mammary a.

Superior vena cava Left superior pulmonary v. Right upper lobe anterior segment pulmonary a.

Left mainstem bronchus Left pulmonary a.

Right mainstem & upper lobe bronchi

Esophagus

Azygos v.

Descending thoracic aorta

Vertebral body

Trapezius m.

Erector spinae m.

Intercostal v.

Thoracic duct

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195

Cisterna Chyli/Thoracic Duct Axial 4

Superior vena cava Pectoralis major m.

Sternum

Thymus

Pectoralis minor m.

Left internal mammary a. & v. Aortic arch

Rib

Scapula Infraspinatus m. Trapezius m. Esophagus

Azygos v. Erector spinae m.



Trachea

Vertebral body

Thoracic duct

NORMAL ANATOMY At the level of the aortic arch at the cranial aspect of the azygos vein, the thoracic duct is again seen to the left of midline, posterior to the esophagus.

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Cisterna Chyli/Thoracic Duct Axial 4

Pectoralis major m.

Sternum

Thymus

Left internal mammary a. & v.

Pectoralis minor m.

Superior vena cava Rib Aortic arch Trachea Azygos v. Scapula

Infraspinatus m.

Esophagus

Trapezius m.

Erector spinae m.

Vertebral body

Thoracic duct

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Cisterna Chyli/Thoracic Duct Axial 5

Right common carotid a.

Trachea Left clavicle Left common carotid a.

Pectoralis major m. Pectoralis minor m.

Left subclavian v.

Right subclavian v.

Scapula Scapula Rib

Left subclavian a. Right subclavian a. Trapezius m. Right superior intercostal v.



Thoracic duct Esophagus Vertebral body

NORMAL ANATOMY Within the superior mediastinum, the thoracic duct is visible to the left of midline. The thoracic duct courses cranially and eventually empties into the junction of the left subclavian and left internal jugular veins. The thoracic duct drains lymph from the entire body except for the right head and neck, right thorax, and right arm.

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Cisterna Chyli/Thoracic Duct Axial 5

Pectoralis minor m.

Pectoralis major m.

Right common Left carotid a. Trachea clavicle

Left common carotid a.

Left subclavian v.

Right subclavian v. (enhanced)

Right subclavian a.

Left subclavian a.

Right superior intercostal v. Scapula

Scapula

Thoracic duct

Esophagus

Rib

Trapezius m.

Vertebral body

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Cisterna Chyli/Thoracic Duct Coronal 1

Descending thoracic aorta

Scapula

Thoracic duct

Intercostal a.

Rib Azygos v.

Descending thoracic aorta Intercostal a.

Liver

Stomach

Spleen

Diaphragm



NORMAL ANATOMY This coronal image, and those that follow, accompanies Cisterna Chyli/Thoracic Duct Axial 1-5 above and shows the position of the cisterna chyli and course of the thoracic duct in the coronal plane. The thoracic duct is not always visible on thoracic CT scans, but is well seen in this patient. The thoracic duct originates from the cisterna chyli and ascends within the posterior mediastinum. In this image, the thoracic duct is well visualized to the left of midline, in proximity to the azygos vein. The thoracic duct usually ascends on the right side, often crossing to the left of midline at approximately the level of the 5th thoracic vertebral body.

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Cisterna Chyli/Thoracic Duct Coronal 1

Scapula

Intercostal a.

Descending thoracic aorta

Thoracic duct

Azygos v. Rib

Descending thoracic aorta Intercostal a.

Liver

Diaphragm

Stomach

Spleen

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201

Cisterna Chyli/Thoracic Duct Coronal 2

Scapula Descending thoracic aorta

Intercostal a.

Thoracic duct

Rib Esophagus

Azygos v. Thoracic duct Azygos v.

Descending thoracic aorta Intercostal aa.

Liver



Thoracic duct

Diaphragm

Stomach

Spleen

NORMAL ANATOMY The thoracic duct is again seen coursing within the posterior mediastinum to the left of midline superiorly, in close proximity to the esophagus. Inferiorly, the thoracic duct is again visible medial to the azygos vein as it is crossing midline from right to left.

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Cisterna Chyli/Thoracic Duct Coronal 2

Intercostal a.

Scapula

Descending thoracic aorta

Thoracic duct

Azygos v.

Rib Esophagus Azygos v. Thoracic duct

Descending thoracic aorta

Intercostal aa.

Thoracic duct

Liver

Diaphragm

Stomach

Spleen

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203

Cisterna Chyli/Thoracic Duct Coronal 3

Scapula Descending thoracic aorta

Intercostal a.

Thoracic duct Azygos v. Esophagus Rib

Thoracic duct

Descending thoracic aorta

Intercostal a.

Liver



Diaphragm

Stomach

Spleen

NORMAL ANATOMY Slightly anterior to the two preceding views, the thoracic duct is shown on both sides of midline, to the right inferiorly and to the left superiorly.

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Cisterna Chyli/Thoracic Duct Coronal 3

Scapula

Intercostal a.

Thoracic Descending duct thoracic aorta

Azygos v. Esophagus Rib

Thoracic duct Descending thoracic aorta Intercostal a.

Thoracic duct

Liver

Diaphragm

Stomach

Spleen

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205

Cisterna Chyli/Thoracic Duct Coronal 4

Intercostal aa.

Descending thoracic aorta

Scapula

Thoracic duct

Esophagus

Azygos v.

Rib Pulmonary v. Pulmonary a.

Descending thoracic aorta

Thoracic duct

Liver



Diaphragm

Stomach

Spleen

NORMAL ANATOMY Still slightly more anteriorly located than preceding views, portions of the central pulmonary arteries and veins are shown. At this level, the thoracic duct is seen inferiorly, to the right of midline, adjacent to the descending thoracic aorta.

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Cisterna Chyli/Thoracic Duct Coronal 4

Scapula

Intercostal aa.

Descending thoracic aorta

Thoracic duct Azygos v.

Esophagus Pulmonary a. Rib Pulmonary v.

Thoracic duct

Descending thoracic aorta

Liver

Diaphragm

Stomach

Spleen

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207

Cisterna Chyli/Thoracic Duct Coronal 5

Scapula

Descending thoracic aorta

Thoracic duct Azygos v.

Esophagus Pulmonary a. Rib Pulmonary v.

Descending thoracic aorta

Liver



Cisterna chyli

Diaphragm

Stomach

Spleen

NORMAL ANATOMY The left superior pulmonary vein is shown as it enters the left atrium. The cisterna chyli is now visible posteriorly on the right at the thoracoabdominal junction. The cranial portion of the thoracic duct is visible to the left of midline, adjacent to the esophagus and thoracic aorta.

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Cisterna Chyli/Thoracic Duct Coronal 5

Thoracic duct

Scapula

Descending thoracic aorta

Esophagus Azygos v.

Pulmonary a. Rib

Pulmonary v.

Descending thoracic aorta

Liver

Cisterna chyli

Diaphragm

Stomach

Spleen

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209

Cisterna Chyli/Thoracic Duct Coronal 6

Scapula

Right superior intercostal v.

Thoracic duct

Azygos v.

Descending thoracic aorta Esophagus Pulmonary a. Rib Pulmonary v.

Left atrium

Descending thoracic aorta

Liver



Diaphragm

Stomach

Spleen

NORMAL ANATOMY The cranial portion of the thoracic duct is shown in close proximity to the esophagus. The right superior intercostal vein, which drains the 2nd, 3rd, and 4th posterior intercostal veins, can be seen draining into the azygos vein.

210

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Cisterna Chyli/Thoracic Duct Coronal 6

Right superior intercostal v.

Scapula

Thoracic duct

Descending thoracic aorta

Esophagus Azygos v. Pulmonary a.

Rib

Left atrium

Pulmonary v.

Descending thoracic aorta

Liver

Diaphragm

Stomach

Spleen

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

211

Cisterna Chyli/Thoracic Duct Coronal 7

Scapula

Thoracic duct Right superior intercostal v.

Descending thoracic aorta Esophagus

Azygos v.

Pulmonary a. Rib Pulmonary v.

Left atrium

Descending thoracic aorta

Liver



Diaphragm

Stomach

Spleen

NORMAL ANATOMY Again, the cranial portion of the thoracic duct is shown in close proximity to the esophagus, beginning to extend cranial to the thoracic aortic arch. The right superior intercostal vein is again seen draining into the azygos vein.

212

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Cisterna Chyli/Thoracic Duct Coronal 7

Scapula

Right superior intercostal v.

Thoracic Descending duct thoracic aorta

Azygos v.

Esophagus

Pulmonary a.

Left atrium

Rib Pulmonary v.

Descending thoracic aorta

Liver

Diaphragm

Stomach

Spleen

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

213

Cisterna Chyli/Thoracic Duct Coronal 8

Trachea

Esophagus

Thoracic duct Azygos v.

Descending thoracic aorta

Right mainstem bronchus

Aortopulmonary window

Right upper lobe bronchus

Pulmonary a. Pulmonary v. Rib

Left atrium

Liver



Diaphragm

Esophagus

Stomach

Spleen

NORMAL ANATOMY This view, anteriorly located relative to preceding views, shows the cranial portion of the thoracic duct adjacent to the esophagus, cranial to the thoracic aortic arch.

214

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Cisterna Chyli/Thoracic Duct Coronal 8

Esophagus

Trachea

Thoracic duct

Descending thoracic aorta

Azygos v. Right mainstem bronchus

Aortopulmonary window

Right upper lobe bronchus

Pulmonary a. Pulmonary v.

Rib

Esophagus

Liver

Left atrium

Diaphragm

Stomach

Spleen

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

215

Cisterna Chyli/Thoracic Duct Coronal 9

Trachea

Esophagus

Left subclavian a. Thoracic duct

Descending thoracic aorta Right upper lobe pulmonary a.

Aortopulmonary window Pulmonary a.

Right pulmonary a.

Rib Left atrium Left ventricle

Liver

Adrenal gland

Diaphragm

Adrenal gland

Stomach

Spleen

Esophagus



NORMAL ANATOMY The most anteriorly positioned of the preceding views, detailing the course of the thoracic duct, shows the thoracic duct extending cranially toward the root of the neck, prior to entry into the junction of the left subclavian and internal jugular veins.

216

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Cisterna Chyli/Thoracic Duct Coronal 9

Trachea

Esophagus

Thoracic Left duct subclavian a.

Descending thoracic aorta Aortopulmonary window

Right upper lobe pulmonary a.

Pulmonary a.

Right pulmonary a.

Rib

Left atrium Left ventricle

Esophagus

Liver

Adrenal gland

Diaphragm

Adrenal gland

Stomach

Spleen

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

217

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Chapter

6

VENOUS ANATOMY AND VARIANTS 1 2

1

AXIALâ•… 220

CORONALâ•… 224 1

2

SAGITTALâ•… 226

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

219

Venous Axial 1

Left brachiocephalic v.

Sternum

Left superior intercostal v.

Aortic arch

Superior vena cava

Pulmonary aa.



Clavicle

Vertebral body

Ribs

NORMAL VARIANT An axial volume rendered image of the thorax showing the normal left superior intercostal vein coursing along the lateral aspect of the aortic arch, emptying into the left brachiocephalic vein. The left superior intercostal vein typically drains the 2nd, 3rd, and 4th intercostal veins on the left, and connects the left brachiocephalic and accessory hemiazygos veins. The left superior intercostal vein provides a collateral pathway for blood flow from the upper extremities and trunk to the heart in the setting of venous stenosis or obstruction.

220

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Venous Axial 1

Sternum

Left superior intercostal v.

Clavicle

Left brachiocephalic v.

Superior vena cava Aortic arch Pulmonary aa.

Vertebral body

Ribs

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

221

Venous Axial 2

Right internal mammary a. & v.

Sternum (body)

Ascending aorta Left internal mammary a.

Pectoralis major m.

Thymus Persistent left superior vena cava

Pectoralis minor m. Rib Subscapularis m.

Left superior intercostal v.

Scapula Infraspinatus m. Descending thoracic aorta

Scapula

Accessory hemiazygos v.

Trachea (at carina) Trapezius m.



Erector spinae m.

Vertebral body

Esophagus

NORMAL VARIANT This scan, performed at the caudal surface of the aortic arch, shows a common venous anomaly affecting the thorax—the persistent left superior vena cava. The prevalence of this anomaly is estimated at nearly 0.3% of the general population, and it may occasionally be associated with other congenital cardiovascular anomalies. In its most common form, the persistent left superior vena cava forms at the confluence of the left internal jugular and subclavian veins and descends along the left aspect of the aortic arch and mediastinum, passing anterior to the left hilum, crossing the posterior wall of the left atrium, eventually emptying into the coronary sinus. Rarely, the persistent left superior vena cava empties into the left atrium, creating a right-to-left shunt. The enhanced persistent left superior vena cava is shown as it passes lateral to the aortic arch.

222

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Venous Axial 2

Pectoralis Subscapularis m. Rib minor m.

Right Persistent Left internal Left Pectoralis mammary Sternomanubrial Ascending internal left superior superior major m. intercostal v. a. & v. mammary a. Thymus vena cava junction aorta

Scapula Scapula

Infraspinatus m.

Trachea (at carina)

Trapezius m.

Erector spinae m.

Vertebral body

Esophagus

Accessory hemiazygos v.

Descending thoracic aorta

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

223

Venous Coronal 1

Right brachiocephalic a.

Left brachiocephalic v.

Right internal jugular v.

Left common carotid a. Left internal jugular v.

Clavicle Right subclavian v.

Persistent left superior vena cava Left subclavian v. Left subclavian a.

Rib



Pulmonary aa. & vv.

Ascending aorta

Heart

Aortic arch

Main pulmonary a.

NORMAL VARIANT A coronal volume rendered image of the thorax, providing a different perspective of the persistent left superior vena cava that was shown above. The origin of persistent left superior vena cava at the confluence of the left subclavian and internal jugular veins is clearly shown, as well as the course of this venous anomaly as it descends along the left aspect of the aortic arch and mediastinum, eventually emptying into the coronary sinus.

224

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Venous Coronal 1

Right internal jugular v.

Right Left brachiocephalic a. brachiocephalic v.

Left internal jugular v.

Left common carotid a. Clavicle Left subclavian a.

Right subclavian v.

Left subclavian v.

Persistent left superior vena cava

Scapula Pulmonary aa. & vv.

Rib

Ascending aorta

Heart

Main pulmonary a.

Aortic arch

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225

Venous Sagittal 1

Azygos v. (arch) Azygos v.

Aortic arch Clavicle

Intercostal vv.

Superior vena cava

Vertebral spinous processes

Vertebral body

Rib

Diaphragm



PATHOLOGIC PROCESS An oblique, sagittal volume rendered image performed in a patient with a right subclavian venous stenosis. This condition causes blood from the right upper extremity and chest wall to route through various chest wall and thoracic veins as the body attempts to bypass the obstructed subclavian vein. When the right upper extremity venous system is injected with intravenous contrast for thoracic CT, this situation creates a unique opportunity to demonstrate the intercostal and azygos venous systems of the thorax. The arch of the azygos vein is well visualized. The azygos vein normally courses within the posterior mediastinum on the right, adjacent to the lower eight thoracic vertebral bodies, eventually extending anteriorly, superior to the root of the right lung, to empty into the superior vena cava. The azygos vein typically receives blood flow from intercostal veins, mediastinal veins, bronchial veins, esophageal veins, and the paravertebral venous plexus. When thoracic veins become obstructed, the azygos system assumes the role of a major collateral pathway for blood flow from the upper extremities and thorax to reach the heart.

226

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Venous Sagittal 1

Azygos v.

Azygos v. (arch)

Aortic arch

Clavicle

Superior vena cava

Intercostal vv.

Vertebral spinous processes

Rib

Vertebral body

Diaphragm

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227

Venous Sagittal 2

Left brachiocephalic v.

Left common carotid a. Left subclavian a.

Clavicle Aortic arch

Descending thoracic aorta Left superior intercostal v.

Main pulmonary a. Manubrium (sternum)

Pulmonary v.



Left pulmonary a.

Vertebral body

Ribs

NORMAL VARIANT An oblique sagittal volume rendered image of the thorax that represents a different perspective of the left superior intercostal vein as it courses from posterior to anterior, adjacent to the aortic arch, emptying into the left brachiocephalic vein. The left superior intercostal vein typically drains the 2nd, 3rd, and 4th intercostal veins on the left, and connects the left brachiocephalic and accessory hemiazygos veins. The left superior intercostal vein provides a collateral pathway for blood flow from the upper extremities and trunk to the heart in the setting of venous stenosis or obstruction.

228

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Venous Sagittal 2

Clavicle

Left brachiocephalic v.

Left common carotid a.

Left subclavian a.

Manubrium (sternum) Descending thoracic aorta Aortic arch Left superior intercostal v.

Main pulmonary a.

Ribs

Pulmonary v.

Left pulmonary a.

Vertebral body

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229

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PART

2

CARDIAC ANATOMY

CHAPTER 7â•…OVERVIEW OF CARDIAC ANATOMYâ•… 233 CHAPTER 8â•…CARDIAC ANATOMY USING CTâ•… 239 CHAPTER 9â•…CARDIAC ANATOMY USING MRâ•… 373

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

231

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Chapter

7

OVERVIEW OF CARDIAC ANATOMY

HEART: ANTERIOR EXPOSURE╅ 234 CORONARY ARTERIES AND �CARDIAC VEINS╅ 235 RIGHT ATRIUM AND RIGHT �VENTRICLE╅ 236 LEFT ATRIUM AND LEFT VENTRICLE╅ 237 ATRIA, VENTRICLES, AND INTERVENTRICULAR �SEPTUM╅ 238

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

233

Heart: Anterior Exposure

Pericardium (?QPA@CA) at site of reflection from great vessels Right vagus nerve

Brachiocephalic trunk Left brachiocephalic v.

Right recurrent laryngeal nerve

Arch of aorta

Right brachiocephalic vein

Left common carotid a.

Phrenic nerve

Left internal jugular v.

Subclavian a. & v.

Left vagus nerve (X)

Internal thoracic a. & v.

Ligamentum arteriosum

Phrenic nerve and pericardiacophrenic a. & v.

Left recurrent laryngeal nerve Pulmonary trunk

Superior vena cava

Left pulmonary a.

Right pulmonary a. Transverse pericardial sinus

Transverse pericardial sinus

Right superior pulmonary v.

Left superior pulmonary v.

Hilum of right lung Mediastinal pleura (?QPA@CA)

Hilum of left lung

Pericardium (?QPA@CA)

Right ventricle

Right auricle (atrial appendage) Right atrium

234

Coronary sulcus and right coronary a.

Left auricle (atrial appendage)

Conus arteriosus

Anterior interventricular sulcus and anterior interventricular branch of left coronary a.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Apex of heart Left ventricle Inferior border (acute margin) of heart

Mediastinal Pericardium part of parietal (?QPA@CA) pleura Left border (?QPA@CA) (obtuse margin) of heart

Coronary Arteries and Cardiac Veins

Sinoatrial (SA) nodal branch

Left auricle (?QP) Left coronary a.

Atrial branch of right coronary a. Circumflex branch of left coronary a. Right coronary a. Great cardiac v. Left (obtuse) marginal a.

Anterior cardiac v.

Anterior interventricular branch (left anterior descending) of left coronary a.

Small cardiac v.

Right (acute) marginal branch of right coronary a.

Diagonal branch of anterior interventricular a.

Interventricular septal branches

Sternocostal surface

Sinoatrial (SA) nodal branch

Oblique v. of left atrium (of Marshall)

Sinoatrial (SA) node

Great cardiac v.

Circumflex branch of left coronary a. Small cardiac v.

Left marginal branch Coronary sinus Posterior left ventricular branch

Right coronary a. Posterior interventricular branch (posterior descending) of right coronary a.

Posterior vein of left ventricle

Middle cardiac v. Interventricular septal branches

Right marginal branch

Diaphragmatic surface

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235

Right Atrium and Right Ventricle

Ascending aorta

Pulmonary trunk Right auricle (atrial appendage)

Superior vena cava

Conus arteriosus

Right pulmonary a.

Crista terminalis

Pericardial reflection

Atrioventricular part of membranous septum

Right superior pulmonary v.

Septal cusp of tricuspid valve

Left atrium Right inferior pulmonary v.

Pectinate mm. Opening of coronary sinus

Interatrial septum

Valve (thebesian) of coronary sinus

Limbus of fossa ovalis Fossa ovalis Valve (eustachian) of inferior vena cava Inferior vena cava

Opened right atrium: right lateral view

Pericardial reflection Aorta Transverse pericardial sinus Superior vena cava Right auricle (atrial appendage) Right atrium Membranous part of interventricular septum Anterior cusp Tricuspid valve

Septal cusp Posterior cusp

Pulmonary trunk Transverse pericardial sinus Anterior semilunar cusp Right semilunar cusp

Pulmonary valve

Left semilunar cusp Conus arteriosus Supraventricular crest Septal papillary m. Interventricular septum (muscular part)

Septomarginal trabecula (moderator band)

Chordae tendineae Posterior papillary m. Anterior papillary m. Trabeculae carneae

236

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Opened right ventricle: anterior view

Left Atrium and Left Ventricle

Transverse pericardial sinus

Pericardial reflection

Arch of aorta Ligamentum arteriosum

Left auricle (atrial appendage)

Left pulmonary a.

Oblique v. of left atrium (of Marshall)

Right pulmonary a. Posterior cusp

Mitral valve

Left pulmonary vv.

Anterior cusp

Left atrium Anterior papillary m.

Right pulmonary vv.

Chordae tendineae Coronary sinus

Posterior papillary muscle

Inferior vena cava

Flap opened in posterolateral wall of left ventricle

Left auricle (atrial appendage) Conus arteriosus

Arch of aorta Left pulmonary a.

Left semilunar cusp Aortic valve

Right semilunar cusp Posterior semilunar cusp

Membranous septum

Interventricular part Atrioventricular part

Muscular part of interventricular septum Mitral valve (?QP=S=U)

Right pulmonary a. Left superior pulmonary v. Valve of foramen ovale Right pulmonary vv.

Left atrium Coronary sinus Inferior vena cava

Section through left atrium and ventricle with mitral valve cut away

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237

Atria, Ventricles, and Interventricular Septum

Pulmonary trunk Mitral valve

Posterior cusp Anterior cusp

Right superior pulmonary v. Left semilunar cusp Aortic valve

Posterior semilunar (noncoronary) cusp

Membranous septum

Superior vena cava

Anterior cusp of mitral valve Left atrium

Openings of coronary aa. Ascending aorta Right auricle (atrial appendage)

Left auricle (atrial appendage) Left pulmonary vv.

Left semilunar cusp Right semilunar cusp

Aortic valve

Supraventricular crest

Ascending aorta

Atrioventricular part

Outflow to pulmonary trunk

Interventricular part

Right anterior papillary muscle (?QP) Right ventricle

Septomarginal trabecula (moderator band)

Tricuspid valve

Right atrium Anterior cusp (NAPN=?PA@) Septal cusp Posterior cusp Right ventricle Right anterior papillary m. (?QP)

Septal (medial) papillary m.

Left ventricle Left posterior papillary m. Left anterior papillary m.

Right posterior papillary m. Left ventricle Muscular part of interventricular septum

238

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Plane of section

Chapter

8

CARDIAC ANATOMY USING CT

AXIALâ•… 240

2-CHAMBERâ•… 364

3-CHAMBERâ•… 366

4-CHAMBERâ•… 368

SHORT AXISâ•… 370

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

239

Cardiac CT Axial 1

Left internal mammary a.

Right internal mammary a.

Ascending aorta

Main pulmonary a.

Superior vena cava

Pulmonary v. Pulmonary v. Right interlobar pulmonary a.

Left mainstem bronchus Left interlobar pulmonary a.

Bronchus intermedius

Descending thoracic aorta

Esophagus



Intercostal a.

TECHNICAL CONSIDERATION Typically, cardiac CT axial examinations are specifically tailored to image the heart, and therefore the imaging volume is restricted to only a portion of the thorax. Often the examination begins just below the carina, as this first plate shows. Note how the contrast bolus shows bright enhancement of the left-sided cardiovascular structures—the aorta and pulmonary veins— whereas right-sided structures (pulmonary arteries) are poorly enhanced. This is purposely accomplished by following the intravenous contrast bolus with a saline injection to “wash out” dense intravenous contrast from the right heart and thereby improve visualization of the right coronary artery.

240

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Cardiac CT Axial 1

Right internal mammary a.

Ascending aorta

Left internal mammary a.

Main pulmonary a.

Superior vena cava Pulmonary v.

Pulmonary v. Right interlobar pulmonary a.

Left mainstem bronchus Left interlobar pulmonary a.

Bronchus intermedius

Esophagus

Intercostal a.

Descending thoracic aorta

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

241

Cardiac CT Axial 2

Left internal mammary a.

Right internal mammary a. Anterior mediastinum Ascending aorta

Main pulmonary a.

Superior vena cava Pericardial fluid (left pulmonic recess)

Pulmonary v.

Pulmonary v.

Right middle lobe medial segment pulmonary a. Left interlobar pulmonary a.

Right interlobar pulmonary a.

Descending thoracic aorta

Bronchus intermedius

Esophagus



Intercostal a.

NORMAL ANATOMY Several millimeters inferior to Axial 1 again shows intense enhancement of left-sided cardiovascular structures—the ascending and descending thoracic aorta and pulmonary veins. A small amount of normal pericardial fluid is seen within the left pulmonic recess of the transverse sinus of the pericardium. The origin of the right middle lobe pulmonary artery is visible, marking the distal aspect of the right interlobar pulmonary artery and the beginning of the right lower lobe pulmonary artery.

242

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Cardiac CT Axial 2

Ascending aorta

Anterior mediastinum

Left internal mammary a.

Main pulmonary a.

Right internal mammary a.

Pericardial fluid (left pulmonic recess)

Superior vena cava Pulmonary v.

Pulmonary v. Right middle lobe medial segment pulmonary a.

Left interlobar pulmonary a.

Right interlobar pulmonary a.

Bronchus intermedius

Esophagus

Intercostal a.

Descending thoracic aorta

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

243

Cardiac CT Axial 3

Left internal mammary a.

Right internal mammary a.

Main pulmonary a. Ascending aorta

Superior vena cava

Pericardial fluid (left pulmonic recess) Pulmonary v.

Pulmonary v. Right middle lobe medial segment pulmonary a.

Lingular pulmonary a. Descending thoracic aorta

Bronchus intermedius

Intercostal a.



NORMAL VARIANT The medial segment of the right middle lobe and lingular arteries are visible at this level. Usually the right middle lobe pulmonary artery arises from the distal right interlobar pulmonary artery and branches into medial and lateral segments. However, in this patient, the medial and lateral segments of the right middle lobe pulmonary artery arise directly from the right interlobar pulmonary artery.



