The heart muscle, like every other organ or tissue in your body, needs oxygen-rich blood to survive. Blood is supplied to the heart by its own vascular system, called coronary circulation. The aorta (the main blood supplier to the body) branches off into two main coronary blood vessels (also called arteries). These coronary arteries branch off into smaller arteries, which supply oxygen-rich blood to the entire heart muscle. Show
The right coronary artery supplies blood mainly to the right side of the heart. The right side of the heart is smaller because it pumps blood only to the lungs. The left coronary artery, which branches into the left anterior descending artery and the circumflex artery, supplies blood to the left side of the heart. The left side of the heart is larger and more muscular because it pumps blood to the rest of the body.  Tags: heart muscle, aorta, coronary artery, coronary artery disease (CAD), coronary arteries, arteries, blood, coronary artery disease Although CABG has been considered the gold standard for unprotected LCA CAD revascularization, PCI has more recently emerged as a possible alternative mode of revascularization in carefully selected patients. Lesion location is an important determinant when PCI is considered for unprotected LCA CAD. Stenting of the LCA ostium or trunk is more straightforward than treatment of distal bifurcation or trifurcation stenoses, which generally requires a greater degree of operator experience and expertise. In addition, PCI of bifurcation disease is associated with higher restenosis rates than PCI of disease confined to the ostium or trunk. Although lesion location influences technical success and long-term outcomes after PCI, location exerts a negligible influence on the success of CABG. In subgroup analyses, patients with LCA CAD and a SYNTAX score of 33 with more complex or extensive CAD had a higher mortality rate with PCI than with CABG. Physicians can estimate operative risk for all CABG candidates by using a standard instrument, such as the risk calculator from the Society of Thoracic Surgeons (STS) database. These considerations are important factors when one is choosing among revascularization strategies for unprotected LCA CAD and have been factored into revascularization recommendations. Use of a Heart Team approach has been recommended in cases in which the choice of revascularization is not straightforward. The patient’s ability to tolerate and to comply with dual antiplatelet therapy is also an important consideration in revascularization decisions. Experts have recommended immediate PCI for unprotected LCA CAD in the setting of STEMI. The impetus for such a strategy is greatest when LCA CAD is the site of the culprit lesion, antegrade coronary flow is diminished (e.g., thrombolysis in MI flow grade 0, 1, or 2), the patient is hemodynamically unstable, and it is believed that PCI can be performed more quickly than CABG. When possible, the interventional cardiologist and cardiac surgeon should decide together on the optimal form of revascularization for these patients, although it is recognized that they are usually critically ill and therefore not amenable to a prolonged deliberation or discussion of treatment options. View chapter on ClinicalKey Coronary Arteries and Cardiac VeinsIn Imaging Anatomy: Chest, Abdomen, Pelvis (Second Edition), 2017 Single Right Coronary ArteryLeft coronary artery Surgical clip Right coronary artery proper Common right coronary artery trunk Pulmonary trunk Aorta Two images are shown of a patient with D-transposition of the great vessels who underwent arterial switch procedure as an infant. First image is a thick MIP image showing a single coronary artery arising from the right coronary sinus. This single artery divides into a left coronary artery and an RCA proper, which continues in the expected course of the RCA. The anomalous left coronary artery loops in front of the pulmonary trunk in this patient. A single RCA, with anomalous left coronary artery passing in front of the pulmonary trunk, occurs in ∼ 10% of patients with D-transposition of great vessels. Note the location of the pulmonary trunk to the right and anterior to the aorta. Right coronary artery Left coronary artery Volume-rendered image of the same patient shows the course of the left coronary artery, anterior to the pulmonary trunk. View chapterPurchase book Read full chapter URL: https://www.sciencedirect.com/science/article/pii/B9780323477819500210 HeartSusan Standring MBE, PhD, DSc, FKC, Hon FAS, Hon FRCS, in Gray's Anatomy, 2021 Left coronary arteryThe left coronary artery is usually larger in calibre than the right. It supplies a greater volume of myocardium, including almost all of the left ventricle and atrium, and most of the interventricular septum (seeFig. 