diagonal branch. Double inlet left ventricle

Blood, thanks to the "internal motor" - the heart, circulates through the body, saturating each of its cells with nutrients and oxygen. And how does the heart itself receive nourishment? Where does it draw reserves and strength for work? And do you know about the so-called third circle of blood circulation or cardiac? For a better understanding of the anatomy of the vessels that supply the heart, let's look at the main anatomical structures that are usually distinguished in the central organ of the cardiovascular system.

1 External device of the human "motor"

First-year students of medical colleges and medical universities memorize by heart, and even in Latin, that the heart has an apex, a base and two surfaces: anterior-upper and lower, separated by edges. With the naked eye, you can see the cardiac grooves by looking at its surface. There are three of them:

coronal furrow,
anterior interventricular,
Posterior interventricular.

The atria are visually separated from the ventricles by the coronal sulcus, and the border between the two lower chambers along the anterior surface is tentatively the anterior interventricular sulcus, and along the posterior interventricular posterior sulcus. The interventricular grooves join at the apex slightly to the right. These furrows were formed due to the vessels lying in them. In the coronary sulcus, which separates the cardiac chambers, there is the right coronary artery, the sinus of the veins, and in the anterior interventricular sulcus, which separates the ventricles, there is a large vein and the anterior interventricular branch.

The posterior interventricular sulcus is the receptacle for the interventricular branch of the right coronary artery, the middle cardiac vein. From the abundance of numerous medical terminology, the head can go round: furrows, arteries, veins, branches ... Still, we are analyzing the structure and blood supply of the most important human organ - the heart. If it had been arranged in a simpler way, would it have been able to perform such a complex and responsible job? Therefore, we will not give up halfway, and analyze in detail the anatomy of the vessels of the heart.

2 3rd or cardiac circulation

Every adult knows that there are 2 circles of blood circulation in the body: large and small. But anatomists say that there are three of them! So, is the basic anatomy course misleading people? Not at all! The third circle, figuratively named, refers to the blood vessels that fill and “serve” the heart itself. It deserves personal vessels, doesn't it? So, the 3rd or cardiac circle begins with the coronary arteries, which are formed from the main vessel of the human body - Her Majesty's aorta, and ends with the cardiac veins that merge into the coronary sinus.

It in turn opens in . And the smallest venules open into the atrial cavity on their own. It was noticed very figuratively that the vessels of the heart entwine, envelop it like a real crown, a crown. Therefore, the arteries and veins are called coronary or coronary. Note: These are synonymous terms. So what are the most important arteries and veins that the heart has at its disposal? What is the classification of the coronary arteries?

3 Major arteries

The right coronary artery and the left coronary artery are two pillars that deliver oxygen and nutrients. They have branches and branches, which we will discuss next. In the meantime, let us understand that the right coronary artery is responsible for the blood supply to the right heart chambers, the walls of the right ventricle and the posterior wall of the left ventricle, and the left coronary artery supplies the left heart sections.

The right coronary artery goes around the heart along the coronary sulcus on the right, gives off the posterior interventricular branch (posterior descending artery), which descends to the apex, located in the posterior interventricular sulcus. The left coronary also lies in the coronary groove, but on the other, opposite side - in front of the left atrium. It is divided into two major branches - the anterior interventricular (anterior descending artery) and circumflex artery.

The path of the anterior interventricular branch runs in the depression of the same name, to the apex of the heart, where our branch meets and merges with a branch of the right coronary artery. And the left circumflex artery continues to "hug" the heart on the left along the coronary sulcus, where it also combines with the right coronary. Thus, nature created on the surface of the human "motor" an arterial ring of coronary vessels in a horizontal plane.

This is an adaptive element, in case a vascular catastrophe suddenly occurs in the body and blood circulation deteriorates sharply, then despite this, the heart will be able to maintain blood supply and its work for some time, or if one of the branches is blocked by a thrombus, the blood flow will not stop, but will go in another heart vessel. The ring is the collateral circulation of the organ.

The branches and their smallest branches penetrate the entire thickness of the heart, supplying blood not only to the upper layers, but to the entire myocardium, and the inner lining of the chambers. Intramuscular arteries follow the course of the muscular heart bundles, each cardiomyocyte is saturated with oxygen and nutrition due to a well-developed system of anastomoses and arterial blood supply.

It should be noted that in a small percentage of cases (3.2-4%), people have such an anatomical feature as a third coronary artery or an additional one.

4 Forms of blood supply

There are several types of blood supply to the heart. All of them are a variant of the norm and a consequence of the individual characteristics of the laying of the vessels of the heart and their functioning in each person. Depending on the prevailing distribution of one of the coronary arteries on the posterior heart wall, there are:

Legal type. With this type of blood supply to the heart, the left ventricle (the back surface of the heart) is filled with blood mainly due to the right coronary artery. This type of blood supply to the heart is the most common (70%)
Left-handed type. Occurs if the left coronary artery prevails in the blood supply (in 10% of cases).
Uniform type. With an approximately equivalent "contribution" to the blood supply of both vessels. (twenty%).

5 Major veins

Arteries branch into arterioles and capillaries, which, having completed cellular exchange, and taking decay products and carbon dioxide from cardiomyocytes, are organized into venules, and then larger veins. Venous blood can flow into the venous sinus (from which the blood then enters the right atrium), or into the atrial cavity. The most significant cardiac veins that pour blood into the sinus are:

Big. Takes venous blood from the anterior surface of the two lower chambers, lies in the interventricular anterior sulcus. The vein starts at the top.
Average. It also originates at the top, but runs along the back furrow.
Small. It can flow into the middle, is located in the coronal sulcus.

The veins that drain directly into the atria are the anterior and smallest cardiac veins. The smallest veins are not named so by chance, because the diameter of their trunks is very small, these veins do not appear on the surface, but lie in the deep tissues of the heart and open mainly into the upper chambers, but can also pour into the ventricles. The anterior cardiac veins supply blood to the right upper chamber. So, in the most simplified way, you can imagine how the blood supply to the heart occurs, the anatomy of the coronary vessels.

Once again, I would like to emphasize that the heart has its own, personal, coronary circle of blood circulation, thanks to which a separate blood circulation can be maintained. The most important cardiac arteries are the right and left coronary arteries, and the veins are large, medium, small, and anterior.

6 Diagnosis of coronary vessels

Coronary angiography is the "gold standard" in the diagnosis of coronaries. This is the most accurate method, it is performed in specialized hospitals by highly qualified medical workers, the procedure is performed according to indications, under local anesthesia. Through the artery of the arm or thigh, the doctor inserts a catheter, and through it a special radiopaque substance, which, mixing with blood, spreads, making both the vessels themselves and their lumen visible.

Photographs and video recording of the filling of vessels with a substance are made. The results allow the doctor to make a conclusion about the patency of the vessels, the presence of pathology in them, to assess the prospect of treatment and the possibility of recovery. Also, diagnostic methods for examining coronary vessels include MSCT - angiography, Doppler ultrasound, electron beam tomography.

Coronary arteries of the heart

In this section, you will get acquainted with the anatomical location of the coronary vessels of the heart. To get acquainted with the anatomy and physiology of the cardiovascular system, you need to visit the section "Heart Diseases".

Left coronary artery.
Right coronary artery

The blood supply to the heart is carried out through two main vessels - the right and left coronary arteries, starting from the aorta immediately above the semilunar valves.

Left coronary artery.

The left coronary artery starts from the left posterior sinus of Vilsalva, goes down to the anterior longitudinal groove, leaving the pulmonary artery to the right of itself, and the left atrium and the ear surrounded by adipose tissue, which usually covers it, to the left. It is a wide, but short trunk, usually no more than 10-11 mm long.

The left coronary artery is divided into two, three, in rare cases, four arteries, of which the anterior descending (LAD) and circumflex branch (OB), or arteries, are of the greatest importance for pathology.

The anterior descending artery is a direct continuation of the left coronary artery.

Along the anterior longitudinal cardiac sulcus, it goes to the region of the apex of the heart, usually reaches it, sometimes bends over it and passes to the back surface of the heart.

Several smaller lateral branches depart from the descending artery at an acute angle, which are directed along the anterior surface of the left ventricle and can reach the blunt edge; in addition, numerous septal branches depart from it, perforating the myocardium and branching in the anterior 2/3 of the interventricular septum. Lateral branches feed the anterior wall of the left ventricle and give branches to the anterior papillary muscle of the left ventricle. The superior septal artery gives a branch to the anterior wall of the right ventricle and sometimes to the anterior papillary muscle of the right ventricle.

Throughout the entire length of the anterior descending branch lies on the myocardium, sometimes plunging into it with the formation of muscle bridges 1-2 cm long. For the rest of its length, its anterior surface is covered with fatty tissue of the epicardium.

The envelope branch of the left coronary artery usually departs from the latter at the very beginning (the first 0.5-2 cm) at an angle close to a right one, passes in the transverse groove, reaches the blunt edge of the heart, goes around it, passes to the posterior wall of the left ventricle, sometimes reaches the posterior interventricular sulcus and in the form of the posterior descending artery goes to the apex. Numerous branches depart from it to the anterior and posterior papillary muscles, the anterior and posterior walls of the left ventricle. One of the arteries that feed the sinoauricular node also departs from it.