NORMAL ANATOMY The pericardial space is divided into the pericardium proper, consisting of a postcaval recess and right and left pulmonary vein recesses, and the transverse and oblique sinuses. The transverse sinus lies posterior to the ascending aorta and main pulmonary artery and cranial to the left atrium. The transverse sinus is further subdivided into superior and inferior aortic recesses and right and left pulmonic recesses. The oblique sinus also contains the posterior pericardial recess. Small amounts of fluid are commonly seen within some of these compartments in normal patients during thoracic and cardiovascular CT examinations.

244

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Cardiac CT Axial 3

Ascending aorta

Left internal mammary a.

Main pulmonary a.

Right internal mammary a. Pericardial fluid (left pulmonic recess)

Superior vena cava

Pulmonary v.

Pulmonary v.

Right middle lobe medial segment pulmonary a.

Lingular pulmonary a.

Bronchus intermedius

Intercostal a.

Descending thoracic aorta

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

245

Cardiac CT Axial 4

Pericardial fluid, anterior superior pericardial recess

Left internal mammary a.

Pericardium Right internal mammary a.

Ascending aorta Main pulmonary a.

Pericardial fluid, posterior portion superior aortic recess Superior vena cava

Pericardial fluid Pulmonary v. Pulmonary v. Right middle lobe medial segment pulmonary a.

Lingular pulmonary a. Left lower lobe pulmonary a.

Right lower lobe superior segment pulmonary a.

Descending thoracic aorta

Intercostal a.



NORMAL ANATOMY Along the anterior aspect of the ascending aorta and main pulmonary artery, the normal pericardium is visible. A small amount of fluid immediately subjacent to the pericardium in this region, interposed between the ascending aorta and main pulmonary artery (*), is within the anterior portion of the superior recess of the transverse sinus.

246

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Cardiac CT Axial 4

Right internal mammary a.

Pericardium

Pericardial fluid, anterior superior pericardial recess

Left internal mammary a.

Ascending aorta Main pulmonary a.

Pericardial fluid, posterior portion superior aortic recess Superior vena cava

Pericardial fluid

Pulmonary v.

Pulmonary v.

Right middle lobe medial segment pulmonary a.

Lingular pulmonary a. Left lower lobe pulmonary a.

Right lower lobe superior segment pulmonary a.

Intercostal a.

Descending thoracic aorta

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247

Cardiac CT Axial 5

Left internal mammary a. Right atrial appendage

Right internal mammary a.

Ascending aorta

Main pulmonary a.

Right atrial appendage Superior vena cava Pulmonary v. Pulmonary v. Lingular bronchus Lingular pulmonary a.

Bronchus intermedius

Left lower lobe pulmonary a.

Descending thoracic aorta

Spinal cord

248

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Cardiac CT Axial 5

Right internal mammary a.

Right atrial appendage

Left internal mammary a.

Main pulmonary a.

Ascending aorta Right atrial appendage

Pulmonary v.

Superior vena cava

Lingular bronchus

Pulmonary v.

Lingular pulmonary a.

Bronchus intermedius

Left lower lobe pulmonary a.

Spinal cord

Descending thoracic aorta

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

249

Cardiac CT Axial 6

Left internal mammary a. Right atrial appendage Right internal mammary a.

Ascending aorta Main pulmonary a. Right atrial appendage

Left atrium

Superior vena cava

Left superior pulmonary v.

Right superior pulmonary v.

Lingular pulmonary a.

Bronchus intermedius

Left lower lobe pulmonary a. Right lower lobe superior subsegmental pulmonary a.

Descending thoracic aorta

Intercostal a.

250

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Cardiac CT Axial 6

Right internal mammary a.

Right atrial appendage

Left internal mammary a.

Main pulmonary a.

Ascending aorta

Left atrium

Right atrial appendage

Superior vena cava

Left superior pulmonary v.

Right superior pulmonary v. Lingular pulmonary a.

Bronchus intermedius

Left lower lobe pulmonary a.

Right lower lobe superior subsegmental pulmonary a.

Intercostal a.

Descending thoracic aorta

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

251

Cardiac CT Axial 7

Left internal mammary a.

Right internal mammary a. Right atrial appendage

Ascending aorta

Main pulmonary a.

Left atrial appendage Superior vena cava

Left atrium

Right superior pulmonary v. Left superior pulmonary v.

Left lower lobe superior segment pulmonary a. Descending thoracic aorta

252

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Cardiac CT Axial 7

Right internal mammary a.

Right atrial appendage

Left internal mammary a.

Main pulmonary a.

Ascending aorta

Left atrial appendage

Superior vena cava

Left superior pulmonary v.

Right superior pulmonary v.

Left lower lobe superior segment pulmonary a.

Left atrium

Descending thoracic aorta

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

253

Cardiac CT Axial 8

Left internal mammary a. Right internal mammary a.

Right atrial appendage

Ascending aorta Left atrial appendage

Superior vena cava

Right superior pulmonary v.

Left atrium

Left superior pulmonary v.

Left lower lobe basal trunk pulmonary a. Oblique sinus of pericardium Descending thoracic aorta

254

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Cardiac CT Axial 8

Right internal mammary a.

Right atrial appendage

Left internal mammary a.

Left atrium

Ascending aorta Left atrial appendage Superior vena cava

Left superior pulmonary v.

Right superior pulmonary v.

Left lower lobe basal trunk pulmonary a.

Oblique sinus of pericardium

Descending thoracic aorta

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

255

Cardiac CT Axial 9

Right atrial appendage Left atrial appendage Ascending aorta Left anterior descending coronary a.

Crista terminalis Superior vena cava

Left circumflex coronary a.

Right superior pulmonary v.

Left main coronary a. Left atrium

Right middle lobe lateral segment pulmonary a.

Left superior pulmonary v. Left lower lobe basal trunk pulmonary a. Descending thoracic aorta

Spinal cord



NORMAL ANATOMY The crista terminalis is now just visible and will be readily visualized on views that follow. The crista terminalis is a vertical fibromuscular ridge that separates the smooth portion of the right atrium, which receives the superior and inferior vena cavae and coronary sinus, from the right atrial appendage and the remainder of the right atrium containing pectinate muscles. The crista terminalis extends superiorly from the anterior margin of the superior vena cava along the lateral wall of the right atrium inferiorly toward the inferior vena cava. A prominent crista terminalis can occasionally be mistaken for a right atrial mass on imaging studies.

256

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Cardiac CT Axial 9

Right atrial appendage

Left atrium

Left main coronary a.

Left anterior descending coronary a.

Ascending aorta

Left atrial appendage

Crista terminalis

Superior vena cava

Left circumflex coronary a.

Right middle lobe lateral segment pulmonary a.

Left superior pulmonary v.

Left lower lobe basal trunk pulmonary a.

Right superior pulmonary v.

Spinal cord

Descending thoracic aorta

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

257

Cardiac CT Axial 10

Ascending aorta, left sinus of Valsalva

Right ventricular outflow tract

Right atrial appendage

Left anterior descending coronary a. Left atrial appendage

Ascending aorta Crista terminalis

Septal perforator coronary a.

Superior vena cava

Right superior pulmonary v. Left superior pulmonary v. Right lower lobe basal trunk pulmonary a.

Left lower lobe basal trunk pulmonary a.

Descending thoracic aorta

Left atrium

258

Left circumflex coronary a.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Cardiac CT Axial 10

Right atrial appendage

Ascending aorta, left sinus of Valsalva

Right ventricular outflow tract

Left anterior descending coronary a.

Ascending aorta

Left atrial appendage

Crista terminalis Septal perforator coronary a. Superior vena cava Left superior pulmonary v.

Right superior pulmonary v.

Left lower lobe basal trunk pulmonary a.

Right lower lobe basal trunk pulmonary a.

Left atrium

Left circumflex coronary a.

Descending thoracic aorta

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

259

Cardiac CT Axial 11

Ascending aorta, left sinus of Valsalva

Right ventricular outflow tract Ascending aorta

Left anterior descending coronary a.

Crista terminalis

Left atrial appendage Septal perforator coronary a.

Superior vena cava

Left circumflex coronary a.

Right superior pulmonary v.

Left superior pulmonary v. Right lower lobe basal trunk pulmonary a.

Left lower lobe basal trunk pulmonary a.

Descending thoracic aorta

Left atrium



NORMAL ANATOMY This image shows the origin of the first septal perforator branch of the proximal left anterior descending coronary artery (also known as the anterior interventricular branch of the left coronary artery). The first septal perforator coronary artery provides blood flow to the interventricular septum and conduction system of the heart. Disruption of blood flow within the proximal segment of the left anterior descending artery and first septal perforator vessel, as may occur with significant atherosclerosis in the left main or proximal left anterior descending coronary arteries, may result in cardiac dysrhythmias and a large myocardial infarction, leading to sudden cardiac death.

260

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Cardiac CT Axial 11

Ascending aorta

Ascending aorta, left sinus of Valsalva

Right ventricular outflow tract

Left anterior descending coronary a.

Left atrial appendage

Crista terminalis

Septal perforator coronary a.

Superior vena cava

Left circumflex coronary a.

Right superior pulmonary v.

Left superior pulmonary v. Right lower lobe basal trunk pulmonary a.

Left lower lobe basal trunk pulmonary a.

Left atrium

Descending thoracic aorta

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

261

Cardiac CT Axial 12

Conus a.

Ascending aorta, left sinus of Valsalva

Right ventricular outflow tract Ascending aorta Left anterior descending coronary a. Crista terminalis Left atrial appendage

Superior vena cava

Septal perforator coronary a. Left circumflex coronary a.

Right superior pulmonary v.

Left superior pulmonary v.

Right lower lobe basal trunk pulmonary a.

Left lower lobe basal trunk pulmonary a. Descending thoracic aorta

Left atrium

262

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Cardiac CT Axial 12

Ascending aorta

Conus a.

Ascending aorta, left sinus of Valsalva

Right ventricular outflow tract

Left anterior descending coronary a.

Left atrial appendage Crista terminalis Septal perforator coronary a. Superior vena cava Left circumflex coronary a. Right superior pulmonary v.

Left superior pulmonary v.

Right lower lobe basal trunk pulmonary a.

Left lower lobe basal trunk pulmonary a.

Left atrium

Descending thoracic aorta

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

263

Cardiac CT Axial 13

Ascending aorta, left sinus of Valsalva Conus a.

Right ventricular outflow tract

Right atrium Ascending aorta

Left anterior descending coronary a.

Crista terminalis

Septal perforator coronary a. Left atrial appendage Left circumflex coronary a.

Right superior pulmonary v.

Right lower lobe medial basal segment pulmonary a.

Left lower lobe basal trunk pulmonary a. Descending thoracic aorta

Left atrium

264

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Cardiac CT Axial 13

Conus a.

Ascending aorta, left sinus of Valsalva

Right ventricular outflow tract

Left anterior descending coronary a.

Ascending aorta Left atrial appendage Right atrium Septal perforator coronary a.

Crista terminalis

Left circumflex coronary a.

Right superior pulmonary v.

Left lower lobe basal trunk pulmonary a.

Right lower lobe medial basal segment pulmonary a.

Left atrium

Descending thoracic aorta

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

265

Cardiac CT Axial 14

Ascending aorta, left sinus of Valsalva Conus a.

Right ventricular outflow tract Ascending aorta Right atrium

Left anterior descending coronary a.

Crista terminalis

Septal perforator coronary a. Left atrial appendage

Interatrial septum

1st obtuse marginal coronary a. Left circumflex coronary a.

Right lower lobe medial basal segment pulmonary a.

Left lower lobe basal trunk pulmonary a.

Descending thoracic aorta Left atrium

266

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Cardiac CT Axial 14

Conus a.

Right ventricular outflow tract

Left anterior descending coronary a.

Ascending aorta

Septal perforator coronary a.

Right atrium

Left atrial appendage

Crista terminalis 1st obtuse marginal coronary a.

Interatrial septum

Right lower lobe medial basal segment pulmonary a.

Left circumflex coronary a.

Left lower lobe basal trunk pulmonary a.

Left atrium

Ascending aorta, left sinus of Valsalva

Descending thoracic aorta

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

267

Cardiac CT Axial 15

Ascending aorta, noncoronary sinus of Valsalva

Conus a.

Right ventricular outflow tract Right atrium Left anterior descending coronary a.

Septum spurium

Septal perforator coronary a.

Crista terminalis

Left circumflex coronary a. 1st obtuse marginal coronary a.

Interatrial septum Left atrial appendage

Left inferior pulmonary v.

Right lower lobe medial basal segment pulmonary a.

Left lower lobe basal trunk pulmonary a.

Descending thoracic aorta Left atrium



NORMAL ANATOMY A linear low-attenuation structure extending anteriorly from the crista terminalis is visible; this structure represents the septum spurium. The septum spurium is the most prominent of the anterior pectinate muscles arising from the crista terminalis.

268

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Cardiac CT Axial 15

Ascending aorta, noncoronary sinus of Valsalva

Conus a.

Right ventricular outflow tract

Left circumflex coronary a. Left anterior descending coronary a.

Right atrium

Septal perforator coronary a.

Septum spurium

1st obtuse marginal coronary a.

Crista terminalis

Left atrial appendage

Interatrial septum

Left inferior pulmonary v.

Right lower lobe medial basal segment pulmonary a.

Left lower lobe basal trunk pulmonary a.

Left atrium

Descending thoracic aorta

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

269

Cardiac CT Axial 16

Right coronary a. Ascending aorta, right sinus of Valsalva

Conus a.

Right ventricular outflow tract

Left anterior descending coronary a.

Right atrium

Septal perforator coronary a.

Crista terminalis

Left circumflex coronary a.

Interatrial septum

1st obtuse marginal coronary a. Left atrial appendage

Right lower lobe medial basal segment pulmonary a.

Left inferior pulmonary v.

Left lower lobe basal trunk pulmonary artery Descending thoracic aorta Ascending aorta, noncoronary sinus of Valsalva

270

Left atrium

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Cardiac CT Axial 16

Right coronary a.

Conus a.

Right ventricular outflow tract

Ascending aorta, right sinus of Valsalva

Left anterior descending coronary a.

Right atrium

Septal perforator coronary a.

Crista terminalis

Left atrial appendage

Interatrial septum

1st obtuse marginal coronary a.

Right lower lobe medial basal segment pulmonary a.

Left circumflex coronary a. Left lower lobe basal trunk pulmonary a. Ascending aorta, noncoronary sinus of Valsalva

Left atrium

Descending thoracic aorta

Left inferior pulmonary v.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

271

Cardiac CT Axial 17

Right coronary a.

Conus a.

Ascending aorta, right sinus of Valsalva

Right ventricular outflow tract Left anterior descending coronary a.

Right atrium

Septal perforator coronary a. Left circumflex coronary a. 1st obtuse marginal coronary a.

Crista terminalis

Interatrial septum

Left atrial appendage Ascending aorta, left sinus of Valsalva

Right lower lobe medial basal segment pulmonary a.

Left inferior pulmonary v.

Descending thoracic aorta Ascending aorta, noncoronary sinus of Valsalva

272

Left atrium

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Cardiac CT Axial 17

Right coronary a.

Conus a.

Right ventricular outflow tract

Left circumflex coronary a.

Left anterior descending coronary a.

Ascending aorta, right sinus of Valsalva

Septal perforator coronary a.

Right atrium Left atrial appendage Crista terminalis 1st obtuse marginal coronary a.

Interatrial septum

Ascending aorta, left sinus of Valsalva

Right lower lobe medial basal segment pulmonary a.

Left inferior pulmonary v.

Ascending aorta, noncoronary sinus of Valsalva

Left atrium

Descending thoracic aorta

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

273

Cardiac CT Axial 18

Right coronary a. Ascending aorta, noncoronary sinus of Valsalva

Ascending aorta, right sinus of Valsalva

Right ventricular outflow tract Left anterior descending coronary a. Septal perforator coronary a.

Right atrium

Crista terminalis

Anterior interventricular coronary v.

Sinoatrial node a.

Left circumflex coronary a.

Interatrial septum

Left atrial appendage 1st obtuse marginal coronary a. Ascending aorta, left sinus of Valsalva

Left inferior pulmonary v.

Descending thoracic aorta

Left atrium

274

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Cardiac CT Axial 18

Right coronary a.

Ascending aorta, right sinus of Valsalva

Right ventricular outflow tract

Left circumflex coronary a. Left anterior descending coronary a.

Right atrium

Ascending aorta, noncoronary sinus of Valsalva

Anterior interventricular coronary v.

Crista terminalis

Septal perforator coronary a. Left atrial appendage

Sinoatrial node a.

1st obtuse marginal coronary a.

Left inferior pulmonary v.

Interatrial septum

Left atrium

Ascending aorta, left sinus of Valsalva

Descending thoracic aorta

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

275

Cardiac CT Axial 19

Aortic valve leaflets

Conus a.

Right ventricular outflow tract

Right coronary a.

Left anterior descending coronary a. Septal perforator coronary aa. Anterior interventricular coronary v. 1st obtuse marginal coronary a.

Sinoatrial node a. Right atrium Crista terminalis Sinoatrial node a. Interatrial septum

Left atrial appendage Great cardiac v.

Right lower lobe medial basal segment pulmonary a.

Left circumflex coronary a. Left inferior pulmonary v.

Descending thoracic aorta Ascending aorta, noncoronary sinus of Valsalva



Left atrium

NORMAL ANATOMY The sinoatrial nodal coronary artery is visible. The sinoatrial node is the source of the cardiac impulse and is typically located at the junction of the superior vena cava and right atrium, in the superior end of the crista terminalis. The sinoatrial nodal artery usually arises as a single branch from the right coronary artery, as in this patient (see Axials 20 to 25), or, less commonly, the sinoatrial nodal artery may arise from the left circumflex coronary artery. The sinoatrial nodal artery may be followed superiorly toward the location of the sinoatrial node.

276

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Cardiac CT Axial 19

Right coronary a.

Right ventricular Aortic valve leaflets Conus a. outflow tract

Septal perforator coronary aa. Left anterior descending coronary a.

Sinoatrial node a.

Anterior interventricular coronary v.

Right atrium Ascending aorta, noncoronary sinus of Valsalva

Left circumflex coronary a. Left atrial appendage

Crista terminalis Sinoatrial node a.

1st obtuse marginal coronary a.

Right lower lobe medial basal segment pulmonary a.

Great cardiac v.

Left inferior pulmonary v.

Interatrial septum

Left atrium

Descending thoracic aorta

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

277

Cardiac CT Axial 20

Aortic valve leaflets

Conus a.

Right ventricular outflow tract Right coronary a.

Left anterior descending coronary a.

Sinoatrial node a.

Septal perforator coronary a.

Right atrium

1st diagonal coronary a. Anterior interventricular coronary v. Left atrial appendage

Crista terminalis

Interatrial septum

1st obtuse marginal coronary a. Great cardiac v. Left circumflex coronary a.

Right lower lobe anterior & medial basal segment pulmonary aa.

Left inferior pulmonary v. Left lower lobe anterior-medial, lateral, & posterior basal segment pulmonary aa.

Left atrium

278

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Descending thoracic aorta

Cardiac CT Axial 20

Aortic valve leaflets

Conus a.

Right ventricular outflow tract

Septal perforator coronary a. Left anterior descending coronary a.

Right coronary a.

1st diagonal coronary a.

Sinoatrial node a.

Anterior interventricular coronary v.

Right atrium

Left atrial appendage

Crista terminalis

1st obtuse marginal coronary a.

Right lower lobe anterior & medial basal segment pulmonary aa.

Great cardiac v. Left circumflex coronary a. Left lower lobe anterior-medial, lateral, & posterior basal segment pulmonary aa. Interatrial septum

Left atrium

Descending thoracic aorta

Left inferior pulmonary v.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

279

Cardiac CT Axial 21

Aortic valve leaflets

Conus a.

Right ventricular outflow tract

Right coronary a. Sinoatrial node a.

Left anterior descending coronary a. 1st diagonal coronary a.

Right atrium

Septal perforator coronary a. Anterior interventricular coronary v.

Crista terminalis

Interatrial septum

Left atrial appendage 1st obtuse marginal coronary a. Great cardiac v.

Right lower lobe anterior & medial basal segment pulmonary aa.

Left circumflex coronary a. Left inferior pulmonary v. Left lower lobe anterior-medial, lateral, & posterior basal segment pulmonary aa. Descending thoracic aorta Left atrium

280

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Cardiac CT Axial 21

Aortic valve leaflets

Right ventricular outflow tract

Conus a.

Septal perforator coronary a. Left anterior descending coronary a.

Right coronary a.

1st diagonal coronary a.

Sinoatrial node a.

Anterior interventricular coronary v.

Right atrium

Left atrial appendage

Crista terminalis

1st obtuse marginal coronary a.

Right lower lobe anterior & medial basal segment pulmonary aa.

Great cardiac v. Left circumflex coronary a. Left lower lobe anterior-medial, lateral, & posterior basal segment pulmonary aa. Interatrial septum

Left atrium

Descending thoracic aorta

Left inferior pulmonary v.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

281

Cardiac CT Axial 22

Left ventricular outflow tract

Conus a.

Aortic valve leaflet

Right ventricle

Left anterior descending coronary a.

Right coronary a. Sinoatrial node a.

1st diagonal coronary a. Anterior interventricular coronary v.

Right atrium

Septal perforator coronary a.

Crista terminalis

1st obtuse marginal coronary a.

Interatrial septum

Great cardiac v. Left circumflex coronary a.

Right lower lobe anterior & medial basal segment pulmonary aa.

Right inferior pulmonary v.

Left lower lobe anterior-medial, lateral, & posterior basal segment pulmonary aa.

Left atrium

282

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Left inferior pulmonary v. Descending thoracic aorta

Cardiac CT Axial 22

Aortic valve leaflet

Left ventricular outflow tract

Right ventricle

Conus a.

Septal perforator coronary a.

Right coronary a.

Left anterior descending coronary a.

Sinoatrial node a.

1st diagonal coronary a. Anterior interventricular coronary v.

Right atrium Crista terminalis

1st obtuse marginal coronary a.

Right lower lobe anterior & medial basal segment pulmonary aa.

Great cardiac v. Left circumflex coronary a.

Right inferior pulmonary v.

Left lower lobe anterior-medial, lateral, & posterior basal segment pulmonary aa. Interatrial septum

Left atrium

Descending thoracic aorta

Left inferior pulmonary v.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

283

Cardiac CT Axial 23

Right ventricle Left ventricular outflow tract

Septal perforator coronary a.

Left anterior descending coronary a.

Right coronary a.

1st diagonal coronary a.

Sinoatrial node a.

Right atrium

Anterior interventricular coronary v.

Crista terminalis

Great cardiac v.

Interatrial septum 1st obtuse marginal coronary a.

Left circumflex coronary a.

Right inferior pulmonary v.

Right lower lobe posterolateral basal trunk pulmonary a.

Left lower lobe anterior-medial, lateral, & posterior basal segment pulmonary aa.

Left atrium

284

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Left inferior pulmonary v. Descending thoracic aorta

Cardiac CT Axial 23

Right ventricle

Left ventricular outflow tract

Septal perforator coronary a.

Right coronary a.

Left anterior descending coronary a.

Sinoatrial node a.

1st diagonal coronary a.

Right atrium

Anterior interventricular coronary v.

Crista terminalis

1st obtuse marginal coronary a.

Right inferior pulmonary v.

Great cardiac v. Left circumflex coronary a.

Right lower lobe posterolateral basal trunk pulmonary a.

Left lower lobe anterior-medial, lateral, & posterior basal segment pulmonary aa. Interatrial septum

Left atrium

Descending thoracic aorta

Left inferior pulmonary v.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

285

Cardiac CT Axial 24

Right ventricle Left ventricular outflow tract

Septal perforator coronary a.

Left anterior descending coronary a.

Right coronary a.

1st diagonal coronary a. & lateral diagonal branch

Sinoatrial node a.

Anterior interventricular coronary v.

Right atrium Crista terminalis

1st obtuse marginal coronary a. Interatrial septum

Great cardiac v.

Right inferior pulmonary v.

Left circumflex coronary a.

Right lower lobe posterolateral basal trunk pulmonary a.

Left lower lobe anterior-medial, lateral, & posterior basal segment pulmonary aa.

Left atrium

286

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Left inferior pulmonary v. Descending thoracic aorta

Cardiac CT Axial 24

Interatrial septum

Sinoatrial Right node a. coronary a.

Right ventricle

Left anterior descending coronary a.

1st diagonal coronary a. & lateral diagonal branch

Anterior interventricular coronary v.

Right atrium

Septal perforator coronary a.

Crista terminalis

1st obtuse marginal coronary a. Right inferior pulmonary v.

Great cardiac v. Left circumflex coronary a.

Right lower lobe posterolateral basal trunk pulmonary a.

Left lower lobe anterior-medial, lateral, & posterior basal segment pulmonary aa. Left atrium

Left ventricular outflow tract

Descending thoracic aorta

Left inferior pulmonary v.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

287

Cardiac CT Axial 25

Right ventricle Left ventricular outflow tract

Mitral valve, anterior leaflet Septal perforator coronary a.

Acute marginal coronary a.

Left anterior descending coronary a.

Right coronary a.

1st diagonal coronary a. & lateral diagonal branch Right atrium

Anterior interventricular coronary v.

Crista terminalis

1st obtuse marginal coronary a.

Interatrial septum

Great cardiac v. Right inferior pulmonary v.

Left circumflex coronary a.

Right lower lobe posterolateral basal trunk pulmonary a.

Left lower lobe anterior-medial, lateral, & posterior basal segment pulmonary aa. Left inferior pulmonary v.

Left atrium

Descending thoracic aorta

288

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Cardiac CT Axial 25

Left ventricular outflow Right Right coronary a. tract ventricle

Septal perforator coronary a.

Left anterior descending coronary a.

1st diagonal coronary a. & lateral diagonal branch

Acute marginal coronary a. Anterior interventricular coronary v.

Right atrium

Crista terminalis

1st obtuse marginal coronary a.

Right inferior pulmonary v.

Great cardiac v. Left circumflex coronary a.

Right lower lobe posterolateral basal trunk pulmonary a.

Left lower lobe anterior-medial, lateral, & posterior basal segment pulmonary aa. Interatrial septum

Left atrium

Mitral valve, anterior leaflet

Descending thoracic aorta

Left inferior pulmonary v.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

289

Cardiac CT Axial 26

Right ventricle Left ventricular outflow tract

Mitral valve, anterior leaflet Septal perforator coronary a.

Acute marginal coronary aa.

Left descending coronary a. 1st diagonal coronary a. & lateral diagonal branch Anterior interventricular coronary v.

Right coronary a.

Right atrium Crista terminalis

Interatrial septum

1st obtuse marginal coronary a. Great cardiac v. Left circumflex coronary a.

Right inferior pulmonary v.

Right lower lobe posterolateral basal trunk pulmonary a.

Left lower lobe anterior-medial, lateral, & posterior basal segment pulmonary aa.

Left atrium

290

Left inferior pulmonary v. Descending thoracic aorta

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Cardiac CT Axial 27

Interatrial septum

Right ventricle

Septal perforator coronary a.

Left anterior descending coronary a.

1st diagonal coronary a. & lateral diagonal branch

Acute marginal coronary aa. Right coronary a. Anterior interventricular coronary v.

