Which arteries supply blood to the heart muscle. Features of the anatomy of the coronary arteries

In embryos at an early stage of development, the walls of the heart are formed by loosely arranged muscle fibers that supply blood from the chambers, like the spongy subendocardium in adult frogs. As the embryo grows, the walls of the heart thicken, the muscle layers are more compact. Intramural coronary arteries, capillaries, and veins are formed from intramuscular sinusoids to supply the metabolically active myocardium with substrates. Sinusoids form connections with the coronary sinus. Shortly thereafter, around day 44 of gestation, extramural vessels begin to develop from the base of the aorta, protruding toward the apex of the heart. They develop penetrating branches that enter the myocardium and connect with the primitive system of sinusoids. The same rudiments are laid at the base of the pulmonary artery.

Accessory coronary arteries

These coronary arteries are typical branches coronary arteries, departing by an independent mouth from the sinuses of Valsalva, therefore only their mouth is additional. The most common pathology of the right coronary artery. The presence of 2 to 5 additional orifices in the right coronary sinus is described. Its first branch - the artery of the cone - in 50% of patients departs in the form of an independent artery from the right sinus of Valsalva. In this case, it is called the right accessory coronary artery.

1% healthy people and more often with a bicuspid aortic valve, the anterior descending artery and the circumflex branch of the left coronary artery depart as independent mouths from the left sinus. The anterior descending artery can depart by an independent mouth from the right sinus. The first branch of the penetrating coronary artery can depart from the left coronary sinus by a separate mouth.

None of these variants of coronary artery anatomy has clinical consequences and is not included in the list of coronary artery anomalies.

Stenosis and atresia of the mouth of the coronary artery

This rare congenital anomaly often affects the left coronary artery. It may be the result of:

intrauterine inflammation;

fibromuscular dysplasia;

congenital malformation.

The absence of the extramural part of the coronary artery is more often observed in pulmonary atresia with an intact interventricular septum and in aortic atresia. The pressure in small and sharply hypertrophied right or left ventricles exceeds the pressure in the aorta. Coronary blood circulation is carried out through expanded sinusoids that have a connection with the coronary arteries. El-Said et al described atresia of the left coronary artery in a 14-year-old boy who complained of heart pain, exercise fatigue, and syncope. He listened systolic murmur at the apex, the ECG periodically recorded ventricular extrasystoles, with bicycle ergometry, a shift of the ST segment below the isoline by 3 mm was noted. Coronary angiography revealed retrograde filling of the left coronary artery through collaterals. The authors performed aorto coronary artery bypass surgery using v. saphena. similarity clinical symptoms and ECG data in such patients with endocardial fibroelastosis is the reason for the diagnosis of isolated fibroelastosis or abnormal origin of the left coronary artery from pulmonary trunk. Molander described the case history of a 19-year-old boy who, from the age of 4, was observed for insufficiency mitral valve. Catheterization did not shed light on the etiology of the disease. The patient died suddenly. Autopsy revealed old and recent myocardial infarction and severe stenosis of the left coronary artery.

Tangential origin of the coronary arteries from the aorta

Normally, the coronary arteries depart from the aorta at a right angle. Witat et al analyzed 22 sudden adult deaths. In 10 of them, the right coronary artery and in 3, both coronary arteries departed from the aorta along a tangent, at an angle of less than 450 between the coronary artery and the aortic wall. The mouth of the affected artery was in the form of a gap, and in 9 people the mouth was partially covered by a protruding ridge like a valve. Other reports of ischemia or death from intramural origin of the coronary arteries suggest that this anomaly is not uncommon. Sudden deaths have been described in adults, but a 5-month-old infant has been reported to have died from this cause.

If this anomaly is detected during echocardiography or coronary angiography, it is necessary to take surgical intervention.

Abnormal path of the coronary artery between the aorta and the pulmonary artery

One of the coronary arteries may pass between the aorta and the pulmonary trunk with normal origin from various sinuses. The unnatural path of the artery is also found in various variants of the origin of the coronary arteries:

the only coronary artery arising from the right aortic sinus and the left main coronary artery or anterior descending artery passing between main arteries;

the only coronary artery extending from the left sinus of the aorta and the right coronary artery, passing between the main arteries.

When the mouths of both coronary arteries are in the same sinus, the mouth of the abnormal artery may have a slit-like shape.

The artery passing between the aorta and the pulmonary trunk can be infringed by the myocardium, especially during exercise, and cause sudden death. Patients are often asymptomatic until fainting occurs. frequency and natural flow abnormal arrangement of the coronary arteries between main vessels not studied. All patients with anginal pain and fainting spells coronary angiography is indicated and, if this pathology is detected, surgical intervention.

If there are two ostia in the same sinus, the operation involves the expansion and remodeling of the abnormal ostium to eliminate compression between the main arteries. In this case, shunting may be ineffective due to competing blood flow from the aorta and reduced blood flow through the anastomosis, followed by thrombosis. However, if there is only one coronary artery and the passage of the left main or right coronary artery between large vessels, the elimination of obstruction by reimplantation or remodeling of the orifice may not be possible, so bypass becomes the only choice.

Operation technique

After studying the anatomy and starting cardiopulmonary bypass, the aorta is clamped, the heart is relaxed, and the aorta is opened by a transverse incision. The orifice of the anomalous coronary artery is slit-like and narrow. Since the orifice may be located in close proximity to the commissure, it must be separated from the aortic wall. The orifice is cut along the long axis of the coronary artery and a part of the common wall between the aorta and the artery is cut. The artery is anastomosed to the aorta with 7/0 or 8/0 prolene. The aortic valve commissure is sutured into place with spacers. The aortic incision is sutured, the clamp is removed from the aorta after air is removed from the heart cavities. The operation is completed in the standard way.

Abnormal origin of the left coronary artery and its branches from the right sinus of Valsalva

Among all anomalies of the coronary arteries, the most common is the departure of the left circumflex coronary artery from the right coronary artery. The circumflex artery passes behind the aorta and reaches its normal area of blood supply. This anomaly does not clinical significance, however, it can be squeezed with double prosthetic mitral and aortic valves. This artery is characterized by a high probability of being affected by atherosclerotic plaques.

Significantly less common among the anomalies of the coronary arteries is the departure of the left main coronary artery from the right sinus of Valsalva. There are 4 options for the passage of this artery:

behind the aorta;

in front of the excretory tract of the right ventricle;

in the thickness of the interventricular septum below the conical part of the right ventricle;

between the aorta and the right ventricular outflow tract.

With the exception of the two described cases, the first three routes are not accompanied by sudden death or premature myocardial ischemia. The passage of a coronary artery between two main arteries often leads to sudden death in childhood and in adults during or immediately after heavy exercise, since under these conditions the increase in pressure in the aorta and pulmonary artery increases the compression of the left coronary artery up to its occlusion. Preceding signs are dizziness and pain in the heart during physical exertion. At autopsy, in most cases, a slit-like orifice of the left main coronary artery was found, its origin from the aorta at an acute angle and its increment to the aortic wall for about 1.5 cm.

In some patients, the anterior descending coronary artery arises from the right coronary sinus of Valsalva or from the right main coronary artery. This anomaly is rare in the absence of congenital heart disease, but is often seen in tetralogy of Fallot. The artery usually passes along the anterior surface of the right ventricular outflow tract or in the thickness of the interventricular septum and rarely between the aorta and the right ventricular outflow tract. Sometimes near the mouth common artery an atheromatous plaque is located, so most of the heart is in a state of ischemia, as in stenosis of the main left coronary artery.

