Maryann Vejdani-Jahromi

 

“Sarcoidosis, a Scare, Chest Pain and an Octopus”

This is a story about a 59 year  old woman who had sarcoidosis, who had a scare developed chest pain that sounded like acute coronary syndrome and was short of breath

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Introduction to Coronary Artery Anatomy

Coronary Arteries

Corona = Crown or wreath from  mid 17th century (in the sense ?resembling a crown?): from Latin coronarius, from corona ?wreath, crown?.

CORONARY ARTERIES
Corona = Crown or wreath from  mid 17th century (in the sense ?resembling a crown?): from Latin coronarius, from corona ?wreath, crown?.
Courtesy Ashley Davidoff MD
Anatomical Specimen injected with Barium
The Left Side Anterior View
     LAD Coursing in the Interventricular Groove
LAD
Ashley Davidoff MD
Branches
3-5 Diagonals supplying the anterior portion of the LV
DIAGONALS OF THE LAD
Ashley Davidoff MD

OBTUSE MARGINALS OFF THE CIRCUMFLEX (3-4 vessels)
supplying the lateral and posterior portion of the LV

CIRCUMFLEX ARTERY
Ashley Davidoff MD

INFUNDIBULAR BRANCH SUPPLYING THE ARC OF VIEUSSENS
Important collateral from proximal LAD to proximal RCA

 

CIRCUMFLEX AND OBTUSE MARGINALS
in lateral projection supplying the lateral and posterior portions of the LV

OBTUSE MARGINALS OFF THE CIRCUMFLEX
Ashley DAvidoff MD

OBTUSE MARGINALS OFF THE CIRCUMFLEX POSTERIOR VIEW in a right dominant system.  In this case only about 50% of the inferior portion of the LV is supplied by the LCA

OBTUSE MARGINALS OFF THE CIRCUMFLEX
Ashley Davidoff MD

RIGHT SIDE – DOMINANT

MAIN RCA IN ANTERIOR A-V GROOVE

RCA
Ashley Davidoff MD

INFUNDIBULAR BRANCH SUPPLYING THE ARC OF VIEUSSENS in the RVOT

INFUNDIBULAR BRANCH SUPPLYING THE ARC OF VIEUSSENS
Ashley Davidoff MD

ANTERIOR RV BRANCHES AND ACUTE MARGINAL ARTERY (arrow)

ANTERIOR RV BRANCHES AND ACUTE MARGINAL ARTERY (arrow)
Ashley Davidoff MD
RIGHT SIDE POSTERIOR VIEW – CONTINUATION OF THE RCA
POSTERIOR VIEW
CONTINUATION OF THE RCA
Ashley Davidoff MD

PDA
Note it runs side by side with the middle cardiac vein

PDA
Ashley Davidoff MD

POSTERIOR LV BRANCHES

POSTERIOR LV BRANCHES
Ashley Davidoff MD

A-V NODAL ARTERY

A-V NODAL ARTERY
Ashley Davidoff MD
3D
Scaffolding of the Heart

Basic Structure – a Cross Made of Two Intersecting Circles

SCAFFOLDING OF THE HEART AND CORONARY ARTERIAL SYSTEM
The Cross in 3 Dimensions
The infrastructure of the heart as a cross has horizontal and vertical components that have 3 dimensions (b). The tricuspid valve and annulus (blue ring) and mitral valve and annulus (red horizontal ring) are aligned in the horizontal plane (c). The right coronary artery (RCA) and circumflex (LCx) supply the right and left side while the left anterior descending (LAD) and posterior descending artery (PDA) align along the the vertical limb.
Ashley Davidoff MD
Horizontal circle consists of the mitral and tricuspid annuli and the Circumflex and RCA run in their respective A-V grooves.  The LAD and PDA run anteriorly and posteriorly in their respective interventricular grooves
SCAFFOLDING OF THE HEART AND CORONARY ARTERIAL SYSTEM
The Cross in 3 Dimensions
The infrastructure of the heart as a cross has horizontal and vertical components that have 3 dimensions.
The tricuspid valve and annulus (blue ring) and mitral valve and annulus (red horizontal ring) are aligned in the horizontal plane (c). The right coronary artery (RCA) and circumflex (LCx) supply the right and left side while the left anterior descending (LAD) and posterior descending artery (PDA) align along the the vertical limb.
Ashley Davidoff MD