Right atrium Crista terminalis

1st obtuse marginal coronary a. Right inferior pulmonary v.

Great cardiac v. Left circumflex coronary a.

Right lower lobe posterolateral basal trunk pulmonary a.

Left lower lobe anterior-medial, lateral & posterior basal segment pulmonary aa. Left atrium

Left ventricular outflow tract

Mitral valve, Descending anterior thoracic leaflet aorta

Left inferior pulmonary v.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

291

Cardiac CT Axial 27

Right ventricle

Mitral valve, anterior leaflet Left ventricular outflow tract Septal perforator coronary a.

Acute marginal coronary aa.

Left anterior descending coronary a. 1st diagonal coronary a. & lateral diagonal branch Anterior interventricular coronary v.

Right coronary a.

Right atrium

Interatrial septum 1st obtuse marginal coronary a. Left circumflex coronary a. Great cardiac v.

Right inferior pulmonary v.

Left lower lobe lateral, & posterior basal segment pulmonary aa. Left atrium

292

Left inferior pulmonary v. Descending thoracic aorta

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Cardiac CT Axial 27

Interatrial septum

Right ventricle

Left ventricular outflow tract

Septal perforator coronary a.

Left anterior descending coronary a. 1st diagonal coronary a. & lateral diagonal branch

Acute marginal coronary aa.

Anterior interventricular coronary v.

Right coronary a.

Mitral valve, anterior leaflet

Right atrium

1st obtuse marginal coronary a. Left circumflex coronary a.

Right inferior pulmonary v.

Great cardiac v. Left lower lobe lateral & posterior basal segment pulmonary aa. Left atrium

Descending thoracic aorta

Left inferior pulmonary v.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

293

Cardiac CT Axial 28

Right ventricle

Mitral valve, anterior leaflet Left ventricular outflow tract Septal perforator coronary a.

Left anterior descending coronary a.

Acute marginal coronary aa. Right coronary a.

1st diagonal coronary a. & lateral diagonal branch

Tricuspid valve

Right atrium

Left ventricle

Interatrial septum 1st obtuse marginal coronary a. Left circumflex coronary a. Right inferior pulmonary v.

Great cardiac v.

Right lower lobe lateral & posterior basal segment pulmonary aa.

Left lower lobe lateral & posterior basal segment pulmonary aa. Left atrium



Left inferior pulmonary v. Descending thoracic aorta

NORMAL ANATOMY The left ventricular outflow tract is shown, demonstrating that the inflow (mitral valve) and outflow tracts of the left ventricle are closely related to one another. This contrasts with the right ventricle, in which the inflow portions (tricuspid valve) and outflow portions (right ventricular outflow tract, infundibulum, and pulmonic valve) are widely separated. Note that the left ventricular outflow tract is smooth, and that the anterior leaflet of the mitral valve is closely related to the aortic valvular apparatus (see Axials 22 to 25).

294

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Cardiac CT Axial 28

Tricuspid valve (approximate location)

Right ventricle

Septal perforator coronary a. Left anterior descending coronary a. 1st diagonal coronary a. & lateral diagonal branch

Acute marginal coronary aa.

Left ventricle Right coronary a.

Mitral valve, anterior leaflet 1st obtuse marginal coronary a.

Right atrium Interatrial septum

Left circumflex coronary a.

Right inferior pulmonary v.

Great cardiac v. Left inferior pulmonary v.

Right lower lobe lateral & posterior basal segment pulmonary aa.

Left lower lobe lateral & posterior basal segment pulmonary aa. Left atrium

Left ventricular outflow tract

Descending thoracic aorta

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

295

Cardiac CT Axial 29

Right ventricle

Mitral valve, anterior leaflet Septal perforator coronary a.

Acute marginal coronary a.

Left anterior descending coronary a.

Right coronary a.

1st diagonal coronary a. & lateral diagonal branch

Tricuspid valve Right atrium

Left ventricle

Interatrial septum Chordae tendineae 1st obtuse marginal coronary a. Left circumflex coronary a. Great cardiac v.

Pulmonary v.

Left inferior pulmonary v. Right lower lobe lateral & posterior basal segment pulmonary aa.

Left lower lobe posterior basal subsegmental pulmonary a. Left atrium

296

Descending thoracic aorta

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Cardiac CT Axial 29

Tricuspid valve (approximate location)

Right ventricle

Mitral valve, anterior leaflet Left anterior descending coronary a.

Acute marginal coronary a.

1st diagonal coronary a. & lateral diagonal branch

Right coronary a.

Left ventricle Chordae tendineae

Right atrium

1st obtuse marginal coronary a.

Interatrial septum

Left circumflex coronary a. Pulmonary v.

Great cardiac v. Left inferior pulmonary v.

Right lower lobe lateral & posterior basal segment pulmonary aa.

Left lower lobe posterior basal subsegmental pulmonary a. Left atrium

Descending thoracic aorta

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

297

Cardiac CT Axial 30

Septal perforator coronary a. Mitral valve, anterior leaflet

Right ventricle

Acute marginal coronary a.

Left anterior descending coronary a.

Right coronary a.

1st diagonal & lateral diagonal branch coronary aa.

Tricuspid valve Right atrium

Left ventricle

Interatrial septum

Papillary m. Chordae tendineae Left circumflex coronary a.

Pulmonary v. Great cardiac v.

Pulmonary v. Right lower lobe lateral & posterior basal segment pulmonary aa.

Left lower lobe posterior basal subsegmental pulmonary a. Left atrium

298

Descending thoracic aorta

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Cardiac CT Axial 30

Tricuspid valve (approximate location)

Right ventricle

Mitral valve, anterior leaflet Left anterior descending coronary a.

Acute marginal coronary a.

1st diagonal & lateral diagonal branch coronary aa.

Right coronary a.

Left ventricle Right atrium

Papillary m. Chordae tendineae

Interatrial septum

Left circumflex coronary a.

Pulmonary v.

Great cardiac v. Pulmonary v. Right lower lobe lateral & posterior basal segment pulmonary aa.

Left lower lobe posterior basal subsegmental pulmonary a. Left atrium

Descending thoracic aorta

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

299

Cardiac CT Axial 31

Septal perforator coronary a. Mitral valve, anterior leaflet

Right ventricle

Left anterior descending coronary a.

Acute marginal coronary a.

1st diagonal coronary a. & lateral diagonal branch

Right coronary a.

Tricuspid valve Left ventricle (trabeculae carneae)

Right atrium

Papillary m. Interatrial septum

Chordae tendineae Mitral valve, posterior leaflet Left circumflex coronary a.

Pulmonary v. Great cardiac v.

Right lower lobe posterior basal segment pulmonary a.

Left lower lobe posterior basal subsegmental pulmonary a. Left atrium

300

Descending thoracic aorta

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Cardiac CT Axial 31

Tricuspid valve (approximate location)

Right ventricle

Mitral valve, anterior leaflet

Septal perforator coronary a. Left anterior descending coronary a.

Acute marginal coronary a.

1st diagonal coronary a. & lateral diagonal branch

Right coronary a.

Left ventricle (trabeculae carneae)

Right atrium

Papillary m. Chordae tendineae

Interatrial septum

Mitral valve, posterior leaflet

Pulmonary v.

Left circumflex coronary a. Great cardiac v.

Right lower lobe posterior basal segment pulmonary a.

Left lower lobe posterior basal subsegmental pulmonary a. Left atrium

Descending thoracic aorta

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

301

Cardiac CT Axial 32

Mitral valve, anterior leaflet

Right ventricle

Interventricular septum

Interventricular septum

Left anterior descending coronary a.

Acute marginal coronary a.

1st diagonal coronary a. & lateral diagonal branch

Right coronary a.

Left ventricle (trabeculae carneae)

Tricuspid valve

Papillary m.

Right atrium

Chordae tendineae

Interatrial septum

Mitral valve, posterior leaflet 2nd obtuse marginal coronary a. Left circumflex coronary a.

Pulmonary v.

Great cardiac v. Left lower lobe posterior basal subsegmental pulmonary a.

Right lower lobe posterior basal subsegmental pulmonary a. Left atrium

302

Descending thoracic aorta

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Cardiac CT Axial 32

Tricuspid valve (approximate location)

Interventricular septum

Right ventricle

Interventricular septum

Chordae tendineae Left anterior descending coronary a.

Acute marginal coronary a.

1st diagonal coronary a. & lateral diagonal branch

Right coronary a.

Left ventricle (trabeculae carneae)

Right atrium Papillary m. Interatrial septum

Mitral valve, posterior leaflet

Pulmonary v.

2nd obtuse marginal coronary a. Left circumflex coronary a.

Right lower lobe posterior basal subsegmental pulmonary a.

Left lower lobe posterior basal subsegmental pulmonary a. Left atrium

Mitral valve, anterior leaflet

Descending thoracic aorta

Great cardiac v.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

303

Cardiac CT Axial 33

Right ventricle

Mitral valve, anterior leaflet

Interventricular septum

Interventricular septum

Left anterior descending coronary a.

Acute marginal coronary a.

1st diagonal coronary a. & lateral diagonal branch

Right coronary a.

Left ventricle (trabeculae carneae)

Tricuspid valve

Papillary m.

Right atrium

Chordae tendineae

Interatrial septum

Mitral valve, posterior leaflet 2nd obtuse marginal coronary a. Pulmonary vv.

Left circumflex coronary a. Great cardiac v.

Right lower lobe posterior basal subsegmental pulmonary a.

Left lower lobe posterior basal subsegmental pulmonary a. Left atrium



Descending thoracic aorta

TECHNICAL CONSIDERATION The mitral valve (left atrioventricular valve) is clearly open, indicating that this image was acquired during diastole. As discussed above in the Introduction, at lower heart rates, cardiac CT axial examinations are performed during diastole, when cardiac motion is minimal—this allows for nearly motion-free images.

304

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Cardiac CT Axial 33

Tricuspid valve (approximate location)

Mitral valve, anterior leaflet

Right ventricle

Interventricular septum Left anterior descending coronary a.

Acute marginal coronary a.

1st diagonal coronary a. & lateral diagonal branch

Right coronary a.

Left ventricle (trabeculae carneae)

Right atrium

Papillary m. Interatrial septum

Chordae tendineae Mitral valve, posterior leaflet 2nd obtuse marginal coronary a.

Pulmonary vv.

Left lower lobe posterior basal subsegmental pulmonary a.

Right lower lobe posterior basal subsegmental pulmonary a. Left atrium

Great cardiac v.

Descending thoracic aorta

Left circumflex coronary a.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

305

Cardiac CT Axial 34

Right ventricle Interventricular septum

Left anterior descending coronary a.

Acute marginal coronary a.

1st diagonal coronary a.

Right coronary a.

Left ventricle (trabeculae carneae)

Tricuspid valve Right atrium

Papillary m. Chordae tendineae Mitral valve, anterior leaflet

Interatrial septum

Mitral valve, posterior leaflet 2nd obtuse marginal coronary a.

Pulmonary vv.

Left circumflex coronary a. Coronary sinus Right lower lobe posterior basal subsegmental pulmonary a.

Left lower lobe posterior basal subsegmental pulmonary a. Left atrium

306

Descending thoracic aorta

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Cardiac CT Axial 34

Tricuspid valve (approximate location)

Right ventricle

Interventricular septum

Left anterior descending coronary a. 1st diagonal coronary a.

Acute marginal coronary a. Right coronary a.

Left ventricle (trabeculae carneae)

Right atrium

Papillary m. Chordae tendineae

Interatrial septum

Mitral valve, posterior leaflet Pulmonary vv.

2nd obtuse marginal coronary a. Left circumflex coronary a.

Right lower lobe posterior basal subsegmental pulmonary a.

Left lower lobe posterior basal subsegmental pulmonary a. Left atrium

Mitral valve, anterior leaflet

Coronary sinus

Descending thoracic aorta

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

307

Cardiac CT Axial 35

Right ventricle Interventricular septum

Acute marginal coronary a.

Left anterior descending coronary a.

Right coronary a.

1st diagonal coronary a. Left ventricle (trabeculae carneae)

Tricuspid valve

Papillary m.

Right atrium Interatrial septum

Mitral valve, posterior leaflet 2nd obtuse marginal coronary a.

Pulmonary vv.

Left circumflex coronary a. Coronary sinus

Right lower lobe posterior basal subsegmental pulmonary a.

Left lower lobe posterior basal subsegmental pulmonary a. Left atrium

308

Descending thoracic aorta

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Cardiac CT Axial 35

Tricuspid valve (approximate location)

Right ventricle

Interventricular septum

Left anterior descending coronary a. 1st diagonal coronary a.

Acute marginal coronary a.

Left ventricle (trabeculae carneae)

Right coronary a.

Papillary m.

Right atrium Mitral valve, posterior leaflet

Interatrial septum

2nd obtuse marginal coronary a.

Pulmonary vv.

Left circumflex coronary a. Right lower lobe posterior basal subsegmental pulmonary a.

Left lower lobe posterior basal subsegmental pulmonary a. Left atrium

Coronary sinus

Descending thoracic aorta

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

309

Cardiac CT Axial 36

Right ventricle Interventricular septum

1st acute marginal coronary a.

Left anterior descending coronary a.

Right coronary a.

1st diagonal coronary a.

2nd acute marginal coronary a.

Left ventricle (trabeculae carneae) Papillary m.

Tricuspid valve Right atrium

2nd obtuse marginal coronary a.

Pulmonary vv.

Left circumflex coronary a. Right lower lobe posterior basal subsegmental pulmonary a.

Left lower lobe posterior basal subsegmental pulmonary a. Coronary sinus

310

Descending thoracic aorta

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Cardiac CT Axial 36

Tricuspid valve

Right ventricle

1st acute marginal coronary a.

Interventricular septum

Left anterior descending coronary a.

2nd acute marginal coronary a.

1st diagonal coronary a. Left ventricle (trabeculae carneae)

Right coronary a.

Papillary m. Right atrium 2nd obtuse marginal coronary a.

Pulmonary vv.

Left circumflex coronary a. Left lower lobe posterior basal subsegmental pulmonary a.

Right lower lobe posterior basal subsegmental pulmonary a. Coronary sinus

Descending thoracic aorta

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

311

Cardiac CT Axial 37

Right ventricle Interventricular septum

1st acute marginal coronary a. Left anterior descending coronary a.

Right coronary a. 2nd acute marginal coronary a.

Left ventricle (trabeculae carneae)

Tricuspid valve

Papillary m.

Right atrium

2nd obtuse marginal coronary a. Pulmonary v.

Left circumflex coronary a.

Right lower lobe posterior basal subsegmental pulmonary a. Coronary sinus

312

Cardiac v.

Descending thoracic aorta

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Cardiac CT Axial 37

1st acute marginal coronary a.

Right ventricle

Interventricular septum

Left anterior descending coronary a.

Tricuspid valve (approximate location) Left ventricle (trabeculae carneae)

2nd acute marginal coronary a. Right coronary a.

Papillary m.

Right atrium 2nd obtuse marginal coronary a.

Pulmonary v.

Right lower lobe posterior basal subsegmental pulmonary a.

Coronary sinus

Cardiac v.

Descending thoracic aorta

Left circumflex coronary a.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

313

Cardiac CT Axial 38

Right ventricle Interventricular septum

1st acute marginal coronary a.

Left anterior descending coronary a. Left ventricle (trabeculae carneae)

2nd acute marginal coronary a. Right coronary a. Tricuspid valve

Right atrium

2nd obtuse marginal coronary a. Left circumflex coronary a. Pulmonary v.

Right lower lobe posterior basal subsegmental pulmonary a. Coronary sinus Cardiac v.



Descending thoracic aorta

NORMAL ANATOMY This view, and views located both cranial and caudal to this level, shows an irregular surface of the left ventricle, representing trabeculae carneae. Most of the left ventricle is covered by a mesh of trabeculae carneae, sparing only the left ventricular outflow tract (aortic vestibule). Trabeculae carneae are also present within the right ventricle but cannot be seen on this examination because the iodinated contrast has been “washed” from the right cardiac chambers by the use of a saline injection following the intravenous contrast injection (see Introduction above). See the section detailing cardiac MR anatomy for demonstration of right ventricular chamber anatomy.

314

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Cardiac CT Axial 38

Right ventricle

1st acute marginal coronary a.

Interventricular septum Left anterior descending coronary a.

Tricuspid valve (approximate location) 2nd acute marginal coronary a.

Left ventricle (trabeculae carneae)

Right coronary a.

Right atrium 2nd obtuse marginal coronary a.

Pulmonary v.

Coronary sinus

Cardiac v.

Descending thoracic aorta

Left circumflex coronary a.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

315

Cardiac CT Axial 39

Right ventricle Interventricular septum

1st acute marginal coronary a.

Left anterior descending coronary a.

2nd acute marginal coronary a.

Left ventricle (trabeculae carneae)

Right coronary a.

Tricuspid valve Right atrium

2nd obtuse marginal coronary a. Pulmonary v.

Left circumflex coronary a.

Right lower lobe posterior basal subsegmental pulmonary a. Coronary sinus

Descending thoracic aorta Cardiac v.

316

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Cardiac CT Axial 39

1st acute marginal coronary a.

Right ventricle

Interventricular septum

Tricuspid valve (approximate location)

Left anterior descending coronary a.

2nd acute marginal coronary a.

Left ventricle (trabeculae carneae)

Right coronary a.

Right atrium

2nd obtuse marginal coronary a.

Pulmonary v.

Right lower lobe posterior basal subsegmental pulmonary a.

Coronary sinus

Cardiac v.

Descending thoracic aorta

Left circumflex coronary a.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

317

Cardiac CT Axial 40

Right ventricle Interventricular septum

1st acute marginal coronary a. Left anterior descending coronary a.

2nd acute marginal coronary a. Right coronary a.

Left ventricle (trabeculae carneae)

Tricuspid valve

Right atrium

2nd obtuse marginal coronary a. Pulmonary v.

Left circumflex coronary a.

Right lower lobe posterior basal subsegmental pulmonary aa.

Coronary sinus

318

Descending thoracic aorta Cardiac v.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Cardiac CT Axial 40

Tricuspid valve (approximate location)

Right 1st acute marginal ventricle coronary a.

Interventricular septum

Left anterior descending coronary a. 2nd acute marginal coronary a. Right coronary a.

Left ventricle (trabeculae carneae)

Right atrium

2nd obtuse marginal coronary a.

Pulmonary v.

Right lower lobe posterior basal subsegmental pulmonary aa.

Coronary sinus

Cardiac v.

Descending thoracic aorta

Left circumflex coronary a.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

319

Cardiac CT Axial 41

Interventricular septum Right ventricle

1st acute marginal coronary a. Left anterior descending coronary a.

2nd acute marginal coronary a.

Left ventricle (trabeculae carneae)

Right coronary a.

Posterolateral coronary artery branch Inferior vena cava 2nd obtuse marginal coronary a. Left circumflex coronary a. Pulmonary v. Right lower lobe posterior basal subsegmental pulmonary aa.

Left lower lobe posterior basal subsegmental pulmonary a. Posterior interventricular v.

320

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Descending thoracic aorta

Cardiac CT Axial 41

Right 1st acute marginal ventricle coronary a.

Interventricular septum

Left anterior descending coronary a.

2nd acute marginal coronary a.

Left ventricle (trabeculae carneae)

Right coronary a.

Inferior vena cava 2nd obtuse marginal coronary a.

Pulmonary v.

Right lower lobe posterior basal subsegmental pulmonary aa.

Left circumflex coronary a.

Posterolateral coronary artery branch

Posterior interventricular v.

Descending thoracic aorta

Left lower lobe posterior basal subsegmental pulmonary a.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

321

Cardiac CT Axial 42

Interventricular septum Right ventricle

1st acute marginal coronary a. Left anterior descending coronary a.

2nd acute marginal coronary a.

Left ventricle (trabeculae carneae)

Right coronary a.

Posterolateral coronary artery branch Inferior vena cava

2nd obtuse marginal coronary a. Left circumflex coronary a. Pulmonary v. Left lower lobe posterior basal subsegmental pulmonary a. Posterior interventricular v.

322

Descending thoracic aorta

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Cardiac CT Axial 42

1st acute marginal coronary a.

Right ventricle

Interventricular septum

Left anterior descending coronary a.

2nd acute marginal coronary a. Left ventricle (trabeculae carneae)

Right coronary a.

Inferior vena cava

2nd obtuse marginal coronary a. Pulmonary v.

Left circumflex coronary a.

Posterolateral coronary artery branch

Posterior interventricular v.

Descending thoracic aorta

Left lower lobe posterior basal subsegmental pulmonary a.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

323

Cardiac CT Axial 43

Interventricular septum Right ventricle

1st acute marginal coronary a.

Left anterior descending coronary a.

2nd acute marginal coronary a.

Left ventricle (trabeculae carneae)

Right coronary a.

Posterolateral coronary artery branch Inferior vena cava 2nd obtuse marginal coronary a. Left circumflex coronary a.

Pulmonary v. Left lower lobe posterior basal subsegmental pulmonary a. Posterior interventricular v.

324

Descending thoracic aorta

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Cardiac CT Axial 43

1st acute marginal coronary a.

Right ventricle

Interventricular septum

Left anterior descending coronary a.

2nd acute marginal coronary a. Left ventricle (trabeculae carneae)

Right coronary a. Posterolateral coronary artery branch Inferior vena cava

2nd obtuse marginal coronary a.

Pulmonary v. Left lower lobe posterior basal subsegmental pulmonary a. Posterior interventricular v.

Descending thoracic aorta

Left circumflex coronary a.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

325

Cardiac CT Axial 44

Interventricular septum Right ventricle

1st acute marginal coronary a.

Left anterior descending coronary a.

2nd acute marginal coronary a. Left ventricle (trabeculae carneae)

Right coronary a.

Posterolateral coronary artery branch

Inferior vena cava

2nd obtuse marginal coronary a. Left circumflex coronary a.

Pulmonary v.

Posterior interventricular v.

326

Descending thoracic aorta

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Left lower lobe posterior basal subsegmental pulmonary a.

Cardiac CT Axial 44

1st acute marginal coronary a.

Right ventricle

Interventricular septum Left anterior descending coronary a.

2nd acute marginal coronary a. Left ventricle (trabeculae carneae)

Right coronary a.

Inferior vena cava 2nd obtuse marginal coronary a.

Left lower lobe posterior basal subsegmental pulmonary a. Posterior interventricular v.

Descending thoracic aorta

Left circumflex coronary a.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

327

Cardiac CT Axial 45

Interventricular septum Right ventricle

1st acute marginal coronary a.

Left anterior descending coronary a.

2nd acute marginal coronary a. Left ventricle (trabeculae carneae)

Right coronary a. Posterolateral coronary artery branch

2nd obtuse marginal coronary a. Left circumflex coronary a.

Posterior interventricular v.

Descending thoracic aorta

Cardiac v.

328

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Cardiac CT Axial 45

1st acute marginal coronary a.

Right ventricle

Interventricular septum

Left anterior descending coronary a.

2nd acute marginal coronary a.

Left ventricle (trabeculae carneae)

Right coronary a. Posterolateral coronary artery branch

2nd obtuse marginal coronary a.

Inferior vena cava

Posterior interventricular v.

Cardiac v.

Descending thoracic aorta

Left circumflex coronary a.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

329

Cardiac CT Axial 46

Interventricular septum Right ventricle

Left anterior descending coronary a.

1st acute marginal coronary a.

2nd acute marginal coronary a. Left ventricle (trabeculae carneae)

Atrioventricular node coronary a. Right coronary a. Posterolateral coronary artery branch Inferior vena cava

2nd obtuse marginal coronary a. Left circumflex coronary a.

Posterior interventricular v. Cardiac v.



Descending thoracic aorta Intercostal a.

Hemiazygos v.

NORMAL ANATOMY The atrioventricular nodal coronary artery arising from the right coronary artery is shown. The atrioventricular nodal coronary artery arises from the right coronary artery in 90% of patients.

330

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Cardiac CT Axial 46

1st acute marginal coronary a.

Right ventricle

Interventricular septum

Left anterior descending coronary a. 2nd acute marginal coronary a. Left ventricle (trabeculae carneae)

Atrioventricular node coronary a. Right coronary a. Posterolateral coronary artery branch

2nd obtuse marginal coronary a.

Inferior vena cava

Left circumflex coronary a.

Posterior interventricular v.

Cardiac v.

Intercostal a.

Hemiazygos v.

Descending thoracic aorta

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

331

Cardiac CT Axial 47

Interventricular septum Right ventricle

Left anterior descending coronary a.

1st acute marginal coronary a.

2nd acute marginal coronary a. Left ventricle (trabeculae carneae)

Atrioventricular node coronary a. Right coronary a.

2nd obtuse marginal coronary a. Left circumflex coronary a.

Posterior interventricular v. Cardiac v.

332

Descending thoracic aorta Intercostal a.

Hemiazygos v.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Cardiac CT Axial 47

1st acute marginal coronary a.

Right ventricle

Interventricular septum Left anterior descending coronary a.

2nd acute marginal coronary a. Left ventricle (trabeculae carneae)

Atrioventricular node coronary a. Right coronary a.

2nd obtuse marginal coronary a.

Inferior vena cava

Left circumflex coronary a.

Posterior interventricular v.

Cardiac v.

Intercostal a.

Hemiazygos v.

Descending thoracic aorta

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

333

Cardiac CT Axial 48

Interventricular septum Right ventricle

1st acute marginal coronary a.

Left anterior descending coronary a.

2nd acute marginal coronary a. Left ventricle (trabeculae carneae)

Atrioventricular node coronary a.

Right coronary a.

Inferior vena cava

2nd obtuse marginal coronary a. Left circumflex coronary a.

Posterior interventricular v. Spinal cord

334

Intercostal a.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Descending thoracic aorta Hemiazygos v.

Cardiac CT Axial 48

Right ventricle

1st acute marginal coronary a.

Interventricular septum Left anterior descending coronary a.

2nd acute marginal coronary a. Left ventricle (trabeculae carneae)

Atrioventricular node coronary a.

Right coronary a.

2nd obtuse marginal coronary a. Left circumflex coronary a.

Inferior vena cava

Descending thoracic aorta

Posterior interventricular v.

Spinal cord

Intercostal a.

Hemiazygos v.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

335

Cardiac CT Axial 49

Interventricular septum Right ventricle

Left anterior descending coronary a.

1st & 2nd acute marginal coronary aa.

Left ventricle (trabeculae carneae)

Right coronary a.

Inferior vena cava

2nd obtuse marginal coronary a. Left circumflex coronary a.

Posterior interventricular v. Spinal cord

336

Intercostal a.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Descending thoracic aorta Hemiazygos v.

Cardiac CT Axial 49

1st & 2nd acute marginal coronary aa.

Right ventricle

Interventricular septum Left anterior descending coronary a.

Left ventricle (trabeculae carneae) Right coronary a.

2nd obtuse marginal coronary a.

Inferior vena cava

Left circumflex coronary a. Descending thoracic aorta

Posterior interventricular v.

Spinal cord

Intercostal a.

Hemiazygos v.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

337

Cardiac CT Axial 50

Interventricular septum Right ventricle

Left anterior descending coronary a.

