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The arteries of the free ventricular walls in man.

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The Arteries of the Free Ventricular Walls in Man
THOMAS N. JAMES
Section on Cardiovascular Research, Henry Ford Hospital,
Detroit 2, Michigan
The gross anatomy of the arteries of the
atria and of the interventricular septum
have been described in previous reports
(James and Burch, '58a, '58b). This report is a description of the coronary arteries of the right and left ventricles exclusive of the septum, that is, the so-called
"free" walls of the two ventricles. A
knowledge of anatomy of the coronary arteries of the free ventricular walls is important in understanding coronary disease
and its relationship to acute myocardial
infarction.
The method has been published previously (James and Burch, '58a, '58b; Stern,
Ranzenhofer, and Liebow, '54). Briefly, it
consists of injection of colored vinyliteacetone solution into the coronary arteries,
which have been separately cannulated.
The chambers of one side of the heart
were then filled with a thicker solution,
the right side usually being employed for
two reasons: (A) When unfilled it collapsed out of shape whereas the left ventricle did not. (B) The veins could be filled
in the same injection directly from the
chambers. Casting both sides of the heart
made examination of the septa1 arteries
difficult. After the plastic hardened, the
myocardium was corroded away with concentrated hydrochloric acid.
Eighty-two fresh (unfixed) h u m a n
hearts were studied and they form the
basis of this report. There were 62 males
and 20 females.
other). There was a second right coronary
ostium in about half the hearts (Schlesinger, Zoll and Wessler, '49). Because of
its size (usually about 1 mm in diameter)
no attempt was made routinely to cannulate and inject it.
In most hearts the two coronaries followed the familiar course in the atrioventricular and interventricular sulci. Their
principal variations were not in these initial courses but in the eventual length of
the vessels, their manner of termination,
and the areas supplied on the free ventricular walls.
The point of termination of the left
circumflex coronary artery was at the
margo obtusus or between the margo obtusus and the crux of the heart in 67
(82% ) of the hearts (table 1 and fig. 1).
In only 13 hearts ( 1 6 % ) did the left
circumflex coronary artery reach or pass
the crux of the heart. The right coronary
artery reached or passed the crux from
the opposite direction in 76 hearts (94% )
(table 2).
The left anterior descending coronary
artery, which always reached the apex of
TABLE 1
Point o f termination o f the l ef t circumflex
coronary artery i n 82 human hearts
Before margo obtusus
At margo obtusus
Between margo obtusus and crux
At crux
Between crux and margo acutus
Not present
l(l%)
14 (17% )
53 (65% )
7(9%)
6(7%)
l(l%)
RESULTS
The aortic origins of the two main coronary arteries only rarely varied from the
classical descriptions (Alexander and
Griffith, '56). In this series there was only
one variation, a heart in which the left circumflex and left anterior descending coronary arteries arose separately from the aorta (their ostia were within 2 mm of each
TABLE 2
Point o f termination o f the right coronary
artery i n 82 human hearts
At margo acutus
Between margo acutus and crux
At crux
Between crux and margo obtusus
At margo obtusus
l(l%)
5(6%)
7(9%)
53 (65% )
16 (19% )
371
372
THOMAS N. JAMES
TABLE 3
Point o f termination o f the l e f t anterior descending coronary artery i n 82 human hearts
Anterior apex
Posterior apex
More than two but less than 5 cm up
posterior interventricular sulcus
More than 5 cm up posterior interventricular sulcus
13 ( 1 6 % )
20 (24%)
31 (38%)
18 (22% )
TABLE 4
Point of termination o f the posterior descending
coronary artery i n 82 human hearts
Provided by the left circumflex
coronary artery:
Half way down posterior interventricular sulcus
Three-quarters way down posterior interventricular sulcus
At the apex
Provided by the right coronary
artery:
One quarter way down posterior
interventricular sulcus
Half way down posterior interventricular sulcus
Three-quarters way down posterior
interventricular sulcus
Apex
4(5%)
1 ( 1% )
l(l%)
the heart, continued for a variable distance (table 3). It terminated on the anterior or posterior aspect of the apex in
33 hearts (40%), and ascended 2 cm or
more up the posterior interventricular sulcus in the remaining 49 (GO% ). The
posterior descending coronary artery (table 4) usually arose from the right coronary artery (93% ) but in G hearts (7% )
was provided by the left circumflex artery.
