The heart has arteries. Blood vessels of the heart: coronary arteries and veins of the heart. Types of blood supply to the heart. Lymphatic drainage

The heart is muscular organ, ensuring blood circulation in the body according to the principle of a pump. The heart is provided with autonomous innervation, which determines the involuntary, rhythmic work of the muscular layer of the organ - the myocardium. In addition to nerve structures, the heart also has its own blood supply system.

Most of us know that the cardiovascular system The human circulation consists of two main circles of blood circulation: large and small. However, specialists in cardiology consider the vascular system that nourishes the tissues of the heart as the third or coronary circulation.

If we consider a three-dimensional model of the heart with the vessels supplying it, we can see that a network of arteries and veins surrounds the heart like a crown. This is where the name of this circulatory system comes from - coronary or coronary circle.

The coronary circle of hemocirculation consists of vessels, the structure of which is not fundamentally different from other vessels of the body. The vessels through which oxygenated blood moves to the myocardium are called coronary arteries. Vessels providing outflow of deoxygenated, i.e. venous blood are coronary veins. About 10% of all blood passing through the aorta enters the coronary vessels. The anatomy of the vessels of the coronary circle of hemocirculation is different for each person and is individual.

Schematically, the coronary circulation can be expressed as follows: aorta – coronary arteries – arterioles – capillaries – venules – coronary veins – right atrium.

Let's consider the hemocirculation scheme along the coronary circle in stages.

Arteries

The coronary arteries arise from the so-called sinuses of Valsalva. This is an enlarged portion of the aortic root located directly above the valve.

The sinuses are named according to the arteries emerging from them, i.e. the right sinus gives rise to the right artery, the left sinus gives rise to the left artery. The right one runs along the coronary groove on the right, then stretches back to the apex of the heart. Through the branches extending from this highway, blood rushes into the thickness of the myocardium of the right ventricle, washes the tissues of the posterior part of the left ventricle and a significant portion of the cardiac septum.

The left coronary artery, leaving the aorta, is divided into 2 and sometimes 3 or 4 vessels. One of them is ascending and runs along the groove dividing the ventricles in front. Multiple small vessels extending from this branch provide blood flow to the anterior walls of both ventricles. The other vessel is descending and runs along the coronary sulcus on the left. This line carries enriched blood to the tissues of the atrium and ventricle on the left.

Next, the artery goes around the heart on the left and rushes to its apex, where it forms an anastomosis - the fusion of the right cardiac artery and the descending branch of the left. Along the descending anterior artery, smaller vessels branch off, providing blood to the anterior region of the myocardium of the left and right ventricles.

The third coronary artery occurs in 4% of the population. An even rarer case is when a person has only one heart artery.

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Also sometimes there is a doubling of the cardiac arterial trunks. In this case, instead of one arterial trunk, two parallel vessels go to the heart.

For coronary arteries characterized by partial autonomy, expressed in the fact that they are able to independently maintain the required level of blood flow in the myocardium. This functional feature coronary arteries is extremely important, because The heart is an organ that works constantly, continuously. That is why a violation of the condition of the heart arteries (atherosclerosis, stenosis) can lead to fatal consequences.

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“Spent”, i.e. saturated with carbon dioxide and other products of tissue metabolism, blood from the heart tissue flows into the coronary veins.

Big coronary vein begins at the apex of the heart, stretches along the anterior (ventral) interventricular groove, turns to the left along the coronary groove, rushes back and flows into the coronary sinus.

This is a venous structure, about 3 cm in size, located on the posterior (dorsal) part of the heart in the coronary sulcus, has an outlet in the cavity of the right atrium, the mouth does not exceed 12 mm in diameter. The structure is considered to be part of a large vein.

The middle coronary vein emerges at the apex of the heart, next to big vein, but runs along the dorsal interventricular groove. The middle vein also drains into the coronary sinus.

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The small coronary vein is located in the groove separating the right ventricle and atrium from each other, usually passes into the middle vein, and sometimes directly into the coronary sinus.

The oblique cardiac vein collects blood from posterior region myocardium of the left atrium. The posterior vein drains venous blood from tissues back wall left ventricle. These are small vessels that also flow into the coronary sinus.

There are also anterior and small cardiac veins, which have independent exits into the cavity of the right atrium. The anterior veins carry out the outflow of venous blood from the thickness of the muscular layer of the right ventricle. Small veins drain blood from the intracavitary tissues of the heart.

Normal blood flow

As mentioned above, the coronary vessels have individual anatomical features for each person. The normal limits are quite wide, unless we are talking about serious structural anomalies, when the vital activity of the heart suffers significantly.

In cardiology, there is such a thing as blood flow dominance, an indicator that determines which arteries give off the posterior descending (or interventricular) artery.

