Coronary anatomy for Interventional Cardiologists toufiqur rahman

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


• 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 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


• 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

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


SEGMENTS OF LAD


Distal


PRINCIPAL SEGMENTS OF LCX

Thank [email protected]

Asia Pacific Congress of Hypertension, 2014, February

Cebu city, Phillipines

Seminar on Management of Hypertension, Gulshan, Dhaka

Coronary anatomy for Interventional Cardiologists toufiqur rahman

Health & Medicine

Transcript of Coronary anatomy for Interventional Cardiologists toufiqur rahman