coronary anatomy for interventional cardiologists toufiqur rahman
TRANSCRIPT
Coronary Anatomy for Interventional Cardiologists
Dr. Md.Toufiqur Rahman
MBBS, FCPS, MD, FACC, FESC, FRCPE, FSCAI, FAPSC, FAPSIC, FAHA, FCCP, FRCPG
Associate Professor of CardiologyNational Institute of Cardiovascular Diseases(NICVD),
Sher-e-Bangla Nagar, Dhaka-1207
Consultant, Medinova, Malibagh branchHonorary Consultant, Apollo Hospitals, Dhaka and
STS Life Care Centre, Dhanmondi [email protected]
CRT 2014Washington DC, USA
Right Coronary Artery
• OriginRight aortic sinus (lower origin than LCA)
• CourseDown right AV groove toward crux of the heart, gives off PDA (85%) from which septals arise, continues in LAV groove giving off posterior LV branches (posterolaterals). PDA may originate more proximally, bifurcate early or be small with part of “its territory” supplied by an acute marginal branch.
• Supplies25% to 35% of Left Ventricle
Basic AnatomyBasic Anatomy
Right Coronary Artery
• Conus Arteryusually very proximal; (~50% have a separate origin)-courses anteriorly and upward over the RV outflow tract toward the LAD. May be an important source of collaterals.
• SA Nodal Artery(~60%) usually 2nd branch of RCA-courses obliquely backward through upper portion of atrial septum and anteromedial wall of the RA-supplies SA node, usually RA and sometimes LA.
Other BranchesOther Branches
Right Coronary Artery
• Right Ventricular (Acute Marginal) Branches)Arise from mid RCA; supply anterior RV; may be a collateral source.
• AV Nodal ArteryArises at or near crux; supplies AV node.
• PDASupplies inferior wall, ventricular septum, posteromedial papillary muscle.
Other BranchesOther Branches
Right Coronary Artery
• LAO (30) Cranial(30)particularly for distal bifurcation (AP Cranial may be better).
• RAOmain shaft; cranial enhances distal vessels and very proximal; caudal may help with Shepherd’s crook.
• Lateralbifurcations with RV branches-distal bifurcation, particularly with cranial.
Optimal View(s)Optimal View(s)
RAO Angiogram of RCA
Left Coronary Artery
• Originupper portion of left aortic sinus just below the sinotubular ridge. Typically 0-10 mm in length. Rarely no LM (separate origins).
• Catheterization Technique“The Judkins’ 4-Left coronary catheter will find the LCA orifice unless thwarted by the operator”. Just in case-other Judkins sizes for smaller or larger aortas; Amplatz, XB type curves. Watch for “damping”; For separate ostia-separate catheters, larger for Cx, or counterclockwise rotation for LAD.
• Optimal ViewsLAO caudal and cranial; AP-caudal, cranial or flat. Limit views. May need IVUS
Left Main Coronary ArteryLeft Main Coronary Artery
Left Anterior Descending Artery• Course
down the anterior interventricular groove-usually reaches apex. In 22% of cases does not reach apex.
• Branchesseptals and diagonals-supply lateral wall of LV, anterolateral papillary muscle; 37% have median ramus (courses like 1st diagonal).
• LADSupplies anterolateral, apex and septum; ~45%-55% of left ventricle.
Left Circumflex Artery• Origin
from distal LMCA.• Course
down distal left AV groove.• Branches
obtuse marginal, posterolaterals-supply posterolateral LV, anterolateral papillary muscle. SA node artery-38%.
• Supplies15%-25% of LV, unless dominant (supplies 40-50% of LV).
Left Coronary Artery• AP (30)Caudal
LMCA, proximal LAD, Cx, distal LAD. Poor for mid LAD- RAO may be useful.
• AP (40)CranialLMCA, LAD, diagonals, septals, distal Cx-may need RAO to separate LAD and Cx.
• (45)LAO (35) CranialLMCA, LAD, diagonals, septals, and distal Cx.
• (45)LAO (30) CaudalLMCA, Cx,and prox LAD.
• Laterals (cranial, caudal)may be helpful.
Optimal ViewsOptimal Views
SeptalSeptal
LADLAD
CxCx
DiagonalDiagonal
AP Cranial View of LCA
Dominance:
• Definition 1:the coronary artery which reaches the crux of the heart and then gives off the PDA
• Definition 2: (Allows for codominance)the artery which gives off the PDA as well as a large posterolateral branch
LeftDominant
Circulation
LeftDominant
Circulation
LCA Angiogram
Distal LADDistal LAD
Prox LADProx LADLMLM
OMOM
Distal CxDistal Cx
Occluded Median RamusOccluded Median Ramus
Dominant Cx AP CaudalDominant Cx AP Caudal
LCA Angiogram-Dominant Cx LAO-Caudal
Distal LADDistal LAD
LMLM
Prox CxProx Cx
LPDALPDA
OccludedMedianRamus
OccludedMedianRamus
Prox LADProx LAD
The Coronary Arteries Are Complementary
• Large PDA Small LAD• Huge Cx (posterolaterals) Small RCA continuation in AV Groove• Etc, etc, etc…..
