Coronary circulation: Difference between revisions

	Coronary Angiography
Home
General Principles Overview ; Historical Perspective ; Contraindications ; Appropriate Use Criteria for Revascularization ; Complications ; Technique ; Film Quality
Anatomy & Projection Angles
Normal Anatomy Coronary arteries Dominance Right System Left System Left Main Left Anterior Descending Circumflex Median Ramus
Anatomic Variants Separate Ostia Anomalous Origins Case Example Fistula
Projection Angles Standard Views Left Coronary Artery Right Coronary Artery
Epicardial Flow & Myocardial Perfusion
Epicardial Flow TIMI Frame Count ; TIMI Flow Grade TIMI Grade 0 Flow TIMI Grade 1 Flow TIMI Grade 2 Flow TIMI Grade 3 Flow TIMI Grade 4 Flow Pulsatile Flow Deceleration
Myocardial Perfusion TIMI Myocardial Perfusion Grade TMP Grade 0 TMP Grade 0.5 TMP Grade 1 TMP Grade 2 TMP Grade 3
Lesion Complexity
ACC/AHA Lesion-Specific Classification of the Primary Target Stenosis
Preprocedural Lesion Morphology Eccentricity Irregularity Ulceration Intimal Flap Aneurysm Sawtooth Pattern Length Ostial location Angulation Proximal tortuosity Degenerated SVG Calcification Total occlusion Coronary Artery Thrombus TIMI Thrombus Grade TIMI Thrombus Grade 0 TIMI Thrombus Grade 1 TIMI Thrombus Grade 2 TIMI Thrombus Grade 3 TIMI Thrombus Grade 4 TIMI Thrombus Grade 5 TIMI Thrombus Grade 6
Lesion Morphology Quantitative Coronary Angiography Definitions of Preprocedural Lesion Morphology Irregular Lesion Disease Extent Arterial Foreshortening Infarct Related Artery Restenosis Degenerated SVG Collaterals Aneurysm Bifurcation Trifurcation Ulceration
Left ventriculography

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Latest revision as of 15:41, 13 November 2013

Template:Infobox Anatomy Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Rim Halaby, M.D. [3]

Overview

The coronary circulation is the circulation of blood in the blood vessels that supply blood to and from the heart muscle itself. Although blood fills the chambers of the heart, the muscle tissue of the heart, the myocardium, is so thick that it requires coronary blood vessels to deliver blood deep into it. The coronary arteries are the vessels that deliver oxygen-rich blood to the myocardium. Cardiac veins are the vessels that remove the deoxygenated blood from the heart muscle. Epicardial coronary arteries are the coronary arteries that run on the surface of the heart. These arteries, when healthy, are capable of autoregulation to maintain coronary blood flow at levels appropriate to the needs of the heart muscle. These relatively narrow vessels are commonly affected by atherosclerosis and can become blocked, causing angina or a heart attack. Subendocardial coronary arteries run deep within the myocardium. The coronary arteries are classified as end circulation, since they represent the only source of blood supply to the myocardium: there is very little redundant blood supply, which is why blockage of these vessels can be so critical.

Coronary Arteries and Veins

Coronary Arteries

he coronary arteries supply oxygenated blood to the heart muscle itself. Although blood fills the chambers of the heart, the muscle tissue of the heart, or myocardium, is so thick that it requires coronary blood vessels to deliver blood deep into it. There are two primary arteries supplying the heart, the left coronary artery and the right coronary artery. These two epicardial coronary arteries course along the surface of the heart and this is why they are called "epicardial" (on top of the heart) arteries. Smaller arteries dive deep into the heart muscle and are called subendocardial coronary arteries.

Click here for details about coronary arteries.

Cardiac Veins

The cardiac veins are the vessels that remove the deoxygenated blood from the heart muscle and return it to the right atrium.

Click here for details about cardiac veins.

Shown below is an image depicting the coronary arteries and cardiac veins.

Blood Supply to the Papillary Muscles

The papillary muscles tether the mitral valve (the valve between the left atrium and the left ventricle) and the tricuspid valve (the valve between the right atrium and the right ventricle) to the wall of the heart.
If the papillary muscles are not functioning properly, the mitral valve leaks during contraction of the left ventricle and causes some of the blood to travel "in reverse", from the left ventricle to the left atrium, instead of forward to the aorta and the rest of the body.
This leaking of blood to the left atrium is known as mitral regurgitation.

