354 Venugopal GE. et al. / International Journal of Biological & Pharmaceutical Research. 2016; 7(11): 354-359.

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A STUDY OF BRANCHING PATTERN OF IN HUMAN CADAVERS

G.E. Venugopal*, V. Muniappan, K. Vengadachalam

Department of Anatomy, Rajah Muthiah Medical College, Annamalai University, Chidambaram, Tamil Nadu, India.

ABSTRACT Coronary artery disease is the commonest cause of diseases and the most important cause of death all over the world. Coronary artery occlusion may either result in myocardial infarction or lead onto ischemia and angina pectoris. The recent advances in direct coronary artery surgery, the newly invented techniques in bypass surgery and the modern methods of revascularisation require a complete knowledge of the . The study of coronary arteries regarding its course and distribution was conducted at the Department of anatomy-RMMC, Annamalai University. 50 heart specimen age group of 20 – 65 years were studied. After cadaveric dissection, 50 heart specimens were collected from dissection hall for a period of 3 years.Manual dissection was done in 50 adult heart specimens, from dissection hall.Detailed description of material collection.It arises from the anterior , the artery passes at first anteriorly and slightly to the right between the right auricle and pulmonary trunk where the sinus usually bulges. Reaching the atrioventricular (coronary) sulcus it descends in this almost vertically to the right (acute) cardiac border, curving around it into the posterior part of the sulcus , where it approaches its junction with both interatrial and interventricular grooves, a region appropriately termed the crux of the heart.LCA arises from the left posterior aortic sinus .In its course, it lies between the pulmonary trunk and the left auricle emerging to reach the atrioventricular sulcus, in which if turns to the left. In this situation, it may give rise occasionally to the „artery of the ‟ (James 1961) the LCA – reaches the atrioventricular (or) & divides into 3 main branches of which the anterior interventricular (descending) ramus is commonly described as the continuation of LCA.As the study of the various patterns of coronary arteries with variations, is essential for the clinicians, the coronary arterial pattern was studied in 50 heart specimens. According to the description of our Bible, Gray‟s Anatomy (39th edition), the study was carried out and compared with our present observations.

Key Words: Coronary artery, Anatomy.

INTRODUCTION The introduction of selective coronary arteries and their variations is therefore absolutely arteriography (Sones, 1959) provides accurate visualization necessary for interpretation of angiography, ECG-gated of the artery and its pathology. The recent development of multi-director row CT findings and intelligent plan of electrocardiographically (ECG)-gated multi-detector row coronary surgery. computed tomography (Cardiac CT) allows accurate and The heart is supplied by the right and left noninvasive depiction of coronary artery pathology. A coronary arteries which encircle the base of the ventricles sound knowledge of normal anatomy of the coronary like a crown. Variation with relation to origin, course and termination are most frequently reported in the right Corresponding Author coronary artery. According to angiographic study in western population done (Topez et al., 1992), the right G.E. Venugopal coronary artery was the most common anomalous artery. Email: [email protected] 355 Venugopal GE. et al. / International Journal of Biological & Pharmaceutical Research. 2016; 7(11): 354-359.

