clinical anatomy cardiovascular

7/23/2019 clinical anatomy cardiovascular

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GROSS & CLINICALANATOMY

DANTE JOSE D. MERCADO, MD

CHIEF OF SECTION GROSS ANATOMY

CARDIOVASCULAR

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Coronary Arteries

Right Coronary Artery - lodged in the anterior

coronary sulcus.

Trace its origin from the right aortic sinus

at the base of theascending aorta where it is covered by a flap of the rightauricular appendage. Follow the artery as it winds aroundthe right cardiac border to reach the diaphragmatic surfacewhere 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 ofthe heart to the apex.

Posterior (or inferior) interventricular artery at thediaphragmatic surface coursing through the posterior (orinferior) interventricular groove.

The right coronary artery gives small twigs to theatrial and ventricular walls including the SA and AVnodes and the inferior part of the interventricular

septum.


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Right Coronary


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Coronary Arteries

Left Coronary Artery - allegedly supplies a greater part of thecardiac tissues. It may be easier to expose it as it emerges onthe left side of the pulmonary trunk beneath the flap of the leftauricular appendage. After identifying it at this point, trace itsorigin from the left posterior aortic sinus

at the base of theascending aorta. Then verify its division into:

Anterior or descending interventricular artery - the branch thatcourses 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 interventricularseptum

which is coincident with the inferior or posteriorinterventricular groove.

Circumflex Artery - the branch that winds around the left border ofthe heart until it meets the end of the right coronary artery near theposterior interventricular sulcus.

The branches along their course give off atrial and ventricular branches.Anastomoses between the branches of the coronary arteries are notvery adequate as verified by cases of sudden and total occlusion oflarger arterioles. Gradual occlusion sometimes provides time for thedevelopment of new branches to meet the demand of cardiac tissuesfor nutrition and oxygen. Terminal pre-capillary twigs do notanastomose and are termed as end-arteries

. Significance?


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Left Coronary


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Venous Drainage

Coronary Sinus - principal venous channel draining almost

all the veins of the heart. It courses through the tissues atthe A-V groove on the inferior surface of the heart, finallyopening into the right atrium.

Among its many tributaries, the following are distinguishedwith these names:

Great Cardiac Vein accompanying the descending inter-

ventricular artery in the IV groove. It joins the coronary sinus atthe latter

s commencement at the left cardiac border. Middle Cardiac vein - accompanying the posterior inter-

ventricular 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 draindirectly into the corresponding cardiac chambers where theyare located.


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Cardiac Veins


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CORONARY ARTERIES

The branches of the coronary arteries areend arteries in the sense that they supplyregions of cardiac muscle without overlapfrom other large branches.

Although there is a rich anastomosis

between arterioles, this blood supply isinadequate for the requirementsof the cardiac muscle when there is a suddenocclusion of a major branch.

As a result, the region supplied by theoccluded branch becomes infarcted andsoon undergoes necrosis.


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Myocardial Infarct

An area of myocardium that has undergonenecrosis is called an INFARCT.


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Case Study

While having a heateddiscussion with his wife, a 48-year-old businessmanexperienced a sudden, crushingsubsternal pain in his chest thatradiated along the medial aspect

of his left arm. When his wifenoted that he was pale,perspiring, and writhing in pain,she called a physician and anambulance.

The ambulance paramedicsadministered O2 and rushed himto the hospital, where he wasadmitted to the ICU. He wasplaced under observation withECG monitoring for detection ofpotential fatal arrhythmias.


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Case Study

On questioning, the resident learnedthat 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 MyocardialInfarction


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Coronary Insufficiency

The most common cause of ischemic

heart disease resulting fromatherosclerosisof the coronary arteries.

ANGIN PECTORISChest pain, a clinical syndrome

characterized by substernaldiscomfort that results frommyocardial ischemia.

The important feature of anginapectoris is its relation to exertion.It is relieved by 1 to 2 minutes of

rest.

Sublingual nitroglycerin dilates thecoronary arteries, increases bloodflow to the heart and relieves thepain.


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MYOCARDIAL INFARCTION (MI)

A disease of the myocardium,

characterized by necrosis of ventricularmuscle that results from suddenocclusion of a part of the coronarycirculation.

The pain is often more severe than with

angina, and it does not disappear after 1to 2 minutes of rest. There is a feeling ofheaviness of the chest, which mayradiate to the left upper extremity.


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Coronary Angiography

Coronary Angiography - long narrowcatheters are passed into theascending aorta via the femoral orbrachial arteries; under fluoroscopiccontrol, the tip of the catheter isplaced just inside the mouth of acoronary artery and contrastmaterial is injected.


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Coronary ArteryNormal With Plaque


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Coronary Artery with Plaque

LumenLipidCore

FibrousCap


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Coronary Artery with Thrombus

Thrombus

Fibrous Cap

Lipid Core


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BLOODFLOW

INTRALUMINALTHROMBUS

PROPAGATIONTHROMBUS

INTRAPLAQUETHROMBUS

LIPIDPOOL


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Genesis of Atherosclerotic Plaque


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TREAT AND PREVENTCOMPLICATIONS OF

ACUTE ISCHEMIA ORNECROTIC MYOCARDIUM

Beta-blocade

?antiarrhythmic agents

PROMOTE HEALINGAce inhibitors

? Antiperfusioninjury agents

OPEN ARTERY IFTOTALLY OCCLUDED

ThrombolysisDirect PTCA

PROMOTE VASODILATIONNitrates

?Calcium channel blockers

PREVENT THROMBOSIS

Antiplatelet therapyAntithrombin therapy

Other coagulationsystem manipulation

REDUCE RECURRENT TRIGGERSBed restBP control

Beta-blockade

TREATMENT


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Coronary Artery Bypass Grafting

Aorto-Coronary Bypass -a segment of vein isconnected to the aortaand then to the coronaryartery beyond thestenosis.


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CABG


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Coronary Angioplasty


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Coronary Angioplasty


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clinical anatomy cardiovascular

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