Most of the free wall of the left ventricle
was supplied by branches of the left coronary artery (table 5). The anterior half
of the left ventricular wall (table 6) was
almost completely supplied by the left
coronary artery in all the hearts. The
posterior half of the left ventricle (table 7)
was supplied by both right and left coronary arteries, but predominantly by the
left (including branches of both the left
circumflex and terminal left anterior descending).
2(2%)
23 (28%)
30 (37% )
21 (26% )
TABLE 7
Blood supply o f the posterior left ventricle ( f r o m
middle o f margo obtusus to posterior interventricular sulcus) i n 82 human
hearts
By coronary artery
Left
Right
TABLE 5
%
%
Blood supply of the free wall o f the left ventricle
( f r o m anterior interventricular sulcus to
posterior interventricular sulcus) i n
82 human hearts
100
0
10
20
30
40
50
60
70
80
90
100
By coronary artery
Left
Right
lo
%
0
100
90
80
70
60
50
No. hearts
12 (15%)
19 (23% )
25 (30% )
14 (17% )
7 (9% )
5(6%)
10
20
30
40
50
TABLE 6
Blood supply o f the anterior left ventricle ( f r o m
anterior interventricular sulcus to middle
of margo obtusus) i n 82 human
hearts
By coronary artery
Left
Right
%
%
0
100
90
80
10
20
No. hearts
78 (95% )
3 (4%)
l(l%)
90
80
70
60
50
40
30
20
10
0
No. hearts
~
_
_
_
_
_
11 (13%)
9 (11%)
10iizslo i
11 ii30,'o j
16 (20%)
3 (4%)
9 (11%)
4 (5%)
2(2%)
3 (4%)
4 (5%)
~
_
TABLE 8
Blood supply of the free wall of the right
ventricle ( f r o m anterior interventricular
sitlcus to posterior interventricular
sulcus) i n 82 human hearts
By coronary artery
Right
Left
%
%
0
100
90
80
70
60
50
40
10
20
30
40
50
60
No. hearts
_______
4 (5%)
30 (37%;
28 (349; j
14 (17%;)
3 (4%1
2 (2% )
1(l%)
_
_
_
~
FREE WALL ARTERIES
TABLE 9
373
their length with a terminal curve downward (fig. 3). Those of the left circumflex artery also arose at an acute angle
with the parent trunk and were directed
From coronary artery
toward the margo obtusus, almost parallel
No. hearts
Right
Left
to the primary branches of the left anterior descending coronary artery; near
%
%
100
0
7 (9%)
their termination they usually also coursed
15 (18% )
90
10
toward
the apex of the heart.
80
20
31 (38% )
The primary branches of the right cor70
30
14 (17% )
60
40
12 (14%)
onary artery originated almost at right
50
50
3 (4% )
angles from the parent trunk, thence
coursed roughly parallel to each other and
TABLE 10
to the margo acutus in the direction of
Blood supply of the posterior right ventricle (from the anterior interventricular sulcus, near
posterior interventricular sulcus to margo
which they anastomosed with s m a 11
acutus) in 82 human hearts
branches of the left anterior descending
artery. Posteriorly the primary branches
From coronary artery
No. hearts
of the right coronary artery usually arose
Right
Left
perpendicularly from both the atrioven%
%
tricular sulcus and the interventricular sul100
0
22 (27% )
cus. The primary branches of the anterior
90
10
32 (39% )
80
20
16 (19% )
right coronary artery, unlike those of the
70
30
3 (4%)
left, followed an anteriorly looping course
60
40
3 (4% )
in their origin, due to the relatively deeper
50
50
3 (4%)
placement of the parent trunk in the fat
40
60
l(l%)
30
70
1(1%)
of the atrioventricular sulcus (fig. 4).