1st & 2nd acute marginal coronary aa.

Left ventricle (trabeculae carneae)

Inferior vena cava

2nd obtuse marginal coronary a. Left circumflex coronary a.

Posterior interventricular v. Posterior descending coronary a. Spinal cord



Intercostal a.

Descending thoracic aorta Hemiazygos v.

NORMAL ANATOMY Coronary arterial dominance is variably defined by the vessel that gives rise to the posterior descending coronary artery (also known as the posterior interventricular coronary artery) or the atrioventricular nodal coronary artery. In approximately 85% of individuals, the right coronary artery is dominant, as is the case for this patient.

338

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Cardiac CT Axial 50

Right ventricle

1st & 2nd acute marginal coronary aa.

Interventricular septum Left anterior descending coronary a.

Left ventricle (trabeculae carneae)

Posterior interventricular v.

2nd obtuse marginal coronary a.

Inferior vena cava

Left circumflex coronary a. Descending thoracic aorta

Posterior descending coronary a.

Spinal cord

Intercostal a.

Hemiazygos v.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

339

Cardiac CT Axial 51

Interventricular septum Right ventricle

Left anterior descending coronary a.

1st acute marginal coronary a.

Left ventricle (trabeculae carneae)

Posterior descending coronary a. Posterior interventricular v.

2nd obtuse marginal coronary a.

Inferior vena cava

Left circumflex coronary a.

Pericardial fluid

Spinal cord

340

Descending thoracic aorta Intercostal a.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Hemiazygos v.

Cardiac CT Axial 51

Posterior descending coronary a.

1st acute marginal coronary a.

Right ventricle

Interventricular septum Left anterior descending coronary a.

Left ventricle (trabeculae carneae) Posterior interventricular v. 2nd obtuse marginal coronary a. Inferior vena cava

Left circumflex coronary a.

Descending thoracic aorta

Pericardial fluid

Spinal cord

Intercostal a.

Hemiazygos v.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

341

Cardiac CT Axial 52

Interventricular septum Right ventricle

1st acute marginal coronary a.

Left anterior descending coronary a.

Left ventricle (trabeculae carneae)

Posterior descending coronary a. Posterior interventricular v.

Inferior vena cava

2nd obtuse marginal coronary a. Left circumflex coronary a.

Pericardial fluid

Spinal cord

342

Intercostal a.

Descending thoracic aorta Hemiazygos v.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Cardiac CT Axial 52

Posterior descending coronary a.

1st acute marginal Right coronary a. ventricle

Interventricular septum Left anterior descending coronary a.

Left ventricle (trabeculae carneae)

2nd obtuse marginal coronary a.

Inferior vena cava

Left circumflex coronary a.

Descending thoracic aorta

Pericardial fluid

Spinal cord

Intercostal a.

Hemiazygos v.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

343

Cardiac CT Axial 53

Interventricular septum Right ventricle

Left anterior descending coronary a.

1st acute marginal coronary a.

Posterior descending coronary a.

Left ventricle

Posterior interventricular v. Liver

2nd obtuse marginal coronary a.

Inferior vena cava

Left circumflex coronary a.

Pericardial fluid

Spinal cord Intercostal a.

344

Descending thoracic aorta Hemiazygos v.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Cardiac CT Axial 53

Posterior descending coronary a.

1st acute marginal Right coronary a. ventricle

Interventricular septum

Left anterior descending coronary a. Left ventricle

2nd obtuse marginal coronary a.

Liver

Left circumflex coronary a.

Inferior vena cava

Descending thoracic aorta

Pericardial fluid

Spinal cord

Intercostal a.

Hemiazygos v.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

345

Cardiac CT Axial 54

Interventricular septum Right ventricle

Left anterior descending coronary a.

1st acute marginal coronary a.

Posterior descending coronary a.

Left ventricle

Posterior interventricular v. Liver

2nd obtuse marginal coronary a.

Inferior vena cava

Left circumflex coronary a.

Pericardial fluid

Spinal cord

346

Descending thoracic aorta Intercostal a.

Hemiazygos v.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Cardiac CT Axial 54

Posterior descending coronary a.

1st acute marginal Right coronary a. ventricle

Interventricular septum

Left anterior descending coronary a.

Posterior interventricular v.

Left ventricle

2nd obtuse marginal coronary a.

Liver

Left circumflex coronary a. Inferior vena cava

Descending thoracic aorta

Pericardial fluid

Spinal cord

Intercostal a.

Hemiazygos v.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

347

Cardiac CT Axial 55

Interventricular septum Right ventricle

1st acute marginal coronary a.

Left anterior descending coronary a.

Pericardial fluid

Posterior descending coronary a.

Left ventricle

Posterior interventricular v. 2nd obtuse marginal coronary a.

Liver

Inferior vena cava

Pericardial fluid

Esophagus

348

Spinal cord

Intercostal a.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Descending thoracic aorta Hemiazygos v.

Cardiac CT Axial 55

1st acute marginal coronary a.

Right ventricle

Interventricular septum

Left anterior descending coronary a.

Left ventricle

Posterior interventricular v.

Posterior descending coronary a.

2nd obtuse marginal coronary a.

Liver Inferior vena cava

Descending thoracic aorta

Esophagus

Spinal cord

Intercostal a.

Hemiazygos v.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

349

Cardiac CT Axial 56

Interventricular septum Right ventricle Pericardium

1st acute marginal coronary a.

Left anterior descending coronary a.

Pericardial fluid Left ventricle

Posterior descending coronary a. Posterior interventricular v. Liver

Inferior vena cava

Pericardial fluid

Esophagus Intercostal a. Spinal cord

350

Intercostal a.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Descending thoracic aorta Hemiazygos v.

Cardiac CT Axial 56

Right ventricle

Pericardium

Interventricular septum

Left anterior descending coronary a.

1st acute marginal coronary a. Pericardial fluid

Left ventricle

Posterior interventricular v. Liver

2nd obtuse marginal coronary a.

Posterior descending coronary a. Inferior vena cava

Descending thoracic aorta

Pericardial fluid

Esophagus

Intercostal a.

Spinal cord

Intercostal a.

Hemiazygos v.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

351

Cardiac CT Axial 57

Interventricular septum Right ventricle Pericardium

Left anterior descending coronary a. Pericardial fluid Posterior descending coronary a.

Left ventricle

Posterior interventricular v. Liver

Esophagus

352

Spinal cord

Hemiazygos v.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Descending thoracic aorta

Cardiac CT Axial 57

Pericardium

Right ventricle

Interventricular septum

Left anterior descending coronary a. Posterior interventricular v.

Left ventricle

Posterior descending coronary a.

Pericardial fluid

Liver

Inferior vena cava

Descending thoracic aorta

Esophagus

Spinal cord

Hemiazygos v.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

353

Cardiac CT Axial 58

Interventricular septum Right ventricle Pericardium

Left anterior descending coronary a. Left ventricle

Posterior descending coronary a. Posterior interventricular v.

Liver

Esophagus

354

Spinal cord

Descending thoracic aorta Hemiazygos v.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Cardiac CT Axial 58

Pericardium

Right ventricle

Interventricular septum

Left anterior descending coronary a.

Left ventricle Posterior descending coronary a.

Liver

Inferior vena cava

Descending thoracic aorta

Esophagus

Spinal cord

Hemiazygos v.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

355

Cardiac CT Axial 59

Interventricular septum Right ventricle Pericardium

Left anterior descending coronary a. Posterior descending coronary a.

Left ventricle

Posterior interventricular v. Liver

Spleen

Esophagus

356

Spinal cord

Descending thoracic aorta Hemiazygos v.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Cardiac CT Axial 59

Pericardium

Right ventricle

Interventricular septum Left anterior descending coronary a.

Posterior interventricular v. Left ventricle

Posterior descending coronary a.

Liver

Descending thoracic aorta

Inferior vena cava

Spleen

Esophagus

Spinal cord

Hemiazygos v.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

357

Cardiac CT Axial 60

Interventricular septum Right ventricle Pericardium

Left anterior descending coronary a. Left ventricle Posterior interventricular v. Posterior descending coronary a.

Liver

Spleen

Intercostal a.

Esophagus

358

Spinal cord

Descending thoracic aorta Hemiazygos v.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Cardiac CT Axial 60

Right ventricle

Pericardium

Interventricular septum

Left anterior descending coronary a. Posterior interventricular v.

Left ventricle Posterior descending coronary a. Liver Inferior vena cava Spleen

Intercostal a.

Esophagus

Spinal cord

Hemiazygos v.

Descending thoracic aorta

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

359

Cardiac CT Axial 61

Interventricular septum Right ventricle Pericardium

Left anterior descending coronary a. Left ventricle

Posterior interventricular v.

Liver

Spleen

Intercostal a.

Esophagus

360

Spinal cord

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Descending thoracic aorta

Cardiac CT Axial 61

Pericardium

Right ventricle

Interventricular septum

Left anterior descending coronary a.

Left ventricle

Posterior interventricular v.

Liver

Inferior vena cava

Spleen

Intercostal a.

Esophagus

Spinal cord

Descending thoracic aorta

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

361

Cardiac CT Axial 62

Pericardium

Right ventricular apex Left anterior descending coronary a. (distal) Left ventricular apex

Posterior interventricular v.

Liver

Stomach

Inferior vena cava

Spleen Intercostal a.

Intercostal a.

362

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Descending thoracic aorta

Cardiac CT Axial 62

Pericardium

Right ventricular apex

Left anterior descending coronary a. (distal) Left ventricular apex

Posterior interventricular v.

Liver Stomach

Spleen

Intercostal a.

Descending thoracic aorta

Intercostal a.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

363

Cardiac CT 2-Chamber 1

Intercostal aa.

Left superior pulmonary v. Left atrium

Left atrial appendage

Left circumflex & obtuse marginal coronary aa. Great cardiac v. Left atrial appendage Chordae tendineae Anterior interventricular coronary v. Trabeculae carneae

Rib

Trabeculae carneae

Vertebral body Descending thoracic aorta



Coronary sinus

Mitral valve

Papillary m.

Left ventricle

TECHNICAL CONSIDERATION Cardiac imaging is often interpreted with images displayed in planes oriented with reference to the cardiac axis, as opposed to the axes of the body as is typical for most imaging applications (the axial, coronal, and sagittal planes). Cardiac imaging planes typically include “two-chamber,” “three-chamber,” “four-chamber,” and “short axis” planes, and are commonly used for cardiac CT, MRI, nuclear medicine, and echocardiography. This “two-chamber” or “vertical long axis” view of the heart is useful for assessing the left ventricular cavity, left ventricular inferior and anterior wall motion, the mitral valve, and the left atrial appendage.

364

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Cardiac CT 2-Chamber 1

Left atrium

Left superior pulmonary v.

Left atrial appendage

Great cardiac v. Left atrial appendage Left circumflex & obtuse marginal coronary aa.

Intercostal aa.

Anterior interventricular coronary v. Chordae tendineae

Coronary sinus

Trabeculae carnae

Rib

Left ventricle Descending thoracic aorta

Trabeculae carneae

Vertebral body

Mitral valve

Papillary m.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

365

Cardiac CT 3-Chamber 1

Interventricular septum

Left ventricle Pericardium Left anterior descending coronary a.

Right ventricle

Sternum

Trabeculae carneae

Right atrial appendage Aortic valve

Ascending aorta

Left atrium

Mitral valve (posterior leaflet)

Vertebral body Left ventricular outflow tract Intercostal a.



Mitral valve (anterior leaflet) Descending thoracic aorta

TECHNICAL CONSIDERATION This “three-chamber” view of the heart is useful for displaying the left ventricular outflow tract, left atrium, and mitral and aortic valves. The anteroseptal and inferolateral walls of the left ventricle are also well demonstrated. Note how the continuity between the aortic valve apparatus and anterior mitral valve are well shown in this view.

366

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Cardiac CT 3-Chamber 1

Right ventricle

Interventricular septum

Left ventricle

Pericardium

Sternum Left anterior descending coronary a. Right atrial appendage

Trabeculae carneae

Ascending aorta Mitral valve (anterior leaflet)

Aortic valve

Left atrium

Mitral valve (posterior leaflet)

Vertebral body

Left ventricular outflow tract

Intercostal a.

Descending thoracic aorta

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

367

Cardiac CT 4-Chamber 1

Pericardium Xyphoid Interventricular septum

Costochondral junction

Right ventricle

Left anterior descending coronary a.

Right coronary a. Trabeculae carneae

Right atrium

Left ventricle

Interatrial septum Crista terminalis Papillary m. & chordae tendineae Mitral valve Left circumflex coronary a.

Pulmonary aa.

Great cardiac v.

Pulmonary v.

Pulmonary v.

Left atrium Vertebral body



Intercostal a.

Descending thoracic aorta

TECHNICAL CONSIDERATION This “four-chamber” or “horizontal long axis” view is oriented through the mid portions of the right and left ventricles, along a plane extending through the mitral valve to the apex of the heart. This projection provides a more precise analysis of ventricular size and morphology than standard axial, coronal, or sagittal imaging and is useful for assessing the function of the mitral and tricuspid valves. Left ventricular septal and lateral wall motion is also evaluable in this view.

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NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Cardiac CT 4-Chamber 1

Interventricular septum

Xyphoid

Pericardium

Costochondral junction

Left anterior descending coronary a.

Right ventricle Trabeculae carneae Right coronary a.

Left ventricle Mitral valve

Right atrium Papillary m. & chordae tendineae

Crista terminalis Interatrial septum

Left circumflex coronary a. Pulmonary v.

Pulmonary aa.

Pulmonary v. Left atrium

Vertebral body

Intercostal a.

Descending thoracic aorta

Great cardiac v.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

369

Cardiac CT Short Axis 1

Trabeculae carneae Rib

Papillary mm.

Left anterior descending & diagonal coronary aa.

Left ventricle

Septal perforating coronary a.

Sternum

Costochondral junction

Left internal mammary a.

Pericardial fluid

Descending thoracic aorta

Right ventricle

Liver

Interventricular septum Pericardial fluid

Spleen

Anterior interventricular coronary v. Esophagus Posterior descending coronary a.

Posterior interventricular coronary v. (middle cardiac v.)



TECHNICAL CONSIDERATION This “short axis” view is oriented orthogonal to the four-chamber view, perpendicular to the long axis of the left ventricle from the mitral valve to the apex of the heart. This view is used for calculation of ventricular volumes and ejection fraction as well as assessment of left ventricular wall motion.

370

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Cardiac CT Short Axis 1

Septal perforating coronary a.

Left ventricle

Left anterior descending & diagonal coronary aa.

Rib Sternum

Interventricular septum Costochondral junction Anterior interventricular coronary v.

Right ventricle

Trabeculae carneae

Left internal mammary a.

Papillary mm. Posterior descending coronary a.

Pericardial fluid

Liver

Spleen Pericardial fluid

Esophagus Posterior interventricular coronary v. (middle cardiac v.)

Descending thoracic aorta

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

371

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â•…â•…â•…â•…â•…

Chapter

9

CARDIAC ANATOMY USING MR 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

AXIALâ•… 374

2-CHAMBERâ•… 412

4-CHAMBERâ•… 416

3-CHAMBERâ•… 414

SHORT AXISâ•… 418

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

373

Cardiac MR Axial 1

Sternocleidomastoid mm. Clavicle

Right subclavian v.

Sternothyroid & sternohyoid mm. Left brachiocephalic v.

Pectoralis major m. Pectoralis minor m.

Left internal mammary a. Left common carotid a. Right lung

Left subclavian a. Left lung Rib

Trapezius m.

Vertebral body Spinal cord

Trachea Esophagus Erector spinae m.

Aberrant right subclavian a.



NORMAL VARIANT This axial MR image shows a common vascular variation—an aberrant right subclavian artery. Thoracic CT Soft Tissue Axial Plates 1 to 5 show the normal origin and course of the right subclavian artery. The aberrant right subclavian artery is one of the most common congenital vascular anomalies affecting the aortic arch and great vessels. Normally the right subclavian artery arises from the right brachiocephalic artery and courses into the right upper extremity (see Thoracic CT Soft Tissue Axial Plates 1 to 5). In contrast, the aberrant right subclavian artery typically arises from the distal aspect of the aortic arch or proximal descending thoracic aorta and courses through the mediastinum, posterior to the esophagus, to reach the right upper extremity.

374

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Cardiac MR Axial 1

Clavicle

Sternocleidomastoid mm.

Sternothyroid & sternohyoid mm.

Left brachiocephalic v.

Pectoralis major m. Pectoralis minor m. Right subclavian v.

Left internal mammary a. Left common carotid a.

Aberrant right subclavian a.

Trachea Esophagus Right lung

Left subclavian a. Rib

Vertebral body

Left lung

Trapezius m.

Spinal cord

Erector spinae m.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

375

Cardiac MR Axial 2

Sternocleidomastoid mm. Right brachiocephalic v.

Sternothyroid & sternohyoid mm.

Clavicle

Left brachiocephalic v.

Pectoralis major m. Pectoralis minor m. Left internal mammary a. Left common carotid a. Right lung Left subclavian a.

Left lung

Trapezius m.

Vertebral body Spinal cord

Trachea Erector spinae m.

Aberrant right subclavian a.

376

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Esophagus

Cardiac MR Axial 2

Right brachiocephalic v.

Clavicle

Sternothyroid & Sternocleidomastoid mm. sternohyoid mm.

Left brachiocephalic v.

Pectoralis major m. Pectoralis minor m. Left internal mammary a. Left common carotid a.

Trachea Aberrant right subclavian a.

Esophagus Left subclavian a.

Right lung

Left lung

Trapezius m.

Vertebral body

Spinal cord

Erector spinae m.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

377

Cardiac MR Axial 3

Right brachiocephalic v.

Clavicle

Trachea

Manubrium

Sternothyroid & sternohyoid mm. Left brachiocephalic v.

Pectoralis major m. Pectoralis minor m.

Left internal mammary a. & v. Aortic arch Rib

Right lung

Left lung

Trapezius m.

378

Vertebral body Spinal cord Aberrant right subclavian a.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Esophagus Erector spinae m.

Cardiac MR Axial 3

Clavicle

Manubrium

Sternothyroid & sternohyoid mm.

Pectoralis major m. Left brachiocephalic v.

Pectoralis minor m.

Left internal mammary v. & a.

Right brachiocephalic v.

Aortic arch

Trachea

Esophagus Rib Right lung Left lung

Aberrant right subclavian a.

Trapezius m.

Vertebral body

Spinal cord

Erector spinae m.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

379

Cardiac MR Axial 4

Left brachiocephalic v. Trachea (carina) Right brachiocephalic v.

Manubrium Aortic arch

Pectoralis major m. Pectoralis minor m.

Left internal mammary a. & v.

Right lung Left lung

Rib

Trapezius m.

Vertebral body Spinal cord

380

Aberrant right subclavian a. Esophagus

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Erector spinae m.

Cardiac MR Axial 4

Right brachiocephalic v.

Left brachiocephalic v.

Manubrium

Left internal mammary v. & a.

Pectoralis major m. Pectoralis minor m.

Aortic arch

Trachea (carina) Esophagus

Aberrant right subclavian a.

Right lung

Left lung

Trapezius m.

Vertebral body

Spinal cord

Erector spinae m.

Rib

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

381

Cardiac MR Axial 5

Right internal mammary a. & v.

Right & left mainstem bronchi

Manubrium

Ascending aorta Pericardial fluid

Superior vena cava

Pectoralis major m. Pectoralis minor m.

Left internal mammary v. & a. Right lung

Left lung

Azygos v. (arch)

Right superior intercostal v. Rib

Trapezius m.



Vertebral body Spinal cord

Esophagus

Descending aorta Erector spinae m.

TECHNICAL CONSIDERATION These two MR images illustrate two of the many MR techniques used to examine the thoracic and cardiovascular system: “black blood” and “white blood” imaging techniques, named for the appearance of flowing blood on the image. There are a number of ways in which “black blood” images may be created, but these techniques have in common the lack of significant signal associated with flowing blood—hence, the vessels and cardiac chambers appear black. “White blood” sequences are often used for functional analysis and, although the bright signal within the vessels and cardiac chambers gives the impression that intravenous contrast has been injected, these imaging sequences do not require the use of intravenous contrast to generate signal within the vascular system.

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NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Cardiac MR Axial 5

Right internal mammary a. & v.

Manubrium

Left internal mammary v. & a.

Pectoralis major m.

Pectoralis minor m. Ascending aorta

Superior vena cava Right & left mainstem bronchi

Pericardial fluid

Azygos v. (arch) Right lung

Descending aorta Left lung

Esophagus Right superior intercostal v.

Vertebral body

Trapezius m.

Spinal Erector cord spinae m.

Rib

Superior Ascending vena cava aorta

Pectoralis major m. Pectoralis minor m.

Right & left mainstem bronchi Pericardial fluid

Azygos v. (arch) Right lung

Descending aorta

Esophagus

Left lung

Vertebral body

Trapezius m.

Spinal Erector cord spinae m.

Rib

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

383

Cardiac MR Axial 6

Right & left mainstem bronchi

Manubrium

Ascending aorta Pericardial fluid

Superior vena cava

Pectoralis major m. Left internal mammary v. & a.

Pectoralis minor m.

Right upper lobe pulmonary a.

Left atrial appendage

Right upper lobe bronchus

Left pulmonary a.

Right lung

Left lung Azygos v. Left superior pulmonary v. Left upper lobe pulmonary a.

Right superior intercostal v.

Rib

Trapezius m.

Vertebral body Spinal cord

384

Esophagus

Erector spinae m.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Left upper lobe apical-posterior segment bronchus Descending aorta

Cardiac MR Axial 6

Superior Ascending vena cava aorta

Left internal Manubrium mammary v. & a.

Pectoralis major m.

Pericardial fluid

Pectoralis minor m.

Left atrial appendage

Right & left mainstem bronchi

Left pulmonary a.

Right upper lobe pulmonary a.

Left superior pulmonary v.

Right upper lobe bronchus Azygos v. Right lung

Descending aorta Left upper lobe pulmonary a.

Esophagus

Left lung

Right superior intercostal v. Left upper lobe apical-posterior segment bronchus

Vertebral body Trapezius m. Superior vena cava

Erector Spinal cord spinae m.

Rib

Ascending Pericardial aorta fluid Manubrium

Pectoralis major m.

Left atrial appendage

Pectoralis minor m. Left pulmonary a.

Right & left mainstem bronchi Right upper lobe pulmonary a.

Left superior pulmonary v.

Azygos v. Right lung

Left upper lobe pulmonary a. Left lung

Esophagus

Vertebral body

Descending aorta Trapezius m.

Erector Spinal cord spinae m.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

385

Cardiac MR Axial 7

Right & left mainstem bronchi

Manubrium

Superior vena cava

Ascending aorta Pericardial fluid

Pectoralis major m.

Left internal mammary v. & a.

Pectoralis minor m. Main pulmonary a. Right upper lobe pulmonary a.

Left atrial appendage

Right upper lobe bronchus

Left superior pulmonary v.

Right lung

Left pulmonary a. Left lung

Azygos v.

Left upper lobe pulmonary a.

Right superior intercostal v.

Trapezius m.

Rib

Vertebral body Spinal cord



Esophagus

Erector spinae m.

Left upper lobe apical-posterior segment bronchus Descending aorta

DIAGNOSTIC CONSIDERATION A small amount of pericardial fluid is shown surrounding the ascending aorta. The normal pericardial sac is composed of an outer fibrous layer and an inner serous pericardial sac. The serous pericardium consists of an inner visceral layer (the epicardium), which is intimately adherent to the heart and epicardial fat, and an outer parietal layer, which lines the inner surface of the fibrous pericardium. The pericardial sac is divided into the pericardium proper and a number of sinuses and recesses. Up to 25 mL of fluid may be present within the pericardial sac under normal conditions. On MR and CT, normal pericardium is often seen, and the thickness of normal pericardium typically does not exceed 2 mm.

386

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Cardiac MR Axial 7

Superior vena cava

Manubrium

Ascending Left internal mammary v. & a. aorta

Pectoralis major m.

Pericardial fluid

Pectoralis minor m.

Main pulmonary a.

Pericardial fluid Left atrial appendage

Right upper lobe pulmonary a.

Esophagus

Right & left mainstem bronchi

Left pulmonary a.

Right upper lobe bronchus

Left upper lobe pulmonary a.

Azygos v.

Left upper lobe apical-posterior segment bronchus

Right lung Right superior intercostal v.

Left lung Descending thoracic aorta

Vertebral body

Trapezius m.

Erector spinae m.

Manubrium

Spinal cord Ascending aorta

Rib

Pericardial fluid

Pectoralis major m. Pectoralis minor m. Superior vena cava

Main pulmonary a. Left atrial appendage

Pericardial fluid

Left pulmonary a.

Right & left mainstem bronchi

Esophagus

Azygos v.

Left superior pulmonary v.

Right lung

Left upper lobe pulmonary a.

Right superior intercostal v.

Descending thoracic aorta

Vertebral body Trapezius m.

Erector spinae m.

Spinal cord

Left lung

Rib

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

387

Cardiac MR Axial 8

Superior vena cava

Pericardial fluid

Manubrium

Ascending aorta

Left internal mammary v. & a. Pectoralis major m. Pectoralis minor m.

Main pulmonary a. Left atrial appendage

Right pulmonary a. Left superior pulmonary v.

Bronchus intermedius

Left lung

Right lung

Left upper lobe bronchus

Azygos v.

Lingular pulmonary a. Left interlobar pulmonary a.

Rib

Trapezius m.

388

Vertebral body Spinal cord

Left mainstem bronchus Erector spinae m. Descending aorta Esophagus

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Cardiac MR Axial 8

Pectoralis major m.

Manubrium

Left internal mammary v. & a.

Pectoralis minor m. Ascending aorta Superior vena cava Main pulmonary a. Pericardial fluid

Left atrial appendage

Right pulmonary a.

Left superior pulmonary v.

Bronchus intermedius Esophagus

Left mainstem bronchus Left upper lobe bronchus

Right lung Azygos v.

Lingular pulmonary a. Left interlobar pulmonary a.

Vertebral body

Left lung Trapezius m.

Erector spinae m.

Spinal Descending Rib cord thoracic aorta

Manubrium

Ascending aorta

Pectoralis major m.

Pectoralis minor m. Superior vena cava Main pulmonary a.

Pericardial fluid

Left atrial appendage

Right pulmonary a.

Left superior pulmonary v.

Bronchus intermedius Esophagus Right lung

Left mainstem bronchus Descending thoracic aorta Lingular pulmonary a.

Azygos v.

Left interlobar pulmonary a.

Vertebral body

Trapezius m.

Erector Spinal spinae m. cord

Left lung

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

389

Cardiac MR Axial 9

Pericardial fluid Superior vena cava

Left atrium

Sternum

Ascending aorta Left internal mammary v. & a. Right ventricular outflow tract

Pectoralis major m. Pectoralis minor m.

Left main coronary a. Left anterior descending coronary a.

Right superior pulmonary v.

Anterior interventricular v.