Right coronary artery.

The right coronary artery originates in the anterior sinus of Vilsalva. First, it is located deep in the adipose tissue to the right of the pulmonary artery, goes around the heart along the right atrioventricular sulcus, passes to the posterior wall, reaches the posterior longitudinal sulcus, and then, in the form of a posterior descending branch, descends to the apex of the heart.

The artery gives 1-2 branches to the anterior wall of the right ventricle, partly to the anterior septum, both papillary muscles of the right ventricle, the posterior wall of the right ventricle and the posterior interventricular septum; the second branch also departs from it to the sinoauricular node.

There are three main types of myocardial blood supply: middle, left and right. This subdivision is based mainly on variations in the blood supply to the posterior or diaphragmatic surface of the heart, since the blood supply to the anterior and lateral regions is fairly stable and not subject to significant deviations.

At middle type all three main coronary arteries are well developed and fairly evenly developed. The blood supply to the entire left ventricle, including both papillary muscles, and the anterior 1/2 and 2/3 of the interventricular septum is carried out through the system of the left coronary artery. The right ventricle, including both right papillary muscles and the posterior 1/2-1/3 septum, receives blood from the right coronary artery. This appears to be the most common type of blood supply to the heart.

At left type blood supply to the entire left ventricle and, in addition, to the entire septum and partly the posterior wall of the right ventricle is carried out due to the developed circumflex branch of the left coronary artery, which reaches the posterior longitudinal groove and ends here in the form of the posterior descending artery, giving part of the branches to the posterior surface of the right ventricle .

Right type observed with a weak development of the circumflex branch, which either ends without reaching the obtuse edge, or passes into the coronary artery of the obtuse edge, not spreading to the posterior surface of the left ventricle. In such cases, the right coronary artery, after leaving the posterior descending artery, usually gives a few more branches to the posterior wall of the left ventricle. In this case, the entire right ventricle, the posterior wall of the left ventricle, the posterior left papillary muscle and partly the apex of the heart receive blood from the right coronary arteriole.

Myocardial blood supply is carried out directly :

a) capillaries lying between muscle fibers, braiding them and receiving blood from the system of coronary arteries through arterioles;

b) a rich network of myocardial sinusoids;

c) Viessant-Tebesia vessels.

With an increase in pressure in the coronary arteries and an increase in the work of the heart, the blood flow in the coronary arteries increases. The lack of oxygen also leads to a sharp increase in coronary blood flow. The sympathetic and parasympathetic nerves seem to have little effect on the coronary arteries, with their main action directly on the heart muscle.

Outflow occurs through the veins, which are collected in the coronary sinus

Venous blood in the coronary system is collected in large vessels, usually located near the coronary arteries. Some of them merge, forming a large venous canal - the coronary sinus, which runs along the back surface of the heart in the groove between the atria and ventricles and opens into the right atrium.

Intercoronary anastomoses play an important role in coronary circulation, especially in pathological conditions. There are more anastomoses in the hearts of people suffering from ischemic disease, so the closure of one of the coronary arteries is not always accompanied by necrosis in the myocardium.

In normal hearts, anastomoses are found only in 10-20% of cases, and they are of small diameter. However, their number and magnitude increase not only in coronary atherosclerosis, but also in valvular heart disease. Age and gender by themselves have no effect on the presence and degree of development of anastomoses.

Heart (cor)

The circulatory system consists of a huge number of elastic vessels of various structures and sizes - arteries, capillaries, veins. At the center of the circulatory system is the heart, a living suction-suction pump.

The structure of the heart. The heart is the central apparatus of the vascular system, highly capable of automatic action. In humans, it is located in the chest behind the sternum, for the most part (2 / 3) in the left half.

The heart lies (Fig. 222) on the tendon center of the diaphragm almost horizontally, located between the lungs in the anterior mediastinum. It occupies an oblique position and faces its wide part (base) up, back and to the right, and its narrower cone-shaped part (top) forward, down and to the left. The upper border of the heart is located in the second intercostal space; the right border protrudes approximately 2 cm beyond the right edge of the sternum; the left border passes, not reaching the mid-clavicular line (passing through the nipple in men) by 1 cm. The tip of the cardiac cone (the junction of the right and left contour lines of the heart) is placed in the fifth left intercostal space down from the nipple. In this place, at the moment of contraction of the heart, a cardiac impulse is felt.

Rice. 222. Position of the heart and lungs. 1 - heart in a heart shirt; 2 - diaphragm; 3 - tendon center of the diaphragm; 4 - thymus gland; 5 - lung; 6 - liver; 7 - crescent ligament; 8 - stomach; 9 - nameless artery; 10 - subclavian artery; 11 - common carotid arteries; 12 - thyroid gland; 13 - thyroid cartilage; 14 - superior vena cava

In shape (Fig. 223), the heart resembles a cone, with its base up and its top down. Large blood vessels enter and leave the wide part of the heart - the base. The weight of the heart in healthy adults ranges from 250 to 350 g (0.4-0.5% of body weight). By the age of 16, the weight of the heart increases 11 times compared to the weight of the heart of a newborn (V.P. Vorobyov). The average size of the heart: length 13 cm, width 10 cm, thickness (anteroposterior diameter) 7-8 cm. In terms of volume, the heart is approximately equal to the clenched fist of the person to whom it belongs. Of all vertebrates, birds have the largest relative heart size, requiring a particularly powerful motor to move blood.

Rice. 223. Heart (front view). 1 - nameless artery; 2 - superior vena cava; 3 - ascending aorta; 4 — a coronal furrow with the right coronal artery; 5 - right ear; 6 - right atrium; 7 - right ventricle; 8 - apex of the heart; 9 - left ventricle; 10 - anterior longitudinal furrow; 11 - left ear; 12 - left pulmonary veins; 13 - pulmonary artery; 14 - aortic arch; 15 - left subclavian artery; 16 - left common carotid artery

In higher animals and humans, the heart is four-chambered, that is, it consists of four cavities - two atria and two ventricles; its walls consist of three layers. The most powerful and functionally important layer is the muscular layer, the myocardium. Muscular tissue of the heart is different from skeletal muscle; it also has transverse banding, but the ratio of cell fibers is different than in the muscles of the skeleton. The muscle bundles of the heart muscle have a very complex arrangement (Fig. 224). In the walls of the ventricles, it is possible to trace three muscle layers: the outer longitudinal, the middle annular and the inner longitudinal. Between the layers there are transitional fibers that make up the predominant mass. The outer longitudinal fibers, deepening obliquely, gradually pass into the annular, which also obliquely gradually pass into the internal longitudinal; the papillary muscles of the valves are also formed from the latter. On the very surface of the ventricles lie fibers covering both ventricles together. Such a complex course of muscle bundles provides the most complete contraction and emptying of the heart cavities. The muscular layer of the walls of the ventricles, especially in the left, which drives the blood in a large circle, is much thicker. The muscle fibers that form the walls of the ventricles are assembled from the inside into numerous bundles, which are located in different directions, forming fleshy crossbars (trabeculae) and muscle protrusions - papillary muscles; tendon cords go from them to the free edge of the valves, which stretch when the ventricles contract and do not allow the valves to open in the atrial cavity under the pressure of blood.

Rice. 224. The course of the muscle fibers of the heart (semi-schematically)

The muscle layer of the walls of the atria is thin, since they have a small load - they only drive blood into the ventricles. Superficial muscle pins, facing inside the atrial cavity, form the pectinate muscles.

From the outer surface on the heart (Fig. 225, 226) two grooves are noticeable: longitudinal, covering the heart in front and behind, and transverse (coronal), located annularly; along them are the own arteries and veins of the heart. These grooves inside correspond to the partitions that divide the heart into four cavities. The longitudinal interatrial and interventricular septum divides the heart into two halves completely isolated from one another - the right and left hearts. The transverse septum divides each of these halves into an upper chamber - the atrium (atrium) and a lower one - the ventricle (ventriculus). Thus, two non-communicating atria and two separate ventricles are obtained. The superior vena cava, inferior vena cava and coronary sinus flow into the right atrium; the pulmonary artery departs from the right ventricle. The right and left pulmonary veins flow into the left atrium; the aorta departs from the left ventricle.

Rice. 225. Heart and large vessels (front view). 1 - left common carotid artery; 2 - left subclavian artery; 3 - aortic arch; 4 - left pulmonary veins; 5 - left ear; 6 - left coronary artery; 7 - pulmonary artery (cut off); 8 - left ventricle; 9 - apex of the heart; 10 - descending aorta; 11 - inferior vena cava; 12 - right ventricle; 13 - right coronary artery; 14 - right ear; 15 - ascending aorta; 16 - superior vena cava; 17 - unnamed artery

Rice. 226. Heart (rear view). 1 - aortic arch; 2 - left subclavian artery; 3 - left common carotid artery; 4 - unpaired vein; 5 - superior vena cava; 6 - right pulmonary veins; 7 - inferior vena cava; 8 - right atrium; 9 - right coronary artery; 10 - middle vein of the heart; 11 - descending branch of the right coronary artery; 12 - right ventricle; 13 - apex of the heart; 14 - diaphragmatic surface of the heart; 15 - left ventricle; 16-17 - common drain of the cardiac veins (coronary sinus); 18 - left atrium; 19 - left pulmonary veins; 20 - branches of the pulmonary artery

The right atrium communicates with the right ventricle through the right atrioventricular orifice (ostium atrioventriculare dextrum); and the left atrium with the left ventricle through the left atrioventricular orifice (ostium atrioventriculare sinistrum).