Wrap Around LAD
Short LAD/Large RCA with Apical Extension
BYPASS GRAFTS• SVG
Left coronary grafts generally arise from left side of the aorta. Best cannulated with Judkins’ Right, IMA, LCB or MP.– Right sided grafts-arise from right side of the
aorta-MP usually best.• IMA
don’t forget to check subclavians.
All distal vessels must be accounted for; op notes and old films are extremely helpful.All distal vessels must be accounted for; op notes and old films are extremely helpful.
SVG-OM-LAO CaudalDemonstrating Graft OstiumDemonstrating Graft Ostium
Ostium
SVG-OM 1 AP CaudalDemonstrating AnastomosisDemonstrating Anastomosis
SVGSVG
LIMA to LADOrigin from left subclavian (AP Cranial)Origin from left subclavian (AP Cranial)
LIMA to LADDistal Anastomosis-AP CranialDistal Anastomosis-AP Cranial
LIMALIMA
LADLAD
RIMA to RCA
RIMA to RCA
Ulcerated Plaque
NORMMAL CORONARY ARTERY ANATOMY
BRAUNWALD, 2nd Ed; 1984
LAORAO
Branch of RCA
Percentage Area perfused Best view
RCA RA & part of LA, RV, Posterosupirior IVS,SA node AV node
60 LAO
Conus branch 60% (40% separate)
RVOT RAO 30
SA nodal 59%,c39% Sinus node, RA,LA RAO 30
RV Branch 100% RV RAO 30
AMAV node
100%87.9%
Inferior& diaphramatic surface of RVAV node
RAO,LAOLAO CR
PDPL/PLV
86%,c14%20%
Post. & diaph. Area of septumPost. & diaph LV wall
LAO, CRLAO CR
RIGHT CORONARY ARTERY-ANATOMICAL CONSEDERATIONS
LVB 80%,c20% Diaphramatic surface of LV LAO CR
Braunwald;2nd ed,1984
Br. of LCA Percentage Area perfused Best view
LM Entire LV, LA except post.portion of IVS when PD is br. of RCA
AP,RAO CR,LAO CA,
LAD 98% Ant.2/3rd of IVS,ant. Portion of LV RAO,LAO, LAO CR, RAO CA,
Ist diagonal (1)
100% High lateral wall of LV LAO CR
Ist Septal (1) 99.8% Superior & ant. Portionof IVS RAO , RAO CR
Septals (minor) several
100% Inferior & ant. 1/3rd of IVS RAO CR
Second Diogonal (1or 3)
100% Lower lateral aspect of lv free wall LAO, LAO CR
LEFT CORONARY ARTERY-ANATOMICAL CONSEDERATIONS
Br. of LCA
Percentage
Area perfused Best view
LCX 97% Obtuse margin of heart & its entire post. wall, post.IVS when PD is br. of LCX
RAO,LAO, RAO CA
OM (1 or 2)
97% Obtuse margin of heart and adjacent post. LV RAO,RAO CA
SA node 39%, 59 rca SA node RA, LA RAO, LAO
PL(1or 2) 80%,rca 20%
Posterior & diaphramatic LV wall RAO
PD 18%, (rca78%,2%c)
Posterior IVS & Diaphramatic LV RAO
AV node 11.9% AV node, lower port of IAS LAO
LEFT CORONARY ARTERY-ANATOMICAL CONSEDERATIONS
Braunwald;2nd ed,1984
Right & left dominant depending on which PD artery cross the crux. When both arteries reach the crux without crossing it ,the circulation is considered as balance circulation
Braunwald 2nd ed; 1984
RIGHT DOMINANT(85%)
When PD arise from RCA & cross the crax
LEFT DOMINANT( 15%):
When PD arise from LCX & cross the crax
CODOMINANT ( BALANCE) 7.5%:
When RCA give rise to PDA & LCX gives rise to all posterolateral branches
Braunwald 6th ed;2001
RIGHT DOMINANT, LEFT DOMINANT & CODOMINANT
SEGMENTS OF RCA
RV
Acute marginal
BRAUNWALD, 2nd Ed; 1984
SEGMENTS OF LAD
BRAUNWALD, 2nd Ed; 1984
Distal
BRAUNWALD, 2nd Ed; 1984
PRINCIPAL SEGMENTS OF LCX
Thank [email protected]
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