20
80
1(1%)
Major variations of the main coronary
artery trunks are not common (Alexander
The free wall of the right ventricle and Griffth, '56). In this study the proxi(table 8) was supplied principally by the mal right coronary immediately divided
right coronary artery. Although the an- into two equal gradually diverging trunks
terior half of the right ventricle often re- in 7 hearts. In two other hearts the right
ceived blood supply from the left anterior coronary artery distributed in an unusual
descending coronary artery (table 9), the manner, one in which a large branch
posterior half was almost exclusively s u p curved behind the aorta and emerged in
plied by the right coronary artery (table the anterior left atrioventricular sulcus to
10). A small portion of the posterior aspect of the right ventricle near the apex
TABLE 11
was frequently supplied by a branch from Blood supply of the posterior wall (from margo
obtusus to margo acutus and from atriothe anterior descending artery after it
ventricular sulcus to apex) in 82
curved around the apex (figs. 2 and 5).
human hearts
The blood supply of the entire posterior
By
coronary
artery
wall (diaphragmatic surface) of the heart
No. hearts
was obtained slightly more from the right
Right
Left
coronary artery (table 11). This area was
%
%
the most variable of the heart in relation
100
0
4 (5%)
to its blood supply (fig. 2).
90
10
5 (6%)
80
20
9 (11% )
Despite variations in number and size,
70
30
10 (12%)
the primary (large) branches of the three
60
40
25 (30% )
main coronary trunks originated in certain
50
50
17 (21% )
general patterns. Those of the left anteri40
60
5 (6% )
30
70
3 (4%)
or descending coronary artery arose at an
20
80
3 (4%)
acute angle with the parent trunk and
10
90
l(l%)
descended toward the apex for most of
Blood supply of the anterim right ventricle (from
margo acutus to anterior interventricular
sulcus) in 82 human hearts
3 74
THOMAS N. JAMES
form the left circumflex artery (there was
no such branch from the left main artery),
and the other heart in which a similar
large branch passed behind the aorta but
then descended into the interventricular
septum and emerged in the middle of the
anterior interventricular sulcus. In one
heart the major branches of the posterior
descending artery crossed over each other
in different planes (fig. 5).
Variations in the left coronary arterial
trunk were also minor and even less common. The left anterior descending coronary artery was replaced by two parallel
and equal trunks in 4 hearts (fig. 6). Although the major trunks were visible in
the epicardium in almost all hearts, in one
the left anterior descending artery dipped
perpendicularly into the myocardium and
emerged equally perpendicularly further
down (fig. 7).
Differential branching of the terminal
coronary arteries of the left and right ventricle has long been recognized (Whitten,
'30). Over the left ventricle the epicardial
branches (of either left or right coronary
artery origin) terminate by penetrating the
myocardium perpendicular to their epicardial course (fig. 5). Over the thinner
right ventricle the epicardial branches (of
left or right origin) terminate in a plane
parallel to their epicardial course.
Anastomoses between the left and right
coronary arteries were demonstrated in
most of the 82 hearts despite the viscid
injection fluid used (fig. 8). Had less
viscid fluid been used more anastomoses
might have been noted.
Because of the relatively small number
of females in this study sexual differences
in topography of the free wall arteries have
to be interpreted without the finality which
statistical significance affords. From table
12 certain general observations may be
made. When only the extremes of posterior wall preponderance by one coronary artery or the other are considered (group A ) ,
right coronary artery predominance seems
more common in the females; conversely,
the left coronary artery was not predominant to this extreme on the posterior wall
in any of the females. In males, although
right coronary artery predominance was
usual, left coronary artery predominance
was present in 11% . When analysis was
TABLE 12
Distribution of right and left coronary arteries
on the posterior wall o f the )heart, according
to sex, in 82 human hearts
Per cent distribution
by nght
coronary art.
