左侧肋间后动脉用于冠状动脉搭桥术的应用解剖

目的：为左侧肋间后动脉冠状动脉搭桥术提供解剖学基础。方法：在３０具成人尸体标本上,对左侧肋间后动脉及心脏冠状动脉的后降支和左缘支进行了观察。结果：左侧第８、９、１０肋间动脉到后降支（房窒交点下方１ｃｍ处＿平均外径分别为２．５、２．６、２．８ｍｍ,与冠状动脉后降支此点处外径（２．５ｍｍ）较为接近;到左缘支点处的平均外径为２．７、２．８、２．６ｍｍ,与左缘地此点处外径（２．１ｍｍ）较为接近;到后降支中     

Coronary artery distribution in bonnet monkeys (Macaca radiata)

Full use of nonhuman primates as a model for coronary vascular disease has been hampered by several factors, including the limited availability of detailed coronary anatomic data. This study was undertaken to identify the gross coronary arterial anatomy of the Bonnet monkey (Macaca radiata). The hearts of sixteen adult male Bonnet monkeys were subjected to postmortem coronary angiography and gross morphological examination. The main left coronary artery divided into the left anterior descending coronary artery (LAD) and the left circumflex coronary artery (LCA). The posterior descending coronary artery (PDCA) arose from the LCA in 31% of the cases and from the right coronary artery (RCA) in 56% of the hearts. Hearts from two animals (13%) had paired arteries, arising from the LCA and RCA, located in the posterior interventricular groove. The arterial supply to the sinoatrial node originated from the LCA in 69% of the animals and from the RCA in the remainder. The atrioventricular node was supplied by a branch of the RCA in 69% of the animals and from the LCA in the remainder. The coronary anatomy of the bonnet monkey resembles that of man more closely than does the dog in terms of origin of the PDCA, supply of the sinoatrial and atrioventricular nodes, and perfusion of the interventricular septum. The Bonnet monkey may therefore be a useful model for certain specific pathophysiological studies on the coronary circulation.     

Terminal branching pattern of the right coronary artery in left-dominant hearts: a cadaveric study

BackgroundLeft coronary dominance has been reported to be associated with increased mortality and severity in case of myocardial ischemia involving left coronary artery. The present cadaveric study was proposed to objectively study and document the termination and branching pattern of the right coronary artery in left-coronary-dominant hearts in relation to the blood supply to the posterior surface of the right ventricle.MethodsSeventy-five cadaveric hearts were studied. The coronary vessels were injected with colored cellulose acetate butyrate and dissected. The coronary dominance was determined. In left-dominant hearts, branches and termination of the right coronary artery were studied.ResultsLeft coronary dominance was found in 13% of the specimens. The number of ventricular branches was found to be present as 0, 1, 2, and 4 in two, four, two, and two of the cases, respectively. The average length of the ventricular branch was 12.7 mm with a range of 5–35 mm. The atrial branch was found in 50% of hearts, varying from 2 to 3 mm in length. In three hearts, the acute marginal artery did not give any posterior ventricular branch, while two, three, and five posterior ventricular branches were seen in four, two, and one heart(s), respectively. The length of the posterior ventricular arteries was between 5 and 15 mm.ConclusionThe RCA is an inconstant and unreliable source of posterior right ventricular perfusion in a significant percentage of population with left-coronary-dominant hearts. This might be the reason for the increased morbidity and mortality seen in the event of left coronary ischemia.     

Short left circumflex artery

There was evidence of posterior infarction in 61 of 212 hearts studied. The condition was associated with a relatively short circumflex branch of the left coronary artery (LCX) in 24 hearts and with a longer LCX in 37 hearts. Total occlusion of LCX was found in two (8%) hearts with a shorter circumflex branch and in 27 (73%) hearts with a longer circumflex branch. The right coronary artery (RCA) was occluded in nearly all hearts with posterior infarction. In those hearts with a shorter LCX, occlusion of RCA appeared to be the major factor in the pathogenesis of posterior myocardial infarction.     

