Heart AnatomyHeart Anatomy

Coronary Arteries , Veins & Coronary Arteries , Veins & Lymphatic componentsLymphatic components

Salah TarabshehSalah Tarabsheh

Coronary arteriesCoronary arteries

The coronary arteries & their branches form a The coronary arteries & their branches form a circle & loop around the heart.circle & loop around the heart.

Coronary= encircling like a crown.Coronary= encircling like a crown. The heart is supplied by two coronary arteries The heart is supplied by two coronary arteries

(right & left) which arise from the ascending (right & left) which arise from the ascending aorta.aorta.

The right coronary artery arises from the anterior The right coronary artery arises from the anterior aortic sinus, while the left coronary artery arises aortic sinus, while the left coronary artery arises from the left posterior aortic sinus.from the left posterior aortic sinus.

Cont……..Cont……..

An arterial circle surrounds the heart lying in the A-V An arterial circle surrounds the heart lying in the A-V groove, from this arterial circle, an arterial loop runs in groove, from this arterial circle, an arterial loop runs in the anterior & inferior interventricular grooves.the anterior & inferior interventricular grooves.

The circle is formed by the RCA & left CX artery, while The circle is formed by the RCA & left CX artery, while the loop is formed by the LAD & PDA.the loop is formed by the LAD & PDA.

Variability in the origin of the PDA is expressed by the Variability in the origin of the PDA is expressed by the term dominance.term dominance.

A right dominant coronary circulation is one in which A right dominant coronary circulation is one in which the PDA is a terminal branch of the RCA, & so for the the PDA is a terminal branch of the RCA, & so for the left dominance.left dominance.

Left dominance occurs more commonly in males.Left dominance occurs more commonly in males.

Left Main Coronary ArteryLeft Main Coronary Artery

Extends from the ostium in the left sinus of valsalva to Extends from the ostium in the left sinus of valsalva to its bifurcation into the left anterior descending & left its bifurcation into the left anterior descending & left circumflex branches.circumflex branches.

Usual length 10-20 mm with a range of 0-40 mm.Usual length 10-20 mm with a range of 0-40 mm. Normally courses between the pulmonary trunk & the Normally courses between the pulmonary trunk & the

left atrial appendage to reach the left A-V groove, left atrial appendage to reach the left A-V groove, occasionally an additional artery originates from the left occasionally an additional artery originates from the left main & called ramus intermedius & courses parallel to main & called ramus intermedius & courses parallel to the diagonals.the diagonals.

In 1% of the population, the left main artery is absent & In 1% of the population, the left main artery is absent & the LAD & CX originate from separate ostia.the LAD & CX originate from separate ostia.

Left Anterior Descending Artery Left Anterior Descending Artery (LAD)(LAD)

Courses along the anterior interventricular sulcus Courses along the anterior interventricular sulcus to the apex of the heart.to the apex of the heart.

Part of it may be burried in muscles.Part of it may be burried in muscles. In most cases the LAD extends around the apex In most cases the LAD extends around the apex

into the posterior interventricular sulcus into the posterior interventricular sulcus supplying the apical portion of both right & left supplying the apical portion of both right & left ventricles.ventricles.

Supplies branches to the right ventricular free Supplies branches to the right ventricular free wall, to the septum & to the left ventricular free wall, to the septum & to the left ventricular free wall.wall.

Cont I…….Cont I…….

Anastomosis between branches supplying the right Anastomosis between branches supplying the right ventricular free wall & infundibular branches of the ventricular free wall & infundibular branches of the proximal right coronary artery (Loop of Vieussens).proximal right coronary artery (Loop of Vieussens).

Branches of the LAD:Branches of the LAD: On the surface of the heart → diagonalsOn the surface of the heart → diagonals Perpendicular into the ventricular septum → Septal Perpendicular into the ventricular septum → Septal

branches branches

Diagonals supply the left ventricular free wall Diagonals supply the left ventricular free wall anteriorely & laterally.anteriorely & laterally.

Cont IICont II…..…..