The upper part of the right atrium is the right ear of the heart (auricula cordis dextra), which looks like a flattened cone and is located on the anterior surface of the heart, covering the aortic root. In the cavity of the right ear, the muscle fibers of the atrium wall form parallel muscle rollers.

The left heart auricle (auricula cordis sinistra) departs from the anterior wall of the left atrium, in the cavity of which there are also muscle rollers. The walls in the left atrium are smoother from the inside than in the right.

The inner shell (Fig. 227), lining the inside of the heart cavity, is called the endocardium (endocardium); it is covered with a layer of endothelium (a derivative of the mesenchyme), continuing on the inner lining of the vessels extending from the heart. On the border between the atria and ventricles there are thin lamellar outgrowths of the endocardium; here the endocardium, as if folded in half, forms strongly protruding folds, also covered with endothelium on both sides - these are the heart valves (Fig. 228) that close the atrioventricular openings. In the right atrioventricular opening there is a tricuspid valve (valvula tricuspidalis), consisting of three parts - thin fibrous elastic plates, and in the left - a bicuspid valve (valvula bicuspidalis, s. mytralis), consisting of two of the same plates. These flap valves open during atrial systole only towards the ventricles.

Rice. 227. The heart of an adult with the ventricles opened in front. 1 - ascending aorta; 2 - arterial ligament (overgrown ductus arteriosus); 3 - pulmonary artery; 4 - semilunar valves of the pulmonary artery; 5 - left ear of the heart; 6 - anterior cusp of a bicuspid valve; 7 - anterior papillary muscle; 8 — a back leaflet of the bicuspid valve; 9 - tendon threads; 10 - posterior papillary muscle; 11 - left ventricle of the heart; 12 - right ventricle of the heart; 13 - rear cusp of the tricuspid valve; 14 - medial cusp of the tricuspid valve; 15 - right atrium; 16 - anterior cusp of the tricuspid valve, 17 - arterial cone; 18 - right ear

Rice. 228. Heart valves. Opened heart. The direction of blood flow is shown by arrows. 1 - bicuspid valve of the left ventricle; 2 - papillary muscles; 3 - semilunar valves; 4 - tricuspid valve of the right ventricle; 5 - papillary muscles; 6 - aorta; 7 - superior vena cava; 8 - pulmonary artery; 9 - pulmonary veins; 10 - coronary vessels

At the exit site of the aorta from the left ventricle and the pulmonary artery from the right ventricle, the endocardium also forms very thin folds in the form of concave (into the ventricular cavity) semicircular pockets, three in each hole. In their form, these valves are called semilunar (valvulae semilunares). They open only upward towards the vessels during ventricular contraction. During the relaxation (expansion) of the ventricles, they automatically close and do not allow the reverse flow of blood from the vessels to the ventricles; when the ventricles are compressed, they reopen with a current of ejected blood. The semilunar valves are devoid of musculature.

It can be seen from the foregoing that in humans, as in other mammals, the heart has four valve systems: two of them, valvular, separate the ventricles from the atria, and two, semilunar, separate the ventricles from the arterial system. There are no valves at the place where the pulmonary veins enter the left atrium; but the veins approach the heart at an acute angle in such a way that the thin wall of the atrium forms a fold, partly acting as a valve or damper. In addition, there are thickenings of annular muscle fibers of the adjacent part of the atrial wall. These thickenings of muscle tissue during atrial contraction compress the mouths of the veins and thereby prevent the reverse flow of blood into the veins, so that it enters only the ventricles.

In an organ that performs such a big job as the heart, support structures naturally develop, to which the muscle fibers of the heart muscle are attached. This soft cardiac "skeleton" includes: tendon rings around its openings equipped with valves, fibrous triangles located at the aortic root and the membranous part of the ventricular septum; they all consist of bundles of collagen fibrils with an admixture of elastic fibers.

The heart valves are composed of dense and elastic connective tissue (doubling of the endocardium - duplication). When the ventricles contract, the cusp valves, under pressure from the blood in the cavity of the ventricles, straighten out like stretched sails and touch so tightly that they completely close the openings between the atrial cavities and the ventricular cavities. At this time, the tendon threads mentioned above support them and prevent them from turning inside out. Therefore, blood from the ventricles cannot get back into the atria; under the pressure of the contracting ventricles, it is pushed out of the left ventricle into the aorta, and from the right into the pulmonary artery. Thus, all the valves of the heart open only in one direction - in the direction of blood flow.

The size of the cavities of the heart, depending on the degree of filling with blood and the intensity of its work, varies. So, the capacity of the right atrium ranges from 110-185 cm 3, the right ventricle - from 160 to 230 cm 3, the left atrium - from 100 to 130 cm 3 and the left ventricle - from 143 to 212 cm 3.

The heart is covered with a thin serous membrane, which forms two sheets, passing one into the other at the place where large vessels leave the heart. The inner, or visceral, leaf of this sac, which directly covers the heart and is tightly soldered to it, is called the epicardium (epieardium), the outer, or parietal, leaf is called the pericardium (pericardium). The parietal sheet forms a bag covering the heart - this is a heart bag, or a heart shirt. The pericardium is adjacent to the sheets of the mediastinal pleura from the sides, adheres to the tendon center of the diaphragm from below, and is attached in front by connective tissue fibers to the posterior surface of the sternum. Between both sheets of the heart bag around the heart, a slit-like hermetically closed cavity is formed, always containing a certain amount (about 20 g) of serous fluid. The pericardium insulates the heart from its surrounding organs, and the fluid moistens the surface of the heart, reducing friction and making its movements slip during contractions. In addition, the strong fibrous tissue of the pericardium limits and prevents excessive stretching of the muscle fibers of the heart; if there were no pericardium, which anatomically limits the volume of the heart, it would be in danger of overstretching, especially during periods of its most intense and unusual activity.

Incoming and outgoing vessels of the heart. The superior and inferior vena cava join the right atrium. At the confluence of these veins, a wave of contraction of the heart muscle arises, quickly covering both atria and then passing to the ventricles. In addition to the large vena cava, the coronary sinus of the heart (sinus eoronarius cordis) also flows into the right atrium, through which venous blood flows from the walls of the heart itself. The opening of the sinus closes with a small fold (thebesian valve).

Four years of intravenous veins flow into the left atrium. The largest artery in the body, the aorta, emerges from the left ventricle. It goes first to the right and up, then, bending back and to the left, it spreads through the left bronchus in the form of an arc. The pulmonary artery emerges from the right ventricle; it goes first to the left and up, then turns to the right and divides into two branches, heading towards both lungs.

In total, the heart has seven input - venous - openings and two output - arterial - openings.

Circles of blood circulation(Fig. 229). Due to the long and complex evolution of the development of the circulatory organs, a certain system of supplying the body with blood has been established, which is characteristic of humans and all mammals. As a rule, blood moves inside a closed system of tubes, which includes a permanently powerful muscular organ - the heart. The heart, as a result of its historical automatism and regulation by the central nervous system, continuously and rhythmically drives blood throughout the body.

Rice. 229. Scheme of blood circulation and lymph circulation. The red color indicates the vessels through which arterial blood flows; blue - vessels with venous blood; purple color shows the portal vein system; yellow - lymphatic vessels. 1 - right half of the heart; 2 - left half of the heart; 3 - aorta; 4 - pulmonary veins; superior and inferior vena cava; 6 - pulmonary artery; 7 - stomach; 8 - spleen; 9 - pancreas; 10 - intestines; 11 - portal vein; 12 - liver; 13 - kidney

Blood from the left ventricle of the heart through the aorta first enters large arteries, which gradually branch into smaller ones and then pass into arterioles and capillaries. Through the thinnest walls of the capillaries, there is a constant exchange of substances between the blood and body tissues. Passing through a dense and numerous network of capillaries, the blood gives oxygen and nutrients to the tissues, and in return receives carbon dioxide and cellular metabolic products. Changing in its composition, the blood further becomes unsuitable for maintaining respiration and nutrition of cells, it turns from arterial to venous. Capillaries begin to gradually merge first into venules, venules into small veins, and the latter into large venous vessels - the superior and inferior vena cava, through which blood returns to the right atrium of the heart, thus describing the so-called large, or bodily, circle of blood circulation.

The venous blood that has entered the right ventricle from the right atrium is sent by the heart through the pulmonary artery to the lungs, where it is released from carbon dioxide and saturated with oxygen in the smallest network of pulmonary capillaries, and then returns again through the pulmonary veins to the left atrium, and from there to the left ventricle of the heart, from where it again comes to supply the tissues of the body. The circulation of blood along the way from the heart through the lungs and back is a small circle of blood circulation. The heart not only performs the work of a motor, but also acts as an apparatus that controls the movement of blood. Switching blood from one circle to another is achieved (in mammals and birds) by complete separation of the right (venous) half of the heart from its left (arterial) half.

These phenomena in the circulatory system have become known to science since the time of Harvey, who discovered (1628) blood circulation, and Malpighi (1661), who established blood circulation in capillaries.