The anterolateral papillary muscle:
- It receives two blood supplies: the LAD and LCX.
- It is therefore somewhat resistant to coronary ischemia (insufficiency of oxygen-rich blood).
The posteromedial papillary muscle:
- It is supplied only by the PDA.
- This makes the posteromedial papillary muscle significantly more susceptible to ischemia.
The clinical significance of the nature of blood supply to the papillary muscles is that a myocardial infarction involving the PDA is more likely to cause mitral regurgitation.

Coronary flow

During contraction of the ventricular myocardium (systole), the subendocardial coronary vessels (the vessels that enter the myocardium) are compressed due to the high intraventricular pressures. However the epicardial coronary vessels (the vessels that run along the outer surface of the heart) remain patent. Because of this, blood flow in the subendocardium stops.
As a result most myocardial perfusion occurs during heart relaxation (diastole) when the subendocardial coronary vessels are patent and under low pressure. This contributes to the filling difficulties of the coronary arteries.

Failure of oxygen delivery via increases in blood flow to meet the increased oxygen demand of the heart results in tissue ischemia, a condition of oxygen debt.
- Brief ischemia is associated with intense chest pain, known as angina.
- Severe ischemia can cause the heart muscle to die of oxygen starvation, called a myocardial infarction.
- Chronic moderate ischemia causes contraction of the heart to weaken, known as myocardial hibernation.

In addition to metabolism, the coronary circulation possesses unique pharmacologic characteristics. Prominent among these is its reactivity to adrenergic stimulation. The majority of vasculature in the body constricts to norepinephrine, a sympathetic neurotransmitter the body uses to increase blood pressure.
- In the coronary circulation, norepinephrine elicits vasodilation, due to the predominance of beta-adrenergic receptors in the coronary circulation.
- Agonists of alpha-receptors, such as phenylephrine, elicit very little constriction in the coronary circulation.

