coronary circulation and anomalies dr ravi ghatnatti Ipgmer, kolkata

CORONARY ANATOMY

 Left Main or left coronary artery

(LCA) Left anterior descending (LAD) diagonal branches (D1, D2) septal branches Circumflex (Cx) Marginal branches (M1,M2)
Right coronary artery
Acute marginal branch (AM) AV node branch Posterior descending artery (PDA)

 The LCA divides almost

immediately into the circumflex artery (Cx) and left anterior descending artery (LAD). On the left an axial CT-image. The LCA travels between the right ventricle outflow tract anteriorly and the left atrium posteriorly and divides into LAD and Cx.

 Left main artery dividing into Cx with obtuse

marginal branch (OM) AND LAD with diagonal branches (DB)

 In 15% of cases a third branch arises in between the LAD and

the Cx, known as the ramus intermedius or intermediate branch. This intermediate branche behaves as a diagonal branch of the Cx.

 The LAD travels in the anterior

interventricular groove and continues up to the apex of the heart. The LAD supplies the anterior part of the septum with septal branches and the anterior wall of the left ventricle with diagonal branches. The LAD supplies most of the left ventricle and also the AV-bundle.

 The diagonal branches

come off the LAD and run laterally to supply the antero-lateral wall of the left ventricle. The first diagonal branch serves as the boundary between the proximal and mid portion of the LAD (2). There can be one or more diagonal branches: D1, D2 , etc.

 The Cx lies in the left AV

groove supplies the vessels of the lateral wall of the left ventricle. Obtuse marginals (M1, M2). 10% of patients have a left dominant circulation in which the Cx also supplies the posterior descending artery (PDA).

 In 50-60% the

first branch of the RCA -Rt conus branch. In 36%- Directly from aorta

 Also known as ARTERIA CONI ARTERIOSI, THIRD CORONARY.

Anastomoses with a similar left coronary

branch around pulmonary trunk ANNULUS OF VIEUSSENS

In 60% a sinus node artery arises as second branch of the RCA. The RCA continues in the AV groove posteriorly and gives off a branch to the AV node. In 65% of cases -right dominant circulation. The PDA supplies the inferior wall of the left ventricle and inferior part of the septum.

 The large acute

marginal branch (AM) supplies the lateral wall of the right ventricle.

American Heart Association classification of coronary artery segmental anatomy.Coronary artery segments are numbered 1 through 15.

Dewey M et al. Ann Intern Med 2006;145:407-415

2006 by American College of Physicians

Figure on a circumferential polar plot, of the 17 myocardial segments and the recommended nomenclature for tomographic imaging of the heart

Assignment of the 17 myocardial segments to the territories of the left anterior descending (LAD), right coronary artery (RCA), and the left circumflex coronary artery (LCX).

collaterals
Kugel's artery
ARTERIA ANASTOMOTICA AURICULARIS MAGNA

This artery passes from either the proximal right or left coronary artery down along the anterior margin of the atrial septum to anastomose with the A-V node branch of the distal RC artery

Arterial calibre

Both main stems and larger branches :

1.5-5.5mm Diametre increases up to 30th yr

Effect of Coronary Artery Diameter in Patients Undergoing Coronary Bypass Surgery

Small mid-LAD diameter is associated with

substantially increased risk of in-hospital mortality with CABG.support the hypothesis that smaller coronary arteries explain higher perioperative mortality with CABG in women and smaller people.

Nancy J. O'Connor, MS; Jeremy R. Morton, MD; John D. Birkmeyer, MD; Elaine M. Olmstead, BA; Gerald T. O'Connor, PhD, DSC; for the Northern New England Cardiovascular Disease Study Group

SPECIAL FEATURE
Subintimal fibro-muscular-elastic thickening, already developing during the first months of life. The coronary arteries represent the enlarged vasavasorum of larger vessels in the heart.