Origin of the right coronary artery or its branches from the left sinus of Valsalva

Departure of the right main coronary artery from the left sinus of Valsalva accounts for 30% of all anomalies of the coronary arteries. The artery follows between the aorta and the outflow tract of the right ventricle, then passes in the atrioventricular sulcus and branches normally. This option is considered relatively benign, but there are many reports of myocardial ischemia, infarction and sudden death. AT clinical picture pain in the heart, arrhythmia at rest or during exercise predominate. During pathological anatomical studies, the right coronary artery often departed at an angle to the aorta, and the mouth had a slit-like shape.

Anomalies of the coronary vessels associated with CHD

With various heart defects, a certain set of anomalies of the coronary arteries sometimes occurs. Below is a brief description of this pathology.

Tetralogy of Fallot

About 40% of patients have an unusually long, large conus artery that supplies a significant mass of the myocardium. In 4-5% of cases, the anterior interventricular branch departs from the right coronary artery and crosses the outflow tract of the right ventricle. Sometimes there is a single coronary artery arising from the right or left sinus. Its large branches may cross the anterior surface of the right ventricle or pass behind the aorta outside the ventricular outflow tract. Other, rare branching options are also possible. The main left coronary artery occasionally passes anterior to the pulmonary artery.

If a large artery crosses the right ventricular outflow tract, repair of the defect becomes more difficult. To prevent the intersection of the artery and infarction in the area of its blood supply, surgeons use various techniques:

parallel to the course of the artery incision of the right ventricle;

incisions above and below the artery;

creation of a tunnel under the artery;

bypassing the narrowed area with an external conduit.

The use of these methods does not guarantee the creation of a free outlet to the pulmonary artery. In young children, unfavorable anatomy of the coronary arteries may influence the choice of palliative surgery.

Abnormal passage of the coronary arteries may be suspected by echocardiography and angiography of the aortic root. Although the surgeon sees the coronary arteries during surgery, it is important to establish accurate diagnosis before the intervention, in order to eliminate the surprise factor and plan an adequate operation in advance. In addition, if the patient has epicardial adhesions from a previous operation, or if the artery passes through the myocardium, it cannot be seen during the operation, so it can be severely severed. In this regard, in all patients who have previously undergone intrapericardial interventions, it is worth performing angiography of the aortic root. In practice, there have been episodes of intersection of a significant coronary artery, which required shunting of the internal mammary artery.

Full TMA

With this defect, the mutual orientation of the aorta and the main pulmonary artery differs from the norm, the aortic sinuses are also located unusually. The left sinus facing the pulmonary artery is called the left sinus presenting, even if it is anterior, and the right sinus is called the right sinus presenting, even if it is posterior.

The coronary arteries arise predominantly from the adjacent sinuses. In 60% of cases, they depart from their own sinuses and branch normally when the aorta is located in front and somewhat to the right of the pulmonary artery. But since the aorta is located in front, the left main and circumflex arteries pass in front of the outflow tract of the right ventricle.

In 60% of patients, the right coronary artery departs from the posterior sinus, in 20%, the right coronary artery departs from the posterior sinus with simultaneous independent discharge of the anterior descending branch from the left sinus. Other anatomical variants are less common. In 8% of cases, a single coronary artery is observed, which departs from the right adjacent sinus and then follows posteriorly to the pulmonary trunk, or departs from the left adjacent sinus and goes anteriorly to the right ventricular outflow tract. In 5% of cases, both main arteries originate from the same adjacent sinus, usually from the right, and one or both arteries pass intramurally, giving the impression that they originate from different sinuses. There may be other rare variants.

Coronary artery options affect the planning and conduct of surgery arterial switch, since it may be difficult to move the mouths of the coronary arteries into the neoaorta without tension. To solve these problems, various techniques for coronary artery tunneling have been developed.

Corrected TMA

The aorta is located in front and to the left of the pulmonary trunk and both main coronary arteries originate from the adjacent sinuses. The anterior sinus is usually non-coronary. Due to the peculiarities of the anatomy, there is confusion in the issue of naming coronary arteries that do not originate from their sinuses. Some authors describe the coronary vessels as right or left sided, according to the sinuses from which they originate. Others describe arteries by the territory they supply. This terminology is used here.

The left coronary artery supplies the anatomically left ventricle, however, departs from the right adjacent sinus. It passes in front of the pulmonary artery and divides into the left anterior descending and circumflex branches. The latter passes in front of the right atrial appendage in the atrioventricular groove.

The right coronary artery supplies blood to the right ventricle. It originates from the left sinus accumbens and passes in the atrioventricular sulcus in front of the left atrial appendage, continuing as the posterior descending artery. The most common variant is a single coronary artery originating from the right sinus sinus accumbens.

Double inlet left ventricle

With this defect, there is no true interventricular septum and a typical interventricular sulcus. The branches of the coronary arteries that run along the edges of the vestigial outlet chamber are the delimiting rather than the anterior descending arteries, which normally supply the anterior part of the interventricular septum.

When the outlet chamber is located in front and on the right, the relative position of the aorta and pulmonary trunk is the same as with complete transposition. The right coronary artery arises from the right adjacent sinus of the aorta and passes in the right atrioventricular sulcus. The left main coronary artery originates from the left adjacent sinus and follows in the left atrioventricular sulcus as a circumflex artery. The left and right delimiting arteries, respectively, depart from the left and right coronary arteries.

When the outlet chamber is located in front and on the left, the orientation large vessels the same as in corrected transposition. The right and left main coronary arteries arise from their own adjacent sinuses, and the anterior descending coronary artery may arise from the left or right coronary arteries, or there may be two delimiting arteries that delimit the vestigial outlet chamber. With any of these options, there may be several large diagonal arterial branches that run parallel to the delimiting branches and cross the right ventricular outflow tract, making it difficult to fix the artificial interventricular septum.

Right ventricle with two outlets

In most forms of this group of anomalies, the coronary arteries usually originate normally, except that due to the clockwise rotation of the aortic sinuses, the right coronary artery arises anteriorly and the left coronary artery arises posteriorly. When the aorta is located anteriorly and to the right, the anatomy of the coronary arteries is the same as in complete transposition, i.e. the right coronary artery arises from the right adjacent sinus. In 15% of cases, there may be a single coronary artery originating anteriorly or posteriorly. Sometimes the left anterior descending artery arises from the right coronary artery and crosses the right ventricular outflow tract, as in tetralogy of Fallot. When the aorta is located on the left, the right coronary artery flows to the right from the anterior sinus of the aorta anterior to the pulmonary artery until it reaches the atrioventricular sulcus.

common truncus arteriosus

The right and left coronary arteries arise normally from their sinuses. If the valve has more than three leaflets, the usual description has to be abandoned. The most constant is the departure of the left main coronary artery from the posterior sinus. From a surgical point of view, options such as an unusually high and close location of orifices or a single orifice are important. Large diagonal branches of the right coronary artery can cross the anterior surface of the right ventricle and supply the interventricular septum, and even part of the free wall of the left ventricle. Crossing these arteries can lead to severe myocardial damage, heart failure, and death.

single coronary artery

The only coronary artery was first described by Tebesi in 1716, followed by Hyrtl in 1841. As an isolated defect, this anomaly is extremely rare - 1 case in 2000-7000 of all coronary angiography performed, somewhat more often among males. Smith proposed the following classification of this anomaly:

The only coronary artery that is a variant of the normal left or right coronary artery.

The only coronary artery from which the normal left and right arteries originate.

The only coronary artery with a circumflex location that differs from its normal location.