If the supply of the posterior interventricular branch occurs at the expense of the right and one of the branches of the left arteries, they speak of codominance - typical for 20% of the population. In this case, uniform nutrition of the myocardium occurs. The most common type of dominance is the right one – it is present in 70% of the population.

In this option, the dorsal descending artery arises from the right coronary artery. Only 10% of the population has a left type of blood flow dominance. IN in this case The posterior descending artery branches off from one of the branches of the left coronary artery. With right and left dominance of blood flow, uneven blood supply to the heart muscle occurs.

The intensity of cardiac blood flow is variable. Thus, at rest the blood flow rate is 60–70 mg/min per 100 g of myocardium. During exercise, the speed increases 4–5 times and depends on the general condition of the heart muscle, the degree of its endurance, the frequency of heart contractions, and the characteristics of its functioning. nervous system this person, aortic pressure.

Interestingly, during systolic contraction of the myocardium, the movement of blood in the heart practically stops. This is a consequence of powerful compression of all vessels by the muscular layer of the heart. With diastolic relaxation of the myocardium, blood flow in the vessels is resumed.

The heart is a unique organ. Its uniqueness lies in its almost complete autonomy of operation. Thus, the heart has not only an individual hemocirculation system, but also its own nerve structures, which set the rhythm of its contractions. Therefore, it is necessary to create conditions to maintain the health of all systems that ensure the full functioning of this important organ.

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In embryos early stage During development, the heart wall is formed by loosely arranged muscle fibers that are supplied with blood from chambers, like the spongy subendocardium in adult frogs. As the embryo grows, the walls of the heart thicken and the muscle layers are more compact. To supply substrates metabolically active myocardium Intramural coronary arteries, capillaries and veins are formed from intramuscular sinusoids. Sinusoids form connections with the coronary sinus. Shortly thereafter, around day 44 of gestation, extramural vessels begin to develop from the base of the aorta and protrude toward the apex of the heart. They develop penetrating branches that enter the myocardium and connect to the primitive sinusoidal system. The same rudiments are laid at the base pulmonary artery.

Additional coronary arteries

These coronary arteries are typical branches of the coronary arteries, arising as an independent mouth from the sinuses of Valsalva, so only their mouth is additional. The most common pathology is the right coronary artery. The presence of 2 to 5 additional orifices in the right coronary sinus has been described. Its first branch, the conus artery, arises as an independent artery from the right sinus of Valsalva in 50% of patients. In this case, it is called the right accessory coronary artery.

1% healthy people and more often with bicuspid aortic valve the anterior descending artery and the circumflex branch of the left coronary artery arise as independent orifices from the left sinus. The anterior descending artery can arise as an independent orifice from the right sinus. The first branch of the penetrating coronary artery may arise from the left coronary sinus as a separate orifice.

None of these variants of coronary artery anatomy have clinical consequences and is not included in the list of coronary artery anomalies.

Stenosis and atresia of the coronary artery ostium

This one is rare congenital anomaly most often affects the left coronary artery. It may be the result of:

intrauterine inflammation;

fibromuscular dysplasia;

congenital malformation.

The absence of the extramural part of the coronary artery is more often observed in pulmonary atresia with an intact interventricular septum and in aortic atresia. The pressure in small and sharply hypertrophied right or left ventricles exceeds the pressure in the aorta. Coronary circulation is carried out through dilated sinusoids connected to the coronary arteries. El-Said et al described atresia of the left coronary artery ostium in a 14-year-old boy who complained of cardiac pain, fatigue on exertion, and syncope. He had a systolic murmur at the apex; ventricular extrasystoles were periodically recorded on the ECG; bicycle ergometry revealed a shift of the ST segment below the isoline by 3 mm. Coronary angiography revealed retrograde filling of the left coronary artery through collaterals. The authors completed coronary artery bypass surgery using v. saphena. Similarities clinical symptoms and ECG data in such patients with endocardial fibroelastosis is a reason to diagnose isolated fibroelastosis or abnormal origin of the left coronary artery from the pulmonary trunk. Molander described the medical history of a 19-year-old boy who had been under observation for insufficiency since the age of 4 mitral valve. Catheterization did not shed light on the etiology of the disease. The patient died suddenly. Autopsy revealed old and recent myocardial infarction and severe stenosis of the left coronary artery.

Tangential origin of the coronary arteries from the aorta

Normally, the coronary arteries arise from the aorta at right angles. Whitat et al analyzed 22 cases sudden death adults. In 10 of them, the right coronary artery and in 3, both coronary arteries departed from the aorta tangentially, at an angle of less than 450 between the coronary artery and the aortic wall. The mouth of the affected artery was in the form of a slit, and in 9 people the mouth was partially covered by a protruding ridge like a valve. Other reports of ischemia or death from intramural origin of the coronary arteries suggest that this anomaly is not uncommon. Sudden deaths have been described in adults, but there is a report of a 5-month-old infant dying from this cause

If this anomaly is detected by echocardiography or coronary artery disease, surgical intervention must be undertaken.