It has been proved that the anomalous coronary arteries are anatomy (Grossman, 2000). The performance of high associated with high incidence of congenital heart diseases. quality coronary arteriography safely defining each and Angiographic recognition of anomalous coronary every coronary stenosis in an optimal view is an important arteries prior to cardiac surgery is important. Failure to measure of an operator‟s skill in cardiac catheterization recognise them can cause inadequate or prolonged which emphasizes the importance of complete knowledge procedures and may lead to misdiagnosis and of coronary artery anatomy. complications such as accidental ligation (Donaldson, 1982). An inadvertent incision of the anomalous artery or MATERIALS & METHODS failure to perfuse the anomalous vessel during Method of Removal of heart specimen from cadavers cardiopulmonary bypass (Longenecker et al.,1961) may The thorax as the shape of a truncated cone, result in acute myocardial infarction (Mahowald et superiorly continuous with neck and inferiorly with al.,1986). Obstruction of the ostium (Lillehei et al., 1964) abdomen. The vital organ heart is situated in the thoracic of an anomalous artery and compression along its course cavity. A transverse incision was made through the by a valvular prosthesis also have been reported (Roberts, manubrium sternum to expose underneath parts. Another 1969). incision was made through the parietal pleura in the first The stress on need for detailed study of the intercostal space extending from the lateral sternal border coronary arteries is further emphasized by the fact that a up to the left mid-axillary line. From the ends of the line high incidence of the coronary anomalies has been the second and subsequent ribs were divided inferiorly up observed in young victims of sudden death as compared to to the level of xiphisternal joint. The lower part of the adults (4-15 percent versus 1 percent respectively) (Engel sternum and the costal cartilage and anterior parts of the HJ et al., 1975) With increasing utilization of coronary ribs were elevated. The parietal pleura extending from arteriography in the diagnosis of ischemic heart disease back of sternum up to the mediastinum on both sides were and with the advent of ECG-gated multi-detector row CT, divided. unexpected origin and course of coronary arteries are The upper part of the sternum was lifted up by encountered more frequently. This study of origin and dividing the sternopericardial ligaments. variation of right coronary artery is done with an The fibrous was separated from the expectation that it will hopefully contribute to better and adjoining structure by dividing the fibrous pericardium. complete interpretation angiographic studies, prevent The heart was exposed and delivered out of middle unwanted surgeries due to misdiagnosis and better mediastinum by cutting branches of Arch of , utilisation of anomalous vessels in bypass Surgeries. superior and inferior vena cava, and The branching structure of vascular system has veins. been the subject of much discussion and debate since it After the removal of heart specimen from the was first suggested that these systems have fracial cadavers they were preserved in 10% formalin solution for architecture (Mandelbrott, 1977). Coronary artery of 1 week. The heart after adequate fixation the manual human heart and their branching characteristics have been dissection was done. the subject of particular attention among researchers. Coronary artery anomalies are a diverse group of The composition of preservative fluid congenital disorders whose manifestations and Formalin ------2 liters pathophysiological mechanisms are highly variable Glycerin ------1 liter (Angelini et al., 2002). The subject of coronary artery Absolute Alcohol ------1 liter anomalies is undergoing profound evolutionary changes H2O ------2 – 4 liters related to the definition, morphogenesis, clinical Salt ------1kg presentation, diagnostic workup, prognosis and treatment of these anomalies. Manual Dissection According to (Engel, 1975), 1-2% of patients Manual Dissection was done in 50 heart studied by selective coronary arteriography, one or more specimen. major elements of the coronary arterial system originated from the sinuses of valsalva in an ectopic manner. The Procedure for Dissection of RCA &LCA failure to recognise variations in coronary arterial origin Materials used can prolong arteriographic procedures and lead to errors in Gloves interpretation of coronary artery anatomy and pathology. Mosquito scissors - 2. Though a number of recent techniques namely Mosquito forceps (toothed) - 2. Electron Beam Computerized Tomography (EBCT), 64 Mosquito artery forceps - 2. slice CT (Angio, 2005) and intravascular ultrasound have The visceral pericardium from the sternocostal of been introduced, selective coronary arteriography remains the heart. Expose the anterior interventricular branch of the the clinical “Gold Standard” for evaluating coronary left coronary artery and the great cardiac vein by scraping 356 Venugopal GE. et al. / International Journal of Biological & Pharmaceutical Research. 2016; 7(11): 354-359. the fat from the anterior interventricular sulcus. Note the surface of the heart to the sternum and costal cartilages. branches of the artery to both ventricles and to the which lies deep to it. Trace the RESULTS artery inferiorly to the diaphragmatic surface and Classified on the basis of segmental branches superiorly to the left of the pulmonary trunk. Branches of RCA are from first segment which Carefully remove the fat from the coronary extends from anterior aortic sinus to the atrioventricular sulcus. Avoid damage to the small anterior cardiac vein sulcus. Second segment extends from atrioventricular which cross it from the right to enter the right sulcus to the right border. Third segment from right border directly. Find the right coronary artery in the depth to left border. of the sulcus. Follow the artery superiorly to its origin from the right aortic sinus (a swelling at the root of the Left Coronary Artery (LCA) ascending aorta deep to the right auricle) and inferiorly till In all 50 heart specimen studied, LCA was it turns on to the posterior surface of the heart. Note the present, in 49 specimens. It takes its origin from the left branches to the right ventricle and atrium. One of these posterior aortic sinus and passes between pulmonary trunk passes over the left surface of the auricle towards the and left atrium to the and divides into superior vena cava. It supplies part of the atrium and the anterior interventricular and circumflex branch.In one heart sino atrial node. specimen the LCA was absent. But the branches of LCA Uncover the surface layer of the myocardium were present with separate origin as anterior (muscle of the heart); note the general direction of its fibres interventricular from anterior aortic sinus and circumflex and the depth of the coronary sulcus, the wall of the atrium artery from right posterior aortic sinus. passing deep to the bulging ventricular muscle. Replace the anterior thoracic wall in position. In Bivalent Pattern Note the relation of the various part of the sternocostal LCA branches into anterior descending artery and circumflex artery. Table 1. Classification on the basis of termination RCA Extend Literature (%) Type I Till the right border 10 % Type II From right border to crux 70 % Type III Crux to left border 20 %