The trunk of a single coronary artery or its main branch can be located behind the aorta, between it and the pulmonary trunk, or pass in front of the trunk of the pulmonary artery. In the latter case, the anomaly is of particular danger, especially in Fallot's tetrad or other defects, accompanied by narrowing of the right ventricular outflow tract, requiring its plastic surgery. Anomalies of the right coronary artery are more common than those of the left. An isolated defect in the form of a single coronary artery can sometimes cause sudden death, ischemia, or myocardial infarction, especially when the left or right artery departs from common trunk or they jointly pass between the aorta and the trunk of the pulmonary artery.

A single coronary artery may be present with a bicuspid aortic valve or be associated with complex heart defects. It occurs most frequently in tetralogy of Fallot, tetralogy of Fallot with pulmonary atresia, TMA, right ventricle with two outlets, left ventricle with two outlets, truncus arteriosus, single/common ventricle, ASD with pulmonary stenosis, heterotaxy.

Quite often, a single coronary artery is found in patients with Fallot's tetralogy. It occurs in 5% of children with TMA; in this case, the artery departs from the posterior sinus and is divided into two normal coronary arteries: the right and left.

The most favorable anomaly of the coronary arteries is the origin of both arteries by a separate or common mouth from one sinus of Valsalva. A normal origin of one coronary artery from the aorta with a branch of the left coronary artery was also noted. Complete absence one of the coronary arteries is an extremely rare anomaly. In this case, the existing coronary artery independently provides coronary circulation. There are many reports in the literature of cases of a single coronary artery, usually associated with another congenital pathology of the heart, as well as cases of a single coronary artery with normal heart morphology.

Intramural passage of the coronary artery

In some cases, the initial section of the left coronary artery, extending from the right aortic sinus, is located in the thickness of the aortic wall. At histological examination the vessels have a single middle shell, it is common to the aorta and coronary artery. This anatomical variant of the location of the coronary artery is sometimes the cause of sudden death. When expanding during systole, the fibrous-rich ascending aorta causes compression of the intramural segment of the left coronary artery, which leads to myocardial ischemia. The treatment of this syndrome consists in surgical plasty of the coronary artery with the isolation of this segment from the aortic wall or in the imposition of a shunt to bypass the intramural segment.

The intramural location of the coronary artery in a child with TMA requires more complex surgical technique during the anatomical correction of this defect.

"Diving Arteries"

Large epicardial coronary arteries normally pass along the surface and only their terminal branches penetrate into the thickness of the myocardium. In 50% of people, the coronary arteries in some places sink into the thickness of the myocardium, and then reappear on its surface. In these cases, a muscular bridge is formed over a large coronary artery. More often "mural" is the left anterior descending branch in its proximal half. This anomaly is found in both infants and the elderly. At the age of up to 20 years, the length of the immersed part is on average 14 mm, at an older age - 20-30 mm. In about 75% of cases, the anterior descending coronary artery passes in the interventricular sulcus and may be covered by several superficial bridges of muscle fibers; in 25%, the anterior interventricular artery deviates towards the right ventricle and passes deep into the interventricular septum, where it is crossed by a muscle bundle emanating from apex of the right ventricle.

Most muscle bridges do not have functional value especially if they are superficial. However, cases are described when, during exercise, the submerged part of the coronary artery narrows, which causes acute coronary insufficiency and sudden death, including in patients after myotomy.

During coronary angiography, it is seen that part of the coronary artery is narrowed in systole, but well passable in diastole. In the presence of pain, careful release of the coronary artery from the muscle tunnel is indicated. Surgery is indicated if there is objective evidence of ischemia on the electrocardiogram and an increase in lactate production in the regional vein. Ischemia usually occurs when there is a long, thick muscle bridge that occludes the artery and relaxes unusually slowly, so diastolic filling of the distal coronary artery is impaired. After performing a thorough myotomy pain syndrome and signs of ischemia disappear.

In children, "diving" coronary arteries are rare and only in cases of ventricular hypertrophy, especially in hypertrophic cardiomyopathy.

Aneurysm of the coronary artery

It was first described in 1812. It belongs to extremely rare anomalies. Only one in five coronary artery aneurysms are congenital. Acquired aneurysm can occur in children due to Kawasaki disease, previous endocarditis, nodular coronaritis, and in adults - as a result of the development of atherosclerosis, syphilitic lesions of the coronary arteries, or against the background of a congenital coronary artery fistula. An aneurysm of a coronary artery can also form as a result of myocardial infarction. congenital aneurysm occurs due to a violation of the structure of the mesothelium of the vessel or a deficiency of normal protein fibers of the connective tissue. Both the right and left coronary arteries can be subjected to aneurysmal expansion, in very rare cases both arteries can be affected, and multiple aneurysms of the coronary arteries are even more rarely diagnosed. A combined defect in the form of TMA with an aneurysm of the coronary arteries has been described. All types of aneurysms of the coronary arteries can either be asymptomatic until they rupture, or lead to the development of ischemia or myocardial infarction. Cases of thrombosis of an aneurysm of a coronary artery are described.

Surgery

Indications for surgery are signs of myocardial ischemia or accidental detection of an aneurysm large sizes. The operation consists in resection of the aneurysm and the imposition of a coronary artery bypass graft or ligation of the aneurysm in its initial and final sections with the imposition of a coronary artery bypass graft below the aneurysm. Indications for surgical intervention can occur in both congenital and acquired aneurysms of the coronary artery. An aneurysm due to Kawasaki disease rarely requires surgical intervention, except in cases of threatened aneurysm rupture or thrombosis.

The heart is muscular organ, which provides blood circulation in the body on the principle of a pump. The heart is provided with autonomous innervation, which determines the involuntary, rhythmic work of the muscle layer of the organ - the myocardium. In addition to nerve structures, the heart also has its own blood supply system.

Most of us know that the human cardiovascular system consists of two main circles of blood circulation: large and small. However, specialists in cardiology consider the vascular system that feeds the tissues of the heart as a third or coronary circle of blood circulation.

If we consider a three-dimensional model of the heart with the vessels that feed it, we can see that a network of arteries and veins surrounds the heart like a wreath or crown. Hence the name of this circulatory system - the coronary or coronary circle.

The coronary circle of hemocirculation is made up of vessels, the structure of which does not fundamentally differ from other vessels of the body. The vessels that carry oxygenated blood to the myocardium are called coronary arteries. Vessels that provide outflow of deoxygenated, i.e. venous blood are the coronary veins. About 10% of all blood passing through the aorta enters the coronary vessels. The anatomy of the vessels of the coronary circle of hemocirculation is different for each person and is individual.

Schematically, the coronary circulation can be expressed as follows: aorta - coronary arteries - arterioles - capillaries - venules - coronary veins - right atrium.

Consider the scheme of hemocirculation in the coronary circle in stages.

arteries

The coronary arteries branch off from the so-called sinuses of Valsalva. This is the dilated portion of the aortic root just above the valve.

The sinuses are named according to the arteries coming out of them, i.e. right sinus gives rise right artery, the left sinus gives rise to the left artery. The right one passes along the coronary sulcus on the right, then stretches back and to the top of the heart. Along the branches extending from this highway, the blood rushes into the thickness of the myocardium of the right ventricle, washes the tissues of the posterior part of the left ventricle and a significant proportion of the cardiac septum.

The left coronary artery, leaving the aorta, is divided into 2, and sometimes 3 or 4 vessels. One of them - ascending, passes along the groove that separates the ventricles, in front. Multiple small vessels, extending from this branch, provide blood flow to the anterior walls of both ventricles. Another vessel, descending, passes along the coronal sulcus on the left. This highway carries enriched blood to the tissues of the atrium and ventricle on the left.

Further, the artery goes around the heart on the left and rushes to its apex, where it forms an anastomosis - the fusion of the right cardiac artery and the descending branch of the left. In the course of the descending anterior artery, smaller vessels branch off, providing blood to the anterior region of the myocardium of the left and right ventricles.