Anomalous coronary artery path between the aorta and pulmonary artery

One of the coronary arteries may pass between the aorta and the pulmonary trunk with its normal origin from various sinuses. An unnatural path of the artery also occurs when various options origin of the coronary arteries:

the only coronary artery arising from the right aortic sinus, and the left main coronary artery or anterior descending artery passing between main arteries;

the only coronary artery arising from the left aortic sinus and the right coronary artery passing between the main arteries.

When the orifices of both coronary arteries are in the same sinus, the orifice of the anomalous artery may have a slit-like appearance.

The artery passing between the aorta and the pulmonary trunk may be strangulated by the myocardium, especially during physical activity, and be the cause of sudden death. Patients often have no symptoms until they faint. Frequency and natural history abnormal location of the coronary arteries between main vessels have not been studied. All patients with anginal pain and fainting states Coronary angiography is indicated and, if this pathology is detected, surgical intervention is indicated.

If there are two orifices in one sinus, surgery involves widening and remodeling the anomalous orifice to relieve compression between the main arteries. In this case, bypass surgery may be ineffective due to competing blood flow from the aorta and decreased blood flow through the anastomosis with subsequent thrombosis. However, when there is a single coronary artery and the left main or right coronary artery passes between major vessels, relief of the obstruction by reimplantation or ostial remodeling may not be possible, so bypass grafting becomes the only choice.

Operation technique

After studying the anatomy and starting artificial circulation, the aorta is clamped, the heart is relaxed, and the aorta is opened with a transverse incision. The mouth of the anomalous coronary artery is slit-like and narrow. Since the orifice may be located in close proximity to the commissure, it is necessary to separate it from the aortic wall. The ostium is cut along the long axis of the coronary artery and part of the common wall between the aorta and the artery is dissected. The artery is anastomosed with the aorta with 7/0 or 8/0 prolene. The aortic valve commissure is secured in place with a padded suture. The aortic incision is sutured, the clamp is removed from the aorta after removing air from the cavities of the heart. The operation is completed in the standard way.

Anomalous origin of the left coronary artery and its branches from the right sinus of Valsalva

Among all the anomalies of the coronary arteries, the most common is the origin of the left circumflex coronary artery from the right coronary artery. The circumflex artery passes behind the aorta and reaches its normal blood supply. This anomaly has no clinical significance, however, it can be compressed during double mitral and aortic valve replacement. This artery is characterized by a high probability of damage by atherosclerotic plaques.

Much less common among coronary artery anomalies is the origin of the left main coronary artery from the right sinus of Valsalva. There are 4 possible options for the passage of this artery:

behind the aorta;

in front of the outflow tract of the right ventricle;

in the thickness of the interventricular septum below the conical part of the right ventricle;

between the aorta and the outflow tract of the right ventricle.

With the exception of the two described cases, the first three routes are not accompanied by sudden death or premature myocardial ischemia. The passage of a coronary artery between two great arteries often leads to sudden death in childhood and in adults during or immediately after heavy exercise, since under these conditions the increase in pressure in the aorta and pulmonary artery increases compression of the left coronary artery until it occludes. Preceding symptoms are dizziness and heart pain during exercise. At autopsy, in most cases, a slit-like mouth of the left main coronary artery was found, arising from the aorta at an acute angle and accreting to the aortic wall for about 1.5 cm.

In some patients, the anterior descending coronary artery arises from the right coronary sinus of Valsalva or from the right main coronary artery. This anomaly is rare in the absence of congenital heart disease, but is quite common in tetralogy of Fallot. The artery usually passes along the anterior surface of the outflow tract of the right ventricle or in the thickness of the interventricular septum and rarely between the aorta and the outflow tract of the right ventricle. Sometimes near the mouth common artery An atheromatous plaque is located, so most of the heart is in a state of ischemia, as in stenosis of the main left coronary artery.

Origin of the right coronary artery or its branches from the left sinus of Valsalva

The origin of the right main coronary artery from the left sinus of Valsalva accounts for 30% of all coronary artery anomalies. The artery follows between the aorta and the outflow tract of the right ventricle, then passes through the atrioventricular groove and branches normally. This option is considered relatively benign, but there are many reports of myocardial ischemia, infarction, and sudden death. IN clinical picture Predominant pain in the heart, arrhythmia at rest or during physical activity. During postmortem examinations, the right coronary artery often emerged at an angle to the aorta, and the orifice had a slit-like shape.

