5.
Branches of Right
Coronary Artery
1.Right conus artery:
Supplies rt ventricular outflow tract.
2.Rt marginal branch:
Supply free wall of rt ventricle.
6.
3.
Branches of Right
Coronary Artery
Rt posterolateral branch:
goes back of lt ventricle
supply inferior aspect of interventricular
septum
4. Atrial branches:
Supply anterior and lateral surface of the
right atrium. One branch supply posterior
surface of both right and left atria.
Artery of Sinuatrial Node (60%)
7.
Branches of Right
Coronary Artery
5. Posterior interventricular (descending)
artery
Runs towards apex in the posterior
interventricular groove.
Supply right & left ventricles, including
its inferior wall.
Supply posterior part of the ventricular
septum (Excluding Apex).
Large septal branch Supply
Atrioventricular Node.
8. Clinical division of the RCA
Proximal - Ostium to 1st main RV branch
Mid
- 1st RV branch to acute marginal
branch
Distal
- acute margin to the crux
9. Area of distribution RCA
Rt atrium
Greater part of rt ventricle except area
adjoining ant interventricular groove
Small part of lt ventricle adjoining post
interventricular groove
Whole of conducting system of heart
except part of lt branch of AV bundle
SA Node –supplied by LCA (40%)
11.
Branches of Left Coronary
Artery
1. Anterior interventricular (descending) artery:
Runs in the anterior interventricular groove to
the Apex.
Passes around the Apex to enter the posterior
interventricular groove & anastomoses
with the terminal branches of Right coronary
artery.
Supply right and left ventricles & anterior
part of ventricular septum.
Left diagonal branch
wrap over anterolateral free wall of lt ventricle
13.
2.
Branches of Left Coronary
Artery
Circumflex artery:
Winds around the left margin of the heart
in the atrioventricular groove.
obtuse marginal branch:
supply lateral free wall of lt ventricle
does not reach crux in pt with rt dominant
circulation
Atrial branches: Supply left atrium.
Artery of Sinuatrial Node (40%)
14. Clinical division of the LAD
Proximal - Ostium to 1st major septal perforator
Mid
- 1st perforator to D2 (90 degree angle)
Distal
- D2 to end
15. Clinical division of the LCX
Proximal - Ostium to 1st major obtuse marginal
branch
Mid
- OM1 to OM2
Distal
- OM2 to end
16. Area of distribution of LCA
Lt atrium
Greater Prt of lt ventricle except post
interventricular groove
Small part of rt ventricle adjoining ant
interventricular groove
Ant part of interventricular septum
Lt branch of AV bundle
17. Conducting system of
Heart
S-A Node: Right coronary artery (60%)
Left coronary artery (40%)
A-V Node and A-V Bundle: Right coronary artery
Right Bundle branch: Left coronary artery
Left Bundle branch: Right & Left coronary
arteries
19. Cardiac dominance
85%-rt dominant coronary artery
8% lt dominant-post descending,posterolateral lt
ventricular and AVnodal artery all supplied by
terminal portion of lt circumflex coronary artery.rt
coronary artery small and supply only rt atrium
and rt ventricle
7%-codominant
RCA-PDA and terminates,circumflex artery-all
post
Lt ventricular branches
20. Congenital anomaly of coronary
circulation
Anomalous pulmary origin of coronary
artery(APOCA)
Most common-origin of LCA from
pulmonary artery
Aortography-large RCA with absence of lt
coronary ostium in lt aortic sinus
21. Anomalous coronary artery
from opposite sinus
Origin of LCA from rt aortic sinus
causes sudden cardiac death after
exercise
in young person
23. Myocardial bridging
All 3 major coronary artery generally
course along epicardial surface of heart
sometime short coronary artery segment
descend into myocardium for variable
distance
occurs in 5-12% of pt and confined to LAD
24. Coronary artery spasm
Dynamic and reversible occlusion of
epicardial coronary artery caused by focal
constriction of smooth muscle cell within
arterial wall
occurs in prinzmetal angina
aggrevated by cigaratte smoking,cocaine
alcohal,GA
Not aggrevated by emotion,cold
25. Most common-separate ostium for LAD
and lcx,simillarly in RCA-conus branch
may have
Separate ostium
Origin of circumflex from rt coronary artery
RCA-originate high in aortic root
26. “ Dominance ”
A misnomer
giving rise to PDA, at least 1 PLV & AV
nodal A
(BARI classification)
- 85% right dominant
- 8% left dominant
- 7% co-dominant
(70%/ 10%/ 20% – Hurst’s THE HEART)
Left dominance is 25-30% in Bi-AoV
Gensini GG. Coronary Arteriography. Mount Kisco,NY: Futura Publishing Co; 1975:260–274.