4% of the population has a third coronary artery. An even rarer case is when a person has only one heart artery.

Feedback from our reader - Alina Mezentseva

I recently read an article that talks about the natural cream "Bee Spas Chestnut" for the treatment of varicose veins and cleaning blood vessels from blood clots. With the help of this cream, you can FOREVER cure VARICOSIS, eliminate pain, improve blood circulation, increase the tone of the veins, quickly restore the walls of blood vessels, clean and restore varicose veins at home.

I was not used to trusting any information, but I decided to check and ordered one package. I noticed the changes in a week: the pain went away, the legs stopped "buzzing" and swelling, and after 2 weeks the venous cones began to decrease. Try it and you, and if anyone is interested, then below is a link to the article.

Also sometimes there is a doubling of the cardiac arterial trunks. In this case, instead of one truncus arteriosus two parallel vessels run to the heart.

The coronary arteries are characterized by partial autonomy, expressed in the fact that they are able to independently maintain the required level of blood flow in the myocardium. This functional feature of the coronary arteries is extremely important, because. The heart is an organ that works constantly, continuously. That is why a violation of the state of the heart arteries (atherosclerosis, stenosis) can lead to fatal consequences.

Vienna

"Spent", i.e. saturated with carbon dioxide and other products of tissue metabolism, blood from the tissues of the heart drains into the coronary veins.

The large coronary vein begins at the apex of the heart, runs along the anterior (ventral) interventricular sulcus, turns left along the coronary sulcus, rushes back and flows into the coronary sinus.

This is a venous structure, about 3 cm in size, located on the posterior (dorsal) part of the heart in the coronary sulcus, has an outlet in the cavity of the right atrium, the mouth does not exceed 12 mm in diameter. The structure is considered to be part of a large vein.

Medium coronary vein exits at the apex of the heart, next to big vein, but runs along the dorsal interventricular sulcus. The middle vein also empties into the coronary sinus.

For the treatment of VARICOSE and cleaning blood vessels from blood clots, Elena Malysheva recommends new method Based on Cream of Varicose Veins. It contains 8 useful medicinal plants that are extremely effective in the treatment of VARICOSIS. In this case, only natural ingredients, no chemicals and hormones!

The small coronary vein is located in the groove separating the right ventricle and atrium from each other, usually passes into the middle vein, and sometimes directly into the coronary sinus.

The oblique cardiac vein collects blood from posterior region left atrial myocardium. Through the posterior vein, venous blood flows from the tissues of the posterior wall of the left ventricle. These are small vessels that also empty into the coronary sinus.

There are also anterior and small cardiac veins, which have independent exits into the cavity of the right atrium. The anterior veins carry out the outflow of venous blood from the thickness of the muscular layer of the right ventricle. The small veins drain blood from the intracavitary tissues of the heart.

Blood flow rate

As mentioned above, coronary vessels have individual anatomical features for each person. The limits of the norm are quite wide, if we are not talking about serious anomalies of the structure, when the vital activity of the heart suffers to a large extent.

In cardiology, there is such a thing as blood flow dominance, an indicator that determines which arteries give off the posterior descending (or interventricular) artery.

If the supply of the posterior interventricular branch occurs due to the right and one of the branches of the left arteries, they speak of codominance - 20% of the population is typical. In this case, it happens uniform nutrition myocardium. The most common right type of dominance is inherent in 70% of the population.

In this variant, the dorsal descending artery arises from the right coronary artery. Only 10% of the population has a left type of blood flow dominance. In this case, the posterior descending artery branches off from one of the branches of the left coronary artery. With right and left dominance of blood flow, uneven blood supply to the heart muscle occurs.

The intensity of cardiac blood flow is unstable. So, at rest, the blood flow rate is 60-70 mg/min per 100 g of myocardium. During load, the speed increases by 4 - 5 times and depends on general condition heart muscle, the degree of its endurance, the frequency of heart contractions, the features of the functioning of the nervous system of a given person, aortic pressure.

Interestingly, during systolic contraction of the myocardium, the movement of blood in the heart practically stops. This is a consequence of powerful compression of all vessels muscle layer hearts. With diastolic relaxation of the myocardium, blood flow in the vessels resumes.

The heart is a unique organ. Its uniqueness lies in the almost complete autonomy of its work. So, the heart has not only individual system hemocirculation, but also its own nerve structures that set the rhythm of its contractions. Therefore, it is necessary to create conditions for maintaining the health of all systems that ensure the full functioning of this important organ.

DO YOU STILL THINK IT IS IMPOSSIBLE TO GET RID OF VARICOSIS!?

Have you ever tried to get rid of VARICOSIS? Judging by the fact that you are reading this article, the victory was not on your side. And of course, you know firsthand what it is:

feeling of heaviness in the legs, tingling ...
swelling of the legs, worse in the evening, swollen veins...
bumps on the veins of the arms and legs ...

Now answer the question: does it suit you? Can ALL THESE SYMPTOMS be tolerated? And how much effort, money and time have you already "leaked" for ineffective treatment? After all, sooner or later the SITUATION WILL AGAIN and the only way out There will only be surgery!

That's right - it's time to start ending this problem! Do you agree? That is why we decided to publish an exclusive interview with the head of the Institute of Phlebology of the Ministry of Health of the Russian Federation - V. M. Semenov, in which he revealed the secret of a penny method of treating varicose veins and complete restoration of blood vessels. Read interview...

Read:

The widespread use of selective coronary angiography and surgical interventions on the coronary arteries of the heart in recent years has made it possible to study the anatomical features coronary circulation living person, to develop a functional anatomy of the arteries of the heart in relation to revascularization operations in patients with coronary heart disease.

Interventions on the coronary arteries for diagnostic and therapeutic purposes place increased demands on the study of vessels on different levels taking into account their variants, developmental anomalies, caliber, angles of departure, possible collateral connections, as well as their projections and relationships with surrounding formations.

When organizing this data, we Special attention drew on information from the surgical anatomy of the coronary arteries, based on the principle of topographic anatomy in relation to the operation plan with the division of the coronary arteries of the heart into segments.

The right and left coronary arteries were conditionally divided into three and seven segments, respectively (Fig. 51).

Three segments were distinguished in the right coronary artery: I - a segment of the artery from the mouth to the outlet of the branch - the artery of the sharp edge of the heart (length from 2 to 3.5 cm); II - section of the artery from the branch of the sharp edge of the heart to the discharge of the posterior interventricular branch of the right coronary artery (length 2.2-3.8 cm); III - posterior interventricular branch of the right coronary artery.

The initial section of the left coronary artery from the mouth to the place of division into the main branches is designated as segment I (length from 0.7 to 1.8 cm). The first 4 cm of the anterior interventricular branch of the left coronary artery is divided

Rice. 51. Segmental division of the coronary

heart arteries:

BUT- right coronary artery; B- left coronary artery

into two segments of 2 cm each - II and III segments. The distal portion of the anterior interventricular branch was segment IV. The circumflex branch of the left coronary artery to the point of origin of the branch of the blunt edge of the heart is the V segment (length 1.8-2.6 cm). The distal section of the circumflex branch of the left coronary artery was more often represented by the artery of the obtuse margin of the heart - segment VI. And, finally, the diagonal branch of the left coronary artery is the VII segment.

The use of segmental division of the coronary arteries, as our experience has shown, is advisable in a comparative study of the surgical anatomy of the coronary circulation according to selective coronary angiography and surgical interventions, to determine the localization and spread of the pathological process in the arteries of the heart, has practical value when choosing a method of surgical intervention in case of coronary heart disease.