Anomalies of coronary vessels accompanying congenital heart disease

With various heart defects, a certain set of anomalies of the coronary arteries sometimes occurs. Below is a brief description of this pathology.

Tetralogy of Fallot

About 40% of patients have an unusually long, large conus artery, which supplies a significant mass of myocardium. In 4-5% of cases, the anterior interventricular branch arises from the right coronary artery and crosses the outflow tract of the right ventricle. Sometimes there is a single coronary artery arising from the right or left sinus. Its large branches may cross the anterior surface of the right ventricle or pass behind the aorta outside the area of ​​the ventricular outflow tract. Other, rare branching options are also possible. The left main coronary artery occasionally passes in front of the pulmonary artery.

If a large artery crosses the right ventricular outflow tract, correction of the defect becomes more difficult. To prevent the intersection of an artery and a heart attack in the area of ​​its blood supply, surgeons use various techniques:

a section of the right ventricle parallel to the course of the artery;

incisions above and below the artery;

creating a tunnel under the artery;

bypassing the narrowed area with an external conduit.

The use of these methods does not guarantee the creation of a free exit into the pulmonary artery. In young children, unfavorable coronary artery anatomy may influence the choice of palliative surgery.

Anomalous passage of the coronary arteries may be suspected by echocardiography and angiography of the aortic root. Although the surgeon sees the coronary arteries during surgery, it is important to establish an accurate diagnosis before surgery to eliminate surprise and plan adequate surgery in advance. In addition, if the patient has epicardial adhesions from a previous operation or if the artery runs deep into the myocardium, it cannot be seen during surgery, so it can be divided with serious consequences. In this regard, all patients who have previously undergone intrapericardial interventions should undergo aortic root angiography. In practice, there have been episodes of crossing a significant coronary artery that required bypass surgery with the internal mammary artery.

Full TMA

With this defect, the mutual orientation of the aorta and the main pulmonary artery differs from the norm, and the aortic sinuses are also located unusually. The left sinus facing the pulmonary artery is called the left presenting sinus, even if it is anterior, and the right sinus is called the right presenting sinus, even if it is posterior.

The coronary arteries arise predominantly from the adjacent sinuses. In 60% of cases, they arise from their own sinuses and branch normally when the aorta is located in front and slightly to the right of the pulmonary artery. But since the aorta is located anteriorly, the left main and circumflex arteries pass in front of the outflow tract of the right ventricle.

In 60% of patients, the right coronary artery arises from the posterior sinus; in 20%, the right coronary artery arises from the posterior sinus with simultaneous independent origin of the anterior descending branch from the left sinus. Other anatomical variants are less common. In 8% of cases, a single coronary artery is observed, which arises from the right adjacent sinus and then follows posteriorly to the pulmonary trunk, or arises from the left adjacent sinus and goes anteriorly to the outflow tract of the right ventricle. In 5% of cases, both main arteries arise from the same adjacent sinus, usually the right one, and one or both arteries run intramural, giving the appearance of arising from different sinuses. There may be other rare variants.

Coronary artery variations influence the planning and performance of arterial switch surgery, as it may be difficult to move the coronary artery ostia into the neoaorta without tension. To solve these problems, various techniques for tunneling the coronary arteries have been developed.

Corrected TMA

The aorta is located anterior and to the left of the pulmonary trunk and both main coronary arteries originate from the adjacent sinuses. The anterior sinus is usually non-coronary. Due to the peculiarities of anatomy, there is confusion regarding the name of coronary arteries that do not arise from their sinuses. Some authors describe the coronary vessels as right- or left-sided, according to the sinuses from which they arise. Others describe arteries by the territory they supply. This is the terminology used here.

The left coronary artery supplies the anatomically left ventricle, however, it arises from the right adjacent sinus. It passes in front of the pulmonary artery and divides into the left anterior descending and circumflex branches. The latter passes in front of the right atrial appendage in the atrioventricular groove.

The right coronary artery supplies the right ventricle. It originates from the left accumbens sinus and passes in the atrioventricular groove anterior to the left atrial appendage, continuing as the posterior descending artery. The most common variant is a single coronary artery arising from the right adjacent sinus.

Dual-flow left ventricle

With this vice there is no true interventricular septum and a typical interventricular groove. The branches of the coronary arteries that run along the edges of the rudimentary exit chamber are delimiting rather than the anterior descending arteries that normally supply the anterior part of the interventricular septum.

When the outlet chamber is located at the front and right, mutual arrangement of the aorta and pulmonary trunk is the same as with complete transposition. The right coronary artery arises from the right adjacent aortic sinus and courses in the right atrioventricular groove. The left main coronary artery arises from the left accumbens sinus and follows as the circumflex artery in the left atrioventricular groove. The left and right delimiting arteries depart from the left and right coronary arteries, respectively.