The relationship of myocardial bridges to coronary artery dominance in the adult human heart

Myocardial bridging is recognized as an anatomical variation of the human coronary circulation in which an epicardial artery lies in the myocardium for part of its course. Thus, the vessel is 'bridged' by myocardium. The anterior interventricular branch of the left coronary artery has been reported as the most common site of myocardial bridges but other locations have been reported. The purpose of this study was to provide more definitive information on the vessels with myocardial bridges, the length and depth of the bridged segment, and the relationship between the presence of bridges and coronary dominance. Two hundred formalin-fixed human hearts were examined. Myocardial bridges were found in 69 (34.5%) of the hearts with a total of 81 bridges. One bridge was found in 59 of these hearts and multiple bridges were observed in ten (eight with double bridges and two with triple bridges). Bridges were most often found over the anterior interventricular artery (35 hearts). Bridges were also found over the diagonal branch of the left coronary artery (14), over the left marginal branch (five) and over the inferior interventricular branch of the left coronary artery (six). Bridges were also found over the right coronary artery (15 hearts), over the right marginal branch (four) and over the inferior interventricular branch of the right coronary artery (two). The presence of bridges appeared to be related to coronary dominance, especially in the left coronary circulation. Forty-six (66.6%) of the hearts with bridges were left dominant. Forty-two of these had bridges over the left coronary circulation and four over the right coronary circulation. Seventeen hearts (24.6%) were right dominant. Eleven of these had bridges over the right coronary circulation and six over the left coronary circulation. The remaining six hearts were co-dominant with four having bridges over the left coronary circulation and two over the right coronary circulation. The mean length of the bridges was 31 mm and the mean depth was 12 mm. The possible clinical implications of myocardial bridging may vary from protection against atherosclerosis to systolic vessel compression and resultant myocardial ischaemia.     

Blood transfusion requirements in coronary artery surgery with and without the activated clotting time (ACT) technique

Summary Control of anticoagulation during cardiopulmonary bypass (CPB) with the automated activated whole blood clotting time (ACT) and reversal of heparin after CPB using a computerized ACT dose-response curve method resulted in significant reductions of blood transfusion requirements, surgical time, and protamine doses in 150 patients undergoing coronary artery bypass grafting procedures (ACT group) as compared to 200 patients for whom a standard fixed dose protocol for heparin and protamine was used (control patients). Mean transfusion requirements were 1,938±60 SEM ml whole blood and 853±48.3 SEM ml red blood cells for control patients and 1,397±59 SEM ml whole blood (P<0.001) and 695±34 SEM ml red blood cells (P<0.01) in the ACT group. ACT group patients also required less protamine with 26.2±0.60 SEM ml Protamine 1,000 (Roche) as compared to 33.9±0.49 SEM ml for control patients (P<0.001) but more heparin with 31,440±783 SEM I.U. versus 26,760±263 SEM I.U. (P<0.001). Surgical time decreased from 321±5.5 SEM min for control patients to 289±5.4 SEM min for ACT group patients (P<0.001).Abbreviations AB autologous blood - ACD right coronary artery - ACT activated clotting time - ACT_o ACT — before heparin administration - ACT₃₆₀ ACT — 5 min. after 360 I.U. heparin/kg body wt. - CPB cardiopulmonary bypass - Cx circumflex branch of the left coronary artery - DIAG diagonal branch of the left coronary artery - ECC extracorporeal circulation - FB fresh blood - FFP fresh frozen plasma - POD postoperative day - RBC red blood cells - RIA descending branch of the left coronary artery - RIP posterior descending branch of the right coronary artery - WB whole blood     

Variations in the origin and course of the posterior interventricular artery in relation to the crux cordis and the posterior interventricular vein: An anatomical study

Corrosion castings of 60 human hearts were used to demonstrate that the point of origin of the posterior interventricular artery (PIA), in relation to the crux cordis, is responsible for its subsequent course with respect to the posterior interventricular vein (PIV). In seven cases (12%), the PIA appeared as the continuation of the left circumflex, descending rightwards and on a deeper level of the PIV. In 53 cases (88%), the PIA arose from the right coronary artery (RCA) and 50 of these were selected to be classified into three groups, according to the PIAs origin and course. In group A (29 cases, 58%) and B (seven cases, 14%), the PIA emerged before the crux cordis and descended to the right or left of the PIV, respectively. In group C (14 cases, 28%), it originated at, or beyond, the crux cordis and descended along the left side of the PIV. Among the 50 cases, the PIA was found to be long in 34 (68%), large in 32 (64%), and long and large in 29 cases (58%). In 18 of the latter 29 cases (62%) or 36% of the 50 cases in total, the PIA arose as a continuation of the RCA (group A) and therefore these cases were easily accessible to interventional cardiologists and also to surgeons, since the PIA lay on the same or on a superficial level in relation to the PIV. This work describes and explains the variations of the PIA and concludes that at least 36% of these may be helpful in coronary artery angioplasty and bypass surgery. Anat. Rec. 252:413–417, 1998. © 1998 Wiley-Liss, Inc.     