Rice. 52. Right-wing type of coronary circulation. Well developed rear interventricular branches

Beginning of the coronary arteries . Sinuses of the aorta, from which the coronary arteries depart, James (1961) proposes to call the right and left coronary sinus. The orifices of the coronary arteries are located in the bulb of the ascending aorta at the level of the free edges of the aortic semilunar valves or 2-3 cm above or below them (V. V. Kovanov and T. I. Anikina, 1974).

The topography of the sections of the coronary arteries, as A. S. Zolotukhin (1974) points out, is different and depends on the structure of the heart and chest. According to M. A. Tikhomirov (1899), the orifices of the coronary arteries in the aortic sinuses can be located below the free edge of the valves "abnormally low", so that the semilunar valves pressed against the wall of the aorta close the orifices, either at the level of the free edge of the valves, or above them, by wall of the ascending aorta.

The level of the location of the mouths is of practical importance. With a high location at the time of left ventricular systole, the orifice is

under the blow of a stream of blood, not being covered by the edge of the semilunar valve. According to A. V. Smolyannikov and T. A. Naddachina (1964), this may be one of the reasons for the development of coronary sclerosis.

The right coronary artery in most patients has a main type of division and plays important role in the vascularization of the heart, especially its posterior diaphragmatic surface. In 25% of patients in the blood supply to the myocardium, we revealed the predominance of the right coronary artery (Fig. 52). N. A. Javakhshivili and M. G. Komakhidze (1963) describe the beginning of the right coronary artery in the region of the anterior right sinus of the aorta, indicating that its high discharge is rarely observed. The artery enters the coronary sulcus, located behind the base of the pulmonary artery and under the auricle of the right atrium. The section of the artery from the aorta to the sharp edge of the heart (segment I of the artery) is adjacent to the wall of the heart and is completely covered by subepicardial fat. The diameter of segment I of the right coronary artery ranges from 2.1 to 7 mm. Along the artery trunk on the anterior surface of the heart in the coronary sulcus, epicardial folds are formed, filled with adipose tissue. Abundantly developed adipose tissue noted along the artery from the sharp edge of the heart. The atherosclerotically altered trunk of the artery along this length is well palpated in the form of a cord. Detection and isolation of segment I of the right coronary artery on the anterior surface of the heart is usually not difficult.

The first branch of the right coronary artery - the artery of the arterial cone, or the fatty artery - departs directly at the beginning of the coronary sulcus, continuing down to the right at the arterial cone, giving branches to the cone and the wall of the pulmonary trunk. In 25.6% of patients, we observed its common beginning with the right coronary artery, its mouth was located at the mouth of the right coronary artery. In 18.9% of patients, the mouth of the conus artery was located next to the mouth of the coronary artery, located behind the latter. In these cases, the vessel originated directly from the ascending aorta and was only slightly inferior in size to the trunk of the right coronary artery.

Muscular branches depart from the I segment of the right coronary artery to the right ventricle of the heart. Vessels in the amount of 2-3 are located closer to the epicardium in connective tissue couplings on the layer of adipose tissue covering the epicardium.

The other most significant and permanent branch of the right coronary artery is the right marginal artery (a branch of the sharp edge of the heart). The artery of the acute edge of the heart, a permanent branch of the right coronary artery, departs in the region of the acute edge of the heart and descends along the lateral surface of the heart to its apex. It supplies blood to the anterior-lateral wall of the right ventricle, and sometimes to the diaphragmatic part of it. In some patients, the diameter of the lumen of the artery was about 3 mm, but more often it was 1 mm or less.

Continuing along the coronary sulcus, the right coronary artery goes around the sharp edge of the heart, passes to the posterior diaphragmatic surface of the heart and ends to the left of the posterior interventricular sulcus, not reaching the blunt edge of the heart (in 64% of patients).

The final branch of the right coronary artery - the posterior interventricular branch (III segment) - is located in the posterior interventricular groove, descending along it to the apex of the heart. V. V. Kovanov and T. I. Anikina (1974) distinguish three variants of its distribution: 1) in the upper part of the furrow of the same name; 2) throughout this groove to the top of the heart; 3) the posterior interventricular branch enters the anterior surface of the heart. According to our data, only in 14% of patients it reached

apex of the heart, anastomosing with the anterior interventricular branch of the left coronary artery.

From the posterior interventricular branch into the interventricular septum at right angles, from 4 to 6 branches depart, supplying blood to the conducting system of the heart.

With a right-sided type of coronary blood supply to the diaphragmatic surface of the heart, 2-3 muscular branches extend from the right coronary artery, running parallel to the posterior interventricular branch of the right coronary artery.

To access the II and III segments of the right coronary artery, it is necessary to lift the heart up and take it to the left. II segment of the artery is located superficially in the coronary sulcus; it can be easily and quickly found and selected. The posterior interventricular branch (III segment) is located deep in the interventricular groove and is covered by subepicardial fat. When performing operations on the II segment of the right coronary artery, it must be remembered that the wall of the right ventricle in this place is very thin. Therefore, it should be handled carefully to avoid perforation.

The left coronary artery, participating in the blood supply to most of the left ventricle, the interventricular septum, as well as the anterior surface of the right ventricle, dominates the blood supply to the heart in 20.8% of patients. Starting in the left sinus of Valsalva, it goes from the ascending aorta to the left and down the coronary sulcus of the heart. The initial section of the left coronary artery (I segment) before the bifurcation has a length of at least 8 mm and not more than 18 mm. Isolation of the main trunk of the left coronary artery is difficult, since it is hidden by the root of the pulmonary artery.

The short trunk of the left coronary artery, 3.5 to 7.5 mm in diameter, turns to the left between the pulmonary artery and the base of the left auricle of the heart and divides into the anterior interventricular and circumflex branches. (II, III, IV segments of the left coronary artery) is located in the anterior interventricular groove of the heart, along which it goes to the apex of the heart. It can end at the apex of the heart, but usually (according to our observations, in 80% of patients) it continues on the diaphragmatic surface of the heart, where it meets the terminal branches of the posterior interventricular branch of the right coronary artery and participates in the vascularization of the diaphragmatic surface of the heart. The diameter of segment II of the artery ranges from 2 to 4.5 mm.

It should be noted that a significant part of the anterior interventricular branch (segments II and III) lies deep, covered by subepicardial fat and muscle bridges. The isolation of the artery in this place requires great care because of the danger of possible damage to its muscular and, most importantly, septal branches leading to the interventricular septum. The distal part of the artery (IV segment) is usually located superficially, clearly visible under thin layer subepi-cardiac tissue and is easily allocated.

From the II segment of the left coronary artery, from 2 to 4 septal branches extend deep into the myocardium, which are involved in the vascularization of the interventricular septum of the heart.

Throughout the anterior interventricular branch of the left coronary artery, 4-8 muscle branches depart to the myocardium of the left and right ventricles. The branches to the right ventricle are smaller in caliber than to the left, although they are the same in size as the muscular branches from the right coronary artery. Much more branches departs to the anterior-lateral wall of the left ventricle. In functional terms, the diagonal branches are especially important (there are 2 of them, sometimes 3), extending from the II and III segments of the left coronary artery.

When searching for and isolating the anterior interventricular branch, an important reference point is the large vein of the heart, which is located in the anterior interventricular groove to the right of the artery and is easily found under a thin layer of the epicardium.

The circumflex branch of the left coronary artery (V-VI segments) departs at a right angle to the main trunk of the left coronary artery, located in the left coronary sulcus, under the left auricle of the heart. Its permanent branch - the branch of the blunt edge of the heart - descends over a considerable distance at the left edge of the heart, somewhat backwards, and in 47.2% of patients reaches the apex of the heart.