When the outlet chamber is located anteriorly and to the left, the orientation of the major vessels is the same as with corrected transposition. The right and left main coronary arteries arise from their own adjacent sinuses, and the anterior descending coronary artery may arise from the left or right coronary arteries or there may be two delimiting arteries that limit the vestigial outlet chamber. With any of these options, there may be several large diagonal arterial branches that run parallel to the delimiting branches and cross the right ventricular outflow tract, making fixation of the artificial interventricular septum difficult.

Right ventricle with two outlets

In most forms of this group of anomalies, the coronary arteries usually arise normally, except that due to clockwise rotation of the aortic sinuses, the right coronary artery arises anteriorly and the left coronary artery arises posteriorly. When the aorta is located anteriorly and to the right, the anatomy of the coronary arteries is the same as with complete transposition, i.e. the right coronary artery arises from the right adjacent sinus. In 15% of cases there may be a single coronary artery arising anteriorly or posteriorly. Sometimes the left anterior descending artery arises from the right coronary artery and crosses the outflow tract of the right ventricle, as in tetralogy of Fallot. When the aorta is located on the left, the right coronary artery courses to the right from the anterior sinus of the aorta in front of the pulmonary artery until it reaches the atrioventricular groove.

Common truncus arteriosus

The right and left coronary arteries arise normally from their sinuses. If the valve has more than three leaflets, the usual description must be abandoned. The most constant is the origin of the left main coronary artery from the posterior sinus. From a surgical point of view, options such as an unusually high and close location of the orifices or a single orifice are important. Large diagonal branches of the right coronary artery can cross the anterior surface of the right ventricle and supply the interventricular septum and even part of the free wall of the left ventricle. Crossing these arteries can lead to severe myocardial damage, heart failure, and death.

Single coronary artery

A single coronary artery was first described by Tebesi in 1716; its next description was presented by Hyrtl in 1841. As an isolated defect, this anomaly is extremely rare - 1 case in 2000-7000 of all coronary angiographies performed, somewhat more often among males. Smith proposed the following classification of this anomaly:

A single coronary artery that is a variant of the normal left or right coronary artery.

The only coronary artery from which the normal left and right arteries arise.

A single coronary artery with a circumflex arrangement that differs from its normal location.

The trunk of a single coronary artery or its main branch can be located behind the aorta, between it and the pulmonary trunk, or pass in front of the trunk of the pulmonary artery. IN the latter case the anomaly is particularly dangerous, especially with tetralogy of Fallot or other defects accompanied by narrowing of the outflow tract of the right ventricle, requiring its plasty. Anomalies of the right coronary artery are more common than the left. An isolated defect in the form of a single coronary artery can sometimes be the cause of sudden death, ischemia or myocardial infarction, especially when the left or right artery moves away from common trunk or they pass together between the aorta and the trunk of the pulmonary artery.

A single coronary artery may be present with a bicuspid aortic valve or accompany complex heart defects. Most often it occurs in tetralogy of Fallot, tetralogy of Fallot with pulmonary atresia, TMA, right ventricle with two outlets, left ventricle with two outlets, general truncus arteriosus, single/common ventricle, ASD with pulmonary artery stenosis, heterotaxy.

Quite often, a single coronary artery is found in patients with tetralogy of Fallot. It occurs in 5% of children with TMA; in this case, the artery arises from the posterior sinus and divides into two normal coronary arteries: the right and left.

The most favorable anomaly of the coronary arteries is the origin of both arteries by separate or common mouth from one sinus of Valsalva. A normal origin of one coronary artery from the aorta with a branch of the left coronary artery from it was also noted. Complete absence one of the coronary arteries is an extremely rare anomaly. In this case, the existing coronary artery independently provides coronary circulation. There are many reports in the literature of cases of a single coronary artery, usually concomitant with another congenital pathology heart, as well as cases of a single coronary artery with normal heart morphology.

Intramural passage of the coronary artery

In some cases, the initial section of the left coronary artery, arising from the right aortic sinus, is located in the thickness of the aortic wall. During histological examination, the vessels have a single middle membrane; it is common to the aorta and coronary artery. This anatomical location of the coronary artery is sometimes the cause of sudden death. When the ascending aorta, rich in fibrous fibers, expands during systole, compression of the intramural segment of the left coronary artery occurs, which leads to myocardial ischemia. Treatment for this syndrome is surgical plastic surgery coronary artery with the isolation of this segment from the aortic wall or the application of a shunt bypassing the intramural segment.

The intramural location of the coronary artery in a child with TMA requires a more complex surgical technique when performing anatomical correction of this defect.