Aberrant penetrating posterior descending artery from proximal right coronary artery

We report a rare variant of the posterior descending artery (PDA) in a 51-year-old African-American male discovered in coronary CT angiography. Arising from the proximal right coronary artery near its ostium, the anomalous PDA penetrated posteriorly toward the atrioventricular junction septum, exited through the inferior pyramidal space into the posterior interventricular groove and continued in the groove as a short PDA. Along its course it gave rise to small branches to the medial wall of the right atrium, the atrioventricular node region, and the inferoseptal wall of the right ventricle.     

Functional dominance of the right coronary artery: Incidence in the human heart

After injection of radiopaque medium, 200 human hearts were studied by direct observation and x-ray analysis. The right coronary artery (RC) was dominant in 178 of these hearts as characterized by giving off the typical posterior interventricular artery (PIV), the posterior descending artery. Within this group, 19 specimens had right coronary arteries that gave off both a large posterior interventricular artery (LPIV) and a branch that continued beyond the crux termed a large extension of the right coronary (LERC). The subgroup of hearts supplied thusly was termed real right dominant (RRD). The RC in these hearts supplied the right ventricle and almost half of the left ventricle. These findings explain why proximal lesions of the RC in RRD hearts can be associated with extensive posterolateral ischemia and mitral dysfunction and should be of practical importance when considering angioplasty or by-pass surgery. The diameters and lengths of the arteries of the RC in RRD hearts were measured and compared with the same parameters in typical right dominant hearts. © 1996 Wiley-Liss, Inc.     

胸廓内动脉冠状动脉搭桥术有关的解剖学

为冠状动脉旁路术,在40具成年尸体上对胸廓内动脉及冠状动脉进行观测。在第四肋间隙,胸廓内动脉外径平均2.3mm,与冠状动脉对角支(2.3mm)、边缘支(2.1mm)、左室后支(2.0mm)、后降支(2.(?)mm)等较为接近。胸廓内动脉自起点至第五肋上缘平均长度为18.6cm,用作游离移植足以桥接升主动脉与任何冠状动脉。用起点原位的胸廓内动脉其有效长度适用于心前、侧壁的冠状动脉搭桥,但不适于与膈面一些血管如右冠状动脉远侧部或后降支搭桥。阐述和讨论了胸廓内动脉与冠状动脉搭桥的各种术式及其解剖基础。     

Variability of human coronary artery geometry: An angiographic study of the left anterior descending arteries of 30 autopsy hearts

A computer-based system is described to measure objectively the geometric parameters of arteries from pairs of projection angiograms. This technique, which employs backprojection to define the vessel axes in 3-D space, was used to obtain selected parameters of coronary artery geometry from radiographic images of autopsy hearts. Results of the first 30 cases are presented, focussing on the distribution of the geometric parameters of the left anterior descending coronary artery (LAD) and its first two major branches. The derived parameters include the angle between the left circumflex artery and the LAD; the angles between the LAD and its early diagonal and septal perforator branches; distances between branch points; and tortuosity. The geometric parameters vary considerably, presumably contributing to a corresponding variability in local hemodynamic and mechanical stresses. Most parameters are uncorrelated. One exception is the angle at the origin of the second diagonal branch, which is positively correlated (p<0.01) with the distance between the ostia of the first two diagonal vessels; this correlation could reflect the existence of “target” perfusion regions. No relation between geometric parameters and age or gender was seen. In this sample, blacks had a larger angle at the left main bifurcation than whites (p<0.05).     