After the branches depart to the blunt edge of the heart and the posterior surface of the left ventricle, the circumflex branch of the left coronary artery in 20% of patients continues along the coronary sulcus or along the posterior wall of the left atrium in the form of a thin trunk and reaches the confluence of the inferior posterior vein.

The V segment of the artery is easily detected, which is located in the fatty membrane under the ear of the left atrium and is covered by a large vein of the heart. The latter sometimes has to be crossed to gain access to the trunk of the artery.

The distal section of the circumflex branch (VI segment) is usually located on the posterior surface of the heart and, if necessary, surgical intervention on it, the heart is lifted and retracted to the left while pulling the left ear of the heart.

The diagonal branch of the left coronary artery (VII segment) goes along the anterior surface of the left ventricle down and to the right, then plunging into the myocardium. The diameter of its initial part is from 1 to 3 mm. With a diameter of less than 1 mm, the vessel is little expressed and is more often considered as one of the muscular branches of the anterior interventricular branch of the left coronary artery.

Anatomy of the coronary arteries

coronary arteries

From an anatomical point of view, the coronary artery system is divided into two parts - right and left. From a surgical perspective, the coronary artery is divided into four parts: the left main coronary artery (trunk), the left anterior descending artery or anterior interventricular branch (LAD) and its branches, the left circumflex coronary artery (OC) and its branches, the right coronary artery (RCA) ) and its branches.

The large coronary arteries form an arterial ring and loop around the heart. The left circumflex and right coronary arteries are involved in the formation of the arterial ring, passing through the atrioventricular sulcus. The formation of the arterial loop of the heart involves the anterior descending artery from the system of the left coronary artery and the posterior descending artery from the system of the right coronary artery, or from the system of the left coronary artery - from the left circumflex artery with the left dominant type of blood supply. The arterial ring and loop are a functional device for the development of collateral circulation of the heart.

Right coronary artery

The right coronary artery (right coronary artery) departs from the right sinus of Valsalva and passes in the coronary (atrioventricular) groove. In 50% of cases, immediately at the place of origin, it gives off the first branch - the branch of the arterial cone (conus artery, conus branch, CB), which feeds the infundibulum of the right ventricle. Its second branch is the artery of the sinoatrial node (S-A node artery, SNA). leaving from the right coronary artery back at a right angle into the gap between the aorta and the wall of the right atrium, and then along its wall to the sinoatrial node. As a branch of the right coronary artery, this artery occurs in 59% of cases. In 38% of cases, the artery of the sinoatrial node is a branch of the left circumflex artery. And in 3% of cases there is a blood supply to the sino-atrial node from two arteries (both from the right and from the circumflex). In the anterior part of the coronary sulcus, in the region of the acute edge of the heart, the right marginal branch departs from the right coronary artery (the branch of the acute edge, acute marginal artery, acute marginal branch, AMB), more often from one to three, which in most cases reaches the apex of the heart. Then the artery turns back, lies down in back coronal sulcus and reaches the "cross" of the heart (the intersection of the posterior interventricular and atrioventricular sulci of the heart).

With the so-called right type of blood supply to the heart, observed in 90% of people, the right coronary artery gives off the posterior descending artery (PDA), which runs along the posterior interventricular groove for a different distance, giving branches to the septum (anastomosing with similar branches from the anterior descending artery, the latter usually longer than the first), the right ventricle and branches to the left ventricle. After the posterior descending artery (PDA) originates, the RCA continues beyond the cross of the heart as the right posterior atrioventricular branch along the distal part of the left atrioventricular sulcus, terminating in one or more posterolateral branches feeding the diaphragmatic surface of the left ventricle. . On the posterior surface of the heart, immediately below the bifurcation, at the point of transition of the right coronary artery into the posterior interventricular sulcus, an arterial branch originates from it, which, piercing the interventricular septum, goes to the atrioventricular node - the artery of the atrioventricular node artery (AVN).

Left coronary artery

The left coronary artery (left coronary artery) originates from the left posterior surface of the aortic bulb and exits to left side coronal sulcus. Its main trunk (left main coronary artery, LMCA) is usually short (0-10 mm, diameter varies from 3 to 6 mm) and is divided into anterior interventricular (left anterior descending artery, LAD) and envelope (left circumflex artery, LCx) branches . In 30-37% of cases, the third branch departs here - the intermediate artery (ramus intermedius, RI), which crosses obliquely the wall of the left ventricle. LAD and OB form an angle between them, which varies from 30 to 180°.

Anterior interventricular branch

The anterior interventricular branch is located in the anterior interventricular sulcus and goes to the apex, giving off the anterior ventricular branches (diagonal, diagonal artery, D) and the anterior septal (septal branch)) along the way. In 90% of cases, one to three diagonal branches are determined. Septal branches depart from the anterior interventricular artery at an angle of approximately 90 degrees, perforate the interventricular septum, feeding it. The anterior interventricular branch sometimes enters the thickness of the myocardium and again lies in the groove and often reaches the apex of the heart along it, where in about 78% of people it turns back to the diaphragmatic surface of the heart and for a short distance (10-15 mm) rises up along the posterior interventricular groove. In such cases, it forms a posterior ascending branch. Here it often anastomoses with the terminal branches of the posterior interventricular artery, a branch of the right coronary artery.

circumflex artery

Anatomy of the coronary arteries.

Professor, Dr. med. Sciences Yu.P. Ostrovsky

On the this moment There are many variants of classifications of coronary arteries adopted in different countries and centers of the world. But, in our opinion, there are certain terminological differences between them, which creates difficulties in the interpretation of coronary angiography data by specialists of different profiles.

We have analyzed the literature on the anatomy and classification of the coronary arteries. Data literary sources compared with their own. A working classification of the coronary arteries has been developed in accordance with the nomenclature adopted in the English literature.

coronary arteries

The large coronary arteries form an arterial ring and loop around the heart. The left circumflex and right coronary arteries are involved in the formation of the arterial ring, passing through the atrioventricular sulcus. The formation of the arterial loop of the heart involves the anterior descending artery from the system of the left coronary artery and the posterior descending artery, from the system of the right coronary artery, or from the system of the left coronary artery - from the left circumflex artery with the left dominant type of blood supply. The arterial ring and loop are a functional device for the development of collateral circulation of the heart.

Right coronary artery

Right coronary artery(right coronary artery) departs from the right sinus of Valsalva and passes in the coronary (atrioventricular) groove. In 50% of cases, immediately at the place of origin, it gives off the first branch - the branch of the arterial cone (conus artery, conus branch, CB), which feeds the infundibulum of the right ventricle. Its second branch is the artery of the sinoatrial node (S-A node artery, SNA). leaving the right coronary artery back at a right angle into the gap between the aorta and the wall of the right atrium, and then along its wall to the sinoatrial node. As a branch of the right coronary artery, this artery occurs in 59% of cases. In 38% of cases, the artery of the sinoatrial node is a branch of the left circumflex artery. And in 3% of cases there is a blood supply to the sino-atrial node from two arteries (both from the right and from the circumflex). In the anterior part of the coronary sulcus, in the region of the acute edge of the heart, the right marginal branch departs from the right coronary artery (the branch of the acute edge, acute marginal artery, acute marginal branch, AMB), more often from one to three, which in most cases reaches the apex of the heart. Then the artery turns back, lies in the back of the coronary sulcus and reaches the "cross" of the heart (the intersection of the posterior interventricular and atrioventricular sulcus of the heart).