57.42;Figs 57.49–57.51). In hearts with right dominance, the right coronary artery supplies a variable amount of the inferior region of the left ventricle (seeFig. 57.41A–C). Fig. 57.49. ECG-gated volume-rendered CT coronary angiogram in a left superior oblique view of the heart. Abbreviation: LCA, branch of left coronary artery. Fig. 57.50. ECG-gated volume-rendered CT coronary angiogram in a left view of the heart. Abbreviations: RCA, branch of right coronary artery; LCA, branch of left coronary artery. Fig. 57.51. ECG-gated volume-rendered CT coronary angiogram in a left posterior oblique view of the heart. Abbreviations: RCA, branch of right coronary artery; LCA, branch of left coronary artery. The left coronary artery arises from the left aortic sinus. The opening of the artery sometimes lies inferior to the margin of the valve leaflets and may be double, usually leading into the circumflex and anterior interventricular (left anterior descending) branches of the left coronary artery. Its initial portion, between its opening and first branches, varies in length from a few millimetres to a few centimetres. The artery lies between the pulmonary trunk and the left atrial auricle, emerging into the atrioventricular sulcus, where it turns left. This part is loosely embedded in subepicardial fat and usually has no branches, but may give off a small atrial branch and, rarely, the sinuatrial nodal artery. Upon reaching the atrioventricular sulcus, the left coronary artery divides into its two main branches: the circumflex and anterior interventricular arteries. The anterior interventricular artery is commonly described as the continuation of the left coronary artery. It descends obliquely forwards and to the left in the interventricular sulcus (Fig. 57.52), sometimes deeply embedded in or crossed by myocardial tissue (myocardial bridges), and by the great cardiac vein and its tributaries. Myocardial bridges are reported to have a frequency varying from 0.5 to 40% when identified clinically and from 15 to 85% when found at autopsy (Fig. 57.53). The wide variation in frequency indicates that many bridges may be asymptomatic during life. The major clinical conditions produced by a myocardial bridge are cardiac ischaemia, atherosclerosis and sudden cardiac death. The incidence of atherosclerosis is increased when the right coronary artery is bridged. Although a relationship between myocardial bridges and sudden cardiac death has not been established, autopsy series have shown histological evidence of otherwise unexplained ischaemia in individuals with myocardial bridges; many died during exercise and had no other risk factors for coronary arterial disease. View chapter on ClinicalKey Angiographic DataMorton J. Kern, Pranav Patel, in The Cardiac Catheterization Handbook (Fifth Edition), 2011 Left Main Coronary Artery StenosisA commonly encountered and potentially critical problem is safe coronary angiography of patients who have LMCA stenosis (Fig. 4-12). The approach to the patient with LMCA stenosis is one of the few situations in which the operator and team may directly affect the life and death of the patient. The LM stenosis may occur at the ostium, mid-body, or distal bifurcation of LAD/CFX and has implications for coronary artery bypass graft (CABG) and PCI decisions. LMCA stenosis is commonly associated with two clinical presentations: 1.Patients who show evidence of significant low workload ischemia or hypotension during exercise treadmill testing. Unstable angina may be caused by LMCA stenosis in about 10% of patients. 2.Patients with atypical angina. The clinical history and resting or stress electrocardiogram (ECG) may not be helpful, and often patients with resting or atypical chest pain syndromes do not have previous exercise test data. Technical notes for the angiography of the LMCA stenosis: 1.Either the Judkins femoral or the radial artery technique can be used safely. Access should be based on the operator’s best working method. 2.Coronary angiography before left ventriculography is recommended to obtain the most important information first, should a complication occur. 3.Careful slow advancement and seating of the Judkins left coronary catheter prevent this preshaped catheter from jumping into the ostia. This maneuver is important for an ostial narrowing. Continuous observation of the arterial pressure for damping is important. 