CORONARY ANAMOLIES

 The definition of a coronary artery

should be made without taking into account of its origin and proximal course but focusing on its intermediate and distal segments and/or its dependent micro vascular bed

CORONARY ARTERY Left anterior descending (LAD)

MINIMALLY REQUIRED FEATURES Location: the anterior interventricular sulcus Subepicardial position (but not infrequently intramyocardial) Provides septal branches and follows the direction of the septum. Accompanied by a conspicuous venous branch (greater cardiac vein)

Circumflex (Cx)

Location: the left side of the coronary sulcus Subepicardial position Provides at least one marginal branch

Right coronary artery (RCA)

Location: the right side of the coronary sulcus Subepicardial position Provides at least the right ("acute") marginal branch

Angelini P Coronary arteryanomalies current clinical issues.Definition, classifications, incidence,clinical relevance and treatment guidelines. Tex Heart Inst J 2002;29:271-278

The variable features of the coronary arteries

LEVEL 1.Ostium VARIABLES Number of ostia Location Size Angle of origination Shape (e.g. slit-like; membrane)

2. Size

Small size Presence of a diaphragm Especially intramural tract Consider angle of origin Intraseptal tract or looping Regional distribution Regional distribution

3. Proximal course

4. Mid-course 5. Intramyocardial ramifications 6. Termination

Coronary anomalies of clinical and surgical relevance

anomalous pulmonary origins of the coronaries(APOC);

anomalous aortic origins of the coronaries (AAOC);

congenital atresia of the left main (CALM)

coronary aterio-venous fistulas (CAVF);

coronary bridging (myocardial bridging); coronary aneurysms (CAn);

coronary stenosis

ANOMALOUS PULMONARY ORIGIN OF THE CORONARY ARTERIES

APOC "Major anomalies"

ALCAPA

severe

Origin form Pulmonary sinus: 1, 2 or NF

ARCAPA ACxPA

severe, rare Severe, rare

-do-do

ARCLCPA

Severe, rare

-do-

ANOMALOUS AORTIC ORIGIN OF THE CORONARIES

AAOC "Minor anomalies"

LMCA from sinus1 1/3 of all coronary RCA from sinus 2 LAD anomalies from sinus 1 LAD from RCA Cx from sinus 1 Cx from RCA Single coronary artery Inverted coronary arteries Other

CORONARY ARTERIO-VENOUS FISTULAS

CAVF "Major anomalies"

RCA to RV LAD to RA RCA, LAD to LV Cx to PA Diag to CS OM to SVC Single coronary to LA

congenital / acquired single / multiple associated with: TOF ASD, VSD, PDA Pulm. atresia + intact septum

Angiographic classification: Type A = proximal (proximal dilated, distal normal) Type B = distal (entire length dilated)

INTRAMYOCARDIAL COURSE (MYOCARDIAL BRIDGING)

Bridging

Cx LAD RCA Multiple Other atypical / rare

Symptomatic or asymptomatic Innocuous or may require surgery

Stenosis at stress test: Group I <50% Group II 50-75% Group III > 75%

CORONARY ANEURYSMS (CAn)

CAn > 1.5 x diameter of adjacent normal coronary artery RCA Cx and LAD Cx and RCA LAD and RCA Cx, LAD and RCA Cx and LAD Cx and RCA LAD and RCA Cx, LAD and RCA Cx LAD RCA Cx LAD Type I (diffuse, 2-3 vessels) Type II (diffuse in 1 vessel + Localized in other) Type III (diffuse in 1 vessel) Type IV (localized in 1 vessel) 88% in males Congenital (types I-IV) Acquired: -atherosclerotic; - Kawasaki, Marfan, Ehlers-Danlos, Takayasu - other systemic diseases, polyarteritis, scleroderma - infectious (incl. syphilis) - traumatic Aneurysm +/- stenosis

ALCAPA

ALCAPA results in the left ventricular myocardium being perfused by relatively desaturated blood under low pressure, leading to myocardial ischemia L-R SHUNT

 INCIDENCE-1in 30,000 to 1 in 300000

The infantile type Few or no collaterals myocardial ischemia ensues Poor feeding

Adult type Accounts for 10-15% Large collaterals Fatigue, Dyspnea, Palpitations and effort angina Mitral regurgitation