With the so-called right type of blood supply to the heart, observed in 90% of people, the right coronary artery gives off the posterior descending artery (PDA), which runs along the posterior interventricular groove for a different distance, giving branches to the septum (anastomosing with similar branches from the anterior descending artery, the latter usually longer than the first), the right ventricle and branches to the left ventricle. After the posterior descending artery (PDA) originates, the RCA continues beyond the cross of the heart as the right posterior atrioventricular branch along the distal part of the left atrioventricular sulcus, terminating in one or more posterolateral branches feeding the diaphragmatic surface of the left ventricle. . On the posterior surface of the heart, immediately below the bifurcation, at the point of transition of the right coronary artery to the posterior interventricular sulcus, an arterial branch originates from it, which, piercing the interventricular septum, goes to the atrioventricular node - the artery of the atrioventricular node artery (AVN).

The branches of the right coronary artery vascularize: the right atrium, part of the anterior, the entire posterior wall of the right ventricle, a small area of the posterior wall of the left ventricle, atrial septum, the posterior third of the interventricular septum, the papillary muscles of the right ventricle and the posterior papillary muscle of the left ventricle.

Left coronary artery

Left coronary artery(left coronary artery) starts from the left posterior surface of the aortic bulb and goes to the left side of the coronary sulcus. Its main trunk (left main coronary artery, LMCA) is usually short (0-10 mm, diameter varies from 3 to 6 mm) and is divided into anterior interventricular (left anterior descending artery, LAD) and envelope (left circumflex artery, LCx) branches . In 30-37% of cases, the third branch departs here - the intermediate artery (ramus intermedius, RI), which crosses obliquely the wall of the left ventricle. LAD and OB form an angle between them, which varies from 30 to 180°.

Anterior interventricular branch

The circumflex branch of the left coronary artery is located in the left part of the coronary sulcus and in 38% of cases gives the first branch to the artery of the sinoatrial node, and then the artery of the obtuse marginal artery (obtuse marginal artery, obtuse marginal branch, OMB), usually from one to three. These fundamentally important arteries feed the free wall of the left ventricle. In the case when there is a right type of blood supply, the circumflex branch gradually becomes thinner, giving branches to the left ventricle. With a relatively rare left type (10% of cases), it reaches the level of the posterior interventricular sulcus and forms the posterior interventricular branch. With an even rarer, so-called mixed type there are two posterior ventricular branches of the right coronary and circumflex arteries. The left circumflex artery forms important atrial branches, which include the left atrial circumflex artery (LAC) and the large anastomosing auricular artery.

The branches of the left coronary artery vascularize the left atrium, the entire anterior and most of the posterior wall of the left ventricle, part of the anterior wall of the right ventricle, the anterior 2/3 of the interventricular septum, and the anterior papillary muscle of the left ventricle.

Types of blood supply to the heart

The type of blood supply to the heart is understood as the predominant distribution of the right and left coronary arteries on the posterior surface of the heart.

The anatomical criterion for assessing the predominant type of distribution of the coronary arteries is the avascular zone on the posterior surface of the heart, formed by the intersection of the coronary and interventricular sulci, - crux. Depending on which of the arteries - right or left - reaches this zone, the predominant right or left type of blood supply to the heart is distinguished. The artery reaching this zone always gives off a posterior interventricular branch, which runs along the posterior interventricular groove towards the apex of the heart and supplies blood to the posterior part of the interventricular septum. Another anatomical feature is described to determine the predominant type of blood supply. It is noted that the branch to the atrioventricular node always departs from the predominant artery, i.e. from an artery that has highest value in the supply of blood from the posterior surface of the heart.

Thus, with predominant right type of blood supply to the heart The right coronary artery supplies the right atrium, the right ventricle, the posterior part of the interventricular septum, and the posterior surface of the left ventricle. The right coronary artery is represented by a large trunk, and the left circumflex artery is poorly expressed.

With predominant left type of blood supply to the heart the right coronary artery is narrow and terminates in short branches on the diaphragmatic surface of the right ventricle, and the posterior surface of the left ventricle, the posterior part of the interventricular septum, the atrioventricular node and most of the posterior surface of the ventricle receive blood from the well-defined large left circumflex artery.

In addition, there are also balanced type of blood supply. in which the right and left coronary arteries contribute approximately equally to the blood supply to the posterior surface of the heart.

The concept of "predominant type of blood supply to the heart", although conditional, is based on anatomical structure and distribution of the coronary arteries in the heart. Since the mass of the left ventricle is much larger than the right one, and the left coronary artery always supplies blood to most of the left ventricle, 2/3 of the interventricular septum and the wall of the right ventricle, it is clear that the left coronary artery is predominant in all normal hearts. Thus, for any of the types coronary blood supply predominant in the physiological sense is the left coronary artery.

Nevertheless, the concept of "predominant type of blood supply to the heart" is valid, it is used to assess anatomical findings during coronary angiography and is of great practical importance in determining indications for myocardial revascularization.

For topical indication of lesions, it is proposed to divide the coronary bed into segments.

Dotted lines in this scheme highlight the segments of the coronary arteries.

So in the left coronary artery in the anterior interventricular branch it is divided into three segments:

1. proximal - from the place of origin of the LAD from the trunk to the first septal perforator or 1DV.

2. medium - from 1DV to 2DV.

3. distal - after the discharge of 2DV.

In circumflex artery It is also customary to distinguish three segments:

1. proximal - from the mouth of the OB to 1 VTK.

3. distal - after the departure of 3 VTK.

Right coronary artery divided into the following main segments:

1. proximal - from the mouth to 1 wok

2. medium - from 1 wok to the sharp edge of the heart

3. distal - up to the RCA bifurcation to the posterior descending and posterolateral arteries.

Coronary angiography

Coronary angiography(coronary angiography) is an X-ray visualization of the coronary vessels after the introduction of a radiopaque substance. The x-ray image is immediately recorded on 35 mm film or digital media for further analysis.

Currently, coronary angiography is the "gold standard" for determining the presence or absence of stenosis in coronary disease.

The purpose of coronary angiography is to determine coronary anatomy and the degree of narrowing of the lumen of the coronary arteries. The information obtained during the procedure includes determining the location, extent, diameter and contours of the coronary arteries, the presence and degree of coronary obstruction, characterization of the nature of the obstruction (including the presence atherosclerotic plaque, thrombus, dissection, spasm, or myocardial bridging).

The data obtained determine the further tactics of the patient's treatment: coronary bypass grafting, intervention, drug therapy.

To conduct high-quality angiography, selective catheterization of the right and left coronary arteries is necessary, for which a large number of diagnostic catheters of various modifications have been created.

The study is performed under local anesthesia and NLA through arterial access. The following arterial accesses are generally recognized: femoral arteries, brachial arteries, radial arteries. Transradial access has recently gained a strong position and has become widely used due to its low trauma and convenience.

After puncture of the artery, diagnostic catheters are inserted through the introducer, followed by selective catheterization of the coronary vessels. The contrast agent is dosed using an automatic injector. Shooting is performed in standard projections, the catheters and intraduser are removed, and a compression bandage is applied.

Basic angiographic projections

During the procedure, the goal is to obtain the maximum full information about the anatomy of the coronary arteries, their morphological characteristics, the presence of changes in the vessels with exact definition localization and nature of lesions.

To achieve this goal, coronary angiography of the right and left coronary arteries is performed in standard projections. (Their description is given below). If necessary, more detailed study shooting in special projections. This or that projection is optimal for the analysis of a certain section of the coronary bed and allows you to most accurately identify the features of the morphology and the presence of pathology in this segment.

Below are the main angiographic projections with an indication of the arteries for visualization of which these projections are optimal.

For left coronary artery There are the following standard projections.

1. Right anterior oblique with caudal angulation.

RAO 30, Caudal 25.

2. Right anterior oblique view with cranial angulation.

RAO 30, cranial 20

LAD, its septal and diagonal branches

3. Left anterior oblique with cranial angulation.

LAO 60, cranial 20.