References

Template:Arteries of chest

Template:WikiDoc Sources

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+{{Coronary angiography2}}
 {{Infobox Anatomy |
    Name         = Coronary circulation |
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 }}
-{{SI}}
+{{CMG}}; '''Associate Editor-In-Chief:''' {{CZ}}; {{Rim}}
-{{CMG}}Him; '''Associate Editor-In-Chief:''' {{CZ}}
 ==Overview==
-The '''coronary circulation''' is the circulation of blood in the [[blood vessel]]s that supply [[blood]] to and from the [[heart]] muscle itself. Although blood fills the chambers of the heart, the muscle tissue of the heart, or [[myocardium]], is so thick that it requires coronary blood vessels to deliver blood deep into it. The vessels that deliver oxygen-rich blood to the myocardium are known as coronary arteries. The vessels that remove the deoxygenated blood from the heart muscle are known as cardiac veins.
+The coronary circulation is the circulation of blood in the [[blood vessel]]s that supply [[blood]] to and from the [[heart]] muscle itself.  Although blood fills the chambers of the heart, the muscle tissue of the heart, the [[myocardium]], is so thick that it requires coronary blood vessels to deliver blood deep into it.   The [[coronary arteries]] are the vessels that deliver oxygen-rich blood to the myocardium.  [[Cardiac veins]] are the vessels that remove the deoxygenated blood from the heart muscle.   Epicardial coronary arteries are the coronary [[artery|arteries]] that run on the surface of the heart.  These arteries, when healthy, are capable of [[autoregulation]] to maintain coronary blood flow at levels appropriate to the needs of the [[myocardium|heart muscle]].  These relatively narrow vessels are commonly affected by [[atherosclerosis]] and can become blocked, causing [[Angina pectoris|angina]] or a [[myocardial infarction|heart attack]].  Subendocardial coronary arteries run deep within the myocardium.  The coronary arteries are classified as end circulation, since they represent the only source of blood supply to the myocardium: there is very little redundant blood supply, which is why blockage of these vessels can be so critical.
-The coronary [[artery|arteries]] that run on the surface of the heart are called epicardial coronary arteries. These arteries, when healthy, are capable of autoregulation to maintain coronary blood flow at levels appropriate to the needs of the [[myocardium|heart muscle]]. These relatively narrow vessels are commonly affected by [[atherosclerosis]] and can become blocked, causing [[Angina pectoris|angina]] or a [[myocardial infarction|heart attack]]. (See also: [[circulatory system]].) The coronary arteries that run deep within the myocardium are referred to as subendocardial.
-The coronary arteries are classified as "end circulation", since they represent the only source of blood supply to the myocardium: there is very little redundant blood supply, which is why blockage of these vessels can be so critical.
-==Coronary anatomy==
+==Coronary Arteries and Veins==
+===Coronary Arteries===
+he coronary arteries supply oxygenated blood to the [[heart]] muscle itself.  Although blood fills the chambers of the heart, the muscle tissue of the heart, or [[myocardium]], is so thick that it requires coronary blood vessels to deliver blood deep into it.  There are two primary arteries supplying the heart, the [[left coronary artery]] and the [[right coronary artery]].  These two epicardial coronary arteries course along the surface of the heart and this is why they are called "epicardial" (on top of the heart) arteries.  Smaller arteries dive deep into the heart muscle and are called subendocardial coronary arteries.
-The exact anatomy of the myocardial blood supply system varies considerably from person to person. A full evaluation of the coronary arteries requires [[cardiac catheterization]] or [[Computed tomography#Cardiac_CT|CT coronary angiography]].
+Click '''[[Coronary arteries|here]]''' for details about coronary arteries.
-In general there are two main coronary arteries, the left and right.
+===Cardiac Veins===
+The [[cardiac veins]] are the vessels that remove the deoxygenated blood from the [[heart muscle]] and return it to the [[right atrium]].
-* [[Right coronary artery]]
+Click '''[[Cardiac veins|here]]''' for details about cardiac veins.
-* [[Left coronary artery]]
-Both of these arteries originate from the beginning (root) of the [[aorta]], immediately above the [[aortic valve]].   As discussed below, the left coronary artery originates from the left [[aortic sinus]], while the right coronary artery originates from the right aortic sinus.
+Shown below is an image depicting the coronary arteries and cardiac veins.
-===Variations===
-Four percent of people have a third, the posterior coronary artery. In rare cases, a person will have one coronary artery that runs around the root of the aorta.
-Occasionally, a coronary artery will exist as a double structure (i. e. there are two arteries, parallel to each other, where ordinarily there would be one).
+[[Image:Coronary_arteries.png‎|500px|Coronary arteries]]
-===Coronary artery dominance===
+==Blood Supply to the Papillary Muscles==
-The artery that supplies the [[posterior descending artery]] (PDA) and the [[posterolateral artery]] (PLA) determines the coronary dominance.
+*The [[papillary muscle]]s tether the [[mitral valve]] (the valve between the [[left atrium]] and the [[left ventricle]]) and the [[tricuspid valve]] (the valve between the [[right atrium]] and the [[right ventricle]]) to the wall of the heart.
+*If the papillary muscles are not functioning properly, the mitral valve leaks during contraction of the left ventricle and causes some of the blood to travel "in reverse", from the left [[ventricle]] to the left atrium, instead of forward to the [[aorta]] and the rest of the body.
+*This leaking of blood to the left atrium is known as [[mitral regurgitation]].
-* If the [[right coronary artery]] (RCA) supplies both these arteries, the circulation can be classified as "right-dominant".
+*'''The anterolateral papillary muscle''':
-* If the [[circumflex artery]] (CX), a branch of the left artery, supplies both these arteries, the circulation can be classified as "left-dominant".
+**It receives two blood supplies: the '''LAD''' and '''LCX'''.
-* If the RCA supplies the PDA and the CX supplies the PLA, the circulation is known as "co-dominant".
+**It is therefore somewhat resistant to coronary [[ischemia]] (insufficiency of oxygen-rich blood).
+*'''The posteromedial papillary muscle''':
-Approximately 60% of the general population are right-dominant, 25% are co-dominant, and 15% are left-dominant.<ref name="pmid15929526">{{cite journal |author=Kaimkhani ZA, Ali MM, Faruqi AM |title=Pattern of coronary arterial distribution and its relation to coronary artery diameter |journal=Journal of Ayub Medical College, Abbottabad : JAMC |volume=17 |issue=1 |pages=40-3 |year=2005 |pmid=15929526 |doi=}}</ref>
+**It is supplied only by the '''PDA'''.
+**This makes the posteromedial papillary muscle significantly more susceptible to ischemia.
-==Blood supply of the papillary muscles==
+*The clinical significance of the nature of blood supply to the papillary muscles is that a [[myocardial infarction]] involving the PDA is more likely to cause mitral regurgitation.
-The [[papillary muscle]]s tether the [[mitral valve]] (the valve between the [[left atrium]] and the [[left ventricle]]) and the [[tricuspid valve]] (the valve between the [[right atrium]] and the [[right ventricle]]) to the wall of the heart.  If the papillary muscles are not functioning properly, the mitral valve leaks during contraction of the left ventricle.  This causes some of the blood to travel "in reverse", from the left ventricle to the left atrium, instead of forward to the aorta and the rest of the body.  This leaking of blood to the left atrium is known as [[mitral regurgitation]].
-The anterolateral papillary muscle receives two blood supplies: the LAD and LCX, and is therefore somewhat resistant to coronary [[ischemia]] (insufficiency of oxygen-rich blood).  On the other hand, the posteromedial papillary muscle is supplied only by the PDA.  This makes the posteromedial papillary muscle significantly more susceptible to ischemia.  The clinical significance of this is that a [[myocardial infarction]] involving the PDA is more likely to cause mitral regurgitation.
 ==Coronary flow==
-During contraction of the [[ventricle (heart)|ventricular]] myocardium ([[systole]]), the subendocardial coronary vessels (the vessels that enter the myocardium) are compressed due to the high intraventricular pressures.  However the epicardial coronary vessels (the vessels that run along the outer surface of the heart) remain patent. Because of this, blood flow in the subendocardium stops.  As a result most myocardial perfusion occurs during heart relaxation ([[diastole]]) when the subendocardial coronary vessels are patent and under low pressure. This contributes to the filling difficulties of the coronary arteries.
+*During contraction of the [[ventricle (heart)|ventricular]] myocardium ([[systole]]), the subendocardial coronary vessels (the vessels that enter the myocardium) are compressed due to the high intraventricular pressures.  However the epicardial coronary vessels (the vessels that run along the outer surface of the heart) remain patent. Because of this, blood flow in the subendocardium stops.
-compression remains the same. Failure of oxygen delivery via increases in blood flow to meet the increased oxygen demand of the heart results in tissue ischemia, a condition of oxygen debt. Brief ischemia is associated with intense chest pain, known as [[Angina pectoris|angina]]. Severe ischemia can cause the heart muscle to die of oxygen starvation, called a [[myocardial infarction]].  Chronic moderate ischemia causes contraction of the heart to weaken, known as myocardial hibernation.
+*As a result most myocardial perfusion occurs during heart relaxation ([[diastole]]) when the subendocardial coronary vessels are patent and under low pressure. This contributes to the filling difficulties of the coronary arteries.
-In addition to metabolism, the coronary circulation possesses unique pharmacologic characteristics. Prominent among these is its reactivity to adrenergic stimulation. The majority of vasculature in the body constricts to [[norepinephrine]], a sympathetic neurotransmitter the body uses to increase blood pressure.
-In the coronary circulation, [[norepinephrine]] elicits vasodilation, due to the predominance of beta-adrenergic receptors in the coronary circulation. Agonists of alpha-receptors, such as phenylephrine, elicit very little constriction in the coronary circulation.
+*Failure of oxygen delivery via increases in blood flow to meet the increased oxygen demand of the heart results in tissue ischemia, a condition of oxygen debt.
+**Brief ischemia is associated with intense chest pain, known as [[Angina pectoris|angina]].
+**Severe ischemia can cause the heart muscle to die of oxygen starvation, called a [[myocardial infarction]].
+**Chronic moderate ischemia causes contraction of the heart to weaken, known as myocardial hibernation.
-==See also==
+*In addition to metabolism, the coronary circulation possesses unique pharmacologic characteristics. Prominent among these is its reactivity to adrenergic stimulation. The majority of vasculature in the body constricts to [[norepinephrine]], a sympathetic neurotransmitter the body uses to increase blood pressure.
-*[[Cardiology]]
+**In the coronary circulation, [[norepinephrine]] elicits vasodilation, due to the predominance of beta-adrenergic receptors in the coronary circulation.
+**Agonists of alpha-receptors, such as phenylephrine, elicit very little constriction in the coronary circulation.
 ==References==
-<references/>
+{{Reflist|2}}
 {{Arteries of chest}}
+{{Coronary Angiography}}
 [[Category:Cardiovascular system]]
@@ Line 81: / Line 78: @@
 [[Category:Arteries]]
 [[Category:Anatomy]]
+[[Category:Angiopedia]]
 {{WikiDoc Help Menu}}
 {{WikiDoc Sources}}