右冠状动脉轴位X线造影的解剖学研究

目的研究右冠状动脉在轴位X线造影上的正常形态、行径、和分布规律。方法9例新鲜心脏标本的右冠状动脉注入造影铸型剂后，对其进行多方位多角度投照，并与相应方位铸型标本对比分析。结果正位时，右冠状动脉分支清楚；左前斜位时，随着角度增大，右冠状动脉主干逐渐伸展；右前斜位40°以内时，分支显示清楚，但随着角度增大，右冠状动脉主干重叠明显；当影像增强器由头倾位向足倾位旋转时，右冠状动脉主干逐渐伸展。结论左前斜位40°～60°、正位+头倾20°适合观察右冠状动脉主干近段；左侧位适合观察右冠状动脉主干中段；右前斜位20°～40°、正位适合观察右冠状动脉的主要分支；左前斜位30°+足倾20°适合观察右冠状动脉主干全段。     

Observation of root variations in human coronary arteries

In dissection courses conducted from 1999 through to 2003, five specimens were found to have coronary arteries with variant roots and branches, as follows: in specimens 1-4, roots of the right coronary artery (RCA) and right conus branch arose independently from the right aortic sinus (RAS); in specimen 5, the RCA and left coronary artery (LCA) originated from the RAS. The LCA pierced the upper part of the muscular interventricular septum and appeared on the surface, then dividing into the anterior interventricular and the circumflex branches. In the present study, we considered that the right conus arteries in specimens 1-4 were the remnant blood capillaries around the aorta towards the RAS in the embryonic stage. In specimen 5, the vessel near the left aortic sinus was poorly developed as a small thin artery. Instead, the LCA was developed from the anterior and posterior interventricular septal branches.     

Reactive hyperaemic flow characteristics of the right coronary artery compared to the left anterior descending coronary artery in the open-chest dog

Reactive hyperaemia, the cardiovascular response to transient occlusion of a vessel, was examined and compared in the right coronary artery (RCA) and the left anterior descending coronary artery (LAD) in the same heart of an open-chest dog. First, to study the relationship between reactive hyperaemia and occlusion time in the RCA and LAD, respective flows were measured and reactive hyperaemia was induced with different occlusion times. Occlusion time required for half the maximum peak percentage reactive hyperaemic flow (%PRH), t _1/2, for the RCA was approximately twice that of the LAD: 11.4±2.3 s versus 5.9±1.4 s. Maximum %PRH of the RCA was significantly greater than that of the LAD while the percentage repayment of the RCA was lower than that of the LAD. Augmentation of right ventricular oxygen consumption shortened t _1/2 and increased percentage repayment significantly. Second, to determine critical pressure, which was defined as the perfusion pressure below which reactive hyperaemia was abolished completely, the RCA and LAD were perfused through a shunt from the carotid artery, perfusion pressure was varied in the range of 100 to 20 mmHg and reactive hyperaemia was induced. Critical pressure in the RCA was significantly lower than in the LAD: 32.2±5.7 mmHg versus 41.5±5.0 mmHg. These results suggest that the RCA has a greater flow reserve than the LAD. These results were consistent with the difference of oxygen metabolism between the right and left ventricles. The difference of oxygen metabolism between the two ventricles would, at least partly, account for these results.     

Correspondence between left ventricular 17 myocardial segments and coronary anatomy obtained by multi-detector computed tomography: an ex vivo contribution

Purpose

The aim of this study was to investigate the correspondence between the coronary arterial anatomy and the supplied myocardium based on the proposed American Heart Association (AHA) 17-segment model.

Methods

Six human cadaveric hearts without signs of infarct were selectively injected with colored contrasted gelatin in the three major coronary arteries. After injection, the hearts were scanned by computed tomography (64-detector scanner LightSpeed VCT, GE Healthcare) with a collimation of 64?×?0.625?mm. Reconstructed image data were analyzed in order to evaluate the blood supply of each myocardial segment.

Results

Coronary artery territory varies due to anatomy variations. Left anterior descending coronary artery (LAD) was the main vessel responsible for the myocardium blood supply in 11 segments. LAD contributed to the blood supply of all apical segments. Left circumflex (LCx) was the main coronary artery for the infero-anterior wall. Right coronary artery (RCA) contributed in all hearts for the blood supply of infero-septal segments. There was an important overlap between LAD and RCA territories at the infero-septal region and between LAD and LCx territories at the antero-lateral region.

Conclusions

In our experiment, LAD territory was larger than the AHA-proposed 17-segment model. The most specific segments were located at the anterior wall and supplied exclusively by LAD. No specific segment could be exclusively attributed to RCA or to LCx. Sometimes, LCx can be the most important artery for the blood supply of the inferior wall even if the origin of the posterior descending artery is the RCA.     