Per cent of
62 males
Group A
0- 20
21- 79
80-100
11,
68
21
Group B
0- 30
31- 69
70-100
16
50
34
Group C
0- 40
41- 59
60-100
21
29
50
Per cent distribution
by right
coronary art.
Per cent of
20 females
Group A
0
55
45
0- 20
21- 79
80-100
Group B
0- 30
31- 69
70-100
5
45
50
Group C
-
0- 40
41- 59
60-100
20
20
60
~~
based on lesser degrees of preponderance
(as in group C) there was virtually no
sexual difference.
DISCUSSION
Previous studies (Gross, '21; Ehrich, De
la Chapelle, and Cohn, '31-'32; Schlesinger,
'40a, '4Qb; Bianchi, '04; Spalteholz, '24),
as well as this one, have agreed in the essential aspects of human coronary artery
anatomy. There have been some minor
differences, especially in respect to the
posterior (diaphragmatic) surface of the
heart, which are most likely due to the
difference in technics employed for the
studies. When the principal or only goal
is examination of gross anatomy of the
coronary arteries, the most accurate technic is probably the injection and corrosion
method. By additionally casting the cardiac chambers an exact spatially oriented
replica of the vascular tree of the heart is
obtained.
3 75
FREE WALL ARTERIES
The variability of the manner in which
the posterior surface of the heart is supplied is perhaps not generally appreciated.
Significant areas are supplied by the right
coronary artery, the left circumflex and
left anterior descending, in that order. As
has been pointed out (Schlesinger, '40a,
'40b; Bianchi, '04) there is in general a
reciprocal relationship between the left
circumflex and right coronary lengths, and
between the left anterior descending and
posterior descending arteries at their junction in the posterior interventricular sulcus.
Near the central point of this variable area
lies the crux of the heart, and the artery
crossing this point supplies the blood for
the atrioventricular node (James and
Burch, '58a, '58b).
Classification of blood supply topographically as well by lengths or terminations of major arteries increases descriptive accuracy, for the two classifications
provide data which is often considerably
different. For example, although a given
heart may have a long left circumflex artery lying in the atrioventricular sulcus,
its branches may be short and virtually all
the posterior free walls be supplied by the
right coronary artery and terminal left anterior descending.
These descriptions of coronary artery
distribution refer to surface area only and
can be misleading when one considers the
volume of muscle supplied by the respective arteries. For example, in a heart in
which the right coronary artery supplies
the entire posterior wall as far as the margo
obtusus and apex cordis (as "preponderant" as the right coronary artery normally
ever becomes), the left coronary artery still
supplies all the anterior wall of the left
ventricle, a variable part of the anterior
wall of the right ventricle, and usually at
least two-thirds o € the septum (James and
Burch, '58b). In this sense the left coronary artery is almost always preponderant
in relation to volume or mass of muscle
supplied, and sometimes overwhelmingly
so.
By considering the variability of the normal coronary arteries one gains a better
understanding of the possible electrocardiographic and clinical syndromes expressed
by the occlusion of a given coronary artery. For example, occlusion of the left
anterior descending coronary artery a few
centimeters below the bifurcation of the
left coronary artery may damage a widely
variable area, depending on the length of
the artery (and of course on the availability of collateral circulation). If the left
anterior descending artery terminated at
the anterior aspect of the apex cordis, the
jeopardized area would only be anterior
and septa1 and relatively small; while if
the artery curved around the apex and ascended over half way up the posterior interventricular sulcus, its occlusion could
produce an infarction of both the anterior
and posterior free walls and a large part
of the septum (Roesler and Dressler, '47).
