CORONARY CIRCULATION

VASCULATURE AND INNERVATION OF THE HEART The endocardium and some subendocardial tissue located immediately external to the endocardium receive oxygen and nutrients by diffusion or microvasculature directly from the chambers of the heart. The blood vessels of the heart, normally embedded in fat, course across the surface of the heart just deep to the epicardium. Both, sympathetic and parasympathetic innervation affects heart vessels. ARTERIAL SUPPLY OF THE HEART The coronary arteries, the first branches of the Ao, supply the myocardium and epicardium. The RCA and LCA arteries arise from the corresponding aortic sinuses at the proximal part of the ascending aorta, just superior to the Ao valve, and pass around opposite sides of the pulmonary trunk. The coronary arteries supply both the atria and the ventricles; however, the atrial branches are usually small and not readily apparent in the cadaveric heart. The ventricular distribution of each coronary artery is not sharply demarcated.

The RCA arises from the Right Aortic Sinus of the ascending Ao and passes to the right side of the pulmonary trunk, running in the coronary groove. Near its origin, the RCA usually gives off an ascending SA nodal branch, which supplies the SA node. The RCA then descends in the coronary groove and gives off the Right Marginal branch, which supplies the right border of the heart as it runs toward (but does not reach) the apex of the heart. After giving off this branch, the RCA turns to the left and continues in the coronary groove to the posterior aspect of the heart. At the crux of the heart - the junction of the septa and walls of the four heart chambers - the RCA gives rise to the AV nodal branch, which supplies the AV node. Dominance of the coronary arterial system is defined by which artery gives rise to posterior IV branch (Posterior Descending a). Dominance of the RCA is ~67%; the RCA gives rise to the large Posterior IV branch, which descends in the posterior IV groove toward the apex of the heart. PDA supplies adjacent areas of both ventricles and sends perforating IV septal branches into the IV septum. The terminal (LV) branch of the RCA then continues for a short distance in the coronary groove. Thus, in the most common pattern of distribution, the RCA supplies the diaphragmatic surface of the heart. Typically, the RCA supplies: The RA. Most of RV. Part of the LV (the diaphragmatic surface). Part (usually the posterior 1/3) of the IV septum. The SA node (~60% of people). The AV node (~80% of people).

The LCA arises from the left aortic sinus of the ascending Ao, passes between the left auricle and the left side of the PT, and runs in the coronary groove. In ~40% of people, the SA nodal branch arises from the circumflex branch of the LCA and ascends on the posterior surface of the left atrium to the SA node. As it enters the coronary groove, at the superior end of the anterior IV groove, the LCA divides into two branches, the Anterior IV branch (LAD branch) and the Cx branch. The Anterior IV branch

(LAD) passes along the IV groove to the apex of the heart. Here it turns around the inferior border of the heart and commonly anastomoses with the posterior IV branch of the RCA. The LAD branch supplies adjacent parts of both ventricles and, via IV septal branches, the anterior 2/3 of the IVS. In many people, the LAD gives rise to a Lateral (Diagonal) branch (LDA), which descends on the anterior surface of the heart.

~67%

The smaller Cx branch of the LCA follows the coronary groove around the left border of the heart to the posterior surface of the heart. The Left Marginal Artery, a branch of the Cx branch, follows the left margin of the heart and supplies the LV. Most commonly, the circumflex branch of the LCA terminates in the coronary groove on the posterior aspect of the heart before reaching the crux, but in approximately one 1/3 of hearts it

continues to supply a branch that runs in or adjacent to the posterior IV groove. Typically, the LCA supplies The LA. Most of the LV. Part of the RV. Most of the IVS (usually its anterior 2/3), including the AVN, through its perforating IV Septal branches (in ~20% of people). The SA node (in ~40% of people).

ARTERIAL SUPPLY TO HEART Artery/Branch Right Coronary SA Nodal Right Marginal Posterior Interventricular AV Nodal Left Coronary SA Nodal Anterior Interventricular Circumflex branch (in 40%) LCA Origin Right aortic sinus RCA near its origin (in 60%) RCA RCA (in 67%) RCA near origin of posterior IV artery Left aortic sinus Course Follows coronary (AV) groove between atria and ventricles Ascends to SAN Passes to inferior margin of heart and apex Runs in posterior IV groove to apex of heart Passes to AVN Runs in AV groove and gives off anterior IV and circumflex branches Ascends on posterior surface of LA to SAN Passes along anterior IV groove to apex of heart Distribution RA, SAN and AVN, and posterior part of IVS PT and SAN RV and apex of heart RV and LV and posterior 1/3 of IVS AVN Most of left atrium and ventricle, IVS, and AV bundles; may supply AVN LA and SA node RV and LV and anterior 2/3 of IVS IV branches Anterior IV branch of LCA (at apex) Anastomoses Cx and anterior IV branches of LCA

RCA

Posterior IV branch of RCA (at

LCA Circumflex Left Marginal Posterior interventricular Circumflex branch LCA (in 33%)

Passes to left in AV groove and runs to posterior surface of heart Follows left border of heart Runs in posterior IV groove to apex of heart

LA and LV

apex) RCA

LV RV and LV and posterior 1/3 of IVS

IV branches Anterior IV branch of LCA (at apex)