Right lung

Left circumflex coronary a.

Right lower lobe pulmonary a.

Great cardiac v. Left atrial appendage

Right lower lobe bronchus

Left superior pulmonary v.

Azygos v.

Left lung Left lower lobe pulmonary a. Rib

Trapezius m.

390

Vertebral body Spinal cord

Left lower lobe bronchus Esophagus

Erector spinae m.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Descending aorta

Cardiac MR Axial 9

Pectoralis major m.

Sternum

Left internal Ascending mammary v. & a. aorta Right ventricular outflow tract

Pectoralis minor m.

Left main coronary a. Superior vena cava

Left anterior descending coronary a. Left circumflex coronary a.

Right superior pulmonary v.

Anterior interventricular v. Left atrial appendage

Left atrium

Great cardiac v. Esophagus Left superior pulmonary v.

Right lower pulmonary a. Right lower lobe bronchus

Descending thoracic aorta

Right lung

Left lower lobe bronchus Azygos v. Left lower lobe pulmonary a. Vertebral body

Trapezius m.

Erector Spinal spinae m. cord

Right internal mammary a. & v.

Sternum

Left lung Ascending aorta

Rib Pectoralis major m.

Right atrial appendage

Pectoralis minor m. Right ventricular outflow tract

Superior vena cava

Left main coronary a. Left anterior descending coronary a.

Pericardial fluid

Anterior interventricular v. Left circumflex coronary a. Left atrial appendage

Right superior pulmonary v. Left atrium

Great cardiac v.

Right lower pulmonary a.

Left superior pulmonary v. Esophagus

Azygos v.

Descending thoracic aorta Right lung

Left lower lobe pulmonary a.

Vertebral body

Trapezius m.

Erector Spinal spinae m. cord

Left lung

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

391

Cardiac MR Axial 10

Left atrium Right atrial appendage Superior vena cava

Sternum

Ascending aorta

Left internal mammary v. & a. Left sinus of Valsalva

Right ventricular outflow tract Pectoralis minor m. Pectoralis major m.

Right superior pulmonary v.

Left ventricle m.

Right middle lobe bronchus & medial & lateral segment bronchi

Left atrial appendage

Right lung

Left circumflex coronary a.

Right lower lobe pulmonary a.

Great cardiac v.

Right lower lobe bronchus

1st obtuse marginal coronary a. Pulmonary v.

Azygos v.

Left lung

Rib

Trapezius m. Vertebral body Spinal cord

392

Left lower lobe segment pulmonary aa. Esophagus

Erector spinae m.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Descending aorta

Cardiac MR Axial 10

Right atrial appendage

Left internal mammary v. & a. Sternum

Ascending aorta

Superior vena cava Pectoralis major m. Left atrium

Right ventricular outflow tract Pectoralis minor m.

Right superior pulmonary v.

Left sinus of Valsalva Right middle lobe bronchus & medial & lateral segmental bronchi

Left ventricle m. Left atrial appendage Left circumflex coronary a.

Right lower lobe bronchus

Great cardiac v.

Esophagus

1st obtuse marginal coronary a. Pulmonary v. Descending thoracic aorta

Azygos v. Vertebral body Right lung

Left lower lobe segment pulmonary aa. Trapezius m.

Rib

Right atrial appendage

Erector spinae m.

Spinal cord

Ascending aorta Sternum

Left lung Left internal mammary v. & a.

Superior vena cava

Right ventricular outflow tract Pectoralis major m.

Left atrium

Pectoralis minor m. Left sinus of Valsalva

Right superior pulmonary v.

Left ventricle m.

Right lower lobe bronchus

Left atrial appendage Right lower pulmonary a.

Great cardiac v.

Esophagus

Pulmonary v. Descending thoracic aorta

Azygos v. Right lung

Left lower lobe segment pulmonary aa.

Trapezius m.

Erector Spinal spinae m. cord

Vertebral body

Left lung

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

393

Cardiac MR Axial 11

Right atrial appendage Left atrium Superior vena cava

Right coronary a.

Ascending aorta Left internal mammary v. & a.

Sternum

Left sinus of Valsalva Right ventricular outflow tract Pectoralis minor m. Pectoralis major m. Left anterior descending coronary a.

Right superior pulmonary v.

Left ventricle m. Right middle lobe medial & lateral segment bronchi

Left atrial appendage Great cardiac v.

Right lung

Left circumflex coronary a. Left inferior pulmonary v. Left lung

Rib

Trapezius m.

394

Esophagus Vertebral body Spinal cord

Left lower lobe segment pulmonary aa. Azygos v.

Erector spinae m. Descending aorta

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Cardiac MR Axial 11

Right atrial appendage

Right coronary a. Sternum

Left internal mammary v. & a. Right ventricular outflow tract

Superior vena cava

Ascending aorta Pectoralis major m.

Right superior pulmonary v.

Pectoralis minor m. Left anterior descending a.

Right middle lobe medial & lateral segment bronchi

Left sinus of Valsalva Left ventricle m.

Left atrium

Great cardiac v.

Esophagus

Left circumflex coronary a.

Azygos v.

Left inferior pulmonary v. Descending thoracic aorta

Vertebral body Right lung

Left lower lobe segment pulmonary aa. Rib Trapezius m. Right atrial appendage

Erector Spinal spinae m. cord

Left lung

Ascending Right ventricular Right aorta outflow tract Sternum coronary a.

Pectoralis major m.

Superior vena cava

Pectoralis minor m. Left anterior descending a.

Right superior pulmonary v.

Left sinus of Valsalva Left ventricle m.

Left atrium

Great cardiac v.

Esophagus

Left circumflex coronary a. Left inferior pulmonary v. Descending thoracic aorta

Azygos v. Vertebral body

Left lower lobe segment pulmonary aa.

Right lung

Trapezius m.

Erector spinae m.

Spinal cord

Left lung

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

395

Cardiac MR Axial 12

Aortic valve Right coronary a. Right atrium

Sternum

Left internal mammary v. & a. Right ventricle

Pectoralis major m.

Pectoralis minor m. Left anterior descending coronary a.

Crista terminalis

Left ventricular outflow tract

Interatrial septum

Left ventricle Left atrium Mitral valve, anterior & posterior leaflets

Right inferior pulmonary v.

Great cardiac v.

Right lung

Left circumflex coronary a. Left lung

Rib

Trapezius m.

396

Vertebral body Esophagus Spinal cord

Erector spinae m. Azygos v.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Left inferior pulmonary v. Descending aorta

Cardiac MR Axial 12

Right coronary a.

Sternum

Left internal mammary Right v. & a. ventricle

Right atrium

Crista teminalis Pectoralis major & minor mm.

Aortic valve

Left anterior descending coronary a. Left ventricular outflow tract

Interatrial septum Left atrium

Left ventricle

Right inferior pulmonary v. Esophagus

Mitral valve, anterior & posterior leaflets

Azygos v.

Great cardiac v.

Vertebral body Right lung

Left circumflex coronary a.

Spinal cord Left inferior pulmonary v.

Trapezius m.

Rib

Erector Descending spinae mm. thoracic aorta

Right coronary a.

Sternum

Left lung

Left internal mammary v. & a.

Right ventricle

Right atrium Left anterior descending coronary a. Crista terminalis Interatrial septum

Pectoralis major & minor mm. Left ventricular outflow tract

Left atrium

Left ventricle

Right inferior pulmonary v.

Mitral valve, anterior & posterior leaflets

Esophagus

Great cardiac v. Azygos v.

Left circumflex coronary a.

Right lung

Left inferior pulmonary v.

Vertebral body

Trapezius m.

Erector spinae m.

Spinal cord

Descending thoracic aorta

Left lung

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

397

Cardiac MR Axial 13

Left internal mammary v. & a. Right atrium

Right coronary a.

Right ventricle Pericardium

Sternum

Moderator band

Crista terminalis

Pectoralis major m. Pectoralis minor m.

Interatrial septum

Left anterior descending coronary a.

Fossa ovalis

Left ventricular outflow tract

Left atrium

Left ventricle Right inferior pulmonary v.

Papillary m. Mitral valve, anterior & posterior leaflets

Right lung

Coronary sinus Left circumflex coronary a. Left lung

Rib

Trapezius m.

Vertebral body Esophagus Spinal cord

398

Erector spinae m. Azygos v.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Descending aorta

Cardiac MR Axial 13

Right coronary a.

Sternum

Left internal mammary v. & a.

Pericardium

Interventricular septum Right ventricle Right atrium

Moderator band Left anterior descending coronary a.

Crista teminalis Pectoralis major & minor mm.

Fossa ovalis

Left ventricular outflow tract

Left atrium

Left ventricle

Right inferior pulmonary v.

Papillary m. Esophagus Mitral valve, anterior & posterior leaflets

Azygos v.

Coronary sinus

Right lung Vertebral body

Left circumflex coronary a. Trapezius m.

Erector spinae m.

Right coronary a.

Spinal Descending cord thoracic aorta

Pericardium

Sternum

Left lung

Left internal mammary v. & a.

Interventricular septum

Right ventricle

Right atrium

Moderator band Left anterior descending coronary a.

Crista terminalis Interatrial septum

Pectoralis major & minor mm. Left ventricular outflow tract

Fossa ovalis Left atrium

Left ventricle Papillary m.

Right inferior pulmonary v.

Mitral valve, anterior & posterior leaflets

Esophagus Azygos v.

Coronary sinus

Right lung Vertebral body Left circumflex coronary a. Trapezius m.

Erector spinae m.

Spinal Descending cord thoracic aorta

Left lung

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

399

Cardiac MR Axial 14

Left internal mammary v. & a. Right coronary a. Right atrium

Right ventricle Pericardium

Sternum

Moderator band Pectoralis major m. Pectoralis minor m. Crista terminalis Interatrial septum

Left anterior descending coronary a.

Inferior vena cava

Interventricular septum Left ventricle Left ventricular outflow tract

Left atrium

Mitral valve, anterior & posterior leaflets Coronary sinus

Right lung

Left circumflex coronary a. Left lung

Vertebral body

Esophagus Spinal cord



Erector spinae m.

Descending aorta

Azygos v.

DIAGNOSTIC CONSIDERATION Right ventricular anatomy with MR is shown. Cardiac CT requires the injection of iodinated contrast material to opacify the cardiac chambers and vessels to allow adequate visualization of these structures, but dense contrast within the right atrium and ventricle can often obscure adjacent anatomy, such as the right coronary artery, on CT. For this reason, cardiac CT examinations are often conducted with an injection of saline or saline-contrast mixtures following the injection of undiluted iodinated contrast to clear the dense contrast from the right cardiac chambers. Although this technique results in excellent imaging for left-sided cardiac structures and the right coronary artery, it may result in suboptimal visualization of right chamber anatomy (see Cardiac CTA plates). However, note the excellent demonstration of right chamber anatomy on MR—the trabeculae carneae, papillary muscles, and moderator band of the right ventricle and the tricuspid valve are readily visible, and intravenous contrast administration is not required for MR to demonstrate such detail.

400

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Cardiac MR Axial 14

Right coronary a.

Pericardium Sternum

Left internal mammary v. & a.

Right ventricle

Interventricular septum

Moderator band Left anterior descending coronary a.

Right atrium Crista teminalis

Pectoralis major & minor mm.

Liver Interatrial septum

Left ventricular outflow tract

Inferior vena cava

Left ventricle

Left atrium

Mitral valve, anterior & posterior leaflets

Esophagus

Coronary sinus

Right lung Azygos v.

Left circumflex coronary a. Erector spinae m.

Spinal cord

Right coronary a.

Vertebral body

Descending thoracic aorta

Sternum Pericardium

Left lung Left internal mammary v. & a. Tricuspid valve

Interventricular septum

Right ventricle

Right atrium Crista terminalis

Pectoralis major & minor mm.

Interatrial septum Inferior vena cava

Left ventricular outflow tract

Left atrium

Left ventricle

Esophagus

Mitral valve, anterior & posterior leaflets

Azygos v. Right lung

Coronary sinus

Vertebral body

Erector spinae m.

Spinal Descending cord thoracic aorta

Left lung

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

401

Cardiac MR Axial 15

Right coronary a. Right atrium

Left internal mammary v. & a. Right ventricle Pericardium

Sternum

Pectoralis major m. Crista terminalis Left anterior descending coronary a.

Inferior vena cava

Interventricular septum Left ventricle (trabeculae carneae)

Liver

Papillary m.

Coronary sinus Left lung

Right lung

Rib

Erector spinae m.

Azygos v.

Vertebral body Esophagus Spinal cord

402

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Descending aorta

Cardiac MR Axial 15

Right coronary a.

Sternum

Pericardium

Left internal mammary v. & a.

Right ventricle

Interventricular septum

Left anterior descending coronary a.

Right atrium Pectoralis major m.

Liver Crista teminalis

Left ventricle Inferior vena cava Papillary m.

Esophagus Azygos v.

Rib

Right lung Coronary sinus

Erector spinae m. Right coronary a.

Spinal Vertebral Descending body thoracic aorta cord Sternum

Pericardium

Left lung Left internal mammary v. & a.

Right ventricle

Right atrium

Pectoralis major m.

Liver Crista terminalis

Left ventricle (trabeculae carneae)

Inferior vena cava Interventricular septum

Esophagus Azygos v.

Papillary m.

Right lung Vertebral body

Trapezius m.

Erector spinae m.

Spinal cord

Descending thoracic aorta

Left lung

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

403

Cardiac MR Axial 16

Right coronary a.

Sternum

Pericardium Right ventricle

Right atrium

Pectoralis major m. Left anterior descending coronary a. Interventricular septum

Inferior vena cava

Left ventricle (trabeculae carneae) Liver

Papillary m.

Coronary sinus Left lung

Rib Right lung

Erector spinae m.

Vertebral body Esophagus

Azygos v.

Spinal cord

404

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Descending thoracic aorta

Cardiac MR Axial 16

Right coronary a.

Sternum

Pericardium Right ventricle

Interventricular septum

Left anterior descending coronary a.

Right atrium Pectoralis major m. Liver Left ventricle

Inferior vena cava Esophagus

Papillary m.

Azygos v. Coronary sinus

Right lung

Vertebral body Erector spinae m. Right coronary a.

Spinal cord Sternum

Descending thoracic aorta

Left lung

Rib

Pericardium

Right ventricle Interventricular septum Pectoralis major m. Right atrium Left anterior descending coronary a.

Inferior vena cava

Left ventricle

Esophagus

Papillary m.

Azygos v. Right lung

Rib Vertebral body Coronary sinus Erector spinae m.

Spinal Descending cord thoracic aorta

Left lung

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

405

Cardiac MR Axial 17

Right coronary a. Right atrium

Pericardium Right ventricle

Sternum

Pectoralis major m.

Left anterior descending coronary a.

Inferior vena cava

Interventricular septum Left ventricle

Liver

Papillary m. Coronary sinus Left lung

Rib

Right lung

Erector spinae m.

406

Vertebral body Esophagus Spinal cord

Azygos v.

Hemiazygos v.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Descending thoracic aorta

Cardiac MR Axial 17

Right coronary a.

Sternum

Pericardium

Right ventricle (trabeculae carneae) Interventricular septum Pectoralis major m.

Right atrium Liver

Left anterior descending coronary a.

Inferior vena cava

Left ventricle

Esophagus Papillary m.

Azygos v.

Coronary sinus Right lung Descending thoracic aorta

Vertebral body

Erector spinae m.

Spinal cord

Right coronary a.

Sternum

Hemiazygos v.

Left lung

Rib

Pericardium

Right ventricle (trabeculae carneae) Pectoralis major m.

Left anterior descending coronary a.

Liver

Left ventricle

Inferior vena cava

Interventricular septum

Esophagus

Papillary m. Coronary sinus

Azygos v. Right lung

Descending thoracic aorta

Vertebral body

Erector spinae m.

Spinal cord

Hemiazygos v.

Left lung

Rib

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

407

Cardiac MR Axial 18

Right coronary a.

Sternum

Pericardium Right ventricle (trabeculae carneae)

Posterior interventricular v. (middle cardiac v.)

Pectoralis major m.

Left anterior descending coronary a. Inferior vena cava

Interventricular septum Left ventricle

Liver

Left lung

Rib Right lung

Erector spinae m.

408

Vertebral body Esophagus Spinal cord

Hemiazygos v. Azygos v.

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Descending thoracic aorta

Cardiac MR Axial 18

Pericardial fluid (normal)

Right ventricle (trabeculae carneae)

Sternum

Left anterior descending coronary a.

Right coronary a.

Pectoralis major m.

Liver

Interventricular septum Inferior vena cava Left ventricle Esophagus Azygos v.

Posterior interventricular v. (middle cardiac v.)

Vertebral body Descending thoracic aorta Right lung

Erector spinae m. Pericardium

Spinal Hemiazygos v. cord

Rib

Left lung

Right ventricle (trabeculae carneae)

Sternum

Pectoralis major m.

Right coronary a.

Left anterior descending coronary a.

Liver Inferior vena cava

Left ventricle Interventricular septum

Esophagus

Posterior interventricular v. (middle cardiac v.)

Azygos v. Vertebral body Right lung

Descending thoracic aorta

Erector spinae m.

Spinal Hemiazygos v. cord

Left lung

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

409

Cardiac MR Axial 19

Pectoralis major m.

Pericardium

Sternum

Right ventricle (trabeculae carneae)

Left anterior descending coronary a.

Liver

Inferior vena cava

Right hepatic v.

Stomach

Spleen Right lung

Rib Left lung

Erector spinae m.

410

Vertebral body Spinal cord Azygos v.

Hemiazygos v. Esophagus

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Descending thoracic aorta

Cardiac MR Axial 19

Pectoralis major m.

Pericardial fluid (normal)

Sternum

Right ventricle (trabeculae carneae) Liver Left anterior descending coronary a.

Inferior vena cava Right hepatic v.

Stomach

Esophagus

Descending thoracic aorta

Azygos v.

Hemiazygos v.

Right lung Spleen

Vertebral body

Erector spinae m.

Spinal cord

Left lung

Rib

Pericardium

Sternum

Right ventricle (trabeculae carneae)

Liver Inferior vena cava

Left anterior descending coronary a.

Right hepatic v.

Descending thoracic aorta

Esophagus Azygos v.

Spleen

Vertebral body

Erector spinae m.

Spinal cord

Left lung

Rib

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

411

Cardiac MR 2-Chamber 1

Left circumflex coronary a.

Spinal cord

Proximal descending thoracic aorta

Left lung

Left superior pulmonary v.

Left anterior descending coronary a.

Left atrial appendage

Left atrium

Left ventricle

Intervertebral disc space

Mitral valve, anterior & posterior leaflets

Thoracic spine vertebral bodies

Distal descending thoracic aorta Diaphragm

Stomach



TECHNICAL CONSIDERATION Cardiac imaging is often interpreted with images displayed in planes oriented with reference to the cardiac axis, as opposed to the axes of the body as is typical for most imaging applications (the axial, coronal, and sagittal planes). Cardiac imaging planes typically include “two-chamber,” “three-chamber,” “four-chamber,” and “short axis” planes, and are commonly used for cardiac CT, MRI, nuclear medicine, and echocardiography. This “two-chamber” or “vertical long axis” view of the heart is useful for assessing the left ventricular cavity, left ventricular inferior and anterior wall motion, the mitral valve, and the left atrial appendage.

412

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Cardiac MR 2-Chamber 1

Spinal cord

Proximal descending thoracic aorta

Left lung

Left anterior descending coronary a. Left superior pulmonary v.

Left circumflex coronary a.

Left atrial appendage

Left ventricle

Left atrium

Intervertebral disc space

Mitral valve, anterior & posterior leaflets

Thoracic spine vertebral bodies Diaphragm

Descending thoracic aorta

Stomach

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

413

Cardiac MR 3-Chamber 1

Ascending aorta

Pectoralis major m.

Sinuses of Valsalva Sternum

Right ventricle

Right superior pulmonary v.

Interventricular septum

Left ventricular outflow tract Thoracic spine vertebral body

Left ventricle

Mitral valve, anterior & posterior leaflets

Spinal cord

Left atrium Left lung Descending thoracic aorta



TECHNICAL CONSIDERATION This is commonly referred to as a “three-chamber” view of the heart; it is useful for displaying the left ventricular outflow tract, left atrium, and mitral and aortic valves. The anteroseptal and inferolateral walls of the left ventricle are also well seen. Note how the continuity between the aortic root and anterior mitral valve are well shown in this view.

414

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Cardiac MR 3-Chamber 1

Right superior pulmonary v.

Ascending Pectoralis aorta major m.

Sinuses of Valsalva

Sternum

Right ventricle

Left atrium Interventricular septum Thoracic spine vertebral body

Left ventricular outflow tract Left ventricle

Spinal cord

Descending thoracic aorta

Mitral valve, anterior & posterior leaflets

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

415

Cardiac MR 4-Chamber 1

Pericardium Interventricular septum Right ventricle

Left anterior descending coronary a. Mitral valve, anterior & posterior leaflets

Tricuspid valve

Left ventricle Right coronary a. Papillary m. Right atrium Coronary sinus

Interatrial septum and fossa ovalis

Left circumflex coronary a. Left lung Liver Left lower lobe pulmonary a.

Left atrium

Right lung

Descending thoracic aorta Spinal cord

Right lower lobe pulmonary a.



Thoracic spine vertebral body

TECHNICAL CONSIDERATION This view, often referred to as a “four-chamber” or “horizontal long axis” view, is oriented through the mid portions of the right and left ventricles, along a plane extending through the mitral valve to the apex of the heart. This projection provides a more precise analysis of ventricular size and morphology than standard axial, coronal, or sagittal imaging and is useful for assessing the function of the mitral and tricuspid valves. Left ventricular septal and lateral wall motion is also evaluable in this view.

416

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Cardiac MR 4-Chamber 1

Right ventricle

Interventricular septum

Pericardium

Left anterior descending coronary a. Pericardium

Left ventricle

Papillary m. Right coronary a. Mitral valve, anterior & posterior leaflets

Tricuspid valve Interatrial septum and fossa ovalis

Coronary sinus Left circumflex coronary a.

Right atrium

Left lung Left atrium Liver

Left lower lobe pulmonary a. Descending thoracic aorta

Right lung

Right lower lobe pulmonary a.

Thoracic spine vertebral body

Spinal cord

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

417

Cardiac MR Short Axis 1

Left anterior descending coronary a.

Anterior interventricular v.

Right ventricle Interventricular septum Left lung

Papillary m.

Left ventricle

Papillary m.

Liver Spleen

Pancreas



Stomach

TECHNICAL CONSIDERATION This view, often referred to as a “short axis” view, is oriented orthogonal to the four-chamber view, perpendicular to the long axis of the left ventricle from the mitral valve to the apex of the heart. This view is used for calculation of ventricular volumes and ejection fraction as well as assessment of left ventricular wall motion.

418

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

Cardiac MR Short Axis 1

Left anterior descending coronary a.

Anterior interventricular v.

Left lung

Interventricular septum

Papillary m. Left ventricle

Right ventricle

Papillary m.

Liver

Pancreas

Stomach

Spleen

NETTER’S CORRELATIVE IMAGING: CARDIOTHORACIC ANATOMY

419

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Index A

Acromion, anterior thoracic wall, 4f–5f Adrenal gland cisterna chyli/thoracic duct, coronal, Â�216f–217f thoracic soft tissue and lung, coronal, Â�22f–23f, 140f–146f Aneurysm, sinus of Valsalva, 56 Aorta arch cardiac MR axial, 378f–382f cisterna chyli/thoracic duct, axial, 196f–198f heart, anterior exposure, 234f–235f opened flap in posterolateral left ventricular wall, 237f–238f pulmonary axial, 162f–163f section through left and ventricle, mitral valve cut away, 237f–238f superior mediastinum, 6f–7f thoracic cage, 5f–6f thoracic lymph nodes axial, 172f–174f thoracic soft tissue and lung axial, 30f–36f coronal, 118f–132f venous anatomy/variants axial, 220f–222f coronal, 224f–226f sagittal, 226f–229f ascending atria, ventricles, and interventricular septum, 238f cardiac CT 3-chamber 1, 366f–368f cardiac CT axial, 240f–278f cardiac MR 3-chamber 1, 414–415, 414f cardiac MR axial, 382f–396f cisterna chyli/thoracic duct, axial, Â�192f–196f opened right atrium, right lateral view, 236f–237f pulmonary axial, 164f–166f thoracic lymph nodes axial, 174f–186f thoracic soft tissue and lung axial, 11, 34f–40f, 42f–55f, 57f–64f coronal, 108f–122f venous anatomy/variants axial, 222f–224f coronal, 224f–226f descending cardiac MR axial, 382f–404f heart chambers, 10f thoracic cardiac CT 2-chamber 1, 364f–366f cardiac CT 3-chamber 1, 366f–368f cardiac CT 4-chamber 1, 368f–370f cardiac CT axial, 240f–364f cardiac CT short axis 1, 370f–371f cardiac MR 3-chamber 1, 414f–416f cardiac MR 4-chamber 1, 416f–418f cardiac MR axial, 404f–412f cisterna chyli/thoracic duct axial, 190f–196f coronal, 189f, 200f–217f

Aorta (Continued) distal, cardiac MR 2-chamber 1, 412f proximal, cardiac MR 2-chamber 1, 412f–414f pulmonary axial, 160f–162f, 164f–166f thoracic lymph nodes axial, 174f–187f thoracic soft tissue and lung axial, 34f–92f coronal, 130f–148f venous anatomy/variants axial, 222f–224f sagittal, 228f–229f opened right ventricle, anterior view, Â�236f–237f pulmonary coronal, 166f–167f Aortic arch. See Aorta, arch. Aortic arch node, of ligamentum arteriosum, lung, 7f–8f Aortic root, thoracic soft tissue and lung, axial, 56f–64f Aortic valve cardiac CT 3-chamber 1, 366f–368f cardiac MR axial, 374, 397f–398f leaflets, cardiac CT axial, 276f–284f semilunar cusp left atria, ventricles, and interventricular septum, 238f section through left and ventricle with mitral valve cut away, 237f–238f posterior atria, ventricles, and interventricular septum, 238f section through left and ventricle, mitral valve cut away, 237f–238f right atria, ventricles, and interventricular septum, 238f section through left and ventricle with mitral valve cut away, 237f–238f thoracic soft tissue and lung, coronal, Â�110f–111f, 114f–118f Aortopulmonary window cisterna chyli/thoracic duct, coronal, Â�214f–217f thoracic soft tissue and lung, coronal, Â�124f–132f Apex of heart, 10f, 234f–235f of lung. See Lung(s), apex. Artery(ies). See specific artery, e.g. Coronary artery(ies). Atrial appendage left atria, ventricles, and interventricular septum, 238f cardiac CT 2-chamber 1, 364f–366f cardiac CT axial, 252f–282f cardiac MR 2-chamber 1, 412f–414f cardiac MR axial, 384f–395f cisterna chyli/thoracic duct, axial, Â�192f–194f

Atrial appendage (Continued) opened flap in posterolateral left ventricular wall, 237f–238f thoracic soft tissue and lung axial, 50f–60f coronal, 114f–126f right atria, ventricles, and interventricular septum, 238f cardiac CT 3-chamber 1, 366f–368f cardiac CT axial, 248f–260f, 284f–286f cardiac MR axial, 392f–396f heart, anterior exposure, 234f–235f opened right atrium, right lateral view, 236f–237f opened right ventricle, anterior view, 236f–237f thoracic soft tissue and lung axial, 50f–62f coronal, 98f–110f thoracic lymph nodes axial, 184f–186f Atrial branch, of right coronary artery, heart, sternocostal surface, 235f–236f Atrioventricular part, of membranous septum, atrium, right, opened, right lateral view, 236f–237f Atrium left atria, ventricles, and interventricular septum, 238f cardiac CT 2-chamber 1, 364f–366f cardiac CT 3-chamber 1, 366f–368f cardiac CT 4-chamber 1, 368f–370f cardiac CT axial, 250f–310f cardiac MR 2-chamber 1, 412f–414f cardiac MR 3-chamber 1, 414f–416f cardiac MR 4-chamber 1, 416f–418f cardiac MR axial, 390f–402f cisterna chyli/thoracic duct, coronal, 210f–217f oblique vein heart, diaphragmatic surface, 235f–236f opened flap in posterolateral left ventricular wall, 237f–238f opened flap in posterolateral left ventricular wall, 237f–238f opened right atrium, right lateral view, 236f–237f section through left and ventricle, mitral valve cut away, 237f–238f thoracic lymph nodes axial, 186f–187f thoracic soft tissue and lung axial, 58f–72f coronal, 122f–124f, 126f–136f right, 10f anatomy, 236f–237f atria, ventricles, and interventricular septum, 238f cardiac CT 4-chamber 1, 368f–370f cardiac CT axial, 264f–320f cardiac MR 4-chamber 1, 416f–418f cardiac MR axial, 396f–408f

Page numbers followed by a f, figures; t, tables; b indicates boxes.