CORONARY CIRCULATION IN 3D – ANATOMICAL SPECIMEN INJECTED WITH BARIUM

LAD and BRANCHES IN THE LAO PROJECTION
The anatomical specimen has been injected with barium and shows LAD arising from the left main coronary artery. The diagonal arteries (d) course toward the patients left to supply the anterior and anterolateral part of the LV. The infundibular artery (I, aka arc of Vieussen?s) courses over the RVOT to join its partner arising from the RCA. The septal arteries have a vertical course toward the diaphragm, and the branch to the anterolateral papillary muscle of the RV (a-l) courses toward the right of the patient. The LAD often terminates with a bifurcation reminiscent of a moustache.
Ashley Davidoff MD
CIRCUMFLEX CORONARY ARTERY –

Note The distal circumflex is usually very small and sometimes not even visible but is recognised by its relationship to the A_V groove and coronary sinus

CIRCUMFLEX CORONARY ARTERY and BRANCHES IN THE LAO PROJECTION
The anatomical specimen has been injected with barium and shows the circumflex (c) arising from the left main coronary artery. The obtuse marginal arteries are large vessels so the distal circumflex continuation  (c c green arrow) is a small vessel that runs in the posterior A-V groove with the coronary sinus
Ashley Davidoff MD

BRANCHES OF THE CIRCUMFLEX CORONARY ARTERY

Note the SA nodal artery arises from the circumflex about 40% of the time and from the RCA 60% of the time

CIRCUMFLEX CORONARY ARTERY and BRANCHES IN THE LAO PROJECTION
The anatomical specimen has been injected with barium and shows the circumflex (c) arising from the left main coronary artery. The obtuse marginal arteries are large vessels so the distal circumflex continuation (c c green arrow) is a small vessel that runs in the posterior A-V groove with the coronary sinus
The S-A nodal artery (s-a) sometimes arises from the circumflex as the first branch. Atrial branches (a) also arise from the proximal circumflex artery.
A number of obtuse marginal arteries (OM1 and OM2 ) supply the posterior and posterolateral parts of the LV and are almost always larger than the distal circumflex itself (c c).
Ashley Davidoff MD

RCA

Note the septal perforators supply about 1/3 of the septum and are important collateral pathway when the LAD is occluded

RCA and BRANCHES IN THE LAO PROJECTION
The coronary arteries have been injected with barium and shows left (bright red overlay) and right (maroon) coronary circulation The proximal RCA (p) courses anteriorly in the A-V groove arising from the right coronary ostium. The acute marginal (am) courses along the right margin of the heart, and the RCA continues posteriorly (p) to the crux of the heart where it gives off 3 branches. The posterior descending artery (PDA), A-V nodal artery (a-v) and posterior left ventricular artery (plv). The PDA supplies the inferior 1/3 of the interventricular septum with perforating septal arteries (s)
This is a dominant RCA
Ashley Davidoff MD

SELECTIVE ANGIOGRAPHY

LAD and BRANCHES IN THE LAO PROJECTION
The angiogram of the left coronary artery in the LAO projection shows the LAD in b, diagonals in c and septal arteries coursing toward the diaphragm in d.
Ashley Davidoff MD

Dominant LCA 15-20% 

CIRCUMFLEX CORONARY ARTERY and BRANCHES IN THE LAO PROJECTION
The angiogram of the LCA (a) shows the circumflex (b) arising from the left main coronary artery. In this left dominant system, there are 4 obtuse marginal arteries (c). Distally the circumflex continues and gives rise to the PDA, (d) AV nodal artery and posterior LV branches
Ashley Davidoff MD

RCA Dominant 80-85%

RCA CORONARY ARTERY and BRANCHES IN THE LAO PROJECTION
The angiogram of a dominant RCA shows the infundibular artery coursing to the RVOT, the acute marginal artery (AM), at the right margin of the heart, PDA and septal perforators,, A-V nodal (AVn) and posterior left ventricular branches (Post LV)
Ashley Davidoff MD

Next Prashanth  Haran,

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