v t e Coronary Angiography
Coronary Anatomy	Normal coronary anatomy • Anomalous origins of coronary arteries (Left coronary artery • Right coronary artery) • Congenital abnormalities of coronary arteries • Coronary artery segments • Cinefilm frame speed • Coronary artery dominance (Left dominance • Right dominance • Co-dominance)
TIMI Flow Grade	TIMI flow grade 0 • TIMI flow grade 1 • TIMI flow grade 2 • TIMI flow grade 3
TIMI Frame Count	TFC for SVG • TIMI Myocardial Frame Count • Washout TIMI Frame Count
TIMI Myocardial Perfusion Grade	TIMI MPG 0 • TIMI MPG 1 • TIMI MPG 2 • TIMI MPG 3
Thrombus Grading	Thrombus Grade 0 • Thrombus Grade 1 • Thrombus Grade 2 • Thrombus Grade 3 • Thrombus Grade 4 • Thrombus Grade 5 • Thrombus Grade 6
Lesion Complexity	Type A • Type B₁ • Type B₂ • Type C
Dissection Classification	Type A • Type B • Type C • Type D • Type E • Type F
Coronary Collaterals	Grade 0 • Grade 1 • Grade 2 • Grade 3 • Rentrop and Cohen’s Collateral Classification
Lesion Morphology	Myocardial bridge •Definitions of Preprocedural Lesion Morphology • Luminal irregularities • Disease extent • Arterial foreshortening • Infarct related artery (Culprit lesion) • Reocclusion • Restenosis • Degenerated saphenous vein graft • Coronary artery fistula
Angiographic complications	Distal embolization • Coronary spasm • Abrupt closure • Side branch loss • Slow flow • No-reflow • Pulsatile flow • Flow deceleration • Ectasia • Intimal flap • Staining •
Performing Coronary Angiography	Patient preparation • Catheter selection • Standard angiographic views • High risk groups • Patients with special need • Access site closure (Manual compression • Assisted compression • Closure devices) •
Quantitative Coronary Angiography (QCA)	Minimal lumen diameter • Percent stenosis • Reference diameter • Lesion length • Residual stenosis • Average reference segment diameter • Plaque area • Plaque volume •
Contrast Media	High-osmolar contrast media • Iso-osmolar contrast media • Low-osmolar contrast media
Left Ventriculography & Aortography	Ejection fraction • Aortography • Quantitative Left Ventricular Analysis (LAO projection • RAO projection • LVA) • Left Ventricular Wall Motion Analysis (Normokinesia • Hypokinesia • Akinesia • Dyskinesia • Aneurysm) • Evaluation of mitral regurgitation • Evaluation of aortic regurgitation
Right Heart Catheterization	Pressure waveforms (Right atrial pressure • Rirght ventricular pressure • Pulmonary artery pressure • Pulmonary artery wedge-pressure) • Endomyocardial biopsy
Complications	Access site complications • Dumping • Contrast hypersensitivity • Contrast induced nephropathy • Hypotension • Hypertension • Dissection • Vessel perforation • Acute myocardial infarction • Ventricular fibrillation • Cardiac arrest • Stroke • ASD • VSD • Pulmonary emboli • Myocardial rupture • Peripheral arterial emboli • Radiation injury