421

Index Atrium (Continued) heart, anterior exposure, 234f–235f opened right ventricle, anterior view, 236f–237f thoracic lymph nodes axial, 186f–187f thoracic soft tissue and lung axial., 62f–78f coronal, 104f–108f, 110f–118f Auricle left atria, ventricles, and interventricular septum, 238f heart, sternocostal surface, 235f–236f opened flap in posterolateral left ventricular wall, 237f–238f section through left and ventricle, mitral valve cut away, 237f–238f right atria, ventricles, and interventricular septum, 238f heart, anterior exposure, 234f–235f opened right atrium, right lateral view, 236f–237f opened right ventricle, anterior view, 236f–237f Auscultation, triangle of, heart chambers, 10f Axilla thoracic lymph nodes axial, 170f–174f thoracic soft tissue and lung, axial, 26f–34f Azygoesophageal recess, thoracic soft tissue and lung, axial , 58, 58f–62f Azygoesophageal recess lymph node, thoracic soft tissue and lung, axial, 54f–56f Azygos fissure as normal variant, pulmonary axial, 162 pulmonary axial, 162f–163f Azygos lobe as normal variant, pulmonary axial, 162 pulmonary axial, 162f–163f Azygos vein arch cardiac MR axial, 382f–384f venous anatomy/variants, sagittal, 226f–228f cardiac MR axial, 384f–412f cisterna chyli/thoracic duct axial, 192f–198f coronal, 189f, 200f–216f esophagus, 9f–10f heart chambers, 10f intercostal vein entering, cisterna chyli/thoracic duct, axial, 190f–192f pulmonary axial, 162f–163f in right subclavian venous stenosis, 226 superior mediastinum, 6f–7f thoracic lymph nodes axial, 174f–187f thoracic soft tissue and lung axial, 34f–84f coronal, 124f–148f venous anatomy/variants, sagittal, 226f–228f

B

Brachial plexus superior mediastinum, 6f–7f thoracic cage, 5f–6f Brachiocephalic artery left, venous anatomy/variants, coronal, 224f–226f right thoracic lymph nodes axial, 170f–172f thoracic soft tissue and lung axial, 22f–30f coronal, 116f–120f venous anatomy/variants, coronal, 224f–226f

422

Brachiocephalic trunk heart, anterior exposure, 234f–235f superior mediastinum, 6f–7f thoracic cage, 5f–6f Brachiocephalic vein left cardiac MR axial, 374f–382f contrast enhancement of, 16 esophagus, 9f–10f heart, anterior exposure, 234f–235f superior mediastinum, 6f–7f thoracic cage, 5f–6f thoracic lymph nodes axial, 170f–172f thoracic soft tissue and lung axial, 20f–30f coronal, 112f–118f venous anatomy/variants axial, 220f–222f sagittal, 228f–229f lung, 7f–8f right cardiac MR axial, 376f–382f contrast enhancement of, 16 esophagus, 9f–10f heart, anterior exposure, 234f–235f superior mediastinum, 6f–7f thoracic cage, 5f–6f thoracic lymph nodes axial, 170f–172f thoracic soft tissue and lung axial, 20f–30f coronal, 114f–120f Bronchial trunk(s) basal, lower lobe, right, thoracic soft tissue and lung, coronal, 134f–136f lower basal, left, thoracic soft tissue and lung, axial, 60f–66f lower lobe, thoracic soft tissue and lung, axial, 58 posterior basal, lower lobe, right, thoracic soft tissue and lung, axial, 66f–68f posterolateral basal, lower lobe, right, thoracic soft tissue and lung, axial, 67f–68f Bronchomediastinal lymphatic trunk, lung, 7f–8f Bronchopulmonary nodes, lung, 7f–8f Bronchus(i) basal segment, thoracic soft tissue and lung, axial, 58 intermediate, right, superior mediastinum, thoracic soft tissue and lung, axial, 6f–7f lingular cardiac CT axial, 248f–250f inferior subsegmental, thoracic soft tissue and lung, coronal, 116f–120f left, pulmonary coronal, 166f–167f superior segment (B6), 124f–126f superior subsegmental, thoracic soft tissue and lung, coronal, 116f–120f thoracic soft tissue and lung axial, 56f–64f, 80f–82f coronal, 126f–132f lobar, superior, right, superior mediastinum, thoracic soft tissue and lung, axial, 6f–7f lower lobe left anterior basal subsegmental, thoracic soft tissue and lung axial, 70f–74f, 78f–82f coronal, 126f–140f anteromedial basal segment (B7 + 8), thoracic soft tissue and lung axial, 66f–70f coronal, 140f–142f basal trunk, thoracic soft tissue and lung axial, 65f–66f coronal, 140f–142f

Bronchus(i) (Continued) cardiac MR axial, 390f–392f lateral basal segment (B9), thoracic soft tissue and lung axial, 66f–76f coronal, 142f–144f lateral basal subsegmental, thoracic soft tissue and lung axial, 78f–84f coronal, 144f–152f medial basal subsegmental, thoracic soft tissue and lung axial, 70f–78f coronal, 126f–140f posterior basal segment (B10), thoracic soft tissue and lung axial, 66f–72f coronal, 142f–146f posterior basal subsegmental pulmonary axial, 160f–162f thoracic soft tissue and lung axial, 72f–84f coronal, 146f–156f pulmonary coronal, 166f–167f superior basal segment (B6), thoracic soft tissue and lung, coronal, 142f–146f superior basal subsegmental, thoracic soft tissue and lung, coronal, 146f–152f superior segment (B6), thoracic soft tissue and lung, axial, 58f–62f thoracic lymph nodes axial, 184f–186f thoracic soft tissue and lung axial, 56f–62f coronal, 136f–142f right anterior basal segment (B8), thoracic soft tissue and lung axial, 66f–72f coronal, 126f–130f anterior basal subsegmental, thoracic soft tissue and lung axial, 72f–76f coronal, 122f–126f, 132f–136f basal segment, pulmonary coronal, 166f–167f basal trunk, thoracic soft tissue and lung axial, 62f–64f coronal, 136f–138f cardiac MR axial, 390f–394f lateral basal segment (B9), thoracic soft tissue and lung axial, 68f–74f, 138f–140f coronal, 140f–142f lateral basal subsegmental (B9), thoracic soft tissue and lung axial, 74f–76f coronal, 142f–144f medial basal segment (B7), thoracic soft tissue and lung, axial, 62f–70f medial basal subsegmental, thoracic soft tissue and lung, axial, 70f–74f posterior basal segment (B10), thoracic soft tissue and lung axial, 68f–72f coronal, 140f–142f posterior basal subsegmental pulmonary axial, 160f–162f thoracic soft tissue and lung, coronal, 142f–150f thoracic soft tissue and lung axial, Â�72f–80f, 82f–84f pulmonary coronal, 166f–167f superior basal segment (B6), Â�thoracic soft tissue and lung, coronal, Â�136f–142f

Index Bronchus(i) (Continued) superior basal subsegmental, Â�thoracic soft tissue and lung, coronal, Â�142f–150f superior segment (B6), thoracic soft tissue and lung, axial, 58f–62f thoracic lymph nodes axial, 184f–186f thoracic soft tissue and lung axial, 58f–62f coronal, 132f–136f superior segment (B6), thoracic soft tissue and lung, axial, 58 main, left, superior mediastinum, thoracic soft tissue and lung, axial, 6f–7f mainstem left cardiac CT axial, 240f–242f cardiac MR axial, 382f–390f cisterna chyli/thoracic duct, axial, 194f–196f pulmonary coronal, 166f–167f thoracic lymph nodes axial, 174f–182f thoracic soft tissue and lung axial, 40f–52f coronal, 130f–138f right cardiac MR axial, 382f–388f cisterna chyli/thoracic duct axial, 194f–196f coronal, 214f–216f pulmonary coronal, 166f–167f thoracic lymph nodes axial, 174f–180f thoracic soft tissue and lung axial, 40f–48f coronal, 126f–136f medial basal segment lower lobe, right, thoracic soft tissue and lung, coronal, 132f–133f thoracic soft tissue and lung, coronal, 133f–134f middle lobe, right cardiac MR axial, 392f–394f lateral & medial segment (B4 + 5) cardiac MR axial, 392f–396f thoracic soft tissue and lung, axial, 60f–64f lateral segment (B4) thoracic lymph nodes axial, 184f–186f thoracic soft tissue and lung axial, 64f–66f coronal, 120f–122f medial segment (B5) thoracic lymph nodes axial, 184f–186f thoracic soft tissue and lung axial, 62f–63f, 65f–66f coronal, 120f–122f medial subsegmental, thoracic soft tissue and lung, coronal, 108f–116f segmental, thoracic soft tissue and lung, axial, 69f–70f subsegmental, thoracic soft tissue and lung, axial, 66f–69f thoracic soft tissue and lung axial, 58f–62f coronal, 122f–128f segmental, nomenclature for, 42 tracheal as normal variant, 164 pulmonary axial, 164f–166f pulmonary coronal, 166f–167f upper lobe left anterior segment (B3), thoracic soft tissue and lung axial, 50f–56f coronal, 128f–132f

Bronchus(i) (Continued) anterior subsegmental, thoracic soft tissue and lung, coronal, 98f–100f, 108f–128f anteromedial basal segment, Â�thoracic soft tissue and lung, coronal, Â�138f–140f apical-posterior segment (B1 + 2) cardiac MR axial, 384f–388f thoracic soft tissue and lung, axial, 48f–52f apical-posterior subsegmental and left upper lobe apical subsegmental pulmonary arteries, diagnostic consideration for, 30 thoracic soft tissue and lung axial, 24f–28f, 30f–48f coronal, 108f–130f, 136f–146f cardiac MR axial, 388f–390f pulmonary axial, 164f–166f pulmonary coronal, 166f–167f thoracic lymph nodes axial, 182f–184f thoracic soft tissue and lung axial, 52f–56f coronal, 132f–136f right anterior segment (B3), thoracic soft tissue and lung axial, 42f–48f coronal, 122f–128f anterior subsegmental, thoracic soft tissue and lung, coronal, 106f, 108f–112f, 114f–122f apical segment (B1), thoracic soft tissue and lung axial, 40f–41f, 43f–44f coronal, 126f–132f apical subsegmental, thoracic soft tissue and lung axial, 24f–26f, 30f–40f coronal, 113f–126f, 132f–142f cardiac MR axial, 384f–388f cisterna chyli/thoracic duct axial, 194f–196f coronal, 214f–216f posterior segment (B2), thoracic soft tissue and lung axial, 42f–46f coronal, 128f–132f posterior subsegmental, thoracic soft Â�tissue and lung, coronal, Â�132f–138f, 140f–142f subsegmental, pulmonary axial, Â�164f–166f thoracic soft tissue and lung axial, 42f–48f coronal, 126f–132f Bronchus intermedius cardiac CT axial, 240f–246f, 248f–252f cardiac MR axial, 388f–390f pulmonary coronal, 166f–167f thoracic lymph nodes axial, 180f–184f thoracic soft tissue and lung axial, 48f–58f coronal, 128f–136f

C

Cardiac nodes, of stomach, esophagus, 8f–9f Cardiac vein(s) anterior, heart, sternocostal surface, Â�235f–236f cardiac CT axial, 312f–320f, 328f–334f great

Cardiac vein(s) (Continued) cardiac CT 2-chamber 1, 364f–366f cardiac CT 4-chamber 1, 368f–370f cardiac CT axial, 276f–306f cardiac MR axial, 390f–398f heart diaphragmatic surface, 235f–236f sternocostal surface, 235f–236f thoracic soft tissue and lung axial, 66f–71f coronal, 131f–136f heart diaphragmatic surface, 235f–236f sternocostal surface, 235f–236f middle cardiac CT short axis 1, 370f–371f cardiac MR axial, 408f–410f heart, diaphragmatic surface, 235f–236f middle, thoracic soft tissue and lung axial, 76f–86f coronal, 110f–118f small, heart diaphragmatic surface, 235f–236f sternocostal surface, 235f–236f Carina pulmonary coronal, 166f–167f thoracic soft tissue and lung, coronal, Â�132f–136f Carinal nodes, lung, 7f–8f Carotid artery(ies), common left cardiac MR axial, 374f–378f cisterna chyli/thoracic duct, axial, Â�198f–200f heart, anterior exposure, 234f–235f superior mediastinum, 6f–7f thoracic cage, 5f–6f thoracic lymph nodes axial, 170f–172f thoracic soft tissue and lung axial, 12f–32f coronal, 120f–126f venous anatomy/variants coronal, 224f–226f sagittal, 228f–229f right cisterna chyli/thoracic duct, axial, Â�198f–200f superior mediastinum, 6f–7f thoracic soft tissue and lung axial, 12f–22f coronal, 118f–124f Celiac nodes, esophagus, 8f–9f Cephalic vein, anterior thoracic wall, 4f–5f Cervical node(s), deep, inferior esophagus, 8f–9f lung, 7f–8f Chordae tendineae cardiac CT 2-chamber 1, 364f–366f cardiac CT 4-chamber 1, 368f–370f cardiac CT axial, 296f–308f opened flap in posterolateral left ventricular wall, 237f–238f opened right ventricle, anterior view, Â�236f–237f Circumflex branch, of left coronary artery, heart diaphragmatic surface, 235f–236f sternocostal surface, 235f–236f Cisterna chyli cisterna chyli/thoracic duct axial, 190f–192f coronal, 208f–210f thoracic duct and, 189–218

423

Index Clavicle anterior thoracic wall, 3 cardiac MR axial, 374f–378f left cisterna chyli/thoracic duct, axial, Â�198f–200f thoracic soft tissue and lung, axial, 12f–18f medial head left, thoracic soft tissue and lung, axial, 18f–20f thoracic soft tissue and lung, axial, 20f–24f thoracic soft tissue and lung, coronal, Â�108f–118f, 121f–142f venous anatomy/variants axial, 220f–222f coronal, 224f–226f sagittal, 226f–229f Clavipectoral fascia, anterior thoracic wall, 4f–5f Colon, thoracic soft tissue and lung, coronal, 96f–122f Conus arteriosus heart, anterior exposure, 234f–235f opened right atrium, right lateral view, 236f–237f opened right ventricle, anterior view, Â�236f–237f section through left and ventricle with mitral valve cut away, 237f–238f Conus artery, cardiac CT axial, 262f–274f, 276f–284f Coracoid process, of scapula anterior thoracic wall, 4f–5f thoracic soft tissue and lung axial, 12f–14f coronal, 133f–142f Coronary artery(ies) anterior, left, cardiac CT 4-chamber 1, 368f–370f atrioventricular node (nodal) anatomy, cardiac CT axial, 330, 338 cardiac CT axial, 330f–336f circumflex, left cardiac CT 2-chamber 1, 364f–366f cardiac CT 4-chamber 1, 368f–370f cardiac CT axial, 256f–348f cardiac MR 2-chamber 1, 412f–414f cardiac MR 4-chamber 1, 416f–418f cardiac MR axial, 390f–402f thoracic soft tissue and lung axial, 56f–66f coronal, 118f–132f descending anterior cardiac MR axial, 410f–412f left cardiac CT 3-chamber 1, 366f–368f cardiac CT axial, 256f–364f cardiac CT short axis 1, 370f–371f cardiac MR 2-chamber 1, 412f–414f cardiac MR 4-chamber 1, 416f–418f cardiac MR axial, 390f–392f, Â�394f–410f cardiac MR short axis, 418f–419f cisterna chyli/thoracic duct, axial, 192f–194f thoracic soft tissue and lung axial, 56f–78f, 82f–88f coronal, 94f–116f posterior anatomy, cardiac CT axial, 338 cardiac CT axial, 338f–360f cardiac CT short axis 1, 370f–371f thoracic soft tissue and lung, axial, Â�78f–82f, 84f–85f

424

Coronary artery(ies) (Continued) diagonal cardiac CT short axis 1, 370f–371f 1st, cardiac CT axial, 278f–312f thoracic soft tissue and lung axial, 62f–66f coronal, 106f–108f, 112f–114f heart diaphragmatic surface, 235f–236f sternocostal surface, 235f–236f lateral branch of, cardiac CT axial, 286f–306f left circumflex branch, heart diaphragmatic surface, 235f–236f sternocostal surface, 235f–236f heart, sternocostal surface, 235f–236f interventricular branch, anterior, heart anterior exposure, 234f–235f sternocostal surface, 235f–236f interventricular septal branches, heart diaphragmatic surface, 235f–236f sternocostal surface, 235f–236f left marginal branch, heart, diaphragmatic surface, 235f–236f posterior left ventricular branch, heart, diaphragmatic surface, 235f–236f main, left cardiac CT axial, 256f–258f cardiac MR axial, 390f–392f thoracic soft tissue and lung axial, 54f–56f coronal, 116f–118f marginal acute cardiac CT axial, 298f–300f thoracic soft tissue and lung, axial, 70f–74f obtuse 1st cardiac CT axial, 266f–298f cardiac MR axial, 392f–394f 2nd, cardiac CT axial, 302f–352f cardiac CT 2-chamber 1, 364f–366f left, thoracic soft tissue and lung axial, 62f–66f coronal, 124f–132f openings, atria, ventricles, and interventricular septum, 238f posterolateral, right, thoracic soft tissue and lung, axial, 82f–84f posterolateral branch, cardiac CT axial, 320f–332f right anatomy, cardiac CT axial, 338 atrial branch, heart, sternocostal surface, 235f–236f cardiac CT 4-chamber 1, 368f–370f cardiac CT axial, 270f–338f cardiac MR 4-chamber 1, 416f–418f cardiac MR axial, 394f–410f heart anterior exposure, 234f–235f diaphragmatic surface, 235f–236f interventricular branch, posterior, heart, diaphragmatic surface, 235f–236f right branch, heart, sternocostal surface, 235f–236f right marginal branch, heart, diaphragmatic surface, 235f–236f sinoatrial (SA) nodal branch, heart diaphragmatic surface, 235f–236f sternocostal surface, 235f–236f thoracic soft tissue and lung axial, 58f–82f coronal, 100f–118f

Coronary artery(ies) (Continued) septal perforating, cardiac CT short axis 1, 370f–371f septal perforator cardiac CT axial, 258f–302f origin, 260 pathology associated with, 260 sinoatrial nodal, cardiac CT axial, 276. See also Sinoatrial node artery. thoracic soft tissue and lung, axial, 66f–74f Coronary sinus(es) cardiac CT 2-chamber 1, 364f–366f cardiac CT axial, 306f–320f cardiac MR 4-chamber 1, 416f–418f cardiac MR axial, 398f–408f heart, diaphragmatic surface, 235f–236f heart chambers, 10f opened flap in posterolateral left ventricular wall, 237f–238f opening of, atrium, right, opened, right lateral view, 236f–237f section through left and ventricle with mitral valve cut away, 237f–238f thebesian valve, opened right atrium, right lateral view, 236f–237f thoracic soft tissue and lung axial, 71f–78f coronal, 118f–134f Coronary sulcus, heart, anterior exposure, 234f–235f Coronary vein, interventricular, anterior, cardiac CT axial, 274f–276f, 278f–294f Costochondral junction cardiac CT 4-chamber 1, 368f–370f cardiac CT short axis 1, 370f–371f thoracic soft tissue and lung axial, 88f–92f coronal, 92f–96f Cricoid cartilage, superior mediastinum, 6f–7f Crista terminalis cardiac CT 4-chamber 1, 368f–370f cardiac CT axial, 256, 256f–291f cardiac MR axial, 396f–404f opened right atrium, right lateral view, 236f–237f thoracic soft tissue and lung, axial, 62f–74f

D

Descending branch left anterior, of left coronary artery, heart, sternocostal surface, 235f–236f posterior, of right coronary artery, heart, diaphragmatic surface, 235f–236f Diagonal branch, of anterior interventricular artery, 235f–236f Diaphragm cardiac MR 2-chamber 1, 412f–414f cisterna chyli/thoracic duct axial, 190f–192f coronal, 189f, 200f–217f crus cisterna chyli/thoracic duct, axial, Â�190f–192f thoracic soft tissue and lung, axial, Â�90f–92f esophagus, 9f–10f fusion of fibrous pericardium to, line of, thoracic cage, 5f–6f superior mediastinum, 6f–7f thoracic cage, 5f–6f thoracic soft tissue and lung axial, 84f–90f coronal, 94f–157f, 96 venous anatomy/variants, sagittal, 226f–228f

Index Drainage of lungs, routes of, 7f–8f pulmonary venous, anomalous, 18

E

Epigastric artery, superior cutaneous branches, anterior thoracic wall, 4f–5f left, thoracic soft tissue and lung, axial, 78f–88f right, thoracic soft tissue and lung, axial, Â�76f–80f, 83f–84f thoracic cage, 5f–6f thoracic soft tissue and lung, coronal, 92f–94f Epiploic veins, esophagus, 9f–10f Erector spinae muscle cardiac MR axial, 374f–412f cisterna chyli/thoracic duct, axial, 190f–198f thoracic soft tissue and lung, axial, 12f–20f, 22f–26f, 30f–32f, 34f–92f venous anatomy/variants, axial, 222f–224f Esophageal branches, of left gastric vein, esophagus, 9f–10f Esophageal veins (plexus) esophagus, 9f–10f superior mediastinum, 6f–7f Esophagus, 9f–10f cardiac CT axial, 240f–244f, 348f–362f cardiac CT short axis 1, 370f–371f cardiac MR axial, 374f–412f cisterna chyli/thoracic duct axial, 192f–200f coronal, 189f, 202f–217f heart chambers, 10f lymph vessels and nodes, 8f–9f pulmonary axial, 164f–166f superior mediastinum, 6f–7f thoracic lymph nodes axial, 170f–187f thoracic soft tissue and lung axial, 12f–88f coronal, 122f–142f veins, 9f–10f venous anatomy/variants, axial, 222f–224f Eustachian valve, of inferior vena cava, atrium, right, opened, right lateral view, 236f–237f

F

Facet joint, heart chambers, 10f Fissure azygos, pulmonary axial, 162f–163f horizontal (minor), 52 right, thoracic soft tissue and lung axial, 52f–56f coronal, 94f–134f thoracic soft tissue and lung, coronal, 116 inferior accessory lower lobe, right, pulmonary axial, Â�160f–162f as normal variant, 160 oblique (major) left pulmonary axial, 160f–166f thoracic soft tissue and lung axial, 30f–92f, 50 coronal, 102f–106f, 108f–156f right pulmonary axial, 160f–162f pulmonary coronal, 166f–167f thoracic soft tissue and lung axial, 30f–40f, 42f, 44f–90f, 50 coronal, 33f–34f, 98f–156f thoracic soft tissue and lung axial, 40f–41f coronal, 116

Foramen ovale, valve, section through left and ventricle with mitral valve cut away, 237f–238f Fossa ovalis cardiac MR 4-chamber 1, 416f–418f cardiac MR axial, 398f–400f limbus, opened right atrium, right lateral view, 236f–237f opened right atrium, right lateral view, 236f–237f

G

Gastric nodes, left, esophagus, 8f–9f Gastric vein(s) left, esophagus, 9f–10f right, esophagus, 9f–10f short, esophagus, 9f–10f Gastro-omental vein, right, esophagus, 9f–10f Gastroepiploic vein, esophagus, 9f–10f Gastroesophageal junction, cisterna chyli/thoracic duct, axial, 190f–192f Glenoid, of scapula, thoracic soft tissue and lung, coronal, 140f–146f Glenoid fossa, of scapula, thoracic soft tissue and lung, axial, 13f–14f

H

Heart anatomy, 231–238 anterior exposure, 234f–235f CT axial, 239, 240f–364f technical consideration, 240–242 MR axial, 374f–412f using CT, 239–372 apex, 10f heart, anterior exposure, 234f–235f arteries, 235f–236f atrium left, 237f–238f right, 236f–237f chambers, 10f CT axial, technical consideration, 304–306 imaging four-chamber view CT, 368f–370f technical consideration, 368–370 MRI, 416f–418f technical consideration, 416–418 planes for, 364 short axis view CT, 370f–371f technical consideration, 370–371 MRI, 418f–419f technical consideration, 418–419 three-chamber view CT, 366f–368f technical consideration, 366–368 MRI, 414f–416f technical consideration, 414–416 two-chamber view CT, 364f–366f technical consideration, 364–366 MRI, 412f–414f technical consideration, 412–414 inferior border, heart, anterior exposure, 234f–235f left border, heart, anterior exposure, 234f–235f MR axial, “black blood” and “white blood” imaging techniques, 382, 383f–384f veins, 235f–236f anatomy/variants, coronal, 224f ventricle left, 237f–238f right, 236f–237f

Hemiazygos vein accessory esophagus, 9f–10f junction with azygos vein, esophagus, 9f–10f venous anatomy/variants, axial, 222f–224f cardiac CT axial, 330f–360f cardiac MR axial, 406f–412f esophagus, 9f–10f thoracic lymph nodes axial, 184f–187f thoracic soft tissue and lung axial, 70f–88f coronal, 148f–149f Hepatic portal vein, esophagus, 9f–10f Hepatic vein(s) esophagus, 9f–10f right, cardiac MR axial, 410f–412f Hilar lymph nodes left, station 10L, thoracic lymph nodes axial, 182f–184f lung, 7f–8f right, station 10R diagnostic significance, 178 thoracic lymph nodes axial, 178f–180f Humerus head, thoracic soft tissue and lung, axial, 12f–13f, 31f–32f thoracic soft tissue and lung, coronal, 134f–148f