Blood supply to the heart(see fig. 226). The heart, carrying an exceptionally important service in the body and doing a great job, itself needs abundant nutrition. This is an organ that is in an active state throughout a person's life and never has a rest period that would last more than 0.4 seconds. Naturally, this organ must be supplied with a particularly abundant amount of blood. Therefore, its blood supply is arranged in such a way that it fully ensures the inflow and outflow of blood.

The heart muscle receives blood before all other organs through two coronary (coronary) arteries (a. eoronaria cordis dextra et sinistra), extending directly from the aorta just above the semilunar valves. About 5-10% of all blood ejected into the aorta enters the abundantly developed network of coronary vessels of the heart, even at rest. The right coronary artery runs along the transverse groove to the right to the posterior half of the heart. It supplies most of the right ventricle, the right atrium, and part of the posterior side of the left heart. Its branch feeds the conduction system of the heart - the Ashof-Tavar node, the bundle of His (see below). The left coronary artery divides into two branches. One of them goes along the longitudinal groove to the apex of the heart, giving numerous lateral branches, the other goes along the transverse groove to the left and posteriorly to the posterior longitudinal groove. The left coronary artery supplies most of the left heart and the anterior part of the right ventricle. The coronary arteries break up into a large number of branches, widely aiastomosing among themselves and crumbling into a very dense network of capillaries, penetrating everywhere, into all parts of the organ. There are 2 times more (thicker) capillaries in the heart than in skeletal muscle.

Venous blood flows from the heart through numerous channels, of which the most significant is the coronary sinus (or a special coronary vein - sinus coronarius cordis), which flows independently directly into the right atrium. All other veins that collect blood from individual sections of the heart muscle also open directly into the cavity of the heart: into the right atrium, into the right and even into the left ventricle. It turns out that 3/5 of all blood passing through the coronary vessels flows through the coronary sinus, while the remaining 2/5 of the blood is collected by other venous trunks.

The heart is also pierced by a rich network of lymphatic vessels. The entire space between the muscle fibers and blood vessels of the heart is a dense network of lymphatic vessels and crevices. Such an abundance of lymphatic vessels is necessary for the rapid removal of metabolic products, which is very important for the heart as an organ that works continuously.

From what has been said, it can be seen that the heart has its own third circle of blood circulation. Thus, the coronary circle is included in parallel to the entire systemic circulation.

The coronary circulation, in addition to nourishing the heart, also has a protective value for the body, greatly mitigating the harmful effects of excessively high blood pressure during a sudden contraction (spasm) of many peripheral vessels of the systemic circulation; in this case, a significant part of the blood is sent along a parallel short and widely branched coronary path.

Innervation of the heart(Fig. 230). Contractions of the heart are made automatically due to the properties of the heart muscle. But the regulation of its activity, depending on the needs of the body, is carried out by the central nervous system. IP Pavlov said that "four centrifugal nerves control the activity of the heart: slowing down, accelerating, weakening and strengthening." These nerves approach the heart as part of branches from the vagus nerve and from the nodes of the cervical and thoracic sympathetic trunk. The branches of these nerves form a plexus (plexus cardiacus) on the heart, the fibers of which spread along with the coronary vessels of the heart.

Rice. 230. Conducting system of the heart. Schematic diagram of the conduction system in the human heart. 1 - Kis-Flak node; 2 - Ashof-Tavar node; 3 - bundle of His; 4 - legs of the bundle of His; 5 - a network of Purkinje fibers; 6 - superior vena cava; 7 - inferior vena cava; 8 - atrium; 9 - ventricles

The coordination of the activity of the parts of the heart, atria, ventricles, the sequence of contractions, relaxations are carried out by a special conduction system peculiar only to the heart. The cardiac muscle has the peculiarity that impulses are conducted to the muscle fibers through special atypical muscle fibers, called Purkinje fibers, which form the conduction system of the heart. Purkinje fibers are similar in structure to muscle fibers and directly pass into them. They look like wide ribbons, are poor in myofibrils and very rich in sarcoplasm. Between the right ear and the superior vena cava, these fibers form a sinus node (Kis-Flak node), which is connected by a bundle of the same fibers to another node (Ashof-Tavar node), located on the border between the right atrium and ventricle. A large bundle of fibers (the bundle of His) departs from this node, which descends in the septum of the ventricles, dividing into two legs, and then crumbles in the walls of the right and left ventricles under the epicardium, ending in the papillary muscles.

The fibers of the nervous system everywhere come into close contact with the Purkinje fibers.

The bundle of His is the only muscular connection between the atrium and the ventricle; through it, the initial stimulus that occurs in the sinus node is transmitted to the ventricle and ensures the completeness of the heart contraction.

The main source of blood supply to the heart is coronary arteries(Fig. 1.22).

The left and right coronary arteries branch from the initial part of the ascending aorta in the left and right sinuses. The location of each coronary artery varies both in height and circumference of the aorta. The mouth of the left coronary artery can be at the level of the free edge of the semilunar valve (42.6% of cases), above or below its edge (in 28 and 29.4%, respectively).

For the mouth of the right coronary artery, the most common location is above the free edge of the semilunar valve (51.3% of cases), at the level of the free edge (30%) or below it (18.7%). The displacement of the orifices of the coronary arteries upward from the free edge of the semilunar valve is up to 10 mm for the left and 13 mm for the right coronary artery, down - up to 10 mm for the left and 7 mm for the right coronary artery.

In single observations, more significant vertical displacements of the orifices of the coronary arteries are also noted, up to the beginning of the aortic arch.

Rice. 1.22. The blood supply system of the heart: 1 - ascending aorta; 2 - superior vena cava; 3 - right coronary artery; 4 - LA; 5 - left coronary artery; 6 - a large vein of the heart

In relation to the midline of the sinus, the mouth of the left coronary artery in 36% of cases is displaced to the anterior or posterior margin. A significant displacement of the beginning of the coronary arteries along the circumference of the aorta leads to the discharge of one or both coronary arteries from the sinuses of the aorta, which are unusual for them, and in rare cases, both coronary arteries come from one sinus. Changing the location of the orifices of the coronary arteries in height and circumference of the aorta does not affect the blood supply to the heart.

The left coronary artery is located between the beginning of the pulmonary trunk and the left auricle of the heart and is divided into circumflex and anterior interventricular branches.

The latter follows the apex of the heart, located in the anterior interventricular groove. The circumflex branch is directed under the left ear in the coronary sulcus to the diaphragmatic (posterior) surface of the heart. The right coronary artery, after leaving the aorta, lies under the right ear between the beginning of the pulmonary trunk and the right atrium. Then it turns along the coronal sulcus to the right, then back, reaches the posterior longitudinal sulcus, along which it descends to the apex of the heart, already being called the posterior interventricular branch. The coronary arteries and their large branches lie on the surface of the myocardium, located at different depths in the epicardial tissue.

The branches of the main trunks of the coronary arteries are divided into three types - main, loose and transitional. The main type of branching of the left coronary artery is observed in 50% of cases, loose - in 36% and transitional - in 14%. The latter is characterized by the division of its main trunk into 2 permanent branches - the envelope and the anterior interventricular. The loose type includes cases when the main trunk of the artery gives off the interventricular, diagonal, additional diagonal and circumflex branches at the same or almost the same level. From the anterior interventricular branch, as well as from the envelope, 4–15 branches depart. The angles of departure of both primary and subsequent vessels are different and range from 35–140°.

According to the International Anatomical Nomenclature, adopted at the Congress of Anatomists in Rome in 2000, the following vessels supplying the heart are distinguished:

Left coronary artery

Anterior interventricular branch (r. interventricularis anterior)
Diagonal branch (r. diagonalis)
Branch of the arterial cone (r. coni arteriosi)
Lateral branch (r. lateralis)
Septal interventricular branches (rr. interventricularis septales)
Enveloping branch (r. circumflex exus)
Anastomotic atrial branch (r. atrialis anastomicus)
Atrioventricular branches (rr. atrioventricularis)
Left marginal branch (r. marginalis sinister)
Intermediate atrial branch (r. Atrialis intermedius).
Posterior LV branch (r. Posterior ventriculi sinistri)
Branch of the atrioventricular node (r. nodi atrioventricularis)

Right coronary artery

Branch of the arterial cone (ramus coni arteriosi)
Branch of the sinoatrial node (r. Nodi sinoatrialis)
Atrial branches (rr. atriales)
Right marginal branch (r. marginalis dexter)
Intermediate precordial branch (r. atrialis intermedius)
Posterior interventricular branch (r. interventricularis posterior)
Septal interventricular branches (rr. interventriculares septales)
Branch of the atrioventricular node (r. nodi atrioventricularis).

By the age of 15–18, the diameter of the coronary arteries (Table 1.1) approaches those of adults. At the age of over 75 years, there is a slight increase in the diameter of these arteries, which is associated with the loss of the elastic properties of the arterial wall. In most people, the diameter of the left coronary artery is larger than the right. The number of arteries extending from the aorta to the heart may decrease to 1 or increase to 4 due to additional coronary arteries, which are not normal.

The left coronary artery (LCA) originates in the posterior internal sinus of the aortic bulb, passes between the left atrium and LA, and after about 10–20 mm divides into the anterior interventricular and circumflex branches.