Similarly occlusion of the left circumflex
artery near its origin may infarct only a
small area of lateral left ventricular wall,
or may infarct all the lateral wall plus the
posterior wall, depending on whether the
area supplied by the artery terminated at
the margo obtusus or passed beyond the
crux of the heart. The same considerations can be made regarding the right coronary artery, depending on its length.
With both these arteries (the left circumflex and right) an occlusion may be
associated with atrioventricular block depending on whether they cross the crux
and supply the artery to the atrioventricular node.
Sexual variation in coronary artery distribution has been noted before by Schlesinger ('40a, '40b), who suggested that the
commoner left coronary artery preponderance in males may at least partially account for the sexual difference observed in
the clinical frequency of coronary artery
disease in the two sexes. The present study
supports Schlesinger's observation, and
further demonstrates that unless the extremes of preponderance are examined
(group A, table 12) the sexual difference
in coronary distribution is not so apparent
(groups B and C ) .
SUMMARY
1. The blood supply to the free walls of
the right and left ventricles has been analyzed in a series of 82 human hearts prepared by the injection and corrosion
method.
2. The anterior half of the left ventricle was supplied almost exclusively by
376
THOMAS N. JAMES
the left coronary artery, but all other areas
demonstrated considerable variation both
in origin and pattern of supply. This
was particularly true of the posterior half
of the left ventricle.
ACKNOWLEDGMENT
Most of this study was done in the Department of Medicine, Tulane University
School of Medicine, New Orleans, Louisiana. The constant encouragement of Dr.
George E. Burch, chairman of the department, i s gratefully acknowledged.
LITERATURE CITED
Alexander, R. W., and G. C. GrifFith 1956
Anomalies of the coronary arteries and their
clinical significance. Circulation, 14: 800-805.
Bianchi, A. 1904 Morfologia delle arteriae coronariae cordis. Arch. Ital. Anat. Embriol., 3:
87-164.
Ehrich, W., C. De la Chapelle and A. E. Cohn
1931-32 Anatomical ontogeny. B. Man. I.
A study of the coronary arteries. Am. J. Anat.,
49-50: 241-282.
Gross, L. 1921 The Blood Supply to the Heart.
New York, Paul B. Hoeber.
James, T. N., and G. E. Burch 1958a The atrial
coronary arteries in man. Circulation, 17:
90-98.
1958b Blood supply of the human interventricular septum. Ibid., 17: 391.396.
Roesler, H., and W. Dressler 1947 An electrocardiographic pattern of infarction of the interventricular septum, extending from the anterior to the posterior aspect of the heart. Am.
Heart J., 34: 817-826.
Schlesinger, M. J. 1940a Significant variations
in the anatomic pattern of the coronary vessels.
Blood, Heart and Circulation. A.A.A.S. Publication No. 13: p. 61-72. Ed. F. R. Moulton.
Science Press, Washington, D. C.
1940b Relation of anatomic pattern
to pathologic conditions of the coronary arteries. Arch. Path., 30: 403415.
Schlesinger, M. J., P. M. Zoll and S. Wessler
1949 The conus artery; a third coronary artery. Am. Heart J., 38: 823-836.
Spalteholz, W. 1924 Die Arterien der Herzwand. Hirzel, Leipzig.
Stern, H.,E. R. Ranzenhofer and A. A. Liebow
1954 Preparation of vinylite casts of the coronary vessels and cardiac chambers. Lab. Invest., 3: 337-347.
Whitten, M. B. 1930 The relation of the distribution and structure of the coronary arteries
to myocardial infarction. Arch. Int. Med., 45:
383400.
FREE WALL ARTERIES
Thomas N. James;
1
PLATE 1
Cast of a normal human heart viewed directly at the marqo obtusus (white arrows),
showing the left circumflex coronary artery (L. C.) termination there. L. A. D., left anterior descending coronary artery; M. P. A., main pulmonary artery; R. A,, right atrium;
G . C. V., great cardiac vein; P. I. V., posterior interventriculsr vein. The left atrium
and ventricle are intentionally not cast, as usual.