4.If the catheter can be positioned beneath the ostia, a “cusp” flush of contrast material in the aortic sinus in an AP or shallow RAO projection may identify an ostial LMCA stenosis. 5.After catheter engagement the operator should look for aortic pressure wave deformation (damping). If pressure damping occurs, a limited contrast flush (1 to 2 ml) and rapid catheter withdrawal (“hit and run”) during cineangiography should be performed to obtain a first look (Fig. 4-13). Rarely, aortic pressure damping occurs without LMCA narrowing because the coronary catheter is seated deeply and subselectively into the LAD artery. Gradual withdrawal and repositioning of the catheter may eliminate pressure damping. The absence of reflux of contrast media into the aortic root on coronary injection is associated with an ostial LMCA stenosis. 6.Limit the number of coronary injections. Distal coronary artery anatomy suitable for bypass grafting is assessed from the few views (usually two or three) that are available. Additional injections should be kept to a minimum. Two projections, an LAO (cranial angulation) and a steeper RAO with caudal angulation are usually sufficient. An LAO-caudal projection for an ostial narrowing is sometimes better. Sometimes one image may be sufficient. Frequent catheter engagement of the LMCA segment and contrast jet stimulation of the lesion may precipitate coronary spasm or occlusion. In less critical LMCA stenosis with 40% to 60% narrowing, more views may be necessary. In some cases IVUS or physiologic measurements (e.g., fractional flow reserve [FFR]) may be necessary. 7.Nonionic or low-osmolar contrast agents are now routinely used. Historically, ionic, high osmolar contrast agents (e.g., meglumine diatrizoate) were associated with lethal complications of hypotension, bradycardia, and reduced coronary perfusion, findings not generally present with nonionic, low-osmolar contrast agents. 8.After the left coronary views are completed, right coronary angiography is performed. In symptomatic patients with RCA occlusion and a critical LMCA stenosis, abdominal aortography and insertion of an intraaortic counterpulsation balloon, intensive care unit admission, and early CABG surgery should be considered. View chapterPurchase book Read full chapter URL: https://www.sciencedirect.com/science/article/pii/B9780323079020100042 Surgery for Congenital Heart DiseaseBRADLEY S. MARINO, ... MERYL S. COHEN, in Pediatric Cardiology, 2006 Anomalous Left Coronary Artery from the Pulmonary Artery (ALCAPA) and Other Coronary Artery AnomaliesNormally, the right coronary artery (RCA) arises from the right sinus of Valsalva and the left coronary artery (LCA) arises from the left sinus of Valsalva. The origins and courses of the coronaries can vary widely. There are particular rare anatomic variations of note, including ALCAPA. ALCAPA usually presents with symptoms of heart failure and coronary ischemia (i.e., irritability while feeding) in the 6– to 12-week-old infant (after pulmonary vascular resistance drops). In addition, infants with ALCAPA often have hemodynamically significant mitral regurgitation secondary to ischemia or infarction of the papillary muscles. Other rare coronary malformations include a coronary that courses between the two great vessels, a high take-off of a coronary artery, and coronary artery fistulae. The LCA coursing between the aorta and the main pulmonary artery may result in compression of the coronary and anginal symptoms or syncope or sudden death during extreme exercise. Unfortunately, patients are commonly completely asymptomatic and the initial presentation can be sudden death. If the origin of a coronary lies significantly above a sinus of Valsalva, an excessive take-off angle, a narrowing of the coronary ostium, or both, may result. Coronary arterial fistulas can occur from either the RCA or LCA to any chamber of the heart, the coronary sinus, the venae cavae, the pulmonary artery, or the pulmonary veins. Although typically there is a single fistulous connection, there may be multiple ones. In patients with coronary fistulas, presentation in infancy is unusual. Late presentation, even into adulthood, is not uncommon. Typically, patients are asymptomatic and present with a murmur or, less commonly, with heart failure caused by a large left-to-right or a large circular shunt from the fistula. Although there can be coronary insufficiency, it is rare for a patient to present with angina as an isolated symptom. Timing of SurgeryALCAPA repair is done at the time of