"Diving Arteries"

Large epicardial coronary arteries normally pass along the surface and only their terminal branches penetrate into the thickness of the myocardium. In 50% of people, the coronary arteries are sometimes buried in the thickness of the myocardium, and then reappear on its surface. In these cases, a muscular bridge is formed over a large coronary artery. Most often, the “mural” is the left anterior descending branch in its proximal half. This anomaly is found in both infants and older people. At the age of up to 20 years, the length of the submerged part is on average 14 mm, at an older age - 20-30 mm. In approximately 75% of cases, the anterior descending coronary artery passes through the interventricular groove and may be covered by several superficial bridges muscle fibers, 25% – front interventricular artery deflects towards the right ventricle and passes deep into the interventricular septum, where it is crossed by a muscle bundle emanating from the apex of the right ventricle.

Most muscle bridges do not have functional significance, especially if they lie superficially. However, cases have been described when, during physical activity, the submerged part of the coronary artery narrows, which becomes the cause of acute coronary insufficiency and sudden death, including in patients after myotomy.

During coronary angiography, it is clear that part of the coronary artery is narrowed in systole, but is well passable in diastole. In the presence of pain, careful release of the coronary artery from the muscle tunnel is indicated. Surgery is indicated if there is objective evidence of ischemia on the electrocardiogram and increased lactate production in the regional vein. Ischemia usually occurs when there is a long, thick muscle bridge that compresses the artery and relaxes unusually slowly so that diastolic filling of the distal coronary artery is impaired. After performing a thorough myotomy pain syndrome and signs of ischemia disappear.

In children, diving coronary arteries are rare and occur only in cases of ventricular hypertrophy, especially hypertrophic cardiomyopathy.

Coronary artery aneurysm

It was first described in 1812. It is an extremely rare anomaly. Only one in five coronary artery aneurysms are congenital. Acquired aneurysm can occur in children as a result of Kawasaki disease, previous endocarditis, nodular coronaritis, and in adults as a result of the development of atherosclerosis, syphilitic lesions of the coronary arteries, or against the background of a congenital fistula of the coronary artery. A coronary artery aneurysm can also form as a result of myocardial infarction. Congenital aneurysm occurs due to a violation of the structure of the vascular mesothelium or a deficiency of normal protein fibers of the connective tissue. Both the right and left coronary arteries can undergo aneurysmal dilatation, very in rare cases Both arteries may be affected, and even more rarely, multiple aneurysms of the coronary arteries are diagnosed. A combined defect in the form of a TMA with a coronary artery aneurysm has been described. All types of coronary artery aneurysms can either be asymptomatic until they rupture, or lead to the development of ischemia or myocardial infarction. Cases of thrombosis of a coronary artery aneurysm have been described.

Surgery

Indications for surgery are signs of myocardial ischemia or accidental discovery of an aneurysm. large sizes. The operation consists of resection of the aneurysm and application of a coronary artery bypass graft, or ligation of the aneurysm at its initial and final sections with the application coronary artery bypass graft below the aneurysm. Indications for surgical intervention may arise for both congenital and acquired coronary artery aneurysm. An aneurysm resulting from Kawasaki disease rarely requires surgical intervention, except in cases of threat of aneurysm rupture or thrombosis.

The LCA supplies blood to a much larger heart array, both in volume and in importance. However, it is customary to consider what type of blood supply (left-coronal, right-coronal or uniform) is present in the patient. We are talking about which artery in a particular case the posterior interventricular artery is formed from, the blood supply area of ​​which is the posterior third of the interventricular septum; that is, in the presence of the right coronal type, the posterior interventricular branch is formed from the RCA, which is more developed than the circumflex branch of the LMCA. However, this does not mean that the RCA supplies blood to a larger array of the heart compared to the LCA. The right coronary type of vascularization is characterized by the fact that the right coronary artery extends beyond the posterior longitudinal groove and supplies the right and most of the left heart with its branches, and the circumflex branch of the left coronary artery ends at the blunt edge of the heart. In the left coronary type, the circumflex branch of the left coronary artery extends beyond the posterior longitudinal groove, giving off the posterior interventricular branch, which usually arises from the right coronary artery and supplies with its branches not only the posterior surface of the left heart, but also most of the right one, and the right coronary artery ends at the sharp edge hearts. With a uniform type of blood supply to the heart, both coronary arteries equally developed. Some authors, in addition to these three types of blood supply to the heart, distinguish two more intermediate ones, designating them “middle-right” and “middle-left”.

The predominance of the right coronary artery of the heart is observed only in 12% of cases, in 54% of cases the left coronary artery predominates, and in 34% both arteries are developed evenly. When the right coronary artery is dominant, there is never such a sharp difference in the development of both coronary arteries as is observed with the left coronary type. This is due to the fact that the anterior interventricular branch, always formed by the left coronary artery, supplies blood to large areas of the LV and RV.