The anterior interventricular branch is a direct continuation of the LCA and runs in the corresponding sulcus of the heart. Diagonal branches (from 1 to 4) depart from the anterior interventricular branch of the LCA, which are involved in the blood supply to the lateral wall of the left ventricle and can anastomose with the envelope branch of the left ventricle. The LCA gives off 6 to 10 septal branches that supply blood to the anterior two-thirds of the interventricular septum. The anterior interventricular branch of the LCA itself reaches the apex of the heart, supplying it with blood.

Sometimes the anterior interventricular branch passes to the diaphragmatic surface of the heart, anastomosing with the posterior interventricular artery of the heart, carrying out collateral blood flow between the left and right coronary arteries (with right or balanced types of blood supply to the heart).

Table 1.1

The right marginal branch used to be called the artery of the acute edge of the heart - ramus margo acutus cordis. The left marginal branch is the branch of the blunt edge of the heart - ramus margo obtusus cordis, since the well-developed LV myocardium of the heart makes its edge rounded, blunt).

Thus, the anterior interventricular branch of the LCA supplies the anterolateral wall of the left ventricle, its apex, most of the interventricular septum, and also the anterior papillary muscle (due to the diagonal artery).

The envelope branch, moving away from the LCA, located in the AV (coronary) groove, goes around the heart on the left, reaches the intersection and the posterior interventricular groove. The circumflex branch can either end at the obtuse edge of the heart or continue in the posterior interventricular sulcus. Passing in the coronary sulcus, the circumflex branch sends large branches to the lateral and posterior walls of the left ventricle. In addition, important atrial arteries depart from the circumflex branch (including r. nodi sinoatrialis). These arteries, especially the sinus node artery, anastomose abundantly with branches of the right coronary artery (RCA). Therefore, the branch of the sinus node is of "strategic" importance in the development of atherosclerosis in one of the main arteries.

The RCA originates in the anterior internal sinus of the aortic bulb. Departing from the anterior surface of the aorta, the RCA is located on the right side of the coronary sulcus, approaches the sharp edge of the heart, goes around it and goes to the crux and then to the posterior interventricular sulcus. At the intersection of the posterior interventricular and coronal sulci (crux), the RCA gives off the posterior interventricular branch, which goes towards the distal part of the anterior interventricular branch, anastomosing with it. Rarely, the RCA ends at the sharp edge of the heart.

The RCA with its branches supplies blood to the right atrium, part of the anterior and entire posterior surface of the left ventricle, the interatrial septum, and the posterior third of the interventricular septum. Of the important branches of the RCA, it should be noted the branch of the cone of the pulmonary trunk, the branch of the sinus node, the branch of the right edge of the heart, the posterior interventricular branch.

The branch of the cone of the pulmonary trunk often anastomoses with the cone branch, which departs from the anterior interventricular branch, forming the annulus of Viessen. However, in approximately half of the cases (Schlesinger M. et al., 1949), the artery of the cone of the pulmonary trunk departs from the aorta on its own.

The branch of the sinus node in 60–86% of cases (Ariev M.Ya., 1949) departs from the RCA, however, there is evidence that in 45% of cases (James T., 1961) it can depart from the envelope branch of the LCA and even from the LCA itself . The branch of the sinus node is located along the wall of the pancreas and reaches the confluence of the superior vena cava into the right atrium.

At the sharp edge of the heart, the RCA gives off a fairly constant branch - the branch of the right edge, which runs along the sharp edge to the apex of the heart. Approximately at this level, a branch departs to the right atrium, which supplies blood to the anterior and lateral surfaces of the right atrium.

At the site of transition of the RCA to the posterior interventricular artery, a branch of the AV node departs from it, which supplies blood to this node. From the posterior interventricular branch, branches to the pancreas depart perpendicularly, as well as short branches to the posterior third of the interventricular septum, which anastomose with similar branches extending from the anterior interventricular artery of the LCA.

Thus, the RCA supplies blood to the anterior and posterior walls of the pancreas, partially to the posterior wall of the left ventricle, the right atrium, the upper half of the interatrial septum, the sinus and AV nodes, as well as the posterior part of the interventricular septum and the posterior papillary muscle.

V.V. Bratus, A.S. Gavrish "Structure and functions of the cardiovascular system"

The coronary arteries are the vessels that provide the heart muscle with the necessary nutrition. Pathologies of these vessels are very common. They are considered one of the main causes of death in the elderly.

The scheme of the coronary arteries of the heart is branched. The network includes large branches and a huge number of small vessels.

The branches of the arteries start from the aortic bulbs and go around the heart, providing sufficient blood flow to different parts of the heart.

Vessels consist of endothelium, muscular fibrous layer, adventitia. Due to the presence of such a number of layers, the arteries are characterized by high strength and elasticity. This allows blood to move normally through the vessels even if the load on the heart is increased. For example, during training, when athletes' blood moves five times faster.

Types of coronary arteries

The entire arterial network consists of:

main vessels;
adnexal.

The last group includes such coronary arteries:

Right. She is responsible for the flow of blood to the cavity of the right ventricle and the septum.
Left. From her blood comes to all departments. It is divided into several parts.
bending branch. It departs from the left side and provides nutrition to the septum between the ventricles.
Anterior descending. Thanks to it, nutrients enter different parts of the heart muscle.
Subendocardial. They pass deep into the myocardium, and not on its surface.

The first four views are located on top of the heart.

Types of blood flow to the heart

There are several options for blood flow to the heart:

Right. This is the dominant view if this branch originates from the right artery.
Left. This method of nutrition is possible if the posterior artery is a branch of the circumflex vessel.
Balanced. This type is isolated if blood flows simultaneously from the left and right arteries.

Most people have the right type of blood supply.

Possible pathologies

Coronary arteries are vessels that provide the vital organ with sufficient oxygen and nutrients. Pathologies of this system are considered one of the most dangerous, as they gradually lead to more serious diseases.

angina pectoris

The disease is characterized by attacks of suffocation with severe pain in the chest. This condition develops when the vessels are affected by atherosclerosis and the heart does not receive enough blood.

Pain is associated with oxygen starvation of the heart muscle. Physical and mental stress, stress and overeating aggravate the symptoms.

myocardial infarction

This is a dangerous problem in which certain parts of the heart die. The condition develops when the blood supply stops completely. This usually occurs when the coronary arteries of the heart are clogged with a blood clot. Pathology has vivid manifestations:

The area that was subject to necrosis can no longer contract, but the rest of the heart works as before. Because of this, the damaged area may rupture. Lack of medical assistance will lead to the death of the patient.

Causes of defeat

Damage to the coronary arteries in most cases is associated with insufficient attention to the state of one's own health.

Every year, such violations lead to the death of millions of people around the world. At the same time, most people are residents of developed countries and are well off.

The provoking factors contributing to violations are:

No less important influence is exerted by age-related changes, hereditary predisposition, gender. Such diseases in an acute form affect men, so they die from them much more often. Women are more protected due to the influence of estrogen, so they are more likely to have a chronic course.

Rice. 70. Isolated anatomical diagram of the corono-arterial tree.

1 - left coronary artery, 2 - anterior interventricular branch, 3 - envelope branch, 4 - obtuse marginal branch, Dj and D2 - 1st and 2nd diagonal arteries, 5 - right coronary artery, 6 - cone artery, 7 - artery of the sinus node, 8 - branch of the sharp edge, 9 - posterior interventricular branch, 10 - artery of the atrioventricular node.

A - aorta. Preservation of the circle of Viessen is shown by two arrows (branches of the conus artery and right ventricular branches of the anterior interventricular artery). Preservation of the primary around the atrial ring is indicated by the large arrow.

In the future, in the work (illustrations), the indicated digital code for the designations of the coronary arteries was used.

naya anatomical diagram of the structure of the corono-arterial tree. As follows from the presented data, as well as from a multi-projection study of coronary angiograms and drawings that reproduce the structure of the coronoarterial tree on corrosive preparations, in projections corresponding to those used in coronary angiography, the former do not reflect the structure of the VA in the corresponding projections. Therefore, we present a description of the anatomy of VA in accordance with the direction and determinability of VA on corrosive preparations in the corresponding projections.

Anteroposterior projection

As follows from Figures 71-74, in the anteroposterior projection, the divergence of the trunks of the right and left VA is clearly defined. This is the only projection that allows them to be visualized regardless of the level of deviation from the sinuses of Valsalva and the degree

	Rice. 71. Corrosive preparation. before
	back projection.	Rice. 72. Corrosive preparation. Before
	1 and 2 - 1st and 2nd facial sinuses of the aorta; Dp D2 - 1st and	Rice. 72. Corrosive preparation. Before
		back projection.
	2nd diagonal arteries; 5 - right coronary	back projection.
		1 and 2 - 1st and 2nd facial sinuses of the aorta.
		1 and 2 - 1st and 2nd facial sinuses of the aorta.

contrast regurgitation. Identification of the origin of the CA and OB of the left VA in this projection is difficult.

The projection makes it possible to visualize a number of distal diagonal branches of the LAD, as well as to assess the involvement of the LAD in the blood supply to the diaphragmatic surface of the heart.

Features of all other VAs and their branches are determined only by comparing the data of a multiprojection study.