27. Venous Drainage of Heart
Coronary Sinus:
Runs in the coronary sulcus (posterior
atrioventricular groove).
Largest vein of heart
About 3 cm long
Ends by opening into post wall of rt
atrium
Tributaries:
Great cardiac vein
Middle cardiac vein
28.
Small cardiac vein
Post vein of lt ventricle
Oblique vein of lt atrium
Rt marginal vein
All drains into coronary sinus which opens
into rt atrium
29. 1.
2.
3.
4.
Great cardiac vein-accompany ant
interventricular artery and then
LCA
Middle cardiac vein –accompany post
interventricular artery and joins middle part of
coronary sinus
Small cardiac vein-accompany rt coronary
artery
Post vein of lt ventricle-runs on diaphragmatic
30. Surrface of lt ventricle and ends in middle of
coronary sinus
5 oblique vein of lt atrium-small vein
running on post surface of lt atrium
6 rt marginal vein-accompany marginal
branch of rt coronary artery
31. Contents of Heart grooves
1. Right atrioventricular groove:
Right coronary artery
Small cardiac vein
2. Left anterior atrioventricular groove:
Left coronary artery
3. Left posterior atrioventricular groove:
Coronary sinus
4. Anterior interventricular groove:
Anterior interventricular artery
Great cardiac vein
5. Posterior interventricular groove:
Posterior interventricular artery
Middle cardiac vein
32. Venous drainage
Ant cardiac vein and venae cordis minimi
opens directly into rt atrium
Ant cardiac vein
3-4 small vein running parrelel to one
another on ant wall of rt ventricle
venae cordis minimi-Thebesian vein or
smallest cardiac vein
Small vein present in all chambers of heart
36. The Cardiac Conduction System
The impulse conduction system of the heart consists
of four structures:
1. The sinoatrial node (SA node)
2. The atrioventricular node (AV node)
3. The atrioventricular bundle (AV bundle)
4. The Purkinje fibers
The cardiac muscle fibers that compose these
structures are specialized for impulse
conduction,rather than the normal specialization of
muscle fibers for contraction.
38. Spread of cardiac exitation
Atrial activation
Septal activation
Activation of anteroseptal region
Activation of major portion of ventricular
myocardium
Activation of posterobasal portion of lt
ventricle
39. Impulses from the SA node are then conducted across
the atria from right to left. The impulse does not
however pass directly to the ventricles.
When both the
right and left atria
are completely
depolarized, they
contract
simultaneously.
40. As the atria depolarize, the impulse is picked up by
another group of specialized muscle fibers called the
atrioventricular node. The AV node is located in the
floor of the right atrium next to the interatrial
septum. This group of fibers is the only conduction
pathway between the atria and ventricles.
As the impulse is conducted through the AV node, its
speed is reduced. This is due to the extremely small
diameter of the conducting fibers.
41. This is an extremely important phenomenon because
the delay in the transmission from atria to ventricles
allows time for the atria to completely depolarize and
contract, thus emptying their contents into the still
fully relaxed ventricles.
42. From the AV node, the impulse travels down
the atrioventricular bundle. The AV bundle
divides into two lines of transmission just
below the AV node and these conduct the
impulse down the length of the interventricular
septum. An important fact about the fibers that
make up the AV bundle is that they are large in
diameter and therefore the impulse speed
increases so it is conducted very rapidly down
them.
43. About halfway down the interventricular
septum the “bundle branches” themselves begin
to branch off into enlarged conduction fibers
called Purkinje fibers. These fibers extend out
to all areas of the two ventricles and since they
are further enlarged, the speed of the impulse
conduction is also additionally increased. Upon
completion of impulse transmission through the
Purkinje fibers, the ventricles will fully
depolarize and then contract simultaneously.
44. What causes what ?
Conduction problem in AV
NODE & HIS BUNDLE1st, 2nd & 3rd degree heart
blocks
Conduction problems in
left & right bundle
branches- RBBB
LBBB
LAHB
LPHB
Bi & Tri
–
46. Left Bundle Branch Block.
Block of the left bundle
or both fasicles of the
left bundle.
