9694] charter 20 THE HEART Great cardiac atey, ‘aren, Circurtex artery Anterior Interventeicular ate Posterior interventricular Great artery cardiac Anterior vein cardiac veine Small cardiac Marginal ven arey, ane Brachiocophalic Left common ‘tune carotid artery Posterior Bee (©) Posterior view: artery: Coronary Circulation. (a) Coronary vessels supplying the ‘Small cardiac fethoctenineceoeimeaia sc acweiorens MIO ary re 9 it and density of the coronary aiey LEFT VENTRICLE ( Coronary circulation and great vessels, anterior view‘The right coronary artery, which follows the coronary sulcus around the heart, supplies blood to (1) the right atrium, (2) por- tions of both ventricles, and (3) portions ofthe conducting system ofthe heart, including the sinowtrial (SA) and atrioventricular (4 nodes. The cell of these nodes are essential to establishing the nor- ‘mal heart rate. We will focus on their functions and their part in regulating the heart rate in a later section. Inferior to the right atrium, the right coronary artery gen- erally gives rise to one or more marginal arteries, which ex- tend across the surface of the right ventricle (Figure 20-9a,be). The right coronary artery then continues across the posterior surface of the heart, supplying the posterior in- terventricular artery, or posterior descending artery, which runs towatd the apex within the posterior interventricular sulcus (Figure 20-9b,ce). The posterior interventricular artery supplies blood to the interventricular septum and adjacent portions ofthe ventricles The left coronary artery supplies blood to the left ventricle, left atrium, and interventricular septum. As it reaches the anter or surface of the heat, it gives rise to a circumflex branch and an anterior interventricular branch, The circumflex artery curves to the let around the coronary sulcus, eventually meeting and fusing with small branches ofthe right coronary artery (Figure 20-9a,b,ce). The much larger anterior interventricular artery, or left anterior descending artery, swings around the pulmonary trunk and runs along the surface within the anterior interven- tricular sulcus (Figure 20-92) 20-2 Anatomy of the Heart [695 ‘The anterior interventricular artery supplies small tributaries continuous with those of the posterior interventricular artery. Such interconnections between arteries are called arterial anasto- moses (a-nas-td-MO-séz; anastomosis, outlet). Because the arter- ies are interconnected in this way, the blood supply tothe cardiae muscle remains relatively constant despite pressure fluctuations in the left and right coronary arteries as the heart beats. The Cardiac Veins The various cardiac veins are shown in Figure 20-9¢. The great cardiac vein begins on the anterior surface of the ventricles, along the interventricular sulcus. This vein drains blood from the region supplied by the anterior interventricular artery, a branch of the let coronary artery. The great cardiac vein reaches the level, of the atria and then curves around the left side ofthe heart with- in the coronary sulcus. The vein empties into the coronary sinus, which lies in the posterior portion of the coronary sulcus. The coronary sinus opens into the right atrium near the base of the inferior vena cava Other cardiac veins that empty into the great cardiac vein or the coronary sinus include (1) the posterior cardiac vein, drain- ing the area served by the circumflex artery, (2) the middle car- diac vein, draining the area supplied by the posterior interventricular artery, and (3) the small eardiac vein, which re- ceives blood from the posterior surfaces of the right atrium and ventricle. The anterior cardiac veins, which drain the anterior surface ofthe right ventricle, empty directly into the right atrium. Coronary Artery Disease ‘The term coronary artery dss (CAD) refers t ares "WD cfjeria or complaebockage of coronary craton, Caria ul clentd a constant eupl of ongen and n- responding redaction nck performance Sach redced Grelatory sappy krown as coronary chemi (e-KE-m-uh), general resto prt or complete blockage ofthe coro ary arei, The usa case ithe formation of say depos, “FIGURE 20-10 Coronary Circulation and Clinical Testing. (a) A color enhanced DSA image of a healthy heart. The ventricular walls have an extensive circulatory supply. (The atria are not shown.) (b) A color enhanced DSA image of a damaged heart Most of the ventricular myocardium is deprived of circulation. ‘or plague, in the wall ofa coronary vessel. The plaque, or an as sociated thrombus (clot), then narrows the passageway and re- ‘duces blood