Left coronary artery

The anatomical diagram of the distribution of the main trunks of the left VA (LAD and OB) and their relationship with the departments and structures of the heart, reproduced from corrosive preparations in the 1st and 2nd anterior oblique projections, is shown in Fig. 75.

1. Left anterior oblique view. In this projection, the trunk of the left VA is in an orthogonal projection, and therefore the assessment of its features is difficult. Visualization of the left VA trunk in this projection also depends on the level of its origin from the 2nd facial (left in the definitive heart) aortic sinus, and on the degree of reflux of the contrast agent into the aorta (with a sharp stenosis or occlusion of the left VA trunk, for example).

On the other hand, in this projection, the bifurcation (trifurcation) of the left VA is clearly visualized (Fig. 75, B; 76, 77 and 78). In this projection, the LAD goes along the right contour of the heart, and the OB and its large branches - along the left.

The LAD is usually recognized by the septal arteries that arise from it at a right angle. The identification of the intermediate branch of the left VA is also very important, since, if it exists, it is responsible for the blood supply to a significant pool, including the anterior surface of the left ventricle and the apex of the heart.

The disadvantage of the projection is the superposition of the proximal segment of the VTC with the OB.

And although in this projection the visualization of the VTC is often not difficult, the detection of constrictions

in its proximal third The 1st oblique projection is accompanied by certain difficulties.

Thus, this projection makes it possible to identify the type of branching of the left VA and structural features of the LAD, OV, and their branches. And although it does not allow assessing the state of

Rice. 75. Anatomical diagram of the distribution of the main trunks of the left coronary artery and their relationship with the departments and structures of the heart, reproduced from corrosion preparations in the 1st (B) and 2nd (A) anterior oblique projections.

Identification of the anterior interventricular branch (ALV) is easily accomplished by the presence of septal branches (SB).

In the 1st anterior oblique projection, the superposition of the envelope branch (OB) and the obtuse marginal branch (OTC) is possible, in the 2nd oblique projection in front of it, the LAD and the diagonal branch (DV) are possible.

A - aorta, LA - pulmonary artery, M - mitral valve.

	Rice. 76. Corrosive preparation. 1st (left
	anterior) oblique projection.	Rice. 77. Corrosive preparation. 1st
	Left coronary artery (1) and its branches.
		(left anterior) oblique view.

		Left coronary artery (1) and its branches,

		i - intermediate artery (a. intermedia).

		The rest of the designations are the same as in Fig. 70.

the trunk of the left VA and sometimes the proximal sections of the LAD (up to the 1st septal branch) and OB, it is very informative for assessing the large left ventricular branches of the LAD (diagonal, intermediate, septal) and OB (VTK and, in part, posterolateral (ZB) left ventricular branch).

In this projection, the LAD and OB are also separated, but it is not very informative for assessing the bifurcation zone of the left VA. With absence

Rice. 78. Selective coronarogram of the left
coronary artery.	Rice. 79. Corrosive preparation. 2nd
1st (left anterior) oblique view.
	Systems of the right (5) and left coronary arteries.
	Septal branches of the anterior interventricular
	Septal branches of the anterior interventricular
	branches (2) are shown by arrows, a typical ogy stroke
	the beating branch (3) is underlined with a dotted line.
	The rest of the designations are the same as in Fig. 70.

	Rice. 80. Corrosive preparation. 2nd	Rice. 81. Selective coronarogram of the left
	Rice. 80. Corrosive preparation. 2nd	coronary artery.
	(right anterior) oblique view.
	Right (5) and left coronal arte systems	LAD - anterior interventricular branch, DV - diagonal
		naya branch, OB - envelope branch, VTK - branch of the obtuse edge.
	Typical course of the envelope branch (3) and departure
	obtuse edge branch extending from it (4) underline	reflux of a contrast agent into the aorta, this project
	chickpea dotted line.	reflux of a contrast agent into the aorta, this project
	chickpea dotted line.	tion is very informative for assessing the condition
	The rest of the designations are the same as in Fig. 70.	tion is very informative for assessing the condition
	The rest of the designations are the same as in Fig. 70.	proximal sections of the LAD and OB and proxies
		proximal sections of the LAD and OB and proxies
		small septal branches of the LAD. According to her

but also assess the development of the right ventricular branches of the LAD. In this projection, the LAD limits the left contour of the heart, and the OB extends to the right of it (Fig. 75, A; 79-81).

The projection is also optimal for the exposure of the VTC and its departure from the OB. In this projection, the zone of divergence of the OV and VTK is located in the projection, where the indicated arterial

nye vessels are maximally diluted. Recognition of the VTC is not difficult: it is the first large branch extending from the OB, heading towards the apex.

Due to the superposition of the DW and LAD, this projection is not very informative for assessing the features of the DW.

Thus, this projection makes it possible to clearly identify the region of division of the OV and VTK, assess the state of the VTK, identify structural features of the proximal sections of the OV and LAD, and visualize the right ventricular branches of the LAD.

Right coronary artery

1. Anterior-posterior projection. This projection makes it possible to identify the origin of the trunk of the right VA from the 1st facial (right in the definitive heart) aortic sinus (see Fig. 71, 72), but is not very informative for assessing the origin of the conus artery.

2. Right anterior oblique view. It is optimal for assessing the origin (independent or from the right VA) and the following of the first large branches of the right VA (see Fig. 70, 79, 82) (cone, sinus node artery, adventitia). In this projection, the cone artery (CA) is directed downward, and the artery of the sinus node is directed upward from the right VA. The projection is also very informative for revealing the nature of the distribution of VA in the region of the infundibular part of the right ventricle. It allows to assess the following of the CA or the LAD deviation from the right VA, which is very important to know when planning operations for conotruncus malformations. Apparently, in this projection (as well as in the anteroposterior one), visualization is optimal from the passage of the OB from the right VA or the 1st facial sinus of the aorta.

The projection makes it possible to assess the degree of development of collaterals between the system of the right VA and the LAD (Fig. 83) and the filling of the distal channel of the latter (flows from the CA and VOC to the LAD). The same projection is the most informative for assessing the deviation of the PAD (from the right or left VA) and determining the type of dominant blood supply.

Rice. 82. Selective coronarogram of the right coronary artery (5).

2nd (right anterior) oblique view.

VOK - branch of the sharp edge, a.AVU - artery of the atrioventricular node, ZMZhV - posterior interventricular branch.

Rice. 83. X-ray from a corrosive preparation.

2nd (right anterior) oblique view.

Collaterals between the right coronary artery (RVA) and the anterior interventricular branch (LAD). Communication between the branches of the conus artery (CA) and the right ventricular branches (RV) through the cone veins (KB).

1st s, 2nd s. and 3rd p. - first, second and third septal branches, OB - circumflex branch, LVA - left coronary artery, PIA - posterior interventricular branch.

Rice. 84. Angiographic scheme of dominant circulation types (according to J. Dodge et al., 1988) (in the 2nd right anterior oblique projection): right (A), balanced (B), left (C).

A - left ventricular branches of the right coronary artery (shaded and shown by a dark arrow), B - paired (from the right and left VA) blood supply to the posterior interventricular branch (9) is darkened and shown by a curved arrow. C - blood supply to the PMA (9) from the system of the left VA is shaded and shown by a light arrow.

/ and 2 - 1st and 2nd facial sinuses of the aorta. The rest of the designations are the same as in Fig. 70.

Rice. 85. Corrosive preparation. Back view of the heart.

The right type of dominance of the blood circulation of the heart. Multiple PADs (9) (three of them) supplying the posterior septum, 2 - circumflex segment of the right coronary artery, 10 - artery of the atrioventricular node.

heart (Fig. 84). With the right type of dominance, the PFA moves away from the right VA (Fig. 85), with the left type, from the left VA (see Fig. 80, 81).

Usually, when studying coronarograms, information is obtained about the state of the coronary arteries - the nature, extent and localization of the pathological process are assessed. An integral part of this process is the assessment of the degree of development of collaterals and the distal bed of large VAs. (Yu.S. Petrosyan and L.S. Zingerman, 1974; S. Ilsley et ah, 1982). Meanwhile, when “reading” an angiogram, the interpretation of another issue is no less important: understanding the anatomy of the VA itself and the role of individual VAs.

in vascularization of the heart. A clear planning of coronary artery bypass surgery is unthinkable without assessing which vessel is studied on the angiogram and without identifying which parts of the heart require revascularization. In this regard, the materials presented here, we believe, may be useful to a certain extent.

in practical purposes.

Literature

1. Abdullaev F. Z., Nasedkina M. A., Mozhina A. A. et al., Characteristic features of pathological anatomy and myocardial lesions in abnormal origin of the left coronary artery from the pulmonary trunk, Arkh. Pat. - 1988. - No. 6. - S. 35-41.

2. Antipov N. V. Conduction system of the heart: detection technique, morphogenesis: Abstracts of reports. VII regional scientific conference of morphologists. - Donetsk, 1990. - S. 9-10.

3. Arutyunov V. D. Viessen-Tebezia vessels in cardiac hypertrophy and myocardial infarction: Proceedings of the 2nd Conf. Latvian pathologists. - Riga, 1962. - S. 109-111.

4. Arkhangelsky A.V. On changes in the papillary muscles of the heart in myocardial infarction. Arch. Pat. - 1959. - No. 9. - S. 48-54.

