PKA Cardiology. Features of the blood supply to the heart and the ability to diagnose the level of occlusion of the heart attack-bound coronary artery. Heart blood supply. General methods for the treatment of heart vessels
Coronary blood circulation ensures blood circulation in myocardium. By coronary arteries, blood enriched with oxygen comes to heart according to a complex circulatory scheme, and the outflow of deoxygenic venous blood From myocardium passes through the so-called coronary veins. There are surface and small deeply arranged arteries. On myocardial surfaces are epicardial vesselsFor which the characteristic difference is self-regulation, which allows to maintain the optimal blood supply to the organ required for normal performance. Epicardial arterys differ in a small diameter, which often leads to atherosclerotic damage and narrowing the walls with the subsequent occurrence of coronary failure.
According to the diagram of the blood vessels, two main trunks of coronary vessels are distinguished:
- right coronary artery - comes from the right aortic sinus, is responsible for the bloodstream of the right and rear-bottom wall of the left ventricles and some part interventricular partition;
- left - comes from the left aortic sinus, then it is divided into 2-3 small arteries (less often four); The most significant are considered front downward (front interventricular) and envelope branches.
In each individual case anatomical structure Heart vessels can vary, therefore, for a full study, cardiography of heart vessels (coronary art) is shown using an iodine-containing contrast agent.
Main branches right coronary artery: The branch of the sinus knot, the cone branch, the right-hand branch, the branch of the sharp edge, the rear interventricular artery and the rear-side artery.
Left coronary artery begins a trunk, which is divided into the front interventricular and envelope arteries. Sometimes between them leaves intermediate artery (a.interMedia). Front interventricular artery (front descending) gives diagonal and septal branches. Basic branches envelope artery are branches of stupid edge.
Miocardial blood circulation varieties
Based on the bloodstand of the rear wall of the heart distinguish the balanced, left and right type of blood circulation. The definition of the predominant type depends on whether one of the arteries of the immudidial section reaches, which was formed as a result of the intersection of two furrows - theft and intergventhroke. One of the arteries reaching this area gives the branching passing towards the tip of the organ.
Consequently prevailing right type of blood circulation The authority is ensured by the right artery having a structure in the form of a large trunk, while the envelope of the artery to this area is poorly developed.
Predominance left type Accordingly, it assumes the preemptive development of the left artery that envelopes the root of the heart and ensuring the blood flow of the organ. In this case, the diameter of the right artery is small enough, and the vessel itself comes only to the middle of the right ventricle.
Balanced type It assumes a uniform blood flow to the above-mentioned portion of the heart on both arteries.
Atherosclerotic lesion of heart vessels
Atherosclerotic heart disease and vessels are a dangerous damage to the vascular walls, characterized by the formation of cholesterol plaques, which become the cause of stenosis and impede the normal flow of oxygen and nutrients to the heart. The symptoms of atherosclerosis of the heart vessels are more often manifested in the form of angina attacks, lead to myocardial infarction, cardiosclerosis, as well as thinning of vascular walls, which threatens them with a gap and without timely treatment leads to disability or fatal outcome.
How is IBS manifest?
The main cause of the development of IBS are atherosclerotic deposits on vascular walls. Other reasons for circulatory disorders are to:
- improper nutrition (the predominance of animal fats, fried and fatty dishes);
- age changes;
- men are several times more likely to suffer from vascular diseases;
- diabetes;
- excess weight;
- genetic predisposition;
- persistent increase of blood pressure;
- the disturbed ratio of lipids in the blood (leaf-like substances);
- harmful habits (smoking, drinking alcoholic beverages and narcotic substances);
- sedentary lifestyle.
Diagnosis of blood vessels
The most informative method, how to check the heart vessels is angiography. For the study of the coronary arteries is applied selective coronary photography of heart vessels - A procedure that allows us to estimate the state of the vascular system and determine the need for surgery, but has contraindications and in rare cases leads to negative consequences.
During the diagnostic study, puncture is performed femoral arteryThrough which the catheter is entered to the vessels of the heart muscle for supplying a contrast agent, as a result of which an image is displayed on the monitor. Next, the section of the narrowing of the walls of the artery is revealed and its degree is calculated. This allows the specialist to predict the further development of the disease.
In Moscow, prices of the coronary of the heart vessels vary on average range from 20,000 to 50,000 rubles, for example, the center is cardio - vascular surgery Bakuleva provides the services of a qualitative study of coronary vessels, the cost of the procedure starts from 30000 rubles.
General methods for the treatment of heart vessels
For treating and strengthening vessels, integrated methods consisting of adjusting nutrition and lifestyle, drug therapy and surgical intervention are used.