I

Infraspinatus muscle cisterna chyli/thoracic duct, axial, 196f–198f thoracic soft tissue and lung axial, 16f–52f coronal, 148f–157f venous anatomy/variants, axial, 222f–224f Infundibulum, ventricular, right, 94f–108f Innominate artery, right, thoracic lymph nodes axial, 170f–172f Innominate vein left, thoracic lymph nodes axial, 170f–172f right, thoracic lymph nodes axial, 170f–172f Interatrial septum atrium, right, opened, right lateral view, 236f–237f cardiac CT axial, 266f–310f cardiac MR 4-chamber 1, 416f–418f cardiac MR axial, 396f–402f opened right atrium, right lateral view, 236f–237f Intercostal artery(ies) cardiac CT 2-chamber 1, 364f–366f cardiac CT 3-chamber 1, 366f–368f cardiac CT 4-chamber 1, 368f–370f cardiac CT axial, 240f–248f, 250f–252f, 330f–352f, 358f–364f cisterna chyli/thoracic duct, coronal, 189f, 200f–208f posterior, anterior thoracic wall, 4f–5f thoracic soft tissue and lung axial, 52f–56f, 70f–74f, 80f–82f, 84f–88f coronal, 146f–148f Intercostal membranes, external, anterior to internal intercostal muscles, anterior thoracic wall, 4f–5f Intercostal muscle(s) external, anterior thoracic wall, 4f–5f thoracic soft tissue and lung axial, 34f–38f, 88f–92f coronal, 98f–110f Intercostal nerve(s) anterior cutaneous branches, anterior Â�thoracic wall, 4f–5f lateral cutaneous branches, anterior thoracic wall, 4f–5f

425

Index Intercostal nodes, esophagus, 8f–9f Intercostal vein(s) anatomy/variants, sagittal, 226f–228f cisterna chyli/thoracic duct, axial, Â�194f–196f entering azygos vein, cisterna chyli/thoracic duct, axial, 190f–192f posterior, right, 6th, esophagus, 9f–10f superior left course and drainage, 228 esophagus, 9f–10f normal anatomy and function, venous anatomy/variants, axial, 220 venous anatomy/variants axial, 220f–224f sagittal, 228f–229f right cardiac MR axial, 382f–388f cisterna chyli/thoracic duct axial, 198f–200f coronal, 210f–214f esophagus, 9f–10f thoracic soft tissue and lung, axial, 82f Interlobar lymph node left, station 11L calcified, diagnostic significance, 184 thoracic lymph nodes axial, 184f–186f right, station 11R calcified, diagnostic significance, 180 thoracic lymph nodes axial, 180f–182f Interlobular lymph vessels, lung, 7f–8f Intersublobar septum, thoracic soft tissue and lung, axial, 83f–85f Interventricular artery, anterior, diagonal branch of, 235f–236f Interventricular branch(es) of left coronary artery anterior, heart, sternocostal surface, Â�235f–236f septal, heart diaphragmatic surface, 235f–236f sternocostal surface, 235f–236f of right coronary artery, posterior, heart, diaphragmatic surface, 235f–236f Interventricular septum cardiac CT 3-chamber 1, 366f–368f cardiac CT 4-chamber 1, 368f–370f cardiac CT axial, 302f–362f cardiac CT short axis 1, 370f–371f cardiac MR 3-chamber 1, 414f–416f cardiac MR 4-chamber 1, 416f–418f cardiac MR axial, 400f–410f cardiac MR short axis, 418f–419f membranous part, opened right ventricle, anterior view, 236f–237f muscular part atria, ventricles, and interventricular septum, 238f opened right ventricle, anterior view, 236f–237f section through left and ventricle with mitral valve cut away, 237f–238f thoracic soft tissue and lung, axial, 72f–84f Interventricular sulcus, anterior heart, anterior exposure, 234f–235f heart chambers, 10f Interventricular vein anterior cardiac CT 2-chamber 1, 364f–366f cardiac CT short axis 1, 370f–371f cardiac MR axial, 390f–392f cardiac MR short axis, 418f–419f thoracic soft tissue and lung, axial, 58f–62f

426

Interventricular vein (Continued) posterior cardiac CT axial, 320f–364f cardiac CT short axis 1, 370f–371f cardiac MR axial, 408f–410f thoracic soft tissue and lung axial, 76f–86f coronal, 110f–118f Intervertebral disc space, cardiac MR 2-chamber 1, 412f–414f Intrapulmonary nodes, lung, 7f–8f

J

Jugular lymphatic trunk, lung, 7f–8f Jugular nodes, internal, esophagus, 8f–9f Jugular vein external esophagus, 9f–10f thoracic cage, 5f–6f internal esophagus, 9f–10f left heart, anterior exposure, 234f–235f thoracic soft tissue and lung, axial, 12f–20f venous anatomy/variants, coronal, 224f–226f lung, 7f–8f right superior mediastinum, 6f–7f thoracic soft tissue and lung axial, 12f–18f coronal, 118f–120f venous anatomy/variants, coronal, 224f–226f thoracic cage, 5f–6f Junction costochondral, thoracic soft tissue and lung axial, 88f–92f coronal, 92f–96f sternal-manubrial, thoracic soft tissue and lung, coronal, 96f–98f Junction line, anterior, thoracic soft tissue and lung, coronal, 94, 94f–98f Juxtaesophageal phrenic nodes, esophagus, 8f–9f

K

Kidney, thoracic soft tissue and lung axial, 90f–92f coronal, 142f–156f

L

Laryngeal nerve, recurrent left heart, anterior exposure, 234f–235f superior mediastinum, 6f–7f thoracic cage, 5f–6f right, heart, anterior exposure, 234f–235f Latissimus dorsi muscle anterior thoracic wall, 4f–5f heart chambers, 10f thoracic soft tissue and lung axial, 30f–56f, 58f–92f coronal, 150f–157f Levator scapulae muscle, thoracic soft tissue and lung axial, 12f–16f coronal, 154f–156f Ligamentum arteriosum aortic arch node, lung, 7f–8f calcified diagnostic significance of, 174 thoracic lymph nodes axial, 174f–176f

Ligamentum arteriosum (Continued) heart, anterior exposure, 234f–235f opened flap in posterolateral left ventricular wall, 237f–238f superior mediastinum, 6f–7f Linea alba, anterior thoracic wall, 4f–5f Lingular vein, thoracic soft tissue and lung axial, 64f–90f coronal, 110f–126f Liver cardiac CT axial, 344f–364f cardiac CT short axis 1, 370f–371f cardiac MR 4-chamber 1, 416f–418f cardiac MR axial, 401f–412f cardiac MR short axis, 418f–419f cisterna chyli/thoracic duct axial, 190f–192f coronal, 189f, 200f–210f, 212f–217f esophagus, 9f–10f thoracic soft tissue and lung axial, 84f–92f coronal, 94f–154f Lobar lymph node, right, station 12R, thoracic lymph nodes axial, 184f–186f Lung(s), 11–158 anatomy and variants, 159–168 apex left, upper lobe, apical-posterior segment, axial, 14f–20f right, upper lobe, apical segment, axial, 14f–18f axial, 11, 12f–92f azygos lobe as normal variant, pulmonary axial, 162 pulmonary axial, 162f–163f coronal, 11 drainage routes, 7f–8f left cardiac MR 2-chamber 1, 412f–414f cardiac MR 3-chamber 1, 414f cardiac MR 4-chamber 1, 416f–418f cardiac MR axial, 374f–412f cardiac MR short axis, 418f–419f hilum, heart, anterior exposure, 234f–235f lower lobe pulmonary coronal, 166f–167f superior segment, axial, 44f–46f thoracic soft tissue and lung, coronal, 106f, 108f, 110f–130f, 137f–152f, 154f–157f thoracic cage, 5f–6f thoracic soft tissue and lung, coronal, 92f–94f upper lobe, axial, 20f–22f, 24f–28f, Â�30f–34f, 36f–52f lymph vessels and nodes, 7f–8f right cardiac MR 4-chamber 1, 416f–418f cardiac MR axial, 374f–412f hilum, heart, anterior exposure, 234f–235f lower lobe pulmonary coronal, 166f–167f superior segment, axial, 44f–46f thoracic soft tissue and lung, coronal, 119f, 106f, 108f–157f middle lobe, thoracic soft tissue and lung axial, 72f–74f, 82f, 84f–88f coronal, 119f, 98f–100f, 117f–118f, 121f–134f thoracic cage, 5f–6f thoracic soft tissue and lung, coronal, 92f–94f upper lobe axial, 20f–22f, 24f–26f, 30f–48f pulmonary coronal, 166f–167f

Index Lymph node(s). See also specific node, e.g. Cervical node(s). azygoesophageal recess, thoracic soft tissue and lung, axial, 54f–56f esophagus, 8f–9f hilar left, station 10L, thoracic lymph nodes axial, 182f–184f right station 10R, thoracic lymph nodes axial, 178f–180f thoracic soft tissue and lung, axial, 46f–48f interlobar left, station 11L calcified, diagnostic significance of, 184 thoracic lymph nodes axial, 184f–186f right, station 11R calcified, diagnostic significance of, 180 thoracic lymph nodes axial, 180f–182f lobar, right, station 12R, thoracic lymph nodes axial, 184f–186f lung, 7f–8f mediastinal, anterior, station 6, thoracic lymph nodes axial, 172f–174f paraaortic, anterior, station 6, thoracic lymph nodes axial, 172f–174f paraesophageal station 8, thoracic lymph nodes axial, 184f–186f station 8L, thoracic lymph nodes axial, 186f–187f paratracheal left calcification in, diagnostic significance, 176 lower, station 4L, thoracic lymph nodes axial, 174f–178f right calcification in, diagnostic significance, 172, 176 lower, station 4R, thoracic lymph nodes axial, 172f–178f upper, station 2R, thoracic lymph nodes axial, 170f–172f upper, diagnostic significance, 170 pulmonary arteries associated with, 182 pulmonary ligament, left, station 9L calcified, diagnostic significance of, 186 thoracic lymph nodes axial, 186f–187f segmental, right, station 13R, thoracic lymph nodes axial, 184f–186f subaortic, station 5, thoracic lymph nodes axial, 178, 178f–180f subcarinal station 7, thoracic lymph nodes axial, 178f–184f thoracic soft tissue and lung, axial, 50f–54f thoracic, 169–188 axial, 169–188 classification, 170 thoracic soft tissue and lung axial, 44f–52f, 56f–58f coronal, 124f–138f Lymph vessels esophagus, 8f–9f lung, 7f–8f Lymphatic duct, right, lung, 7f–8f Lymphatic plexus, subpleural, lung, 7f–8f

M

Mammary artery, internal cardiac CT axial, 362f–364f left cardiac CT axial, 240f–256f cardiac MR axial, 374f–378f, 380f–412f

Mammary artery, internal (Continued) cisterna chyli/thoracic duct, axial, Â�194f–198f thoracic soft tissue and lung axial, 16f–78f coronal, 92f–102f, 109f–110f venous anatomy/variants, axial, 222f–224f right cardiac CT axial, 240f–256f cardiac CT short axis 1, 370f–371f cardiac MR axial, 391f–392f cisterna chyli/thoracic duct, axial, Â�192f–194f thoracic lymph nodes axial, 172f–187f thoracic soft tissue and lung axial, 16f–76f coronal, 99f–126f venous anatomy/variants, axial, 222f–224f thoracic soft tissue and lung, coronal, Â�103f–104f, 107f–108f Mammary vein, internal left cardiac MR axial, 380f–412f cisterna chyli/thoracic duct, axial, Â�196f–198f thoracic soft tissue and lung axial, 34f–52f, 54f–56f, 58f, 60f, 62f–63f coronal, 92f–102f right cardiac MR axial, 391f–392f cisterna chyli/thoracic duct, axial, 192f–194f thoracic lymph nodes axial, 172f–178f thoracic soft tissue and lung, axial, 26f–28f, 34f–41f, 43f–44f, 46f–52f, 54f–56f, 58f, 60f, 62f–63f venous anatomy/variants, axial, 222f–224f Manubrium, cardiac MR axial, 378f–390f thoracic lymph nodes axial, 170f–174f thoracic soft tissue and lung axial, 22f–30f coronal, 96f–110f venous anatomy/variants, sagittal, 228f–229f Marginal artery acute 1st, cardiac CT axial, 310f–352f 2nd, cardiac CT axial, 310f–340f cardiac CT axial, 288f–298f, 300f–310f left, heart, sternocostal surface, 235f–236f Marginal branch left, of left coronary artery, heart, diaphragmatic surface, 235f–236f right, of right coronary artery, heart diaphragmatic surface, 235f–236f sternocostal surface, 235f–236f Marshall, oblique vein of heart, diaphragmatic surface, 235f–236f opened flap in posterolateral left ventricular wall, 237f–238f Mediastinal lymph node, anterior, station 6, thoracic lymph nodes axial, 172f–174f Mediastinal nodes, posterior, esophagus, 8f–9f Mediastinal pleura, heart, anterior exposure, 234f–235f Mediastinum anterior cardiac CT axial, 242f–244f thoracic lymph nodes axial, 172f–180f thoracic soft tissue and lung axial, 30f–32f, 40f–41f coronal, 98f–118f thymic involution and, diagnostic consideration for, 40–41 tissue composition, 106 drainage roots to, from lung, 7f–8f superior, great vessels, 6f–7f

Membranous septum atrioventricular part atria, ventricles, and interventricular septum, 238f opened right atrium, right lateral view, 236f–237f section through left and ventricle with mitral valve cut away, 237f–238f interventricular part atria, ventricles, and interventricular septum, 238f section through left and ventricle with mitral valve cut away, 237f–238f Mesenteric vein inferior, esophagus, 9f–10f superior, esophagus, 9f–10f Mitral valve anterior cusp atria, ventricles, and interventricular septum, 238f opened flap in posterolateral left ventricular wall, 237f–238f cardiac CT 2-chamber 1, 364f–366f cardiac CT 4-chamber 1, 368f–370f leaflet anterior cardiac CT 3-chamber 1, 366f–368f cardiac CT axial, 288f–308f cardiac MR 2-chamber 1, 412f–414f cardiac MR 3-chamber 1, 414f–416f cardiac MR 4-chamber 1, 416f–418f cardiac MR axial, 396f–402f thoracic soft tissue and lung, axial, 68f–74f heart chambers, 10f posterior cardiac CT 3-chamber 1, 366f–368f cardiac CT axial, 300f–310f cardiac MR 2-chamber 1, 412f–414f cardiac MR 3-chamber 1, 414f–416f cardiac MR 4-chamber 1, 416f–418f cardiac MR axial, 396f–402f thoracic soft tissue and lung, axial, 70f–74f posterior cusp atria, ventricles, and interventricular septum, 238f opened flap in posterolateral left ventricular wall, 237f–238f section through left and ventricle with mitral valve cut away, 237f–238f thoracic soft tissue and lung, coronal, Â�122f–128f Moderator band cardiac MR axial, 398f–402f thoracic soft tissue and lung, axial, 64f–68f Musculophrenic artery left, thoracic soft tissue and lung, axial, Â�78f–80f, 82f, 84f–85f right, thoracic soft tissue and lung, axial, Â�76f–80f, 84f–85f thoracic cage, 5f–6f thoracic soft tissue and lung, coronal, Â�92f–94f

N

Neck, posterior triangle of, 4f–5f Nerve. See specific nerve, e.g. Intercostal nerve(s). Nipple, thoracic soft tissue and lung, axial, 48f–50f Node, of ligamentum arteriosum, lung, 7f–8f Non-coronary sinus, thoracic soft tissue and lung, axial, 58f–64f

427

Index O

Oblique muscle external, anterior thoracic wall, 4f–5f internal, anterior thoracic wall, 4f–5f Oblique sinus, of pericardium. See Pericardial sinus(es), oblique. Oblique vein of left atrium heart, diaphragmatic surface, 235f–236f opened flap in posterolateral left ventricular wall, 237f–238f of Marshall heart, diaphragmatic surface, 235f–236f opened flap in posterolateral left ventricular wall, 237f–238f Obtuse marginal artery, heart, sternocostal surface, 235f–236f Omental veins, esophagus, 9f–10f

P

Pancreas cardiac MR short axis, 418f–419f thoracic soft tissue and lung, coronal, 114f–133f Papillary muscle anterior left, atria, ventricles, and interventricular septum, 238f opened flap in posterolateral left ventricular wall, 237f–238f opened right ventricle, anterior view, 236f–237f right, atria, ventricles, and interventricular septum, 238f cardiac CT 2-chamber 1, 364f–366f cardiac CT 4-chamber 1, 368f–370f cardiac CT axial, 298f–314f cardiac CT short axis 1, 370f–371f cardiac MR 4-chamber 1, 416f–418f cardiac MR axial, 398f–400f, 402f–408f cardiac MR short axis, 418f–419f heart chambers, 10f medial, atria, ventricles, and interventricular septum, 238f posterior left, atria, ventricles, and interventricular septum, 238f opened flap in posterolateral left ventricular wall, 237f–238f opened right ventricle, anterior view, 236f–237f right, atria, ventricles, and interventricular septum, 238f septal atria, ventricles, and interventricular septum, 238f opened right ventricle, anterior view, 236f–237f thoracic soft tissue and lung axial, 70f–82f coronal, 110f–120f Paraaortic lymph node, anterior, station 6, thoracic lymph nodes axial, 172f–174f Paraesophageal lymph node station 8, thoracic lymph nodes axial, 184f–186f station 8L, thoracic lymph nodes axial, 186f–187f Paratracheal lymph node(s) esophagus, 8f–9f left lower, station 4L, thoracic lymph nodes axial, 174f–178f lung, 7f–8f

428

Paratracheal lymph node(s) (Continued) right calcification in, diagnostic significance, 172, 176 lower, station 4R, thoracic lymph nodes axial, 172f–178f lung, 7f–8f thoracic soft tissue and lung, axial, Â�30f–32f, 36f–40f upper, diagnostic significance, 170 Paratracheal space, right, thoracic soft tissue and lung, coronal, 120f–126f Parietal nodes, posterior, esophagus, 8f–9f Parietal pleura costal part superior mediastinum, 6f–7f thoracic cage, 5f–6f diaphragmatic part, parietal pleura superior mediastinum, 6f–7f thoracic cage, 5f–6f mediastinal part heart, anterior exposure, 234f–235f superior mediastinum, 6f–7f thoracic cage, 5f–6f superior mediastinum, 6f–7f thoracic cage, 5f–6f Pectinate muscles, opened right atrium, right lateral view, 236f–237f Pectoral nerve lateral, anterior thoracic wall, 4f–5f medial, anterior thoracic wall, 4f–5f Pectoralis major muscle anterior thoracic wall, 4f–5f cardiac MR 3-chamber 1, 414f–416f cardiac MR axial, 374f–412f cisterna chyli/thoracic duct, axial, 192f–200f heart chambers, 10f thoracic soft tissue and lung axial, 12f–70f coronal, 92f–116f venous anatomy/variants, axial, 222f–224f Pectoralis minor muscle anterior thoracic wall, 4f–5f cardiac MR axial, 374f–402f cisterna chyli/thoracic duct, axial, 196f–200f thoracic soft tissue and lung axial, 14f–36f coronal, 107f–114f venous anatomy/variants, axial, 222f–224f Pericardiacophrenic artery heart, anterior exposure, 234f–235f superior mediastinum, 6f–7f thoracic cage, 5f–6f Pericardiacophrenic vein heart, anterior exposure, 234f–235f superior mediastinum, 6f–7f thoracic cage, 5f–6f Pericardial artery(ies), lower lobe, left, basal trunk, cardiac CT axial, 254f–256f Pericardial fluid anterior superior pericardial recess, cardiac CT axial, 246f–248f cardiac CT axial, 246f–248f, 340f–354f cardiac CT short axis 1, 370f–371f cardiac MR axial, 382f–392f diagnostic significance of, 386 left pulmonic recess, cardiac CT axial, Â�242f–246f normal, thoracic soft tissue and lung, coronal, 108, 108f–110f, 116f–118f posterior portion superior aortic recess, cardiac CT axial, 246f–248f

Pericardial sinus(es) oblique anatomy of, 244 cardiac CT axial, 254f–256f heart chambers, 10f transverse, 254f–256f anatomy of, 244 heart, anterior exposure, 234f–235f opened flap in posterolateral left ventricular wall, 237f–238f opened right ventricle, anterior view, 236f–237f Pericardium anatomy, 244 cardiac CT 3-chamber 1, 366f–368f cardiac CT 4-chamber 1, 368f–370f cardiac CT axial, 246f–248f, 350f–364f cardiac MR 4-chamber 1, 416f–418f cardiac MR axial, 398f–412f cut edge, heart, anterior exposure, Â�234f–235f fibrous, fusion to diaphragm, line of, thoracic cage, 5f–6f reflected opened flap in posterolateral left ventricular wall, 237f–238f opened right atrium, right lateral view, 236f–237f opened right ventricle, anterior view, 236f–237f at site of reflection from great vessels, heart, anterior exposure, 234f–235f superior mediastinum, 6f–7f thoracic cage, 5f–6f thoracic soft tissue and lung, axial, 62f–64f, 68f–70f, 76f–88f Peripheral artery, lower lobe, right, thoracic soft tissue and lung, coronal, 156f–157f Phrenic nerve(s) heart, anterior exposure, 234f–235f superior mediastinum, 6f–7f thoracic cage, 5f–6f thoracic soft tissue and lung, axial, 82, 86f–88f Phrenic nodes, superior, esophagus, 8f–9f Phrenic vein, inferior, left, esophagus, 9f–10f Pleura mediastinal, heart, anterior exposure, 234f– 235f parietal. See Parietal pleura. Portal vein, hepatic, esophagus, 9f–10f Posterior artery, basal segment, posterior, lower lobe, left, thoracic soft tissue and lung, axial, 66f–68f Posterior triangle, of neck, 4f–5f Posterior vein, of left ventricle, heart, diaphragmatic surface, 235f–236f Prevascular space, thoracic lymph nodes axial, 170f–172f Pulmonary artery(ies) aortic, thoracic soft tissue and lung, coronal, 133f–138f cardiac CT 4-chamber 1, 368f–370f cisterna chyli/thoracic duct, coronal, 190f, 207f–217f inferior segment, thoracic soft tissue and lung, coronal, 124f–132f interlobar left cardiac CT axial, 240f–244f cardiac MR axial, 389f–390f thoracic lymph nodes axial, 180f–184f thoracic soft tissue and lung axial, 47f–58f coronal, 130f–142f

Index Pulmonary artery(ies) (Continued) right cardiac CT axial, 240f–244f thoracic soft tissue and lung axial, 52f–58f coronal, 123f–126f lateral basal segment, thoracic soft tissue and lung, axial, 64 left cardiac MR axial, 384f–388f cisterna chyli/thoracic duct, axial, Â�194f–196f heart, anterior exposure, 234f–235f opened flap in posterolateral left ventricular wall, 237f–238f section through left and ventricle with mitral valve cut away, 237f–238f superior mediastinum, 6f–7f thoracic lymph nodes axial, 178f–180f thoracic soft tissue and lung axial, 40f–48f coronal, 126f–138f venous anatomy/variants, sagittal, Â�228f–229f lingular cardiac CT axial, 244f–252f cardiac MR axial, 388f–390f inferior segment, thoracic soft tissue and lung axial, 60f–64f coronal, 130f inferior subsegmental, thoracic soft tissue and lung, coronal, 100f–124f superior subsegmental, thoracic soft tissue and lung, coronal, 98f–104f, 108f–132f thoracic soft tissue and lung axial, 58f–60f, 64f–80f coronal, 132f–140f lower lobe anteromedial basal segment, thoracic soft tissue and lung, axial, 60, 60f–64f lateral basal segment, thoracic soft tissue and lung, axial, 60 left anterior basal subsegmental, thoracic soft tissue and lung axial, 11, 70f–92f coronal, 118f–138f anterior-medial basal segment, cardiac CT axial, 278f–294f anteromedial basal segment, thoracic soft tissue and lung axial, 64f–70f coronal, 138f–142f anteromedial basal subsegmental, thoracic soft tissue and lung, axial, 73f–74f basal trunk cardiac CT axial, 256f–272f thoracic soft tissue and lung, coronal, 140f–142f cardiac CT axial, 246f–252f cardiac MR 4-chamber 1, 416f–418f cardiac MR axial, 388f–392f lateral basal segment cardiac CT axial, 278f–298f thoracic soft tissue and lung axial, 70f–76f, 78f–79f coronal, 142f–144f lateral basal subsegmental, thoracic soft tissue and lung axial, 76f–92f coronal, 144f–156f medial basal segment, cardiac CT axial, 264, 283f–284f

Pulmonary artery(ies) (Continued) medial basal subsegmental, thoracic soft tissue and lung axial, 70f–73f, 76f–84f coronal, 126f–140f posterior basal segment cardiac CT axial, 278f–298f thoracic soft tissue and lung axial, 69f–74f, 77f–78f coronal, 144f–150f posterior basal subsegmental, cardiac CT axial, 298f–312f, 320f–328f cardiac CT axial, 298f–300f thoracic soft tissue and lung axial, 68f–88f, 90f–92f coronal, 148f–156f segment, cardiac MR axial, 392f–396f superior basal segment, thoracic soft Â�tissue and lung, coronal, 142f–145f superior basal subsegmental, Â�thoracic soft tissue and lung, coronal, Â�146f–156f superior segment cardiac CT axial, 252f–254f thoracic soft tissue and lung axial, 54f–56f coronal, 143f–146f superior subsegmental, thoracic soft Â�tissue and lung, coronal, 149f–150f thoracic lymph nodes axial, 184f–186f thoracic soft tissue and lung axial, 59f–60f coronal, 138f–142f posterior basal segment, thoracic soft Â�tissue and lung, axial, 60, 60f–66f right anterior basal segment cardiac CT axial, 278f–284f thoracic soft tissue and lung axial, 64f–68f, 71f–76f coronal, 130f anterior basal subsegmental, thoracic soft tissue and lung axial, 68f–90f coronal, 116f–136f basal subsegmental, thoracic soft tissue and lung, axial, 71f–72f basal trunk cardiac CT axial, 258f–264f, Â�284f–291f cisterna chyli/thoracic duct, axial, 192f–194f posterolateral bifurcation of, thoracic soft tissue and lung, axial, 64 thoracic soft tissue and lung axial, 64f–66f coronal, 134f–138f thoracic soft tissue and lung axial, 58f–64f coronal, 130f–134f, 136f–138f branching pattern variations, 42–44, 60, 64 cardiac MR 4-chamber 1, 416f–418f cardiac MR axial, 390f–394f lateral basal segment cardiac CT axial, 294f–300f thoracic soft tissue and lung axial, 66f–78f coronal, 136f–142f lateral basal subsegmental, thoracic soft tissue and lung axial, 70f–90f coronal, 142f–146f