Electrical potential must
travel down RBB.
De-polarisation from
right to left via cell
transmission.
Cell transmission
longer due to LV mass.
48. ECG Criteria for LBBB.
QRS Duration >0.12secs.
Broad, mono-morphic R wave leads I and
V6.
Broad mono-morphic S waves in V1 (can
also have small 'r' wave).
49. LBBB consequence.
Mostly abnormal ECG finding - indicates
heart disease.
Coronary artery disease (indication for
thrombolysis - if associated with chest pain and
raised Troponin).
Valvular heart disease.
Hypertension.
Cardiomegaly.
Heart failure.
Impacts on prognosis - QRS duration.
Use of Bi-Ventricular Pacemakers.
50. Right Bundle Branch Block.
Impulse transmitted
normally by left bundle.
Blocked right bundle
results in cell
depolarisation to
spread impulse
(slower).
Impulse to IV septum
and RV delayed.
Results in an additional
vector.
52. Additional Info RBBB.
Can be normal.
Sometimes related to asthma or other
airway conditions.
Possibly due to RVH in young individuals.
Usually due to CAD in older persons.
Often related to congenital heart disease
(particularly ASD).
Often apparent following cardiac surgery.
54. ECG Features of Left Anterior
Hemi-block.
Abnormal left axis deviation (between -30
and -900).
Either a qR complex or an R wave in lead
I.
rS complex in lead III (possibly also II and
aVF).
Extremely common and un-diagnosed
ECG feature.
NOT ALWAYS ASSOCIATED WITH BBB.
55. ECG Features Left Posterior Hemiblock.
Axis of 90 - 180o - (right axis).
An s wave in lead I and a q wave in lead III.
Exclusion of RAE or RVH.
REMEMBER - most common cause of right
axis is RVH so this must be excluded before
you diagnose LPH.
57. INTRODUCTION TO HEART
BLOCKS
OCCUR WHEN THERE IS A PARTIAL
OR COMPLETE INTERRUPTION IN THE
CARDIAC ELECTRICAL CONDUCTION
SYSTEM.
CAN OCCUR ANYWHERE IN THE ATRIA
BETWEEN THE SA NODE AND THE AV
JUNCTION.
IN THE VENTRICLES BETWEEN THE
AV JUNCTION AND PURKINJE FIBERS.
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58. FIRST-DEGREE HEART
BLOCK
DELAY OF IMPULSE BETWEEN THE
ATRIA AND BUNDLE OF HIS.
OCCURS WHEN THERE IS A PARTIAL
INTERRUPTION ANYWHERE IN THE
ATRIAL OR AV JUNCTIONAL
CONDUCTION SYSTEM.
THE IMPULSE IS EVENTUALLY
CONDUCTED BUT IS DELAYED.
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59. degree heart block
Just prolongation
of PR interval.
Normal PR 1 st = .2
Sec
Here it is .28 Sec
60. MOBITZ I HEART BLOCK
MOBITZ I ( WENCKEBACH OR SECONDDEGREE HEART BLOCK, TYPE I).
PROGRESSIVE BLOCK.
IMPULSE FROM THE ATRIA IS
INTERRUPTED AT THE AV JUNCTION.
THE INTERRUPTION BECOMES LONGER
WITH EACH IMPULSE DELAYING
DEPOLARIZATION OF THE VENTRICLES
UNTIL A COMPLETE INTERRUPTION
BLOCKS THEFor more medical presentations IMPULSE.
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62. MOBITZ II HEART
BLOCK
OCCURS DUE TO AN INTERMITTENT
INTERRUPTION NEAR OR BELOW THE
AV JUNCTION.
INTERRUPTION IS NOT
PROGRESSIVE, BUT OCCURS
SUDDENLY AND WITHOUT WARNING!!
P WAVES BEFORE EVERY QRS
COMPLEX AND ALL ARE THE SAME
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64. THIRD-DEGREE HEART
BLOCK
COMPLETE HEART BLOCK OR
COMPLETE AV DISSOCIATION.
IMPULSE IS COMPLETELY BLOCKED
BETWEEN THE ATRIA AND THE
VENTRICLES.
USUALLY TAKES PLACE BETWEEN
THE AV JUNCTION AND BUNDLE OF
HIS.
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