Coronary Angiography
Home

General Principles Overview Historical Perspective Contraindications Appropriate Use Criteria for Revascularization Complications Technique Film Quality

Anatomy & Projection Angles

Normal Anatomy Coronary arteries Dominance Right System Left System Left Main Left Anterior Descending Circumflex Median Ramus

Anatomic Variants Separate Ostia Anomalous Origins Case Example Fistula

Projection Angles Standard Views Left Coronary Artery Right Coronary Artery

Epicardial Flow & Myocardial Perfusion

Epicardial Flow TIMI Frame Count TIMI Flow Grade TIMI Grade 0 Flow TIMI Grade 1 Flow TIMI Grade 2 Flow TIMI Grade 3 Flow TIMI Grade 4 Flow Pulsatile Flow Deceleration

Myocardial Perfusion TIMI Myocardial Perfusion Grade TMP Grade 0 TMP Grade 0.5 TMP Grade 1 TMP Grade 2 TMP Grade 3

Lesion Complexity

ACC/AHA Lesion-Specific Classification of the Primary Target Stenosis

Preprocedural Lesion Morphology Eccentricity Irregularity Ulceration Intimal Flap Aneurysm Sawtooth Pattern Length Ostial location Angulation Proximal tortuosity Degenerated SVG Calcification Total occlusion Coronary Artery Thrombus TIMI Thrombus Grade TIMI Thrombus Grade 0 TIMI Thrombus Grade 1 TIMI Thrombus Grade 2 TIMI Thrombus Grade 3 TIMI Thrombus Grade 4 TIMI Thrombus Grade 5 TIMI Thrombus Grade 6

Lesion Morphology Quantitative Coronary Angiography Definitions of Preprocedural Lesion Morphology Irregular Lesion Disease Extent Arterial Foreshortening Infarct Related Artery Restenosis Degenerated SVG Collaterals Aneurysm Bifurcation Trifurcation Ulceration

Left ventriculography

Technique Quantification of LV Function Quantification of Mitral Regurgitation