 ECG
Myocardial enzymes X-ray aortic root angiography MRA,CTA

 SURGERY
INFANTS-EMERGERY ADULTS-ELECTIVE PROCEDURES: MODIFIED TAKEUCHI OPERATION DIRECT REIMPLANTATION CORONAR ARTERY BYPASS GRAFTING

ANAMALOUS CORONARY ARTERY COURCE BETWEEN AORTA AND PULMONAR ARTERY

LCA arising from rt sinus of Valsalva The LCA courses between the aorta and pulmonary artery. This interarterial course can lead to compression of the LCA resulting in myocardial ischemia.

 0.1 to 0.3%
No physical finding Innocent murmur in children Sudden death Genetic link

 ECG
Echocardiography Angiography CTA, MRA Intravascular USG Myocardial perfusion scan

 SURGERY
MUST for asymptomatic anamalous left

coronary artery Procedures: Unroofing procedure Creation of a neo-ostium Translocation with reimplantation CABG in adults

The single coronary artery

 Type I: true single coronary: one artery supplies the entire heart ;
" Type II: single artery divides in RCA and LCA

(actually 2 coronaries with common aortic origin); " Type III: other atypical patterns

 Lesions or disease processes affecting its proximal course that might induce dramatic events Single/complex malformations of the heart (tetralogyof Fallot, DORV, persistent truncus arteriosus,pulmonary atresia with intact

septum, TGA, etc.)

Congenital atresia of the left main coronary artery (CALM)

 flow in the LAD and Cx is not centrifugal but centripetal (i.e. retrograde).
No ostium of the left main coronary artery

and the proximal LMCA ends blindly An association was found with supravalvular aortic stenosis especially in Williams syndrome

Fistula
A large LAD giving rise to a large septal branch that terminates in the

right ventricle (blue arrow).

 Left-to-right shunt, left-to-left shunt

Distal coronary circulation steal Diagnosed during murmur evaluation Angina uncommon CCF, atrial fibrillation Spontaneous rupture, endocarditis

Qp/Qs is seldom larger than 1.8 A special distinction pulmonary atresia with intact ventricular septum right ventricular-dependent circulation a proximal coronary artery with severe luminal stenosis / occlusion obliteration the RV cavity leads to ischemia

 Echocardiography
Angiography MRA

 SURGERY
Ligation if distally placed, without CPB Ligated with multiple pledgeted sutures Over sewing of the origin of fistula Direct closure from chambers with pericardial

patch CABG if distal perfusion affected

Myocardial bridging
Incidence at catheterization is

0.5-16% The depth of the vessel under the myocardium is more important that the lenght of the myocardial bridging. Doubtful hemodynamic significance

Complete transposition of the great arteries (TGA)

The normal coronary disposition in TGA is: 1LCx 2R
Two anomalies are associated with intramural

course : LAD and Cx (1LCx 2R) or of the RCA and LAD (1RL 2Cx) The origin and course of the sinus node artery is important in view of the atrial switch
operations (Mustard or Senning).

Congenitally corrected transposition of the great arteries (CC-TGA)

The morphology of the coronary arteries follows that of the ventricles, beyond their origin and proximal course The atrioventricular and ventriculoarterial

discordance render the coronary disposition anomalous Single coronary artery arising from the aortic sinus 1

Tetralogy of Fallot (TOF)

Incidence 2-9%
Anamalies of particular importance are: 1. Vessel crossing the RVOT: conspicuous conal branch, origin of the LAD from the RCA or from the

aortic sinus 1,

 origin of the LMCA from sinus 1,

origin of the Cx from the RCA or aortic

sinus 1, Origin of the RCA from sinus 2 origin of the LAD from the NF sinus of the pulmonary trunk;

2. Coronary artery contributes to pulmonary blood flow (TOF with pulmonary atresia). the coronary artery may be connected to the pulmonary system being the major or sole source of pulmonary flow

To conclude
Coronary anomalies represent a good

example of the dilemma between doing too much and doing too little.

THANK U