Variations in the LAD:Variations in the LAD:

In 4% exists as two parallel vessels.In 4% exists as two parallel vessels. It may terminate before the apex or extend It may terminate before the apex or extend

as far as the posterior atrioventricular as far as the posterior atrioventricular groove.groove.

Circumflex ArteryCircumflex Artery

From the LM coronary artery, with its initial course From the LM coronary artery, with its initial course medial to the base of the left atrial appendage.medial to the base of the left atrial appendage.

Large branch in the proximal segment called atrial Large branch in the proximal segment called atrial circumflex artery, coursing around the left atrium.circumflex artery, coursing around the left atrium.

The ventricular branches are called Obtuse marginal The ventricular branches are called Obtuse marginal arteries, supply the obtuse margin of the heart.arteries, supply the obtuse margin of the heart.

In hearts with left dominance or codominance these In hearts with left dominance or codominance these obtuse marginal arteries supply the inferior surface of the obtuse marginal arteries supply the inferior surface of the LV.LV.

Variations in the origin & length of the CX are common. Variations in the origin & length of the CX are common.

Right Coronary Artery (RCA)Right Coronary Artery (RCA)

Usually single artery.Usually single artery. Courses down the right A-V groove.Courses down the right A-V groove. Branches:Branches:1. Conus artery.1. Conus artery.2. Branches to the anterior right ventricular free 2. Branches to the anterior right ventricular free

wall.wall.3. Anterior right atrial artery\ this artery 3. Anterior right atrial artery\ this artery

commonly gives the SA nodal artery.commonly gives the SA nodal artery.4. Lateral right atrial artery ( usually injured in 4. Lateral right atrial artery ( usually injured in

oblique right atriotomy).oblique right atriotomy).

Cont……………Cont……………

5. Acute marginal artery in the region of the 5. Acute marginal artery in the region of the acute margin of the heart, which courses acute margin of the heart, which courses most of the way to the apex of the heart.most of the way to the apex of the heart.

6. A-V nodal artery at the crux.6. A-V nodal artery at the crux.7. Terminal branches: 7. Terminal branches: - PDA- PDA - Right posterior lateral segment - Right posterior lateral segment artery.artery.

Cont…………..Cont…………..

PDA: PDA: Courses in the posterior interventricular sulcus.Courses in the posterior interventricular sulcus. Branches: - SeptalBranches: - Septal - Right ventricular- Right ventricular - Left ventricular- Left ventricular The posterior lateral artery:The posterior lateral artery: Gives origin to marginal branches to the inferior Gives origin to marginal branches to the inferior

surface of the left ventricle in most hearts with a surface of the left ventricle in most hearts with a right dominant system.right dominant system.

Conus branchConus branch

Arising separately from the anterior aortic Arising separately from the anterior aortic sinus in 36% (3sinus in 36% (3rdrd coronary artery). coronary artery).

Ramifies on the lowest part of the Ramifies on the lowest part of the pulmonary conus and upper part of the pulmonary conus and upper part of the right ventricle.right ventricle.

Commonly anastomosis with branches Commonly anastomosis with branches from the left coronary artery to form from the left coronary artery to form annulus of vieussenis.annulus of vieussenis.

Coronary Arterial supply to Coronary Arterial supply to specialized areas:specialized areas: Ventricular Septum:Ventricular Septum: Predominantly from the LAD, via 4-6 large Predominantly from the LAD, via 4-6 large

septal branches.septal branches. Exclusively from the LAD in hearts with left Exclusively from the LAD in hearts with left

dominant circulation.dominant circulation. Septal branches of LAD are 70-80 mm in length, Septal branches of LAD are 70-80 mm in length,

while that of the PDA are <15 mm, except the A-while that of the PDA are <15 mm, except the A-V nodal artery.V nodal artery.

Until their final terminations, the septal arteries Until their final terminations, the septal arteries of both LAD & PDA course along the right of both LAD & PDA course along the right ventricular side of the septum, where pressure is ventricular side of the septum, where pressure is lower. lower.

