The overall shape of the heart is that of a three-sided pyramid located in the middle mediastinum .When viewed from the heart’s apex, the three sides of the ventricular mass are readily apparent . Two of the edges are named. The acute margin lies inferiorly and describes a sharp anglebetween the sternocostal and diaphragmatic surfaces. The obtuse margin lies superiorly and is much more diffuse. The posterior margin is unnamed but is also diffuse in its transition.

One-third of the cardiac mass lies to the right of the midline and two-thirds to the left. The long axis of the heart is oriented from the left epigastrium to the right shoulder. The short axis, which corresponds to the plane of the atrioventricular groove, is oblique and is oriented closer to the vertical than to the horizontal plane

Anteriorly, the heart is covered by the sternum and the costalcartilages of the third, fourth, and fifth ribs. The lungs contactthe lateral surfaces of the heart, whereas the heart abuts ontothe pulmonary hila posteriorly. The right lung overlies the right surface of the heart and reaches to the midline. In contrast, the left lung retracts from the midline in the area of the cardiacnotch. The heart has an extensive diaphragmatic surface inferiorly. Posteriorly, the heart lies on the esophagus and the tracheal bifurcation and bronchi that extend into the lung. The sternum lies anteriorly and provides rigid protection to the heart during blunt trauma and is aided by the cushioning effects of the lungs.

The Pericardium and Its Reflections

The heart lies within the pericardium, which is attached to the walls of the great vessels and to the diaphragm. The pericardiumcan be visualized best as a bag into which the heart has beenplaced apex first. The inner layer, in direct contact with theheart, is the visceral epicardium, which encases the heart andextends several centimeters back onto the walls of the greatvessels. The outer layer forms the parietal pericardium, whichlines the inner surface of the tough fibrous pericardial sack. A thin film of lubricating fluid lies within the pericardial cavity between the two serous layers. Two identifiable recesses lie within the pericardium and are lined by the serous layer. The first is the transverse sinus, which is delineated anteriorly by the posterior surface of the aorta and pulmonary trunk andposteriorly by the anterior surface of the interatrial groove. The second is the oblique sinus, a cul-de-sac located behind the left atrium, delineated by serous pericardial reflections from the pulmonary veins and the inferior vena cava.

Mediastinal Nerves and Their Relationships to the Heart

The vagus and phrenic nerves descend through the mediastinumin close relationship to the heart .They enter through the thoracic inlet, with the phrenic nerve located anteriorly on the surface of the anterior scalene muscle and lying just posterior to the internal thoracic artery (internal mammary artery) at the thoracic inlet. In this position, the phrenic nerve is vulnerable to injury during dissection and preparation of the internal thoracic artery for use in coronary arterial bypass grafting. On the right side, the phrenic nerve courses on the lateral surface of the superior vena cava, again in harm’s way during dissection for venous cannulation for cardiopulmonary bypass. The nerve then descends anterior to the pulmonary hilum before reflecting onto the right diaphragm, where it branches to provide its innervation. In the presence of a left-sided superior vena cava, the left phrenic nerve is applied directly to its lateral surface. The nerve passes anterior to the pulmonary hilum and eventually branches on the surface of the diaphragm. The vagus nerves enter the thorax posterior to the phrenic nerves and course along the carotid arteries. On the right side, the vagus gives off the recurrent laryngeal nerve that passes around the right subclavian artery before ascending out of the thoracic cavity. The right vagus nerve continues posterior to the pulmonary hilum, gives off branches of the right pulmonary plexus, and exits the thorax along the esophagus. On the left, the vagus nerve crosses the aortic arch, where it gives off the recurrent laryngeal branch. The recurrent nerve passes around the arterial ligament before ascending in the tracheoesophageal groove. The vagus nerve continues posterior to the pulmonary hilum, gives rise to the left pulmonary plexus, and then continues inferiorly out of the thorax along the esophagus. A delicate nerve trunk known as thesubclavian loop carries fibers from the stellate ganglion to the eye and head. This branch is located adjacent to the subclavian arteries bilaterally. Excessive dissection of the subclavian artery during shunt procedures may injure these nerve roots and cause Horner syndrome.