“Sarcoidosis, a Scare, Chest Pain and an Octopus”
This is a story about a 59 year old woman who had sarcoidosis, who had a scare developed chest pain that sounded like acute coronary syndrome and was short of breath
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Introduction to Coronary Artery Anatomy
Corona = Crown or wreath from mid 17th century (in the sense ‘resembling a crown’): from Latin coronarius, from corona ‘wreath, crown’.
Corona = Crown or wreath from mid 17th century (in the sense ‘resembling a crown’): from Latin coronarius, from corona ‘wreath, crown’.
Courtesy Ashley Davidoff MD
Anatomical Specimen injected with Barium
The Left Side Anterior View
LAD Coursing in the Interventricular Groove
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Branches
3-5 Diagonals supplying the anterior portion of the LV
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OBTUSE MARGINALS OFF THE CIRCUMFLEX (3-4 vessels)
supplying the lateral and posterior portion of the LV
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INFUNDIBULAR BRANCH SUPPLYING THE ARC OF VIEUSSENS
Important collateral from proximal LAD to proximal RCA
CIRCUMFLEX AND OBTUSE MARGINALS
in lateral projection supplying the lateral and posterior portions of the LV
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OBTUSE MARGINALS OFF THE CIRCUMFLEX POSTERIOR VIEW in a right dominant system. In this case only about 50% of the inferior portion of the LV is supplied by the LCA
OBTUSE MARGINALS OFF THE CIRCUMFLEX
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RIGHT SIDE – DOMINANT
MAIN RCA IN ANTERIOR A-V GROOVE
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INFUNDIBULAR BRANCH SUPPLYING THE ARC OF VIEUSSENS in the RVOT
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ANTERIOR RV BRANCHES AND ACUTE MARGINAL ARTERY (arrow)
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RIGHT SIDE POSTERIOR VIEW – CONTINUATION OF THE RCA
CONTINUATION OF THE RCA
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PDA
Note it runs side by side with the middle cardiac vein
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POSTERIOR LV BRANCHES
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A-V NODAL ARTERY
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3D
Scaffolding of the Heart
Basic Structure – a Cross Made of Two Intersecting Circles
The Cross in 3 Dimensions
The infrastructure of the heart as a cross has horizontal and vertical components that have 3 dimensions (b). The tricuspid valve and annulus (blue ring) and mitral valve and annulus (red horizontal ring) are aligned in the horizontal plane (c). The right coronary artery (RCA) and circumflex (LCx) supply the right and left side while the left anterior descending (LAD) and posterior descending artery (PDA) align along the the vertical limb.
Ashley Davidoff MD
Horizontal circle consists of the mitral and tricuspid annuli and the Circumflex and RCA run in their respective A-V grooves. The LAD and PDA run anteriorly and posteriorly in their respective interventricular grooves
The Cross in 3 Dimensions
The infrastructure of the heart as a cross has horizontal and vertical components that have 3 dimensions.
The tricuspid valve and annulus (blue ring) and mitral valve and annulus (red horizontal ring) are aligned in the horizontal plane (c). The right coronary artery (RCA) and circumflex (LCx) supply the right and left side while the left anterior descending (LAD) and posterior descending artery (PDA) align along the the vertical limb.
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CORONARY CIRCULATION IN 3D – ANATOMICAL SPECIMEN INJECTED WITH BARIUM
The anatomical specimen has been injected with barium and shows LAD arising from the left main coronary artery. The diagonal arteries (d) course toward the patients left to supply the anterior and anterolateral part of the LV. The infundibular artery (I, aka arc of Vieussen’s) courses over the RVOT to join its partner arising from the RCA. The septal arteries have a vertical course toward the diaphragm, and the branch to the anterolateral papillary muscle of the RV (a-l) courses toward the right of the patient. The LAD often terminates with a bifurcation reminiscent of a moustache.
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CIRCUMFLEX CORONARY ARTERY –
Note The distal circumflex is usually very small and sometimes not even visible but is recognised by its relationship to the A_V groove and coronary sinus
The anatomical specimen has been injected with barium and shows the circumflex (c) arising from the left main coronary artery. The obtuse marginal arteries are large vessels so the distal circumflex continuation (c c green arrow) is a small vessel that runs in the posterior A-V groove with the coronary sinus
Ashley Davidoff MD
BRANCHES OF THE CIRCUMFLEX CORONARY ARTERY
Note the SA nodal artery arises from the circumflex about 40% of the time and from the RCA 60% of the time
The anatomical specimen has been injected with barium and shows the circumflex (c) arising from the left main coronary artery. The obtuse marginal arteries are large vessels so the distal circumflex continuation (c c green arrow) is a small vessel that runs in the posterior A-V groove with the coronary sinus
The S-A nodal artery (s-a) sometimes arises from the circumflex as the first branch. Atrial branches (a) also arise from the proximal circumflex artery.
A number of obtuse marginal arteries (OM1 and OM2 ) supply the posterior and posterolateral parts of the LV and are almost always larger than the distal circumflex itself (c c).
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RCA
Note the septal perforators supply about 1/3 of the septum and are important collateral pathway when the LAD is occluded
The coronary arteries have been injected with barium and shows left (bright red overlay) and right (maroon) coronary circulation The proximal RCA (p) courses anteriorly in the A-V groove arising from the right coronary ostium. The acute marginal (am) courses along the right margin of the heart, and the RCA continues posteriorly (p) to the crux of the heart where it gives off 3 branches. The posterior descending artery (PDA), A-V nodal artery (a-v) and posterior left ventricular artery (plv). The PDA supplies the inferior 1/3 of the interventricular septum with perforating septal arteries (s)
This is a dominant RCA
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SELECTIVE ANGIOGRAPHY
The angiogram of the left coronary artery in the LAO projection shows the LAD in b, diagonals in c and septal arteries coursing toward the diaphragm in d.
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Dominant LCA 15-20%
The angiogram of the LCA (a) shows the circumflex (b) arising from the left main coronary artery. In this left dominant system, there are 4 obtuse marginal arteries (c). Distally the circumflex continues and gives rise to the PDA, (d) AV nodal artery and posterior LV branches
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RCA Dominant 80-85%
The angiogram of a dominant RCA shows the infundibular artery coursing to the RVOT, the acute marginal artery (AM), at the right margin of the heart, PDA and septal perforators,, A-V nodal (AVn) and posterior left ventricular branches (Post LV)
Ashley Davidoff MD