The coronary arteries and their branches, located subepicardially, are surrounded by loose connective tissue, the amount of which increases with age. One of the features of the topography of the coronary arteries is the presence above them in 85% of cases of muscular jumpers in the form of bridges or loops. Muscular bridges are part of the ventricular myocardium and are most often detected in the anterior interventricular groove above the sections of the same branch of the left coronary artery. The thickness of the muscle bridges ranges from 2-5 mm, their width along the arteries varies from 3-69 mm. In the presence of bridges, the artery has a significant intramural segment and acquires a “diving” course. During intravital coronary angiography, their presence is revealed in systole by a conical narrowing of the artery or its sharp bend in front of the jumper, as well as insufficient filling of the vessel under the jumper. In diastole, these changes disappear.

Additional sources of blood supply to the heart include the internal thoracic, superior phrenic, intercostal arteries, bronchial, esophageal and mediastinal branches of the thoracic aorta. Of the branches of the internal thoracic arteries, the pericardial-phrenic arteries are important. The second leading source of additional vascularization of the heart is the bronchial arteries. The average total cross-sectional area of ​​all extracardiac anastomoses at the age of 36-55 years and over 56 years is 1.176 mm2.

V.V. Bratus, A.S. Gavrish "Structure and functions of the cardiovascular system"

The coronary or coronary artery plays important role in the coronary blood supply. The human heart consists of muscles that are constantly, without interruption, in action. For normal operation muscles need a constant flow of blood, which carries the necessary nutrients. These pathways are responsible for supplying blood to the muscles of the heart, that is, coronary blood supply. The coronary blood supply accounts for about 10% of all blood that passes through the aorta.

The vessels that are located on the surface of the heart muscle are quite narrow, despite the amount of blood in percentage, which passes through them. In addition, they are able to regulate blood flow themselves, depending on the needs of the heart. In general, the increase in blood flow can increase up to 5 times.

The coronary arteries of the heart are the only sources of blood supply to the heart, and the supply of the required amount of blood is solely responsible for the function of vascular self-regulation. Therefore, possible stenosis or atherosclerosis of the latter is critically dangerous for human life. Anomalies in the development of the myocardial circulatory system are also dangerous.

Vessels, weaving around the surface and internal structures of the myocardium, can connect with each other, creating a single network of arterial supply to the heart muscle. There is no connection of the network of vessels only at the edges of the myocardium, since such places are fed by separate terminal vessels.

Everyone's blood supply individual person may vary significantly and is individual. However, it can be noted that there are two trunks of the coronary artery: right and left, which originate from the root of the aorta.

The normal development of the coronary vessels leads to the formation of a vascular network, which appearance vaguely resembles a crown or a crown, which is actually where their name came from. Adequate blood flow is very important for the normal and adequate functioning of the heart muscle. In the event of abnormal development of the vascular network designed to provide blood supply to the heart muscle, significant problems for the latter can arise.

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Doctors' opinion...

Abnormal development of the cardiac vasculature does not occur very often, up to 2% of all cases. This refers only to anomalies that lead to serious violations. For example, in the case of formation of the beginning of the left coronary artery from the pulmonary trunk instead of the aorta. As a result, the heart muscle receives venous blood, which is poor in oxygen and nutrients. The situation is further aggravated by the lack of pressure in the pulmonary trunk; the blood is not only poor, but also supplied in insufficient quantities.

Anomalies of this type are called a defect, and they can be of two types. The first type is caused by insufficient development of bypass pathways of blood flow between the two main branches of the arteries, which leads to a more severe development of the anomaly. The second type is due to well-developed bypass pathways. Then the left part of the heart muscle has the opportunity to receive the missing nutrients from the neighboring pathway. The second type of anomaly assumes a more stable condition of the patient, and does not pose an immediate threat to the latter’s life, but also does not imply any stress.

Blood flow dominance

The anatomical location of the posterior descending branch and the anterior interventricular branch determines the dominance of blood flow. Only in the same case good development of both branches of the coronary blood supply, we can talk about the constancy of the areas of nutrition of each branch, and their usual branches. In the case of better development of one of the branches, a shift occurs in the branching of the branches and, accordingly, in the areas for which they are responsible for nutrition.

Depending on the severity of the coronary tract, right and left types of dominance, as well as co-dominance, are distinguished. Uniform blood supply or codominance is noted when the posterior descending branch is supplied by both branches. Right dominance is noted when the posterior interventricular branch is fed by the right coronary artery; it occurs in 70% of cases. Accordingly, the left type of dominance is noted when feeding from the neighboring bloodstream, and occurs in 10% of cases. Codominance occurs in 20% of all cases.