flow, Spasms in the smooth muscles ofthe vessel ‘wall can further decrease or even stop blood flow. Plaques may be visible by angiography or high-resolution ultrasound, and the metabolic effects can be detected in digital subtraction angiogra- phy (DSA) scans of the heart (Figure 20-10a, ba). We will con- sider the development and growth of plaques in Chapter 21 (Reise retonCHAPTER 20. THEHEaRT FIGURE 20-10 Coronary Circulation and I Testing. (continued) @ (€ Balloon angioplasty may be used to remove a circulatory blockage. The catheter is quided through the coronary arteries to the site of blockage and inflated to press the soft plaque against the vessel wall. () A stent is often inserted after balloon angioplasty to help prevent plaques from recurring, This scan shows 3 stent in the anterior interventricular artery One ofthe frst symptoms of CAD is commonly angina pee- i angina, pan spasm + pectoris ofthe chest) Inthe most common form, a temporary ischemia develops when the workload ofthe heart increases. Although the individual ‘may fee comfortable tres, exertion or emotional tres can pro diucea sensation of pressure, chest constriction, and pain that may radiate from the ternal area tothe arms back, and neck Angina can typically be controlled by a combination of drug treatment and changes in lifestyle, including (1) limiting activities known to trigger angina attacks (eg. strenuous ex- ercise) and avoiding stressful situations, (2) stopping smok- ing, and (3) lowering one's fat consumption. Among the medications used to control angina are drugs that block sym- pathetic stimulation (propranolol or metoprolol), vasodilators such as nitroglycerin (ni-tx8-GLIS-et-in), and drugs that block calcium movement into the cardiac muscle cells (calcium channel blockers) ‘Angina can also be treated surgically. single, soft plaque may be reduced with the aid ofa long, slender eatheter (KATHe-ter), a small-diameter tube. The catheter is inserted into large artery and guided into a coronaty artery to the plague. A variety of surgical tols can be slid into the catheter, and the plague can then be removed with laser beams or chewed to pieces bya device that resembles a miniature vesion of a Roto-Rooter® drain cleaner. Debris created during the de- struction of a plague is sucked up by the catheter, preventing the blockage of smaller vessel In balloon angioplasty (AN-j2-3-plas-t; angeion, vessel), the tip of the catheter contains an inflatable balloon (Figure 20-10ce). Once in position, the balloon is inflated, pressing the plaque against the vessel wall. Ths procedure works best in small (under 10 mm), soft plaques. Several factors make angioplasty a highly attractive treatment: (1) The mortality rate during surgery is only about 1 percent; (2) the success is over 90 percent; and (3) the procedure can be per formed on an outpatient basis. Because plaques commonly re- bound or redevelop after angioplasty a fine wire tube called a stent may be inserted into the vessel. The stent pushes against the vessel wall, holding it open (Figure 20-10de), Stents are now part ofthe standard protocol for many cardiac specialist, as the long-term success rate and incidence of complications are significantly lower than those of balloon angioplasty alone. I the circulatory blockage is too large fora single stent, ‘mutiple stents can be inserted along the length of the vessel. When angioplasty and stents are not feasible, coronary bypass surgery may be done. In a coronary artery bypass graft (CABG), a small section is removed from either a small artery (commonly the internal thoracic artery) ot a peripher- (such as the great saphenous vein of the leg) and is used to create a detour around the obstructed portion of a coronary artery. As many as four coronary arteries can be rerouted this way during a single operation. The procedures are named according to the number of vessels repaired, so wwe speak of single, double, triple, or quadruple coronary by- passes. The mortality rate during surgery for such operations \hen they are performed before significant heart damage hhas occurred is 1-2 percent. Under these conditions, the pro- cedure eliminates angina symptoms in 70 percent of the cases and provides partial relief in another 20 percent. Although coronary bypass surgery does offer certain advan- tages, recent studies have shown that for mild angina, it does not yield significantly beter results than drug therapy. Current rec- ‘ommendations are that coronary bypass surgery be reserved for ‘cases of severe angina that do not respond to other treatment al vei