- compliance diet nutritionwith increased use fresh vegetables, fruit and berries, which is useful for strengthening the heart and vessels;
- light gymnastic exercises are prescribed for heart and vessels at home, we recommend swimming, jogging and daily walks in the fresh air;
- assigns of vitamins for brain and heart vessels with increased content retinol, ascorbic acid, tocopherol and thiamine;
- droppers are used to maintain heart and vessels that feed and restore the structure of tissues and walls in the minimum time;
- medications are used for heart and vessels that reduce the painful sensations, output cholesterol, reduced blood pressure;
- a new methodology for improving the activities of the heart and vessels is listening to therapeutic music: American scientists have proven a positive effect on the contractile function of myocardium while listening to classical and instrumental music;
- good results are observed after use folk Medicine: Some medicinal plants Recruitment and vitamin action for the heart and blood vessels are the most popular decoction of hawthorn and dyeing.
Surgical methods of heart vessels
X-ray thrown at work, performing angioplasty and heart stenting
To improve the blood circulation of the coronary arteries, balloon angioplasty is carried out and stenting.
The method of balloon angioplasty implies the introduction of a specialized tool into the affected artery to inflate the walls of the vessel in the area of \u200b\u200bnarrowing. The effect after the procedure is preserved temporarily, since the operation does not imply eliminate the main cause of the stenosis.
For the most effective treatment The stenosis of vascular walls is set to install stents in the heart vessels. The specialized frame is introduced into the affected area and expands the narrowed walls of the vessel, respectively improves myocardial blood supply. According to the reviews of leading cardiac surgeons, after stenting the blood vessels of the heart, life expectancy increases if all medical recommendations are fulfilled.
The average cost of stenting the blood vessels in Moscow ranges from 25,000 to 55,000 rubles, without taking into account the cost of instruments; Prices depend on many factors: the severity of pathology, the number of required stents and cylinders, the rehabilitation period, and so on.
Envelope branch of the left coronary artery It begins at the site of the bifurcation (trifurkation) of the draft barrel and goes on the left atrioventricular (corner) furrow. A flexible branch of the LKA will be called further to simplify the left envelope artery. That is how, by the way, she is called in English-speaking literature - Left Circumflex ARTERY (LCX).
From the envelope of the artery We depart from one to three large (left) edge branches going through the stupid (left) edge of the heart. This is its main branches. They are blood supply to the side wall of the left ventricle. After the edge of the edge branches, the diameter of the envelope of the artery is significantly reduced. Sometimes only the first branch is called (left) edge, and the subsequent - (rear) side branches.
Archier envelope It also gives from one to two branches going to the side and rear surfaces of the left atrium (the so-called front branches to the left atrium: anastomatic and intermediate). In 15% of cases at the left-hand (unauthorized) of the coronary form of blood supply to the heart, the envelope of the artery gives the branch to the rear surface of the left ventricle or the rear branches of the left ventricle (F. H. Netter, 1987). Approximately 7.5% of cases from her, the rear interventricular branch, eating both the back of the interventricular partition, and partly the rear wall of the right ventricle (J. A. Bittl, D. S. Levin, 1997).
Proximal lKA branch envelope Call the segment from her mouth to the extinction of the first edge branch. The edge branches to the left (stupid) edge of the heart usually two or three. Between them is the middle part of the flexible branch of the LKA. Over the last edge, or how it is sometimes called (rear) lateral, the branch should be a distal section of the envelope of the artery.
Right coronary artery
In their primary departments The right coronary artery (PKA) partially covered with the right ear and follows the right atrioventricular furrow (Sulcus Coronarius) in the direction of the crossroads (place on the diaphragm wall of the heart, where the right and left atrioventricular furrows are converged, as well as the rear interventricular headorrod of the heart (Sulcus Interventricularis Posterior)) .
First branch outgoing From the right corverity artery is a branch to the arterial cone (in half of the cases, it moves directly from the right coronary sinus of aorta). When blocking the front interventricular branch of the LKA, the branch to the arterial cone is involved in maintaining collateral blood circulation.
Second branch of PKA - This is a branch to a sinus node (in 40-50% of cases, it can move away from the envelope branch of the LKA). Returning from the PKA, the branch to the sinus corner is directed by the Forward, the blood supply is not only a sinus knot, but also the right atrium (sometimes both atrium). The branch to the sinus unit goes in the opposite direction towards the branch of the arterial cone.
Next branch - This is a branch to the right ventricle (maybe up to three branches running parallel), which supplies the front surface of the right ventricle. In its middle part, a little higher than the sharp (right) edge of the heart of PKA gives the beginning of one or more (right) edge branches, going towards the top of the heart. They are blood supply to both the front and the rear walls of the right ventricle, as well as provide collateral blood flow when blocking the front interventricular branch of the LKA.
Continuing to follow according to the right atrioventricular furrowPKA goeshes the heart and already on the back of its surface (almost reaching the place of intersection of all three furrows of the heart () gives the beginning of the rear interventricular (descending) branch. The latter descends on the rear interventricular furrow, giving, in turn, the beginning of a small lower partitioned branches , blood supply to the bottom of the partition, as well as branches to the rear surface of the right ventricle. It should be noted that anatomy distal department PKA is very variable: in 10% of cases, for example, two rear interventricular branches running in parallel.