Right trunk

The right coronary artery supplies blood to the ventricle of the myocardium along with the right atrium, the posterior third of the septum and part of the conus arteriosus. Location: runs from the root along the coronary sulcus and, going around the edge of the myocardium, reaches the surface of the myocardial ventricle (its back) and the lower surface of the heart. After which it branches into terminal branches: right anterior atrial branching, right anterior ventricular branching. In addition, it is divided into right marginal and posterior ventricular branching. As well as the posterior interventricular branching, the right posterior atrial branching and the left posterior ventricular branching.

Left trunk

The path of the left coronary artery runs to the sternocostal surface of the myocardium between the left auricle and the pulmonary trunk, after which it branches. In 55% of all cases, the length of the latter barely reaches 10 mm.

Supplies blood to most interatrial septum in its back and front. This branch also supplies the left atrium and ventricle. In most cases it has two branches, but sometimes it can branch into three, less often four branches.

The largest branches of this coronary bloodstream, which occur in a greater number of cases, are the circumflex branch and the anterior interventricular branch. Passing from their origin, they branch into smaller vessels, which can connect with small vessels of other branches, creating a single network.

Anatomy coronary circulation highly variable. The characteristics of the coronary circulation of each person are unique, like fingerprints, and therefore each myocardial infarction is “individual”. The depth and prevalence of a heart attack depend on the interweaving of many factors, in particular on the congenital anatomical features of the coronary bed, the degree of development of collaterals, the severity of atherosclerotic lesions, the presence of “prodromes” in the form of angina pectoris, which first appeared during the days preceding the infarction (ischemic “training” of the myocardium), spontaneous or iatrogenic reperfusion, etc.

As is known, heart receives blood from two coronary (coronary) arteries: the right coronary artery and the left coronary artery [respectively a. coronaria sinistra and left coronary artery (LCA)]. These are the first branches of the aorta that arise from its right and left sinuses.

LKA barrel[in English - left main coronary artery (LMCA)] arises from the upper part of the left aortic sinus and goes behind the pulmonary trunk. The diameter of the LKA trunk is from 3 to 6 mm, the length is up to 10 mm. Typically, the LCA trunk is divided into two branches: the anterior interventricular branch (AIV) and the circumflex branch (Fig. 4.11). In 1/3 of cases, the LMCA trunk is divided not into two, but into three vessels: the anterior interventricular, circumflex and median (intermediate) branches. In this case median branch(ramus medianus) is located between the anterior interventricular and circumflex branches of the LMCA.
This vessel- analogous to the first diagonal branch (see below) and usually supplies the anterolateral parts of the left ventricle.

Anterior interventricular (descending) branch of the LCA follows the anterior interventricular groove (sulcus interventricularis anterior) towards the apex of the heart. In the English-language literature, this vessel is called the left anterior descending artery: left anterior descending artery (LAD). We will adhere to the more anatomically accurate (F. H. Netter, 1987) and accepted in Russian literature term “anterior interventricular branch” (O. V. Fedotov et al., 1985; S. S. Mikhailov, 1987). At the same time, when describing coronary angiograms, it is better to use the term “anterior interventricular artery” to simplify the name of its branches.

Main branches last- septal (penetrating, septal) and diagonal. The septal branches depart from the PMV at a right angle and deepen into the thickness of the interventricular septum, where they anastomose with similar branches arising inferiorly from the posterior interventricular branch of the right coronary artery (RCA). These branches may differ in number, length, direction. Sometimes there is a large first septal branch (running either vertically or horizontally - as if parallel to the PMV), from which branches extend to the septum. Note that of all regions of the heart, the interventricular septum of the heart has the densest vascular network. The diagonal branches of the PMV pass along the anterolateral surface of the heart, which they supply with blood. There are from one to three such branches.

In 3/4 of cases PMV does not end in the area of ​​the apex, but, bending around the latter on the right, wraps onto the diaphragmatic surface of the posterior wall of the left ventricle, supplying blood, respectively, to both the apex and partially the posterior diaphragmatic sections of the left ventricle. This explains the appearance of ECG wave Q in lead aVF in a patient with a large anterior infarction. In other cases, ending at the level or not reaching the apex of the heart, the PMV does not play a significant role in its blood supply. The apex then receives blood from the posterior interventricular branch of the RCA.

Proximal area front The interventricular branch (IVB) of the LCA is called the segment from the mouth of this branch to the departure of the first septal (penetrating, septal) branch or to the departure of the first diagonal branch (less strict criterion). Respectively middle section- this is a segment of the PMV from the end of the proximal section to the origin of the second or third diagonal branch. Next is the distal portion of the PMV. When there is only one diagonal branch, the boundaries of the middle and distal sections are determined approximately.

Educational video of the blood supply to the heart (anatomy of arteries and veins)