377
PLATE 2
EXPLANATION O F FIGURES
2
378
Four casts of normal human hearts viewed from the posterior (diaphragmatic) surface,
showing the variation in distribution of the right and left coronary arteries i~nthis area.
In each photograph the smaller arrows indicate the boundaries between the areas supplied by the left and right coronary arteries. A, B and C show the usual preponderance
in this area by the right coronary artery; D shows the exception, i n which t.he left coronary artery is preponderant. The large black arrow in each photograph indicates the
crux of the heart. R. A., right atrium; C. S . , coronary sinus; R. C. A., right coronary
artery; S . I. V., sub-intimal vein of the right atrium; R. V., right ventricle; L. M. A,,
left marginal coronary artery; R. M. V., right marginal vein; and P. I. V., posterior
interventricular vein.
FREE WALL ARTERIES
Thomas N. James
PLATE 2
379
PLATE 3
EXPLANATION OF FIGURES
380
3
Cast of a normal human heart viewed from a point between the anterior interventricular
sulcus and the margo obtusus, showing the manner of branching of the left circumflex
(L. C.) and left anterior descending (L. A. D.) coronary arteries (see text). M. P. A.,
main pulmonary artery; R. A., right atrium; G . C. V., great cardiac vein; L. M. A,, left
marginal coronary artery.
4
Cast of a normal human heart viewed directly a t the anterior right atrium ( R . A.) and
right ventricle ( R . V . ) , showing the manner of branching of the normal right coronary
artery (R. C. A . ) . S. I. V., sub-intimal vein of the right atrium; M. P. A , , main pulmonary
artery.
5
Posterior (diaphragmatic surface) view of a normal human heart cast showing two
posterior descending branches of the right coronary artery (R. C. A.) cicossing over
each other. Note the apex of the right ventricle (R. V.) supplied by a terminal branch
of the left anterior descending coronary artery. The arrows indicate the boundary between regions supplied by the left and right coronary arteries. Differential branching
of the arteries over the right ventricle, where they remain straight and parallel to the
surface, and the left ventricle, where they turn in perpendicularly, is well shown. C S.,
coronary sinus; R. A . , right atrium; S. I. V., sub-intimal vein of the right atrium.
FREE WALL ARTERIES
Thomas N. James
PLATE 3
381
PLATE 4
Cast of a normal human heart viewed directly at the anterior interventricular sulcus,
where there is a variation of the left anterior descending coronary artery (white arrows) with the upper two-thirds being two parallel trunks, diverging i n the terminal
third near the apex. The two black arrows indicate a vein and very small artery
forming Vieussens’ ring (see text). R. A , , right atrium; S. V. C., superior vena cava;
M. P. A.. main pulmonary zrtery; R. V., right ventricle; G. C. V., great cardiac vein.
Cast of a normal human heart with the anterior interventricular sulcus viewed at a n
angle from the anterior surface of the lower right ventricle ( R . V. j , showing a dip in
the left anterior descending coronary artery betmeen the white arrows; it leaves its
normal epicardial course to penetrate deeply but emerges again further down.
6
7
EXPLANATION OF FIGURES
FREE WALL ARTERIES
Thomas N. James
PLATE 4
FREE WALL ARTERIES
PLATE 5
Thomas N. James
8
384
Cast of a normal human heart viewed posteriorly, showing normal arterial anastomoses
i n the region of the crux. The three smaller arrows in the left lower portion of the photograph indicate an artery approximately 300 micra in diameter connecting a terminal
branch of the left marginal coronary artery ( L . A t . A , ) with terminal branches of the
right coronary artery ( R . C. A , ) . Variation i n color of the 4 terminal branches of the
right coronary artery shown between the two larger upper arrows shows that flow between plastic i n the left coronary artery, which was red, and the right coronary artery,
which was blue, has mingled. R. A., right atrium; C. S . , coronary sinus; R. V., right
ventricle.
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