Good morning BLOOD SUPPLY of HEART Dr Qudsia

Good morning

BLOOD SUPPLY of HEART Dr. Qudsia Sultana

• A known hypertensive patient comes to a physician with a history of chest pain which subsides at rest…. • What diagnosis can you make from this history ? ? ?

• A known hypertensive patient comes to a physician with a history of acute severe chest pain associated with sweating, radiating to left hand side or both, short breath……. • What diagnosis can you make from this history ?

Blood supply of heart Arterial supply: üCORONARY ARTERIES AND BRANCHES Venous drainage : üCORONARY SINUS AND TRIBUTARIES

• What are coronary arteries ? ? ?

CORONARY(Crown) ARTERIES q. There are 2 coronary arteries right and left. q. Both arise from ascending aorta. q. Inner 75 -100µm-endothelial surface gets nutrition directly from the blood in the chambers. q. The rest of the heart receives blood from coronary arteries.

CORONARY ARTERIES q. Vasa-vasorum of the ascending aorta. q. Anatomically not end arteries but functionally-end arteries. q. Only arteries -blood flows in diastole

Right coronary artery…. . § Caliber is less than the left coronary § 65% of the cases supplies the SA node § 80% of the cases supplies the AV node § 80% of the cases has right dominance

Right coronary artery Arises from anterior aortic sinus

Course of right coronary artery……. • Appears b/w right auricle & pulmonary trunk--right ant. Coronary sulcus. • Descends—junction of the right and inf border of the heart—right post. Coronary sulcus on the diaphragmatic surface • Reaches crux & ends little left to crux & terminates by anastomosing – circumflex branch of left coronary artery.

Branches of right coronary artery…. . 1) Right conus artery annulus of Vieussens. third coronary artery. 2) Anterior Atrial branches • Nodal artery-SA node 3) Anterior Ventricular branches • Right marginal artery 4) Posterior Atrial and Ventricular branches.

5) Post Interventricular artery. • Septal • Diaphragmatic • Nodal artery-AV node

Areas of distribution…. . 1. Right atrium. 2. Greater part of right ventricular except Ant Interventricular Groove. 3. Small part of left ventricle adjoining the post interventricular groove. 4. Post 1/3 rd of interventricular septum. 5. Entire conducting system except left br. AV bundle.

Left coronary artery…. . Arises from left posterior aortic sinus

Course of left coronary artery…………… • Larger • Passes behind the pulmonary trunk • b/w pulmonary trunk & left auricle. • divides into 2 branches • Ant interventricular artery • Circumflex artery

1. Anterior interventricular artery…… Left anterior descending (LAD) artery…. . Descends in anterior interventricular groove…. Terminates on inferior surface- by anastomosing –post interventricular br of right coronary artery in the post interventricular groove

Branches…. . 1. Left conus artery (annulus of Vieussens) 2. Ventricular branches -Rt ventricle adjoining the ant Interventricular groove -left diagonal artery. 4. Septal branches ant 2/3 rd of the septum

2. Circumflex artery……. . Traverses left ant coronary sulcus – curves left border ; left post. coronary sulcus. Finally ends left of crux to establish anastomosis with right coronary artery. Branches…. 1. Left marginal artery 2. Ventricular branches. 3. Atrial branches • Kugel’s artery 4. SA nodal artery(35%)

Areas of distribution…. 1. left atrium 2. Greater part left ventricle except Post Interventricular Groove. 3. Small part right ventricle at Ant Interventricular Groove. 4. Ant 2/3 rd of interventricular septum 5. Left branch of AV bundle.

Variations Left Coronary Artery • arise- Pulmonary trunk cyanosis-ventricular failure • arise- anterior aortic sinus longer course-compressed-sudden cardiac death

Cardiac dominance… • Right coronary artery-post interventricular branch- Right cardiac dominance. (majority) • Left coronary artery- post interventricular branch- left cardiac dominance (10%) commonly affected by coronary diseasesentire left ventricle and ventricular septumunder its control. • Rarely-post interventricular artery-from both – coronaries-least affected by coronary diseases -Balanced type.

Venous drainage…. Venous blood from heart drains into right atrium through a. Coronary sinus b. Anterior cardiac veins c. Venae cordis minimae (thebesian veins)

1. Coronary sinus…. . • 2 to 3 cm long • Situated – left posterior coronary sulcus • Opens – right atrium. • Valve- Thebasian valve Tributaries are…. . 1. Great cardiac vein begins apex, ascends – AIG, traverses – coronary sulcus. It receives left marginal vein. 2. Small cardiac vein passes along right posterior coronary sulcus.

3. Middle cardiac vein Begins – apex, traverses – PIG, ends – middle of coronary sinus. 4. Posterior vein of left ventricle Present on diaphragmatic surface of left ventricle. 5. Obligue vein of left atrium(vein of Marshall) Descends obliquely – back of left atrium

2. Anterior cardiac veins… ü Drains anterior part of right ventricle…. ü Usually 2 or 3 in number - parallel to each other. ü Opens to right atrium.

3. Venae cordis minimae/Thebesian veins… • Opens into all chambers. • Numerous in right atrium & ventricle.

• Applied anatomy

• A known hypertensive patient comes to a physician with a history of chest pain which subsides at rest…. • What diagnosis can you make from this history ? ? ?

Clinical……. Angina pectoris Incomplete obstruction of coronary artery due to atherosclerotic plaque results decrease blood supply to heart –insufficient oxygen-severe pain in chest region & also in left arm.

• A known hypertensive patient comes to a physician with a history of acute severe chest pain associated with sweating, radiating to left hand side or both, short breath……. • What diagnosis can you make from this history ?

Clinical……. Myocardial infarction Complete obstruction coronary artery due to thrombosis results in death of myocardium - heart attack.

INVESTIGATIONS: ECG CARDIAC ENZYMES e. g. CK, LDH, TROPONIN etc. ECHOCARDIOGRAPHY TREADMILL EXERCISE TEST THALLIUM STRESS TEST CORONARY ANGIOGRAPHY 35

TREATMENT: – CORONARY DILATORS E. g. NITRATES – BETA-BLOCKERS – ANGIOPLASTY (DILATE AREA OF CONSTRICTION) – STENT – BYPASS SURGERY 36

• Coronary Angiography • Radiological proceedure-arteries are visualised after injecting dye into them. • Useful-localization of block. • Proceedure-special catheter is passed -femoral artery-base of ascending aorta-contrast media injected and photographs are taken

PTCA (Percutaneous transluminal coronary angioplasty) Used to increase the diameter of narrowed lumen of coronary artery Percutaneous transluminal coronary angioplasty (PTCA). (a) Coronary angiography demonstrates a severe stenosis in the proximal left anterior descending artery. (b) During PTCA a soft guidewire is passed across the stenosis and then a balloon is expanded that dilates the stenosis. (c) Post. PTC 38

An intracoronary stent. 39

CABG(Coronary artery bypass graft)

CORONARY ARTERY BYPASS SURGERY 42

Question • Blood supply of heart? • Arterial and venous drainage.

Thanks for listening. .