心第3冠状动脉的解剖学

目的:研究心第3冠状动脉的大体解剖学数据,为临床诊治相关疾病提供依据。方法:共收集了118个福尔马林固定的心,观测心第3冠状动脉数量、来源、分布范围、营养区域和长度及管径等解剖学数据。结果:第3冠状动脉出现率为28.8%,其中单支出现率为26.3%,双支出现率为2.5%。它通常分布于动脉圆锥、右心室前壁、室间隔及心尖中的1个或多个位置,也有些少见情况:第3冠状动脉比右冠状动脉大并结束于心尖;第3冠状动脉比右冠状动脉小且结束于心尖;心肌桥覆盖较大的第3冠状动脉。结论:心存在第3冠状动脉情况较多,它与左冠状动脉前降支吻合且分布于心尖和室间隔。因此第3冠状动脉是在疾病诊疗期间需要着重考虑的一个因素。     

The anatomy of the coronary sinus and its tributaries

The coronary sinus and its tributaries were studied by anatomical dissection in 37 adult human cadaveric hearts, which had been fixed in formalin solution. An anastomosis of approximately 1.0mm in calibre was observed between the anterior and posterior interventricular veins in 19% of specimens. Myocardial bridges were detected above the anterior interventricular vein or its tributaries in 8% of specimens. The great cardiac vein formed the base of the arteriovenous trigone of Brocq and Mouchet with the bifurcating branches of the left coronary artery in 89% of specimens and formed an angle accompanying these arterial branches in 11%. In the trigone the anterior interventricular and great cardiac veins were superficial to the arteries in 73% of specimens. The left marginal vein was present in 97% of specimens, emptying into the great cardiac vein in 81% of cases and into the coronary sinus in the remaining 19%. The small cardiac vein was present in 54% of specimens. In the coronary sulcus the great cardiac vein was adjacent to the circumflex branch of the left coronary artery in 76% of specimens and to the right coronary artery in 5% in 19% there was no relationship with either artery. The coronary sinus maintained a relationship with the right coronary artery in 46% of specimens and with the left coronary artery in 32% in 22% it had no relationship with these vessels.     

A Study of Coronary Dominance in the Population of Assam

With the ever increasing load of coronary heart disease, an in-depth study of the coronary arteries has been felt by the medical fraternity. Coronary arteries show wide variations among different populations. These region based variations have not been dealt with enough in the standard books. The knowledge of these variations are of paramount importance when considering various surgical interventions. This study therefore aims to focus on the pattern of coronary dominance in Assam which is ethnically unique from the rest of India. Seventy cadaveric hearts were studied. The population under study included the population of Assam. The coronary arteries were examined by gross dissection and analyzed statistically. The modes of termination of the right coronary artery and the circumflex artery were described with the help of five points: at the right border, between the right border and the crux, at the crux, between the crux and the left border and at the left border. Origin of the posterior interventricular artery was taken as the basis of dominance. Right dominance was found in 70%, left dominance was found in 18.57% while balanced pattern was observed in 11.43% hearts. The results of the study were compared with other authors and variations were noted.     

Dosierung der intrakoronaren Urokinase-Infusion beim akuten Myokardinfarkt

Summary In 11 patients with acute myocardial infarction (mean age 52±6 years) coronary angiography was performed 4.5±3.6 h after the onset of symptoms. The infarct-related artery was in 7 cases the right coronary artery and in 4 cases the left anterior descending branch of the left coronary artery. The infarct-related artery showed total or subtotal occlusion and no perfusion (Thrombolysis in Myocardial Infarction trial (TIMI) grade 0 or 1). In 7 cases Urokinase was infused intracoronarily at a dosage of 250 000 IU over 30 min, but in only 1 case partial reperfusion was achieved. However, all patients treated with 500 000 IU Urokinase over 30 min or 1 Mill IU over 60 min had successful reperfusion (TIMI grade 2 or 3). Thus, it appears that 500 000 IU up to 1 Mill IU of Urokinase over a period of 30 to 60 min is adequate for intracoronary thrombolysis in patients with acute myocardial infarction.

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Abkürzungsverzeichnis TIMI Thrombolysis in Myocardial Infarction trial - PTCA Perkutane transluminale Koronarangioplastie - RCA rechte Koronararterie - RIVA Ramus interventrikularis anterior - IE Internationale Einheiten - min Minuten