SA Node:SA Node:

Single artery in 89%.Single artery in 89%. Double arteries in 11%.Double arteries in 11%. Origin from the RCA in 55-65% & from the CX Origin from the RCA in 55-65% & from the CX

or LM in the reminder.or LM in the reminder. RCA → SA nodal artery-courses posteriorely & RCA → SA nodal artery-courses posteriorely &

superiorly over the anterior wall of the right superiorly over the anterior wall of the right atrium beneath the right atrial appendage to atrium beneath the right atrial appendage to encircle the base of the SVC. It may penetrate encircle the base of the SVC. It may penetrate the inter atrial septum.the inter atrial septum.

CX → SA nodal artery-courses over the left CX → SA nodal artery-courses over the left atrial wall, penetrating the inter atrial septum, atrial wall, penetrating the inter atrial septum, then to the base of the SVC.then to the base of the SVC.

AN Node:AN Node:

The AV node is supplied by the dominant The AV node is supplied by the dominant coronary artery.coronary artery.

Accessory blood supply is from Kugel’s Accessory blood supply is from Kugel’s artery which originates from the proximal artery which originates from the proximal segment of either the RCA or CX artery & segment of either the RCA or CX artery & courses through the inter atrial septum to courses through the inter atrial septum to the crux of the heart to anastomose with the crux of the heart to anastomose with the AV node artery.the AV node artery.

Cont………Cont………

Bundle of His & proximal mms of the main Bundle of His & proximal mms of the main bundle branches → AV nodal artery while the bundle branches → AV nodal artery while the reminder of the bundle & the purkinje system are reminder of the bundle & the purkinje system are supplied by septal branches from the LAD supplied by septal branches from the LAD artery.artery.

Anterior Lateral papillary muscle of the RV→ Anterior Lateral papillary muscle of the RV→ LAD.LAD.

Anterior lateral papillary muscle of the LV Anterior lateral papillary muscle of the LV →LAD →LAD ++ CX. CX.

Posterior medial papillary muscle of the LV → Posterior medial papillary muscle of the LV → either RCA or CX depending on the dominance.either RCA or CX depending on the dominance.

Anastomosis between the Anastomosis between the Coronary ArteriesCoronary Arteries

Anastomosis exist at the arteriolar level Anastomosis exist at the arteriolar level between the terminations of the right & between the terminations of the right & left coronary arteries in the left coronary arteries in the atrioventricular groove & between the atrioventricular groove & between the interventricular branches & conus interventricular branches & conus branches.branches.

These anastomosis on the surface of the These anastomosis on the surface of the heart are insignificant. heart are insignificant.

ContCont…….…….

In the interventricular septum & in the post wall of the In the interventricular septum & in the post wall of the left ventricular wall there are free anastomosis, but still left ventricular wall there are free anastomosis, but still by arterioles only.by arterioles only.

The time factor in occlusion is important i.e. In slow The time factor in occlusion is important i.e. In slow occlusion there is time for healthy arterioles to open up, occlusion there is time for healthy arterioles to open up, but in abrupt occlusion there is not.but in abrupt occlusion there is not.

Potential anastomoses exist between the coronary Potential anastomoses exist between the coronary arteries & pericardial arteries around the roots of great arteries & pericardial arteries around the roots of great vessels.vessels.

These pericardial arteries are derived from the These pericardial arteries are derived from the pericardiophenic, bronchial & internal mammary pericardiophenic, bronchial & internal mammary arteries.arteries.

Cardiac VeinsCardiac Veins

Most of the cardiac veins Most of the cardiac veins accompany the coronary arteries.accompany the coronary arteries.

Most of the cardiac veins end in Most of the cardiac veins end in the coronary sinus, which opens the coronary sinus, which opens into the right atrium.into the right atrium.

The heart is similar to the brain in The heart is similar to the brain in the manner that the veins are not the manner that the veins are not named similar to the named similar to the accompanying arteries.accompanying arteries.

Cont ….Cont ….