Orifice and distal segment of the LCA trunk, middle and distal segment of the LAD, septal and diagonal branches, proximal segment of the OB, VTK.

circumflex branch of the left coronary artery begins at the site of bifurcation (trifurcation) of the LCA trunk and goes along the left atrioventricular (coronal) sulcus. The circumflex branch of the LCA will be referred to hereinafter for simplicity as the left circumflex artery. By the way, this is exactly what it is called in English-language literature - left circumflex artery (LCx).

From circumflex artery depart from one to three large (left) marginal branches running along the blunt (left) edge of the heart. These are its main branches. They supply blood to the lateral wall of the left ventricle. After the departure of the marginal branches, the diameter of the circumflex artery decreases significantly. Sometimes only the first branch is called the (left) marginal, and the subsequent ones are called (posterior) lateral branches.

circumflex artery also gives from one to two branches going to the lateral and posterior surfaces of the left atrium (the so-called anterior branches to the left atrium: anastomotic and intermediate). In 15% of cases, with a left-(non-right-) coronary form of blood supply to the heart, the circumflex artery gives off branches to the posterior surface of the left ventricle or posterior branches of the left ventricle (F. H. Netter, 1987). In approximately 7.5% of cases, the posterior interventricular branch also departs from it, feeding both the posterior part of the interventricular septum and partially the posterior wall of the right ventricle (J. A. Bittl, D. C. Levin, 1997).

Proximal section of the envelope branch of the LCA call the segment from its mouth to the departure of the first marginal branch. There are usually two or three marginal branches to the left (blunt) edge of the heart. Between them is middle part envelope branch of the LCA. The last marginal, or as it is sometimes called (posterior) lateral, branch is followed by the distal section of the circumflex artery.

Right coronary artery

In their initial departments the right coronary artery (RCA) is partially covered by the right ear and follows the right atrioventricular sulcus (sulcus coronarius) in the direction of the decussation (the place on the diaphragmatic wall of the heart where the right and left atrioventricular sulci converge, as well as the posterior interventricular sulcus of the heart (sulcus interventricularis posterior)) .

first branch, outgoing from the right coronary artery is a branch to the arterial cone (in half of the cases it departs directly from the right coronary sinus of the aorta). When blocking the anterior interventricular branch of the LCA, the branch to the arterial cone is involved in maintaining collateral circulation.

The second branch of the PCA is a branch to sinus node(in 40-50% of cases, it can depart from the envelope branch of the LCA). Departing from the RCA, the branch goes posteriorly to the sinus angle, supplying blood not only to the sinus node, but also to the right atrium (sometimes both atria). The branch to the sinus node goes in the opposite direction with respect to the branch of the arterial cone.

Next branch is a branch to the right ventricle (may be up to three branches running parallel), which supplies blood to the anterior surface of the right ventricle. In its middle part, just above the sharp (right) edge of the heart, the RCA gives rise to one or more (right) marginal branches running towards the apex of the heart. They supply blood to both the anterior and posterior walls of the right ventricle, and also provide collateral blood flow with blockage of the anterior interventricular branch of the LCA.

Continuing to follow along the right atrioventricular sulcus, RCA goes around the heart and already on its posterior surface (almost reaching the intersection of all three sulci of the heart () gives rise to the posterior interventricular (descending) branch. The latter descends along the posterior interventricular sulcus, giving, in turn, the beginning of small lower septal branches , supplying the lower part of the septum, as well as branches to the posterior surface of the right ventricle.It should be noted that the anatomy of the distal RCA is very variable: in 10% of cases there may be, for example, two posterior interventricular branches running in parallel.

Proximal section of the right coronary artery call the segment from its beginning to the branch to the right ventricle. The last and the lowest outgoing (if there is more than one) marginal branch limit the middle section of the RCA. This is followed by the distal portion of the RCA. In the right oblique projection, the first - horizontal, second - vertical and third - horizontal segments of the RCA are also distinguished.

Educational video of the blood supply of the heart (anatomy of arteries and veins)

In case of problems with viewing, download the video from the page

The arteries of the heart depart from the aortic bulb - the initial expanded section of the ascending aorta and, like a crown, surround the heart, in connection with which they are called coronary arteries. The right coronary artery begins at the level of the right sinus of the aorta, and the left coronary artery - at the level of its left sinus. Both arteries depart from the aorta below the free (upper) edges of the semilunar valves, therefore, during contraction (systole) of the ventricles, the valves cover the openings of the arteries and almost do not let blood flow to the heart. With relaxation (diastole) of the ventricles, the sinuses fill with blood, blocking its path from the aorta back to the left ventricle, and at the same time open the access of blood to the vessels of the heart.

Right coronary artery

It goes to the right under the ear of the right atrium, lies in the coronary sulcus, goes around the right pulmonary surface of the heart, then follows its posterior surface to the left, where it anastomoses with its end with the circumflex branch of the left coronary artery. The largest branch of the right coronary artery is the posterior interventricular branch, which is directed along the sulcus of the same name towards the apex of the heart. The branches of the right coronary artery supply the wall of the right ventricle and atrium, the posterior part of the interventricular septum, the papillary muscles of the right ventricle, the posterior papillary muscle of the left ventricle, the sinoatrial and atrioventricular nodes of the cardiac conduction system.

Left coronary artery

A little thicker than the right. Located between the beginning of the pulmonary trunk and the left atrial appendage, it is divided into two branches: the anterior interventricular branch and the circumflex branch. The latter, which is a continuation of the main trunk of the coronary artery, goes around the heart on the left, located in its coronary sulcus, where it anastomoses with the right coronary artery on the posterior surface of the organ. The anterior interventricular branch follows the sulcus of the same name towards the apex of the heart. In the region of the cardiac notch, it sometimes passes to the diaphragmatic surface of the heart, where it anastomoses with the terminal section of the posterior interventricular branch of the right coronary artery. The branches of the left coronary artery supply the wall of the left ventricle, including the papillary muscles, most of the interventricular septum, the anterior wall of the right ventricle, and the wall of the left atrium.

The branches of the right and left coronary arteries, connecting, form two arterial rings in the heart: a transverse one, located in the coronary sulcus, and a longitudinal one, the vessels of which are located in the anterior and posterior interventricular sulci.

Branches of the coronary arteries provide blood supply to all layers of the walls of the heart. In the myocardium, where the level of oxidative processes is the highest, microvessels anastomosing with each other repeat the course of the bundles of muscle fibers of its layers.

There are various options for the distribution of branches of the coronary arteries, which are called types of blood supply to the heart. The main ones are as follows: right coronary, when most parts of the heart are supplied with blood by the branches of the right coronary artery; left coronary, when most of the heart receives blood from the branches of the left coronary artery, and medium, or uniform, in which both coronary arteries evenly participate in the blood supply to the walls of the heart. There are also transitional types of blood supply to the heart - middle right and middle left. It is generally accepted that among all types of blood supply to the heart, the middle-right type is predominant.

Variants and anomalies of the position and branching of the coronary arteries are possible. They are manifested in changes in the places of origin and the number of coronary arteries. So, the latter can depart from the aopta directly above the semilunar valves or much higher - from the left subclavian artery, and not from the aorta. The coronary artery may be the only one, that is, unpaired, there may be 3-4 coronary arteries, and not two: two arteries depart to the right and left of the aorta, or two from the aorta and two from the left subclavian artery.

Along with the coronary arteries, non-permanent (additional) arteries go to the heart (especially to the pericardium). These can be mediastinal-pericardial branches (upper, middle and lower) of the internal thoracic artery, branches of the pericardial phrenic artery, branches extending from the concave surface of the aortic arches, etc.