Pulmonary artery(ies) (Continued) lingular, thoracic soft tissue and lung, axial, 80f–92f medial basal segment cardiac CT axial, 264f–274f, 276f–282f thoracic soft tissue and lung, axial, Â�62f–64f, 66f–70f medial basal subsegmental, thoracic soft tissue and lung, axial, 70f–80f origin, cardiac CT axial, 242 posterior basal segment cardiac CT axial, 294f–302f thoracic soft tissue and lung axial, 66f–72f, 75f–78f coronal, 138f–146f posterior basal subsegmental cardiac CT axial, 302f–322f thoracic soft tissue and lung axial, 72f–74f, 76f–90f coronal, 143f–156f posterior subsegmental, upper lobe, left, 42 pulmonary coronal, 166f–167f superior basal segment, thoracic soft tissue and lung, coronal, 135f–136f superior basal subsegmental, thoracic soft tissue and lung, coronal, 136f–156f superior segment cardiac CT axial, 246f–250f thoracic soft tissue and lung axial, 56f–58f coronal, 133f–136f superior subsegmental, 250f–252f thoracic soft tissue and lung, coronal, 139f–146f thoracic soft tissue and lung axial, 56f–58f coronal, 126f–130f thoracic soft tissue and lung, axial, 58f lymph nodes associated with, 182 main cardiac CT axial, 240f–254f cardiac MR axial, 386f–390f cisterna chyli/thoracic duct, axial, Â�194f–196f thoracic lymph nodes axial, 178f–184f thoracic soft tissue and lung axial, 38f–56f coronal, 106f–126f venous anatomy/variants coronal, 224f–226f sagittal, 228f–229f middle lobe, right anterior subsegmental, thoracic soft tissue and lung, axial, 81f–82f basal subsegmental, thoracic soft tissue and lung, axial, 70f–71f lateral segment cardiac CT axial, 256f–258f cisterna chyli/thoracic duct, axial, 192f–194f thoracic soft tissue and lung axial, 62f–68f coronal, 116f–120f lateral subsegmental, thoracic soft tissue and lung, coronal, 96f–118f medial segment cardiac CT axial, 242f–248f cisterna chyli/thoracic duct, axial, 192f–194f origin, cardiac CT axial, 242 thoracic soft tissue and lung, axial, 56f–60f medial subsegmental, thoracic soft tissue and lung, coronal, 94f–118f

429

Index Pulmonary artery(ies) (Continued) origin, 244 subsegmental, thoracic soft tissue and lung axial, 68f–80f coronal, 105f–108f thoracic soft tissue and lung axial, 62f–68f coronal, 116f–124f peripheral, thoracic soft tissue and lung, axial, 18f–20f posterior basal segment, thoracic soft tissue and lung, axial, 64 right cardiac MR axial, 388f–390f cisterna chyli/thoracic duct, coronal, 217f heart, anterior exposure, 234f–235f opened flap in posterolateral left ventricular wall, 237f–238f opened right atrium, right lateral view, 236f–237f section through left and ventricle with mitral valve cut away, 237f–238f superior mediastinum, 6f–7f thoracic lymph nodes axial, 178f–184f thoracic soft tissue and lung, axial, 46f– 52f thoracic soft tissue and lung coronal, 121f–128f segmental, thoracic lymph nodes axial, 186f–187f superior segment, lingular, thoracic soft tissue and lung axial, 60f–64f coronal, 124f–130f thoracic soft tissue and lung axial, 20f–40f, 42f–44f, 73f–74f coronal, 140f–152f truncus anterior thoracic soft tissue and lung, coronal, 124f–126f upper lobe, right, thoracic soft tissue and lung, axial, 40f–48f, 44 upper lobe left anterior segment, 42 thoracic soft tissue and lung axial, 48f–52f coronal, 120f–130f anterior subsegmental, thoracic soft tissue and lung, coronal, 94f–114f, 116f–120f apical-posterior subsegmental, 42 thoracic soft tissue and lung axial, 34f–44f, 106f–108f coronal, 98f–106f, 108f–132f apical subsegmental, and apicalposterior segment left upper lobe bronchus, diagnostic consideration for, 30 branches, 42 cardiac MR axial, 384f–388f thoracic soft tissue and lung, axial, 44f–50f right anterior segment cisterna chyli/thoracic duct, axial, 194f–196f thoracic soft tissue and lung axial, 44f–48f coronal, 116f–125f anterior subsegmental, thoracic soft tissue and lung axial, 48f–49f coronal, 96f–116f

430

Pulmonary artery(ies) (Continued) apical segment, thoracic soft tissue and lung axial, 34f–40f coronal, 126, 124f–132f apical subsegmental, thoracic soft tissue and lung axial, 32f–34f coronal, 113f–124f, 130f–148f cardiac MR axial, 384f–388f cisterna chyli/thoracic duct, coronal, 216f–217f posterior segment, thoracic soft tissue and lung axial, 38f–40f coronal, 128f–138f posterior subsegmental, thoracic soft Â�tissue and lung, coronal, Â�133f–134f, 137f–142f, 144f–152f thoracic soft tissue and lung, coronal, 124f–126f venous anatomy/variants axial, 220f–222f coronal, 224f–226f Pulmonary ligament lymph node left, station 9L, thoracic lymph nodes axial, 186f–187f station 9L, calcified, diagnostic significance of, 186 Pulmonary ligament(s) inferior, thoracic soft tissue and lung, axial, 80, 80f–82f, 84f–86f lung, 7f–8f Pulmonary nodes, lung, 7f–8f Pulmonary trunk atria, ventricles, and interventricular septum, 238f heart, anterior exposure, 234f–235f opened right atrium, right lateral view, 236f–237f opened right ventricle, anterior view, Â�236f–237f outflow to, atria, ventricles, and interventricular septum, 238f superior mediastinum, 6f–7f Pulmonary valve opened right ventricle, anterior view, Â�236f–237f semilunar cusp anterior, opened right ventricle, anterior view, 236f–237f left, opened right ventricle, anterior view, 236f–237f right, opened right ventricle, anterior view, 236f–237f Pulmonary vein(s) anatomy/variants coronal, 224f–226f sagittal, 228f–229f cardiac CT 4-chamber 1, 368f–370f cardiac CT axial, 240f–250f, 296f–326f cardiac MR axial, 392f–394f cisterna chyli/thoracic duct, coronal, 190f, 207f–216f inferior left cardiac CT axial, 268f–298f cardiac MR axial, 394f–398f cisterna chyli/thoracic duct, axial, 192f–194f pulmonary coronal, 166f–167f thoracic soft tissue and lung axial, 64f–70f coronal, 134f–142f

Pulmonary vein(s) (Continued) right cardiac CT axial, 282f–296f cardiac MR axial, 396f–400f heart chambers, 10f opened right atrium, right lateral view, 236f–237f thoracic soft tissue and lung axial, 66f–71f coronal, 128f–134f left atria, ventricles, and interventricular septum, 238f opened flap in posterolateral left ventricular wall, 237f–238f superior mediastinum, 6f–7f middle lobe, right, thoracic soft tissue and lung, coronal, 107f–112f right opened flap in posterolateral left ventricular wall, 237f–238f section through left and ventricle with mitral valve cut away, 237f–238f superior mediastinum, 6f–7f superior left, 250f–252f cardiac CT 2-chamber 1, 364f–366f cardiac CT axial, 252f–264f cardiac MR 2-chamber 1, 412f–414f cardiac MR axial, 384f–392f cisterna chyli/thoracic duct, axial, 194f–196f heart, anterior exposure, 234f–235f section through left and ventricle with mitral valve cut away, 237f–238f thoracic soft tissue and lung axial, 52f–60f coronal, 126f–132f right, 250f–252f cardiac CT axial, 252f–266f cardiac MR 3-chamber 1, 414f–416f cardiac MR axial, 392f–396f cisterna chyli/thoracic duct, axial, 192f–194f heart, anterior exposure, 234f–235f opened right atrium, right lateral view, 236f–237f thoracic lymph nodes axial, 184f–186f thoracic soft tissue and lung axial, 56f–64f coronal, 120f–126f thoracic lymph nodes axial, 186f–187f thoracic soft tissue and lung axial, 20f–64f, 70f–92f coronal, 22f, 100f–106f, 110f–156f

R

Rectus abdominis muscle, anterior thoracic wall, 4f–5f Rectus sheath, anterior layer, anterior thoracic wall, 4f–5f Renal vein left, esophagus, 9f–10f right, esophagus, 9f–10f Rhomboid major muscle, thoracic soft tissue and lung axial, 24f–60f coronal, 157f Rib(s) cardiac CT 2-chamber 1, 364f–366f cardiac CT short axis 1, 370f–371f cardiac MR axial, 374f–376f, 378f–399f, 402f–412f

Index Rib(s) (Continued) cisterna chyli/thoracic duct axial, 190f–192f, 196f–200f coronal, 200f, 200f–217f 1st, thoracic cage, 5f–6f 7th head of, heart chambers, 10f neck of, heart chambers, 10f thoracic lymph nodes axial, 170f–184f, 186f–187f thoracic soft tissue and lung axial, 12f–66f, 84f–92f coronal, 103f, 92f–115f, 142f–157f venous anatomy/variants axial, 220f–224f coronal, 224f–226f sagittal, 226f–229f

S

Sarcoidosis, abnormal lymph nodes in, 170, 170f–174f, 172 Scalene muscle, anterior superior mediastinum, 6f–7f thoracic cage, 5f–6f thoracic soft tissue and lung axial, 12f–14f coronal, 124f–130f Scalene node, lung, 7f–8f Scapula anterior angle, heart chambers, 10f body, thoracic soft tissue and lung, axial, 22f–24f, 26f–34f cisterna chyli/thoracic duct axial, 196f–200f coronal, 200f, 200f–214f coracoid process anterior thoracic wall, 4f–5f thoracic soft tissue and lung axial, 12f–14f coronal, 133f, 134f–142f glenoid, thoracic soft tissue and lung, coronal, 140f–146f glenoid fossa, thoracic soft tissue and lung, axial, 13f–14f spine, thoracic soft tissue and lung, axial, 14f–18f thoracic lymph nodes axial, 170f–184f, 186f–187f thoracic soft tissue and lung axial, 12f–48f, 50f–64f coronal, 142f–157f venous anatomy/variants axial, 222f–224f coronal, 225f–226f Segmental lymph node, right, station 13R, thoracic lymph nodes axial, 184f–186f Septal cusp, of tricuspid valve, atrium, right, opened, right lateral view, 236f–237f Septomarginal trabecula, moderator band of atria, ventricles, and interventricular septum, 238f opened right ventricle, anterior view, Â�236f–237f Septum interatrial. See Interatrial septum. intersublobar, thoracic soft tissue and lung, axial, 83f–85f interventricular. See Interventricular septum. membranous. See Membranous septum. Septum spurium, cardiac CT axial, 268, Â�268f–270f Serratus anterior muscle digitations, anterior thoracic wall, 4f–5f heart chambers, 10f

Serratus anterior muscle (Continued) thoracic soft tissue and lung axial, 20f–92f coronal, 92f–102f, 104f–106f, 108f–114f, 118f–120f, 126f–128f, 133f–134f, 136f–143f Sinoatrial node artery, cardiac CT axial, Â�274f–288f, 276 Sinoatrial (SA) nodal branch, of right coronary artery, heart diaphragmatic surface, 235f–236f sternocostal surface, 235f–236f Sinoatrial (SA) node, heart, diaphragmatic surface, 235f–236f Sinus(es) coronary. See Coronary sinus. non-coronary, thoracic soft tissue and lung, axial, 58f–64f pericardial. See Pericardial sinus(es). of Valsalva. See Valsalva, sinus(es) of. Spinal cord cardiac CT axial, 248f–250f, 256f–258f, 334f–362f cardiac MR 2-chamber 1, 412f–414f cardiac MR 3-chamber 1, 414f–416f cardiac MR 4-chamber 1, 416f–418f cardiac MR axial, 374f–412f thoracic soft tissue and lung axial, 56f, 26f–34f, 54f–76f, 86f–92f coronal, 144f–156f Spine, pulmonary axial, 164f–166f Spleen cardiac CT axial, 356f–364f cardiac CT short axis 1, 370f–371f cardiac MR axial, 410f–412f cardiac MR short axis, 418f–419f cisterna chyli/thoracic duct axial, 190f–192f coronal, 200f, 200f–217f thoracic soft tissue and lung axial, 88f–92f coronal, 120f–157f Splenic vein, esophagus, 9f–10f Sternal-manubrial junction, thoracic soft tissue and lung, coronal, 96f–98f Sternalis muscle, anterior thoracic wall, 4f–5f Sternocleidomastoid muscle(s) anterior thoracic wall, 4f–5f cardiac MR axial, 374f–378f thoracic soft tissue and lung axial, 12f–20f coronal, 102f–110f Sternohyoid muscle anterior thoracic wall, 4f–5f cardiac MR axial, 374f–380f thoracic soft tissue and lung axial, 16f–20f coronal, 112f–116f Sternothyroid muscle anterior thoracic wall, 4f–5f cardiac MR axial, 374f–380f thoracic soft tissue and lung axial, 16f–20f coronal, 112f–116f Sternum body anterior thoracic wall, 4f–5f heart chambers, 10f thoracic soft tissue and lung axial, 32f–72f coronal, 94f–98f venous anatomy/variants, axial, 222f–224f cardiac CT 3-chamber 1, 366f–368f cardiac CT short axis 1, 370f–371f cardiac MR 3-chamber 1, 414f–416f

Sternum (Continued) cardiac MR axial, 390f–412f cisterna chyli/thoracic duct, axial, 192f–198f joint between manubrium & body of, thoracic soft tissue and lung, axial, 30f–32f manubrium. See Manubrium. thoracic lymph nodes axial, 174f–187f thoracic soft tissue and lung, coronal, Â�92f–94f venous anatomy/variants, axial, 220f–222f xiphoid, thoracic soft tissue and lung, axial, 74f–86f Stomach cardiac CT axial, 362f–364f cardiac MR 2-chamber 1, 412f–414f cardiac MR axial, 410f–412f cardiac MR short axis, 418f–419f cisterna chyli/thoracic duct axial, 190f–192f coronal, 200f, 200f–217f thoracic soft tissue and lung axial, 88f–92f coronal, 94f–142f Subaortic lymph node, station 5, thoracic lymph nodes axial, 178, 178f–180f Subcarinal lymph node, station 7, thoracic lymph nodes axial, 178f–184f Subcarinal space thoracic soft tissue and lung, coronal, Â�130f–136f Subclavian artery heart, anterior exposure, 234f–235f left cardiac MR axial, 374f–378f cisterna chyli/thoracic duct axial, 198f–200f coronal, 216f–217f superior mediastinum, 6f–7f thoracic lymph nodes axial, 170f–172f thoracic soft tissue and lung axial, 12f–30f coronal, 122f–132f venous anatomy/variants coronal, 224f–226f sagittal, 228f–229f right aberrant cardiac MR axial, 374f–382f origin and course, cardiac MR axial, 374 cisterna chyli/thoracic duct, axial, Â�198f–200f origin and course, cardiac MR axial, 374 superior mediastinum, 6f–7f thoracic soft tissue and lung axial, 12f–22f coronal, 120f–130f thoracic cage, 5f–6f Subclavian lymphatic trunk, lung, 7f–8f Subclavian vein esophagus, 9f–10f heart, anterior exposure, 234f–235f left cisterna chyli/thoracic duct, axial, Â�198f–200f contrast enhancement, 16 superior mediastinum, 6f–7f thoracic soft tissue and lung axial, 16f–20f coronal, 118f–126f venous anatomy/variants, coronal, Â�224f–226f

431

Index Subclavian vein (Continued) lung, 7f–8f right cardiac MR axial, 374f–376f cisterna chyli/thoracic duct, axial, 198f–200f contrast enhancement, 16 stenosis, azygos system and, 226 superior mediastinum, 6f–7f thoracic soft tissue and lung axial, 16f–20f coronal, 116f–124f venous anatomy/variants, coronal, 224f–226f thoracic cage, 5f–6f Subclavius muscle, invested by clavipectoral fascia, anterior thoracic wall, 4f–5f Submucosal venous plexus, esophagus, 9f–10f Subpleural lymphatic plexus, lung, 7f–8f Subscapularis muscle thoracic soft tissue and lung axial, 14f–52f coronal, 140f–156f venous anatomy/variants, axial, 222f–224f Suprarenal vein, left, esophagus, 9f–10f Supraspinatus muscle, thoracic soft tissue and lung axial, 16f–24f coronal, 148f–157f Supraventricular crest atria, ventricles, and interventricular septum, 238f opened right ventricle, anterior view, Â�236f–237f

T

Thebesian valve, of coronary sinus, opened right atrium, right lateral view, 236f–237f Thoracic artery internal heart, anterior exposure, 234f–235f heart chambers, 10f perforating branches of, anterior thoracic wall, 4f–5f superior mediastinum, 6f–7f thoracic cage, 5f–6f lateral, anterior thoracic wall, 4f–5f Thoracic cage, 5f–6f Thoracic duct, 189–218 cisterna chyli/thoracic duct axial, 192f–200f coronal, 200f, 200f–217f esophagus, 8f–10f heart chambers, 10f lung, 7f–8f normal anatomy, cisterna chyli/thoracic duct axial, 192, 194, 196, 198 coronal, 200, 202, 204, 206, 208, 210, 212, 214, 216 superior mediastinum, 6f–7f thoracic cage, 5f–6f Thoracic nerve, long, anterior thoracic wall, 4f–5f Thoracic vein, internal heart, anterior exposure, 234f–235f heart chambers, 10f Thoracoabdominal nerve, cutaneous branches, anterior thoracic wall, 4f–5f Thoracoacromial artery, pectoral branch, Â�anterior thoracic wall, 4f–5f Thorax anatomy, 1–10 CT scans, contrast-enhanced, diagnostic consideration for, 16–18 heart in, chambers, 10f lymph nodes, axial, 169–188

432

Thorax (Continued) soft tissues, 11–158 axial, 11, 12f–92f coronal, 11, 91f–157f wall, anterior, 4f–5f Thymus cisterna chyli/thoracic duct, axial, 196f–198f involution diagnostic consideration for, 40–41 variable pace of, 106 residual, thoracic soft tissue and lung axial, 30f–32f, 40f–41f coronal, 107f–112f thoracic cage, 5f–6f venous anatomy/variants, axial, 222f–224f Thyroid cartilage, superior mediastinum, 6f–7f Thyroid gland superior mediastinum, 6f–7f thoracic soft tissue and lung axial, 12f–16f coronal, 116f–122f Thyroid vein(s), inferior esophagus, 9f–10f thoracic cage, 5f–6f Trabeculae carneae left ventricle anatomy, cardiac CT axial, 314 cardiac CT 2-chamber 1, 364f–366f cardiac CT 3-chamber 1, 366f–368f cardiac CT 4-chamber 1, 368f–370f cardiac CT axial, 300f–344f cardiac CT short axis 1, 370f–371f cardiac MR axial, 402f–405f right ventricle, cardiac MR axial, 407f–412f anatomy, cardiac CT axial, 314 opened right ventricle, anterior view, 236f–237f Trachea cardiac MR axial, 374f–380f carina cardiac MR axial, 380f–382f thoracic soft tissue and lung, axial, 38f–40f cisterna chyli/thoracic duct axial, 196f–200f coronal, 214f–217f pulmonary axial, 162f–166f pulmonary coronal, 166f–167f superior mediastinum, 6f–7f thoracic cage, 5f–6f thoracic lymph nodes axial, 170f–174f thoracic soft tissue and lung axial, 12f–38f coronal, 110f–136f venous anatomy/variants, axial, 222f–224f Tracheal bronchus as normal variant, 164, 166 pulmonary axial, 164f–166f pulmonary coronal, 166f–167f Tracheobronchial nodes inferior esophagus, 8f–9f lung, 7f–8f superior esophagus, 8f–9f left, lung, 7f–8f right, lung, 7f–8f Transverse sinus. See Pericardial sinus(es), transverse. Trapezius muscle(s) anterior thoracic wall, 4f–5f cardiac MR axial, 374f–404f cisterna chyli/thoracic duct, axial, 194f–200f heart chambers, 10f thoracic soft tissue and lung, axial, 12f–76f venous anatomy/variants, axial, 222f–224f

Triangle, of auscultation, heart chambers, 10f Tricuspid valve anterior cusp atria, ventricles, and interventricular septum, 238f opened right ventricle, anterior view, 236f–237f cardiac CT axial, 294f–320f cardiac MR 4-chamber 1, 416f–418f opened right ventricle, anterior view, Â�236f–237f orifice, heart chambers, 10f posterior cusp atria, ventricles, and interventricular septum, 238f opened right ventricle, anterior view, 236f–237f septal cusp atria, ventricles, and interventricular septum, 238f opened right atrium, right lateral view, 236f–237f opened right ventricle, anterior view, 236f–237f Truncus anterior. See Pulmonary artery(ies), truncus anterior of. Truncus basalis, thoracic soft tissue and lung, axial, 58

V

Vagus nerve (X) left heart, anterior exposure, 234f–235f superior mediastinum, 6f–7f right heart, anterior exposure, 234f–235f superior mediastinum, 6f–7f superior mediastinum, 6f–7f thoracic cage, 5f–6f Valsalva, sinus(es) of aneurysm, 56 cardiac MR 3-chamber 1, 414f–416f diagnostic consideration, 56–58 left cardiac CT axial, 258f–270f, 272f–276f cardiac MR axial, 392f–396f thoracic soft tissue and lung, axial, Â�56f–60f noncoronary, cardiac CT axial, 270f–278f right cardiac CT axial, 270f–276f thoracic soft tissue and lung, axial, 60f–64f Valve(s) cardiac. See specific cardiac valve, e.g. Mitral valve. thebesian, of coronary sinus, atrium, right, opened, right lateral view, 236f–237f Vein(s). See also specific vein, e.g. Pulmonary vein(s), Subclavian vein. anatomy and variants of, 219–230 of esophagus, 9f–10f Vena cava inferior cardiac CT axial, 239, 320f–362f cardiac MR axial, 400f–412f esophagus, 9f–10f eustachian valve of, opened right atrium, right lateral view, 236f–237f opened flap in posterolateral left ventricular wall, 237f–238f opened right atrium, right lateral view, 236f–237f pulmonary axial, 160f–162f section through left and ventricle with mitral valve cut away, 237f–238f

An original upload by [stormrg] Vena cava (Continued) superior mediastinum, 6f–7f thoracic soft tissue and lung axial, 74f–92f coronal, 116f–130f superior atria, ventricles, and interventricular septum, 238f cardiac CT axial, 240f–264f cardiac MR axial, 382f–396f cisterna chyli/thoracic duct, axial, Â�192f–198f esophagus, 9f–10f heart, anterior exposure, 234f–235f heart chambers, 10f left, persistent course of, 224 venous anatomy/variants axial, 222, 222f–224f coronal, 224f–226f opened right atrium, right lateral view, 236f–237f opened right ventricle, anterior view, 236f–237f pulmonary axial, 164f–166f superior mediastinum, 6f–7f thoracic cage, 5f–6f thoracic lymph nodes axial, 172f–184f thoracic soft tissue and lung axial, 30f–62f coronal, 116f–123f venous anatomy/variants axial, 220f–222f sagittal, 226f–228f Venous plexus, submucosal, esophagus, 9f–10f Ventricle left apex, cardiac CT axial, 362f–364f atria, ventricles, and interventricular septum, 238f cardiac CT 2-chamber 1, 364f–366f cardiac CT 3-chamber 1, 366f–368f cardiac CT 4-chamber 1, 368f–370f cardiac CT axial, 282f–284f, 294f–362f cardiac CT short axis 1, 370f–371f cardiac MR 2-chamber 1, 412f–414f cardiac MR 3-chamber 1, 414f–416f cardiac MR 4-chamber 1, 416f–418f

Index Ventricle (Continued) cardiac MR axial, 396f–410f cardiac MR short axis, 418f–419f cisterna chyli/thoracic duct, coronal, 216f–217f posterior vein of, heart, diaphragmatic surface, 235f–236f thoracic soft tissue and lung axial, 68f–86f coronal, 98f–130f right, 10f anatomy, 236f–237f on MR imaging, 400 apex, cardiac CT axial, 362f–364f atria, ventricles, and interventricular septum, 238f cardiac CT 3-chamber 1, 366f–368f cardiac CT 4-chamber 1, 368f–370f cardiac CT axial, 284f–362f cardiac CT short axis 1, 370f–371f cardiac MR 3-chamber 1, 414f–416f cardiac MR 4-chamber 1, 416f–418f cardiac MR axial, 396f–412f cardiac MR short axis, 418f–419f cisterna chyli/thoracic duct, axial, Â�192f–194f heart, anterior exposure, 234f–235f thoracic lymph nodes axial, 186f–187f thoracic soft tissue and lung axial, 64f–80f, 82f–88f coronal, 100f–108f Ventricle muscle, left, cardiac MR axial, Â�392f–396f Ventricular branch, left, posterior, of left Â�coronary artery, heart, diaphragmatic surface, 235f–236f Ventricular outflow tract left anatomy, cardiac CT axial, 294 cardiac CT 3-chamber 1, 366f–368f cardiac CT axial, 282f–296f cardiac MR 3-chamber 1, 414f–416f cardiac MR axial, 396f–402f right cardiac CT axial, 258f–282f cardiac MR axial, 390f–396f thoracic soft tissue and lung axial, 56f–64f coronal, 94f–108f

Vertebra(e) body cardiac CT 2-chamber 1, 364f–366f cardiac CT 3-chamber 1, 366f–368f cardiac CT 4-chamber 1, 368f–370f cardiac MR axial, 374f–412f cisterna chyli/thoracic duct, axial, Â�190f–200f T7, body, heart chambers, 10f thoracic lymph nodes axial, 170f–187f thoracic soft tissue and lung axial, 12f–73f, 76f–80f, 84f–86f, 88f–92f coronal, 134f–156f thoracic spine cardiac MR 2-chamber 1, 412f–414f cardiac MR 3-chamber 1, 414f–416f cardiac MR 4-chamber 1, 416f–418f transverse process, thoracic soft tissue and lung, axial, 82f–84f venous anatomy/variants axial, 220f–224f sagittal, 226f–229f spinous process thoracic soft tissue and lung axial, 81f–82f coronal, 154f–156f venous anatomy/variants, sagittal, Â�226f–228f transverse process, thoracic soft tissue and lung, coronal, 156f–157f Vertebral artery left, thoracic soft tissue and lung axial, 12f–18f coronal, 128f–132f right, thoracic soft tissue and lung axial, 12f–16f coronal, 126f–130f Vertebral lamina, thoracic soft tissue and lung, axial, 30f–34f

X

Xiphoid, cardiac CT 4-chamber 1, 368f–370f Xiphoid process, anterior thoracic wall, 4f–5f

Z

Zygapophyseal joint, heart chambers, 10f

433

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