The veins of the heart fall into three The veins of the heart fall into three groups:groups:

1. Venae cordis minimae.1. Venae cordis minimae. 2. Anterior cardiac veins.2. Anterior cardiac veins. 3. Coronary sinus:3. Coronary sinus: Great cardiac veinGreat cardiac vein Middle cardiac veinMiddle cardiac vein Small cardiac veinSmall cardiac vein Post vein of the LVPost vein of the LV Oblique vein of the LAOblique vein of the LA

Coronary SinusCoronary Sinus

Lies in the posterior part of the AV groove.Lies in the posterior part of the AV groove. Covered by a thin layer of myocardium.Covered by a thin layer of myocardium. It is a wide-bored vessel, about 3 cm long.It is a wide-bored vessel, about 3 cm long. The coronary sinus opening, along with tendon The coronary sinus opening, along with tendon

of todaro & the annulus of the septal leaflet of of todaro & the annulus of the septal leaflet of the tricuspid valve form the boundaries of the the tricuspid valve form the boundaries of the triangle of Koch. The AV node & proximal part triangle of Koch. The AV node & proximal part of the bundle of his lie within this triangle.of the bundle of his lie within this triangle.

Great Cardiac VeinGreat Cardiac Vein

Begins near the apex, ascends first in the Begins near the apex, ascends first in the inter-ventricular groove with left anterior inter-ventricular groove with left anterior descending artery, then at the upper end of descending artery, then at the upper end of the groove, in turns to the left and ends in the groove, in turns to the left and ends in the left end of the coronary sinus.the left end of the coronary sinus.

Receives in its course a number of left Receives in its course a number of left ventricular branches. ventricular branches.

Middle Cardiac VeinMiddle Cardiac Vein

On the diaphragmatic surface.On the diaphragmatic surface.

Begins at the apex of the heart & passes Begins at the apex of the heart & passes backwards in the inferior inter-ventricular backwards in the inferior inter-ventricular groove with the post descending artery & groove with the post descending artery & ends by joining the middle of the coronary ends by joining the middle of the coronary sinus.sinus.

Small Cardiac VeinSmall Cardiac Vein

Begins near the apex of the heart & runs to the Begins near the apex of the heart & runs to the right till the A-V groove where it turns to the left right till the A-V groove where it turns to the left & enters the right end of the coronary sinus.& enters the right end of the coronary sinus.

However it frequently drains directly into the However it frequently drains directly into the right atrium through its anterior wall, in which right atrium through its anterior wall, in which case the vein can be said merely to be the lowest case the vein can be said merely to be the lowest anterior cardiac vein.anterior cardiac vein.

It accompanies the marginal branch of the right It accompanies the marginal branch of the right coronary artery.coronary artery.

Oblique Vein of the LAOblique Vein of the LA

Small vein which descends Small vein which descends obliquely on the back of the left obliquely on the back of the left atrium to end in the coronary atrium to end in the coronary sinus.sinus.

Post Vein of the LVPost Vein of the LV

Joins the coronary sinus to the left Joins the coronary sinus to the left end of the middle cardiac vein.end of the middle cardiac vein.

Veins of the heart that do not Veins of the heart that do not open into the coronary sinusopen into the coronary sinus

Anterior Cardiac Vein.Anterior Cardiac Vein. Venae Cordis Minimae.Venae Cordis Minimae.

Anterior Cardiac VeinsAnterior Cardiac Veins

Series of parallel veins that run across the Series of parallel veins that run across the surface of the right ventricle to open into surface of the right ventricle to open into the right atrium.the right atrium.

They drain independently into the right They drain independently into the right atrium by dipping into the anterior atrium by dipping into the anterior atrioventricular groove.atrioventricular groove.

Venae Cardis MinimaeVenae Cardis Minimae

Small veins of all four chambers of the Small veins of all four chambers of the heart that open directly into their heart that open directly into their respective chambers.respective chambers.

They appear to be most frequent in the They appear to be most frequent in the right atrium.right atrium.

Their contribution to the venous return is Their contribution to the venous return is negligible. negligible.

Lymph drainageLymph drainage

The lymphatics of the heart drain back The lymphatics of the heart drain back along the coronary arteries.along the coronary arteries.