diagnosis. Whether to repair the coronary artery that courses between the aorta and the main pulmonary artery is controversial in an asymptomatic patient because the postoperative risk of sudden death is not known. In general, these coronary anomalies are repaired at the time of diagnosis. Very small fistulous connections will sometimes close spontaneously, and conservative management may be employed. Small coronary arterial fistulas may enlarge over time, and careful follow-up is required. In asymptomatic patients with moderate to large fistulas, elective closure is usually indicated. Symptomatic patients should be addressed at the time of presentation. Method of RepairSurgical intervention for ALCAPA generally involves reimplantation of the coronary from the pulmonary artery to the aorta (Fig. 14-25). If the coronary cannot be mobilized, an aortopulmonary window can be created with a baffle within the pulmonary artery, which channels the coronary blood flow to the aorta (i.e., the Takeuchi repair) (Fig. 14-26). The incision in the pulmonary artery is closed with a patch to compensate for the decrease in pulmonary artery size caused by the baffle. Before surgeons became facile at coronary reimplantation, intervention for ALCAPA previously included ligation of the LCA in those with good collateral circulation from the RCA. This practice has been discontinued due to suboptimal outcomes.55 If mitral regurgitation remains severe, mitral valvuloplasty or mitral valve replacement may be necessary. In patients who have an anomalous course of a coronary artery between the aorta and the pulmonary artery, the method of repair varies depending on the subtype. If the coronary ostium is normal, reimplantation in a manner similar to that described for ALCAPA may be possible. In other cases, the coronary ostium is slit-like and must be remodeled to prevent compression. Finally, in some patients, bypass grafting may be necessary. The manner in which coronary arterial fistulas are addressed is dependent upon location. In some patients, the fistula is very distal and the area of myocardium supplied is insignificant. In such patients, the coronary may be ligated proximal to the fistula. In cases in which the fistula opens into an accessible area such as an atrium or the right ventricle, the opening may be sutured closed or patched from within the heart with an atriotomy (or a pulmonary arteriotomy if the connection is to the PA). In selected cases, the coronary arterial segment over the fistula may be opened longitudinally and the fistula oversewn from within the vessel. The overlying coronary artery is then carefully sutured closed. Coil embolization by cardiac catheterization is often possible to address these lesions, avoiding open-heart surgery altogether. Follow-UpCoronary insufficiency is the primary concern after any intervention on the coronary arteries. In addition to echocardiography to assess ventricular function, nuclear studies are often indicated as a child grows to assess adequate myocardial perfusion. In some cases, cardiac catheterization is necessary to evaluate the coronary. In those with ALCAPA, long-term follow-up of mitral valve and ventricular function is required. View chapterPurchase book Read full chapter URL: https://www.sciencedirect.com/science/article/pii/B9780323023672500213 Percutaneous coronary intervention in left main stem diseaseSEUNG-JUNG PARK MD, PHD, YOUNG-HAK KIM MD, PHD, in Essential Interventional Cardiology (Second Edition), 2008 EMERGENCY INTERVENTION FOR UNPROTECTED LMCA STENOSIS1. Procedure-related complicationsThe LMCA dissection following coronary angiography or interventional procedure is a rare but serious complication. Careful observation or elective CABG may be a reasonable approach for a non-flow limiting dissection. However, emergent CABG or bail-out stenting should be performed for a flow-limiting dissection of the LMCA. A recent retrospective observational study showed that bail-out stenting for LMCA dissection was successful in all cases (n=10) and had very favorable long-term outcomes.19 2. Acute myocardial infarctionBecause there is paucity of data reporting outcomes of acute myocardial infarction patients with acute closure of the LMCA, the role of primary angioplasty remains uncertain. Most patients initially presented with cardiogenic shock, requiring aggressive mechanical support. These patients, unlike other forms of acute myocardial infarction, have a high in-hospital mortality and morbidity because of left ventricular pump failure. In the ULTIMA registry, in-hospital cardiac