5. Aryev M. Ya., Vitushinsky V. A., Rabinerzon A. V.On collateral circulation in the heart under pathological conditions // Ter. arch. - 1935. - T. 13, issue. 3.

6. Bokeria L.A. Tachyarrhythmias. - M.: Medicine, 1989.

7. Van Praag R. Anatomy of a normal heart and a segmental approach to diagnosis // Morphology and morphometry of the heart in normal and congenital heart diseases. - M., 1990. - S. 7-31.

8. Volynsky Yu. D., Todua F. I., Mogilevsky L. S., Kokov L. S.Bronchial and systemic circulation of the lungs in surgery for congenital heart defects of the “blue” type. - 1981. - No. 3. - S. 83-84.

9. Gabain L. I., Fomin A. M. Morphological features of the bloodstream in the papillary muscles of the human heart // Systemic hemodynamics and microcirculation. - Kui byshev, 1983. - S. 23-28.

10. Dubinina R. V. On the variant anatomy of the coronary arteries with different types of blood supply to the heart // Sat. scientific works of the Arkhangelsk honey. institute. T. 1. - 1964. - S. 75-80.

11. Zinkovsky M. F., Shcherbinin V. G., Chepkaya I. L.Residual shunts after correction of atrial defects // Thoracic and heart-vessel, hir. - 1991. - No. 2. - S. 23-27.

12. Zolotova-Kostomarova M. I. Clinic and pathology of myocardial infarction: Dis. ... cand. Sciences. - M., 1951.

13. Ilyinsky, S.P., On the Vessels of Thebesia, Arch. Pat. - 1958. - T. 20, No. 5. - S. 3-11.

14. Ilyinsky S.P. Vessels of Tebezia as a variant of arteriovenous anastomoses of the heart. - L.: Lenizdat, 1962. - S. 227-233.

15. Ilyinsky S. P. Vessels of Tebezia. - L .: Medicine, 1971.

16. Ioseliani D.G. Ischemic heart disease in terms of surgical treatment: Dis. ...

Doctor of Sciences. - M., 1979.

17. Forged V. V., Anikina T. N. Surgical anatomy of human arteries. - M.: Medicine

on, 1 9 7 4 . - S. 33-37.

19. Kolesov V. I. Surgery of the coronary arteries of the heart. - L .: Medicine, 1977. - S. 26-32.

20. Konstantinov B. A. In the debate on the report of V.I. Burakovsky et al. "Basic principles of surgical treatment of Ebstein's anomaly" // Thoracic hir. - 1981. - No. 3. - S. 80-87.

21. Leporsky N. I. To the clinic of complete closure of the mouths of both coronary arteries of the heart in aortic syphilis // Ter. arch. - 1939. - T. 17, No. 4. - S. 3-16.

22. Lisitsin M. S. Types of blood supply to the heart // Vestn. hir. and border region - 1927.

- No. 9. - S. 26.

23. Puddle D. X-ray anatomy of the vascular system. - Budapest: Publishing House of the Academy of Sciences, 1973. - S. 29-33.

24. Melman E. P., Shevchuk M. G. The bloodstream of the heart and its potential reserves.

M.: Medicine, 1976.

25. Mikhailov S. S. Clinical anatomy of the heart. - M.: Medicine, 1987. - S. 184.

26. Mikhailov S. S. Ibid. - S. 190.

27. Monastyrsky L. G. Topographic and anatomical relations of the fibrous ring of the mitral valve to some anatomical formations of the heart. - 1965.

- No. 5. - S. 23-29.

28. Nagy I. [cit. according to V. V. Kovanov and T. N. Anikina (1974)].

29. Nezlin V. S. Coronary disease. - M.: Medicine, 1951.

30. Ognev B. V., Savvin V. P., Savelieva L. A. Blood vessels of the heart in normal and pathological conditions. - M., 1954.

31. Petrosyan Y. S., Abdullaev F. Z., Gharibyan V. A. Angiographic semiotics and pathophysiology of abnormal LVA discharge from the pulmonary trunk. Thoracic and heart-vessel. hir. - 1990. - No. 3. - S. 8-14.

32. Petrosyan Yu. S., Zingerman L. S. Coronary angiography. - M.: Medicine, 1974. - S. 112-125. 33. Prelatov V. A. Mitral valve annuloplasty using a support ring:

Dis. ... Doctor of Sciences. - M., 1985.

34. Rabkin I. Kh., Abugova A. M "Matevosova" L. // Coronary angiography and coronary scanning: Guide to angiography / Ed. I. X. Rabkina. - M.: Medicine, 1977. - S. 67-81.

35. Rabkin I. Kh., Abugov A. M., Shabalkin B. V. Evaluation of collateral circulation according to selective coronary angiography // Kardiologiya. - 1973. - No. 11. - S. 15.

36. Rabkin I. Kh., Matevosov A. L., Khilenko A. V. Coronary scanning in the diagnosis of coronary heart disease // Ibid. - 1974. - No. 2. - S. 5-10.

37. Rabotnikov V. S., Ioseliani D. G. The state of the distal bed of the coronary arteries in patients with coronary heart disease // Ibid. - 1978. - No. 12. - S. 41-44.

38. Ryumina E. N., Berishvili I. I., Aleksi-Meskhishvili V.V. Lung scan in pain

nyh at Fallot's tetrad before and after palliative operations // Med. radiol. - 1979.

- No. 7. - S. 23-32.

39. Savelyev V. S., Petrosyan Yu. S., Zingerman L. S. et al. Angiographic diagnosis of diseases of the aorta and its branches. - M.: Medicine, 1975.

40. Samoilova SV Anatomy of the blood vessels of the heart. - "P .: Medicine, 1970.

41. Sinev A.F. Surgical anatomy of the conduction system of the heart in complex congenital heart defects: Dis. ... Doctor of Sciences. - M., 1982.

42. Smolyannikov A. V., Naddachina T. A. Pathological anatomy of coronary insufficiency. - M., 1963.

43. Sokolov S. S. Surgical anatomy of the "dangerous zones" of the heart in the correction of acquired and congenital malformations // Vestn. hir. - 1978. - No. 11. - S. 48-56.

44. Speransky L. S. Arteries of the heart // International anatomical nomenclature: Appendix 6. - M.: Medicine, 1980. - S. 207-208.

45. Travin A. A., Mikhailin S. I., Filippov B. V., Shinkarenko A. Ya. Surgical anatomy of the arteries sinoatrial and atrioventricular nodes of the heart // Thoracic hir. - 1982. - No. 1. - S. 38-42.

46. Khubutia V. I. Clinical anatomy and operative surgery of the pericardium and coronary vessels. - Ryazan, 1974. - S. 63-103.

47. Tsoy L. A., Chevagina V. N.[cit. according to V. V. Kovanov and T. N. Anikina (1974)].

48. Tsukerman G. I., Travin A. A., Georgadze O. A. On measures to prevent ligation of the circumflex branch of the left coronary artery during mitral valve replacement // Thoracic Surgery. - 1976. - No. 4. - S. 20-24.

49. Shabalkin B.V., Belov Yu.V. Aneurysms of the posterior wall of the left ventricle of the heart. Cardiology. - 1984. - No. 7. - S. 19-23.

50. Shumakov V. I. Surgical correction of mitral valve insufficiency:

Dis. ... cand. Sciences. - M., 1959.

51. Anderson K. R., Ho S. Y., Anderson R. H. Location and vascular supply of sinus node in human heart // Brit. Heart J. - 1979. - Vol. 41. - P. 28-32.

52. Anderson R. H., Becker A. E. Cardiac Anatomy. An integrated text and color atlas. - Gower Medical Publishing. - Pt. 10. - London: Churchill Livingstone, 1980.

53. Austen W. G., Edwards J. E., Frye R. L. et al. A reporting system on patients evaluated for coronary artery disease, report of the AD Hoc. Committee for Grading of Coronary Artery Disease, Council of Cardiovascular Surgery, American Heart Association (editorial) // Circulation. - 1975. - Vol. 51.-P. 7-40.

55. Baroldi G., Scomazzoni G. Coronary circulation in the normal and pathologic heart. - Armed. Forces Institute of Pathology, 1967. - P. 248-263.

56. Becker L. C. Constriction of native coronary collaterals // Cardiovasc. Res. - 2000. - Vol. 47, No. 2. -P. 217-218.

57. Bjork L. Anastomoses between the coronary and bronchial arteries // Acta Radiol. (Diag.). - Stockholm, 1966. - Vol. 4. - P. 93-96.

58. Bjork V. O., Bjork L. Coronary artery fistula // J. Thorac. Cardiovasc. Surg. - 1965.

Vol. 4 9 . -P. 921.

59. Bogers A. J. J. C. Congenital coronary artery anomalies. Clinical and embryological aspects. (Phd. Theses). - Leiden, 1989.

60. Dabizzi R. P., Caprioli G., Aiazzi L. et al. Distribution and anomalies of coronary arteries in tetralogy of Fallot // Circulation. - 1980. - Vol. 61, No. 1. - P. 95-102.

61. DeBakker M. J. T., Jause M. J., Van Capelle F. J. L, Durrer V.Endocardial mapping by simul taneous recording of endocardial electrograms during cardiac surgery for ventricular aneurysm // J. Amer. Coll. cardiol. - 1983. - Vol. 2. - P. 947-953.