They emerge from the fibrous pericardium They emerge from the fibrous pericardium along with the aorta and pulmonary trunk along with the aorta and pulmonary trunk & empty into the tracheo-bronchial lymph & empty into the tracheo-bronchial lymph nodes & mediastinal lymph trunks. nodes & mediastinal lymph trunks.

Lymphatic drainage of the Lymphatic drainage of the thorasic contents thorasic contents

Three groups of LN:Three groups of LN: Brachio cephalicBrachio cephalic Post. mediastinalPost. mediastinal Tracheo bronchialTracheo bronchial

These groups enter the thorasic duct or These groups enter the thorasic duct or right lymphatic duct.right lymphatic duct.

Brachio cephalic LNBrachio cephalic LN

In the superior mediastinum anterior to the In the superior mediastinum anterior to the brachio cephalic veins.brachio cephalic veins.

They drain the thyroid gland, thymus, They drain the thyroid gland, thymus, heart, pericardium & lateral diaphragmatic heart, pericardium & lateral diaphragmatic nodes, their efferents unite with those of nodes, their efferents unite with those of the tracheo bronchial nodes to form the the tracheo bronchial nodes to form the right & left broncho mediastinal nodes.right & left broncho mediastinal nodes.

Posterior mediastinal nodesPosterior mediastinal nodes

Behind the pericardium, near the esophagus & Behind the pericardium, near the esophagus & the descending thorasic aortathe descending thorasic aorta

Their afferents are from:Their afferents are from: OesophagusOesophagus Posterior pericardiumPosterior pericardium DiaphragmDiaphragm Lateral & posterior diaphragmatic nodesLateral & posterior diaphragmatic nodes Sometimes the left lobe of the liverSometimes the left lobe of the liver They drain chiefly to the thorasic duct, but some They drain chiefly to the thorasic duct, but some

join the tracheo-bronchial nodes.join the tracheo-bronchial nodes.

Tracheo-bronchial nodesTracheo-bronchial nodes

1.1. Paratracheal → infront & to the sides of the Paratracheal → infront & to the sides of the trachea.trachea.

2.2. Sup. Tracheo bronchial → at the angle Sup. Tracheo bronchial → at the angle between the trachea & bronchi.between the trachea & bronchi.

3.3. Inferior tracheo bronchial nodes → in the Inferior tracheo bronchial nodes → in the angle between the bronchi.angle between the bronchi.

4.4. Hilar L.N → at the Hilum.Hilar L.N → at the Hilum.

5.5. Pulmonar or intralobar → in the substance.Pulmonar or intralobar → in the substance.

Lymphatic drainage of the heartLymphatic drainage of the heart

Cardiac lymphatic vessels form sub-Cardiac lymphatic vessels form sub-endocardial , myocardia & sub epicardial plexus endocardial , myocardia & sub epicardial plexus ( 1+2 → drain to 3).( 1+2 → drain to 3).

Efferents from the sub epicardial plexus form Efferents from the sub epicardial plexus form left & right cardiac collecting trunks.left & right cardiac collecting trunks.

2-3 left collecting trunks ascend with the LAD, 2-3 left collecting trunks ascend with the LAD, they are joined by a large vessel from the they are joined by a large vessel from the diaphragmatic surface of the LV (which ascends diaphragmatic surface of the LV (which ascends with the PDA). with the PDA).

Cont………..Cont………..

The vessels formed by the union of these two The vessels formed by the union of these two vessels ascends between the pulmonary trunk & vessels ascends between the pulmonary trunk & left atrium, usually ending in an inferior tracheo-left atrium, usually ending in an inferior tracheo-bronchial node.bronchial node.

The right trunk receives afferents from the right The right trunk receives afferents from the right atrium & right boarder & diaphragmatic surfaces atrium & right boarder & diaphragmatic surfaces of the right ventricle → ascends anterior to the of the right ventricle → ascends anterior to the ascending aorta to end in the brachia-cephalic ascending aorta to end in the brachia-cephalic node \ usually the left. node \ usually the left.

THANK YOUTHANK YOU