Table 2. RCA Branches First segment RCA Branches Literature (%) Frequency (observed) Percentage (%) Nodal 65 % 37 74 % Conus Artery 100 % 50 100 %

Second segment Atrial 100 % 50 100 % Ventricular 100 % 50 100 % Right marginal 100 % 50 100 %

Third segment Posterior intervntricular 100 % 50 100 % AVnodal branch 90 % 49 98 % Left Atrial Nil 1 2 % Left Ventricular Nil 1 2 %

Classification of Left Coronary Artery (LCA) Table 3. Stem from left posterior aortic sinus to the level of it’s termination Stem Frequency (observed) Percentage (%) Present 49 98 % Absent Nil 0 % Total 50 100 %

357 Venugopal GE. et al. / International Journal of Biological & Pharmaceutical Research. 2016; 7(11): 354-359.

Table 4. LAD [Anterior interventricular artery] LAD Frequency (observed) Percentage (%) Present 50 100 % Absent Nil 0 % Total 50 100 %

Table 5. Left Marginal [from circumflex] Left marginal Frequency (observed) Percentage (%) Present 50 100 % Absent Nil 0 % Total 50 100 %

Table 6. Circumflex Artery Circumflex Artery Frequency (observed) Percentage (%) Present 49 98 % Abnormal Nil 0 % Total 50 100 %

Table 7. Anterior Diagonal Anterior Diagonal Frequency (observed) Percentage (%) Present 50 100 % Absent Nil 0 % Total 50 100 %

Table 8. LCA on the basis of termination Division Frequency(observed) Percentage (%) Bivalent 49 98 % Trivalent Nil 0 % Absence of LCA 1 2 % Total 50 100 %

DISCUSSION scientist found that RCA arises from the anterior aortic Coronary predominance in man sinus of the ascending aorta and passes forward and to the Majority of people (90%) possesses right right between the pulmonary trunk and right auricle along coronary dominance, where the posterior interventricular the right part of the atrioventricular sulcus. Most of the artery is large & arises from RCA.Minority of population workers found that LCA seemed to be arising in majority (10%) has left coronary dominance, where the posterior of cases from left posterior aortic sinus and in some cases interventricular artery is a branch of left coronary artery. from the pulmonary trunk or from pulmonary artery and These peoples are likely to be affected by coronary artery found that LCA arise from the anterior sinus instead of left diseases because the entire left ventricle & the posterior aortic sinus.In some cases they found that LCA interventricular septum are under the nutritional control of arising from anterior aortic sinus along with RCA. Left coronary artery, obstruction of the LCA may produce Observative finding are coincident with majority output failure of systemic circulation. In rare occasion the of scientist LCA arises from Left Post aortic sinus.In one posterior interventricular branch is derived from both specimen, there is no LCA.As described by other workers, coronary arteries, and runs as two parallel posterior it is observed that the normal branching pattern of LCA interventricularartery. Individual with such balanced type (i.e.) bivalent pattern in 49 specimens (98%) & trivalent of coronary obstruction are least affected by coronary (0%) & absence of LCA in 1 specimen (2%). diseases The coronary circulation was studied by many CONCLUSION anastomist by manual dissection method & other special Due to excessive stress & strain of day to day methods like injecting contrast dye into the vessels then modern life, the incidence of death due to myocardial analysed the X ray picture taken after the dye injection. ischemia also increases. To treat medically & surgically, They found out the normal & abnormal pattern of the basic fundamental knowledge of the coronary arteries coronary arteries & they also correlated the above views is mandatory, not only for clinicians like cardiologist, with developmental anomalies of the heart. Most of the cardiothoracic surgeons & radiologist but also for 358 Venugopal GE. et al. / International Journal of Biological & Pharmaceutical Research. 2016; 7(11): 354-359. anatomists, for teaching undergraduates. The anatomists CONFLICTS OF INTEREST should teach the variations in the blood supply of heart The authors have none to declare. especially of left coronary artery (LCA), so that the clinicians can manage the pathological lesions efficiently. ACKNOWLEDGEMENTS With the above idea I started analyzing the coronary I express my gratitude to Dr. V. Muniappan, arteries (CA) regarding its origin, course, branching Professor & Head, G.E. Venugopal, Lecturer Department pattern, distribution in 50 adult heart specimens. of Anatomy, Rajah Muthiah Medical College, Annamalai University.

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