GROSS & CLINICAL

ANATOMY

CARDIOVASCULAR
2
DANTE JOSE D. MERCADO, MD
CHIEF OF SECTION GROSS ANATOMY

Coronary Arteries
Right Coronary Artery - lodged in the anterior
coronary sulcus.
Trace its origin from the right aortic sinus at the base of the
ascending aorta where it is covered by a flap of the right
auricular appendage. Follow the artery as it winds around
the right cardiac border to reach the diaphragmatic surface
where it ends by joining the circumflex branch of the left
coronary artery.

Among its numerous branches, verify the following,

distinguished by these names:
Marginal artery- courses along the inferior cardiac border of
the heart to the apex.
Posterior (or inferior) interventricular artery at the
diaphragmatic surface coursing through the posterior (or
inferior) interventricular groove.

The right coronary artery gives small twigs to the

atrial and ventricular walls including the SA and AV
nodes and the inferior part of the interventricular
septum.

Right Coronary

Coronary Arteries
Left Coronary Artery - allegedly supplies a greater part of the
cardiac tissues. It may be easier to expose it as it emerges on
the left side of the pulmonary trunk beneath the flap of the left
auricular appendage. After identifying it at this point, trace its
origin from the left posterior aortic sinus at the base of the
ascending aorta. Then verify its division into:

Anterior or descending interventricular artery - the branch that

courses in a similarly named groove on the sternocostal surface of
the heart and following this to the apex.
The artery and the groove marks the position of the interventricular
septum which is coincident with the inferior or posterior
interventricular groove.
Circumflex Artery - the branch that winds around the left border of
the heart until it meets the end of the right coronary artery near the
posterior interventricular sulcus.
The branches along their course give off atrial and ventricular branches.
Anastomoses between the branches of the coronary arteries are not
very adequate as verified by cases of sudden and total occlusion of
larger arterioles. Gradual occlusion sometimes provides time for the
development of new branches to meet the demand of cardiac tissues
for nutrition and oxygen. Terminal pre-capillary twigs do not
anastomose and are termed as end-arteries. Significance?

Left Coronary

Venous Drainage
Coronary Sinus - principal venous channel draining almost
all the veins of the heart. It courses through the tissues at
the A-V groove on the inferior surface of the heart, finally
opening into the right atrium.
Among its many tributaries, the following are distinguished
with these names:

Great Cardiac Vein accompanying the descending interventricular artery in the IV groove. It joins the coronary sinus at
the latters commencement at the left cardiac border.
Middle Cardiac vein - accompanying the posterior interventricular artery.
Oblique vein - small, rudimentary, at the posterior wall of the left
atrium, joining the end of the coronary sinus.
Anterior cardiac veins and vena cordis minimae are names given
to tiny veins along the atrial and ventricular walls that drain
directly into the corresponding cardiac chambers where they
are located.

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Cardiac Veins

CORONARY ARTERIES

The branches of the coronary arteries are

end arteries in the sense that they supply
regions of cardiac muscle without overlap
from other large branches.
Although there is a rich anastomosis
between arterioles, this blood supply is
inadequate for the requirements
of the cardiac muscle when there is a sudden
occlusion of a major branch.
As a result, the region supplied by the
occluded branch becomes infarcted and
soon undergoes necrosis.

Myocardial Infarct
An area of myocardium that has undergone
necrosis is called an INFARCT.

Case Study
While having a heated
discussion with his wife, a 48year-old businessman
experienced a sudden, crushing
substernal pain in his chest that
radiated along the medial aspect
of his left arm. When his wife
noted that he was pale,
perspiring, and writhing in pain,
she called a physician and an
ambulance.
The ambulance paramedics
administered O2 and rushed him
to the hospital, where he was
admitted to the ICU. He was
placed under observation with
ECG monitoring for detection of
potential fatal arrhythmias.

Case Study
On questioning, the resident learned
that the patient had had previous
attacks of substernal discomfort
during stress that he was reluctant
to describe as pain. This discomfort
always passed when he rested.
Asked to describe his present chest
pain, he clenched his fist to
demonstrate its viselike nature.
ECG and CPK MB were done.
Impression: Acute Myocardial
Infarction

Coronary Insufficiency
The most common cause of ischemic
heart disease resulting from
atherosclerosis
of the coronary arteries.
ANGIN PECTORIS
Chest pain, a clinical syndrome
characterized by substernal
discomfort that results from
myocardial ischemia.
The important feature of angina
pectoris is its relation to exertion.
It is relieved by 1 to 2 minutes of
rest.
Sublingual nitroglycerin dilates the
coronary arteries, increases blood
flow to the heart and relieves the
pain.

MYOCARDIAL INFARCTION (MI)

A disease of the myocardium,

characterized by necrosis of ventricular
muscle that results from sudden
occlusion of a part of the coronary
circulation.
The pain is often more severe than with
angina, and it does not disappear after 1
to 2 minutes of rest. There is a feeling of
heaviness of the chest, which may
radiate to the left upper extremity.

Coronary Angiography

Coronary Angiography - long narrow

catheters are passed into the
ascending aorta via the femoral or
brachial arteries; under fluoroscopic
control, the tip of the catheter is
placed just inside the mouth of a
coronary artery and contrast
material is injected.

Normal

Coronary Artery
With Plaque

Coronary Artery with Plaque

Lipid
Core

Fibrous
Cap

Lumen

Coronary Artery with Thrombus

Thrombus
Fibrous Cap

Lipid Core

INTRALUMINAL
THROMBUS

PROPAGATION
THROMBUS

BLOOD
FLOW

INTRAPLAQUE
THROMBUS

LIPID
POOL

Genesis of Atherosclerotic Plaque

TREATMENT

PROMOTE VASODILATION
Nitrates
?Calcium channel blockers
OPEN ARTERY IF
TOTALLY OCCLUDED
Thrombolysis
Direct PTCA
PROMOTE HEALING
Ace inhibitors
? Antiperfusion
injury agents

REDUCE RECURRENT TRIGGERS

Bed rest
BP control
Beta-blockade
PREVENT THROMBOSIS
Antiplatelet therapy
Antithrombin therapy
Other coagulation
system manipulation
TREAT AND PREVENT
COMPLICATIONS OF
ACUTE ISCHEMIA OR
NECROTIC MYOCARDIUM
Beta-blocade
?antiarrhythmic agents

Coronary Artery Bypass Grafting

Aorto-Coronary Bypass a segment of vein is

connected to the aorta
and then to the coronary
artery beyond the
stenosis.

CABG

Coronary Angioplasty