death rate is still very high, occurring in >50% of patients undergoing primary angioplasty because it cannot prevent acute left ventricular failure.20 However, a recent study showed that 10 surviving patients of 18 patients with LMCA infarction at discharge lived well during 39±22 months except only one case of TLR.21 Therefore, new approaches, such as early catheter-based reperfusion therapy plus left ventricular assisted device insertion, will be a good alternative to emergent bypass surgery. View chapterPurchase book Read full chapter URL: https://www.sciencedirect.com/science/article/pii/B9780702029813500246 Atherectomy debulking of calcified left main coronary lesions: strategies and technologiesEdo Kaluski, ... Amit Shah, in Debulking in Cardiovascular Interventions and Revascularization Strategies, 2022 AbstractCalcified left main coronary artery (LMCA) disease is poorly defined by noninvasive imaging while intracoronary imaging before the percutaneous coronary intervention (PCI) although helpful is often not feasible and infrequently done. Forward ablating tools like orbital atherectomy (OA) and rotational atherectomy are the most effective initial strategy for PCI of all severely calcified lesions including LMCA. These two strategies bear certain shortcomings: sidebranch protection is typically imperfect, and ablation requires time and is occasionally accompanied by hemodynamic instability and unique procedural complications such as slow flow, perforations, hypotension, bradyarrhythmias, and device entrapment. Both atherectomy devices generate a relatively small “pilot channels” with minimal lumen diameter <2.25 mm and minimal luminal area <4 mm2. Consequently, postablation it is mandatory to expand the luminal area with balloon or modified balloon angioplasty to secure optimal stent deployment and expansion. Occasionally, the presence of deep calcification will result in suboptimal balloon and stent expansion and minimal stent area even after ablation means have been exhausted. Procedural intracoronary imaging optimizes LMCA PCI planning, results, and outcomes but is especially of value in identifying and treating appropriately calcified LMCA. View chapterPurchase book Read full chapter URL: https://www.sciencedirect.com/science/article/pii/B9780128214510000045 Complex patient subgroupsEmmanouil Brilakis MD, PhD, in Manual of Percutaneous Coronary Interventions, 2021 24.1.5 EngagementCoronary engagement should be performed with extreme care aiming for coaxial positioning, and avoiding deep coronary artery intubation [2]. 24.1.5.1 Evolut-PRO CoreValveEngagement depending on depth of valve implantation If the Evolut-PRO CoreValve is positioned optimally (skirt below coronary ostia), it is feasible to engage the coronary artery in a coaxial manner, assuming the native aortic valve leaflets will not interfere with the path to the coronary ostium (Fig. 24.2, panel A). Figure 24.2. Self-expanding valve and coronary access depending on level of implantation across the annulus. Red dot represents the location of the coronary ostium in relation to the valve frame, and the red line represents the annular plane. The red x’s depict the closest diamonds that can be used to access the coronary ostium. An optimally positioned Evolut-R (Medtronic, Galway, Ireland) (A) would make coronary access potentially easier than one with a higher implant (B). Reproduced with permission from Yudi MB, Sharma SK, Tang GHL, Kini A. Coronary angiography and percutaneous coronary intervention after transcatheter aortic valve replacement. J Am Coll Cardiol 2018;71:1360–78 (Figure 6). Copyright Elsevier.Which of the following are branches of the left coronary artery quizlet?The left coronary artery branches into what? The anterior interventricular artery and the circumflex artery.
What are the branches of the right and left coronary arteries?The coronary arteries consist of two main arteries: the right and left coronary arteries, and their two branches, the circumflex artery and the left anterior descending artery.
Which of the following are typically direct branches of the right coronary artery?The RCA gives two major branches; the conus (arteriosus) artery and the sinoatrial artery.
What are the 4 major coronary arteries?The Coronary Arteries are the blood vessels that supply blood to your heart. They branch off of the aorta at its base. The right coronary artery, the left main coronary, the left anterior descending, and the left circumflex artery, are the four major coronary arteries.
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