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Blood supply of heart
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Maj Dr Poonam SinghDept Of AnatomyNepal Army Institute of Health Sciences
Learning objectives•Coronary Arteries
• Origin• Course • Branches
•Dominance •Anastomosis•Variations•Applied•Venous return 2
Introduction• Coronary arteries
• Vasa vasora arising from aortic sinuses of ascending aorta
• Right - Right aortic sinus (right ant)
• Left – Left aortic sinus (left post)
• Post Aortic sinus - non coronary (Torus aorticus)
• Max filling of sinuses - in diastole
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CruxMeeting point of
•IA groove
• Post AV groove
•Post IV groove
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SA Node & AV Node location
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Rt Coronary Artery Passes to rt & forwards
b/w infundibulum of rt ven & rt auricle
Runs downwards in ant AV groove
Reaches inf margin of heart; winds around it to the diaph surface; runs in post AV groove
Ends by anastomosing with circumflex br of LCA -60%
Conus brs
Ventricular brs
AV nodal br
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Branches of Rt coronary Artery Rt conus artery-
Annulus of Vieussens SA Nodal br – 60% Ant atrial branches Ant ventr branches Rt Marginal artery:
(Largest br) Post ventr branches Post IV br arises near
CRUX – 70% br of RCA Post atrial branches AV Nodal artery – 80%
Conus brs
Ventricular brsAV nodal br
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Conus brs
Ventricular brsAV nodal br
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Lt Coronary Artery Origin: Lt Aortic
sinus
Passes behind infundibulum of Rt ventricle
Length: 0 to 10mm
Bifurcates into Ant IV branch (LAD) & Circumflex artery
Conus brs
Ventricular brsAV nodal br
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LAD (Ant IV) artery Continuation of
LCA Extends beyond the
apex, ends by anastamosing with post IV artery (br of RCA)
Branches: Ant ventr brs:i. Diagonal arteriesii. Lt Conus artery Septal branches
Conus brs
Ventricular brsAV nodal br
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Circumflex artery Runs in Ant AV groove and post AV groove Terminates by anastamosing with RCA near crux
Branches:
i. Atrial brsii. Ventr branchesiii. SA nodal (40% cases)iv. Lt Marginal v. Post IV br (only 10% cases)vi. Kugel’s arteryvii.AV nodal br (10-20%)
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Branches of Coronary arteries
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Coronary dominance CA that gives post IV branch is supposed to be
dominant
Misleading term as LCA supplies greater part of myocardium, but in 70% cases post IV is a br of RCA (Rt coronary dominance)
3 types – Rt (70%), Lt (20%) & Balanced (10%)
Clinical importance: In Lt dominance a block in LCA affect entire Lt ventricle and IVseptum, while in Rt or balanced dominance a block in RCA atleast spares part (2/3) of septum and lt ventricle
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Summary: RCA:• Rt atrium• Lt atrium (ant part)• Rt ventr except a small strip along the Ant IV groove• Diaphragmatic surface of Rt ventricle• Post 1/3 of IV septum• SA Node and AV Node in majority• Most conducting system of heart except Lt branch of
Bundle of His
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LCA:
• Post part of Lt Atrium
• Ant and Lat walls of Lt ventricle
• Ant 2/3 of IV septum
• Lt br of Bundle of His
• SA & AV Nodes in 30% cases
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Coronary Anastomosis
-Anatomically CA are not end arteries but functionally they behave like end arteries.
-Anastomosis occur at: • superficial • subepicardial • Myocardial• subendocardial levels
Important sites:
i) b/w terminations of RCA & LCA near crux of heart ii) b/w their IV brs (in septum)iii) b/w conus As iv) apex Prognosis better in slow occlusion
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VariationsCongenital anomalies
- LCA arising from Pul trunk; cyanosis occurs
- LCA arises from right aortic sinus; may get compressed b/w Pul trunk & aorta in strenuous exercise; may cause sudden cardiac death
- Post IV A arising from Cx A (left dominance)
- SA nodal A in 40% from Cx A; AV nodal A in 20% from Cx A
- LCA arising from Ant or post aortic sinus
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Post IV A arising from Circumflex br of LCA
Post IV Artery
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Single Coronary A
Circumflex br arises from rt aortic sinus
Venous Drainage
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Coronary Sinus
Heart is drained by CS - empties into Rt Atrium.
Two set of veins empty directly into Rt Atrium Venae cordis minimi Ant cardiac vein, s/t Rt marginal vein also
CS - dilatation of Great Cardiac Vein located in post part of AV groove
Opens into Rt atrium b/w IVC and Tricuspid opening guarded by incomplete semicircular “Thebasian valve”
Tributaries- all have valves except oblique V of lt atrium31
Tributaries of Coronary sinus:
1. Great Cardiac vein• Begins near apex of
heart; acc. Ant IV A & more proximally cx artery
• Terminates at lt end of coronary sinus
2. Middle cardiac vein• Accompanies Post IV
artery and opens at termination of coronary sinus
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3. Small Cardiac vein• Accompanies rt marginal artery• Runs in AV groove to end into rt end of CS• May open directly into rt atrium
4. Oblique Vein of Lt Atrium (of Marshall)• Runs in the post surface of Lt Atrium and drains into Lt end of Coronary sinus
5. Post Vein of Lt Ventricle• Runs on diaphragmatic surface of Lt ventricle and ends in middle of coronary sinus
6. Rt Marginal vein• Accompanies Rt Marginal artery and drains into Small Cardiac vein or directly into
the Rt Atrium
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Oblique Vein of Lt Atrium (of Marshall)
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Veins directly emptying into Rt Atrium
1. Ant Cardiac Veins:• 3-4 in no .drains the infundibulum of Rt ventricle• opens into Rt Atrium through its Ant wall
2. Venae Cordis Minimi/ Thebasian veins• Numerous small veins opening into the Post wall of
Rt Atrium
3. Small cardiac vein – may open directly into Rt atrium
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Applied Anatomy:
• Coronary Artery Disease (CAD)
• Coronary Angiography
• PTCA (Percutaneus Transluminal Coronary Angioplasty)
• CABG ( Coronary Artery Bypass Graft)
• Cardiac catheterisation36
Coronary Artery Disease (CAD) & Ischaemic Heart
Diseases (IHD) – due to atherosclerosis
- Angina Pectoris – transient myocardial ischemia- Myocardial Infarction – occlusive thrombus
Investigations for CAD & IHD
a) ECG b) Coronary Angiography
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Treatment of CAD
1. Medical T/t for angina
2. Stents- simple or drug-eluting (vasodilators)
3. Coronary Angioplasty (PTCA) - single vessel disease
4. Coronary Artery Bypass Graft (CABG) – triple vessel disease-median sternotomy-thymus incised-pericardium incised-SVC & IVC cannulated, venous blood goes to bypass machine-graft used: reversed Gr Saph V or Int Th A
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M. I.
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STENTING41
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CABG
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CABG
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CORONARY CATHETRISATION
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Thank you
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