62. Dodge J. T., Brown B. G., Bolson E. L., Dodge H. T.Intrathoracic spatial location of specified

coronary system on the normal human heart // Circulation. - 1988. - Vol. 78, No. 5 (Pt 1).

P.1167-1180.

63. Estes E. H. J., Dalton F. M., Entman M. L. et al. The anatomy and blood supply of the papil lary muscles of the left ventricle // Amer. Heart J. - 1966. - Vol. 71. - P. 356.

64. Favaloro R. G. Surgical treatment of coronary arteriosclerosis. - Baltimore, 1970. - P. 11.

65. Fehn P. A., Howe V. B., Pensinger R. R. Comparative anatomical stenosis of the coronary arteries of canine and parcine heart. II. Interventricular septum // Acta Anat. (Basel). - 1968.

Vol. 7 1 . -P. 223.

66. Freedom R. M., Wilson G., Trusler G. A. et al. Pulmonary atresia and intact ventricular septum // Scand. J. Thorac. Cardiovasc. Surg. - 1983. - Vol. 17. - P. 1-28.

67. Fujita M., McKown D. P., Franklin D. Opening of coronary collaterals by repeated brief coronary occlusions in conscious dogs // Angiology - J. Vase. Dis., 1988. - P. 973-980.

68. Fulton W. F. M. The coronary arteries / Ed. Ch. With Thomas. - Illinois: Springfield, 1963.

69. Geens M., Gonzalez-Lavin L., Dawbarn D., Ross D. N. The surgical anatomy of the pulmonary artery root in relation to the pulmonary valve autograft and surgery of the right ventricular outflow tract // J. Thorac. Cardiovasc. Surg. - 1971. - Vol. 6, No. 2. - P. 262-267.

70. Gensini G. G. Coronary arteriography // Heart disease - A textbook of cardiovascular medicine. 2nd ed. /Ed. E. Braunwald. - W. B. Saunders Co., 1984.

71. Gensini G. G., Buonanno C, Palacio A. Anatomy of the coronary circulation in living man - coronary arteriography // Dis. Chest. - 1967. - Vol. 52. - P. 125-140.

72. Gensini G. G., Esente P. La nomenclature angiografica internazionale della circolarione conarica umena // Giorn. ital. cardiol. - 1975. - Vol. 5, No. 2. - P. 143-198.

73. Gittenberger-de Groot A. C, Sauer U., Oppenheimer-Dekker A., Quaegebeur J. Coronary arteri al anatomy in transposition of the great arteries. A morphological study // Pediat. cardiol.

1983. - Vol. 4 (Suppl. 1.). - P. 15-24.

74. Gray H. Anatomy of the human body, Ed. 25, edited by Charles M. Goss. - Philadelphia: Lea and Febiger, 1948.

75. Gross L. The blood supply to the heart in its anatomical and clinical aspects. - New York: P.B. Hoeber, 1921.

76. Grossman W. G. Anatomy of the coronary arteries // Cardiac catheterization and angiogra phy / Ed. W. G. Grossman, Led and Febinger. - Philadelphia, 1986.

77. Hadziselimovic H., Dilberovic F.,		Blood vessels of the human heart:
Coronarography and dissection //		1980. - Vol. 106, No. 4. - P. 443-449.

78. Harris L., Downar E., Michleborough L. et al. Activation sequence of ventricular tachycardia: Endocardial mapping studies in the human ventricle // J. Amer. Coll. cardiol. - 1987.

Vol. 5 . -P. 1040-1047.

79. Haworth S. G., Macartney F. J. The intrapulmonary arterial circulation in pulmonary atresia with ventricular septal defect and major aorto-pulmonary collateral arteries // Amer. J. Cardiol. (abstr.). - 1979. - Vol. 43. - P. 364.

	Stockley H., Clitsakis D., Layton C. Normal coronary
test? // Brit. Heart J. - 1982. - Vol. 48. - P. 580-583.
	Marchegiani With Le fistole coronariche congenite //	Ann. ital. Chir.

Vol. 4 1 . -P. 977.

82. James T. N. Anatomy of the coronary arteries. - New York: P. B. Hoeber, 1961.

83. James	T. N. Blood supply of the human interventricular septum // Circulation. - 1958.
	1 7 . -P. 391.

84.James	T. N. Burch G. E. The atrial coronary arteries in man // Ibid. - 1958. - Vol. 17.

85. Kiechel F., Blumenthal S., Griffiths S. P. The syndrome of papillary muscle infarction and dysfunction in infants // Congenital cardiac defects - recent advances / Ed. D. Bergsma.

Baltimore, 1972. - Vol. 8, No. 1. - P. 44-50.

86. Kirklin J. W., Bargeron L. M., Pacifico A. D. et al. Management of the tetralogy of Fallot with large aorto-pulmonary collateral arteries // Proceedings of the Fourth Joint Symposium on Congenital Heart disease. - Moscow: Mir, 1981. - P. 24-25.

87. K y gel M. A. Anatomical studies on the coronary arteries and their branches. I. Arteries anastomotica auricularis magna // Amer. Heart J. - 1927. - Vol. 3. - P. 260-270.

88. Kyriakidis M. K., Kourouklis S. V., Papaioannoi J. T. et al. Sinus node coronary arteries stu dies with angiography // Amer. J. Cardiol. - 1983. - Vol. 51. - P. 749.

89. La Porta A., Suy-Verburg R. et al. The spectrum of clinical manifestations of anomalous ori gin of the left coronary artery and surgical management // J. Pediat. Surg. - 1979. - Vol. 14, No. 3. - P. 225-227.

90. Levin D. C. Pathways and functional significance of the coronary collateral circulation // Circulation. - 1974. - Vol. 50.-P. 831-837.

91. Levin D. C, Beckman C F., Garnic J. D. et al. Frequency and clinical significance of failure to visualize the conus artery during coronary arteriography // Ibid. - 1981. - Vol. 63.-P. 833.

92. Levin D. C, Gardiner G. A. Coronary arteriography. In heart disease. - Third edition / Ed. E. Braunwald. - W. B. Saunders Co, Philadelphia, 1988. - P. 268-310.

93. Levin D. C, Harrington D. P., Bettmann M. H. et al. Anatomic variations of the coronary arteries supplying the anterolateral aspect of the left ventricle. Possible explanation for the "unexplained" anterior aneurysm // Invest. Radiol. - 1982. - Vol. 17. - P. 458.

94. Lower R. Tractatus de Corde. - Amsterdam: Elsevier, 1669.

95. MacAlpin R. N., Abbasi A. S., Grollman J. H., Eber L. Human coronary artery size during life. A cinearteriographic study // Radiology. - 1973. - Vol. 108, No. 3. - P. 567-576.

96. Mansaray M., Hynd J. W., Vergroesen J. et al. Measurment of coronary collateral flow and resistance in the presence of an open critical stenoses, and the response to intra-arterial thrombosis // Cardiovasc. Res. - 2000. - Vol. 47, No. 2. - P. 359-366.

	Marcelletti C. Surgery and coronary arteries at	risk // Pediatric Cardiology. 3./eds
	A. E. Becker, T. G. Losekoof, C Marcelletti,	R. H. Anderson. - Edinburgh: Churchill
	Livingstone, 1981. - P. 290-297.
	May A. M. Surgical anatomy of the coronary arteries // Dis. Chest. - 1960. - Vol. 38.

P. 645-657.

99. M with Alpine W. A. Heart and coronary arteries. An anatomical atlas for clinical diagnosis, radiological investigation, and surgical treatment. - Berlin: Heidelberg; New York: Springer-Verlag, 1975.

100. McAlpine W. A. In Heart and coronary arteries. Section II: The normal heart. - Berlin: Heidelberg; New York: Springer, 1975. - P. 20-24.

101. McGoon D. C, Baird D. K., Davis G. D. Surgical management of large bronchial collateral arteries with pulmonary stenosis or atresia // Circulation. - 1975. - Vol. 52. - P. 109.

102. Miller D. C, Schapira J. N., Stinson E. B., Shumway N. E. Left ventricular-coronary sinus fis tula following repeated mitral valve replacement // J. Thorac. Cardiovasc. Surg. - 1978.

Vol. 76, No. 1. - P. 43-45.

103. Moberg A. Anastomoses between extracardiac vessel and the coronary arteries // Acta Med. Scand. - 1968. - Vol. 485 (Suppl.). - P. 5-25.

104. Moran J. M., Michaelis L. L., Sanders J. H., Robert A. J. Separate origin of the first septal branch of left anterior descending coronary artery // J. Cardiovasc. Surg. - 1979. - Vol. 20, No. 6. -P. 621.

105. Nathan H., Orda R., Barkay M. The right bronchial artery. Anatomical considerations and surgical approach. - 1970.

106. Neiman J., Ethevenot G., Guilliere M., Cherrier F. Variations de distribution des arteres coronaries (a propos de 3000 coronarographies) // Bull. Ass. Anat. - 1976. - Vol. 60, no. 176.

P. 769-778.

107. Parker D. L., Pope D. L, Van Bree R. E., Marshall H. Three-dimensional reconstruction of moving arterial beds from digital subtraction angiography // Comput. Biomed. Res. - 1987.

Vol. 20. - P. 166-185.