coronary circulation and coronary anamolies

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coronary circulation and anomalies dr ravi ghatnatti Ipgmer, kolkata

Coronary anatomy: 

Coronary anatomy

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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 )

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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.

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Left main artery dividing into Cx with obtuse marginal branch (OM) AND LAD with diagonal branches (DB)

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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.

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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.

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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.

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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 (PD A).

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In 50-60% the first branch of the RCA - Rt conus branch. In 36%- Directly from aorta

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Also known as – ARTERIA CONI ARTERIOSI, THIRD CORONARY . Anastomoses with a similar left coronary branch around pulmonary trunk – ANNULUS OF VIEUSSENS

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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.

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

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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

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

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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: 

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: 

Arterial calibre Both main stems and larger branches : 1.5-5.5mm Diametre increases up to 30 th yr

Effect of Coronary Artery Diameter in Patients Undergoing Coronary Bypass Surgery : 

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 : 

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: 

Coronary anamolies

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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

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CORONARY ARTERY MINIMALLY REQUIRED FEATURES Left anterior descending (LAD) 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 artery anomalies – 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: 

The variable features of the coronary arteries LEVEL VARIABLES 1.Ostium Number of ostia Location Size Angle of origination Shape (e.g. slit-like; membrane) 2. Size Small size Presence of a diaphragm 3. Proximal course Especially intramural tract Consider angle of origin 4. Mid-course Intraseptal tract or looping 5. Intramyocardial ramifications Regional distribution 6. Termination Regional distribution

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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: 

ANOMALOUS PULMONARY ORIGIN OF THE CORONARY ARTERIES APOC "Major anomalies" ALCAPA severe Origin form Pulmonary sinus: 1, 2 or NF ARCAPA severe, rare -do- ACxPA Severe, rare -do ARCLCPA Severe, rare -do-

ANOMALOUS AORTIC ORIGIN OF THE CORONARIES: 

ANOMALOUS AORTIC ORIGIN OF THE CORONARIES AAOC "Minor anomalies" LMCA from sinus1 RCA from sinus 2 LAD from sinus 1 LAD from RCA Cx from sinus 1 Cx from RCA Single coronary artery Inverted coronary arteries Other 1/3 of all coronary anomalies

CORONARY ARTERIO-VENOUS FISTULAS: 

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): 

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): 

CORONARY ANEURYSMS ( CAn ) CAn Ø > 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 Congenita l (types I-IV) Acquired: -atherosclerotic; - Kawasaki, Marfan , Ehlers- Danlos , Takayasu - other systemic diseases, polyarteritis , scleroderma - infectious (incl. syphilis) - traumatic Aneurysm +/- stenosis

ALCAPA : 

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

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INCIDENCE -1in 30,000 to 1 in 300000 The infantile type Few or no collaterals myocardial ischemia ensues Poor feeding

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

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

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

ANAMALOUS CORONARY ARTERY COURCE BETWEEN AORTA AND PULMONAR ARTERY: 

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 .

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

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ECG Echocardiography Angiography CTA, MRA Intravascular USG Myocardial perfusion scan

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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: 

The single coronary artery

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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

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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): 

Congenital atresia of the left main coronary artery (CALM)

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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 William’s syndrome

Fistula : 

Fistula A large LAD giving rise to a large septal branch that terminates in the right ventricle (blue arrow).

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Left-to-right shunt, left-to-left shunt Distal coronary circulation steal Diagnosed during murmur evaluation Angina uncommon CCF, atrial fibrillation Spontaneous rupture, endocarditis

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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

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Echocardiography Angiography MRA

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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 : 

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): 

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): 

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): 

Tetralogy of Fallot (TOF) Incidence 2-9% Anamalies of particular importance are: Vessel crossing the RVOT : conspicuous conal branch, origin of the LAD from the RCA or from the aortic sinus 1,

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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;

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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: 

To conclude Coronary anomalies represent a good example of the dilemma between “ doing too much” and “doing too little”. THANK U