Proximal region of the right coronary artery Call a segment from its beginning to dumping branches to the right ventricle. The latter and lowest (if more than one) is the edge branch limit the average PKA department. Then follows the distal portion of the PKA. The first - horizontal, second - vertical and third - horizontal segments of PKA are also distinguished in the right-oblique projection.
Educational video of blood supply to the heart (anatomy of arteries and veins)
During problems with watching download video from pageFig. 50. Corrosion preparation.
View of the crown artery and mouth of the aorta from behind.
Strictly rear is located neutica (NES) (H) SI NUS AORT. From the 1st facial sinus of the aorta (1), the right-handed artery (PVA) is leaving, follows first ahead of the trittlec valve, and then, having converted it, the casting post from it. The first major atrial branch of the PVA is the AR Terry of the sinus knot, heading by the hide from the aorta (while in the white arrow). From the 2nd-facial aortic sine (2), the left coronary artery (LVA), which gives the envelope and the red interventricular branches (PMW). The black arrow shows the PMZHV, blood supplying top and the giving vei to the papillary muscles of both ventricles. The stroke of the PMF and the rear interventricular branch (ZMZHV) shows the dying of the axes of the front and rear interventricular partitions of the heart. It can be seen that the front interventricular partition in the cone area is sharply rejected to the left.
Wok is a branch of acute edge.
Adventical artery
The third permanent branch of the right of VA is Adventitious Artery. This not a large artery can be a branch of the conical artery or to move independently (see Fig. 28) from the aorta1 7. It is directed up and right and lies on the front wall of the aorta (above the blue monitural connection), heading to the left and disappearing in a fatty case surrounding the main vessels.
It requires coagulation when the aortic cannulations and during the operations of the aortocortonary shunting, since it can be a source of bleeding.
Giving these three branches, the right in A follows in the right atrioventricular furrow and, having encouraged the right edge of the heart, goes to a diaphragmal surface. On the way, this envelope segment of the right view of the right atrium and right ventricular ku (see Fig. 40, and; 46, 50).
Artery of acute edge
The artery of the sharp edge, or the right edge artery, is one of the largest branches of the right va. She descends from the right va to the acute right edge of the heart and more often reaches the tops (and sometimes it goes to the back surface of the CA) or reaches the middle of the right ventricle (see Fig. 46-48, 50). This is the largest collateral branch of the right (D. Luzha, 1973; D.lewin and G.Gardiner, 1988),forming the most powerful (of all branches) anastomoses with PMGV. Artery participates in the feeding of the front and rear surfaces of the sharp edge of the heart.
On the rear surface of the right ventricle, the right of wa is divided into small finite branches, the following to the right atrium and the right ventricle. Giving a large branch - the branch of the acute edge (the right-handed branch heading for the top) - and the rogue of the NUV three-rolled valve, the right in and then follows the rear surface of the heart along the atrioventricular furrow to the heart of the heart. Here it forms a U-shaped bend along the supply partition and, by giving the arterile an atrioventricular node, on the rushing along the rear interventricular furrow down to the top (Fig. 51).
Artery atrioventricular node
The artery of the atrioventricular node is directed into the thickness of myocardium through the phib of a punk and fatty tissue under coronary sine. According to most authors,
Fig. 51. The course of the right (PVA) and left (LVA) of the coronary arteries in Atrioventricular Barrouts.
A - Heart preparation. Rear view and heart base.
It can be seen that the right corned artery, departing from the aorta (a), envelopes a three-rolled valve (T) and, giving ZMZHV, on the rushing further towards the left atrioventricular furrow. It is involved in the blood supply to the rear wall of the leskogo. Left Crown Artery Enives mitral valve (M) Only in front and does not participate in the nutrition of the rear wall of the left ventricle.
B - scheme. |
Aorta, la - pulmonary artery, T and M - three-rolled and mitral valves, PJ and LV - right and left lugs, LVA - left cornese artery, ZMZHV - rear interventricular branch (from PVA), VTK is a branch of a blunt edge.
(J) - artery atre-ventricular node; (§) - posterior branch.
Here and on all subsequent figures, the CIFR of the digital designations of the VA, shown in Fig. 70.
Fig. 52. Vascularization of the front intervent of the daughter partition (MZHP).
Scheme. View of the MZhP from the right ventricle.
The right upper partitioner artery (1) is more often a branch of the right corner artery (PVA), but it may be to die from the conical artery (ka). The left upper distortion of the rose artery (2) is usually a branch in front of it interventricular branches (PMZHV). Both artery participants in the vascularization of an atrioventricular node and the Horsis Bound. Other septal branches of PMZHV (shown by arrows) W. McAlpine (1975) determines the front pavement branches.
Fig. 53. Vascularization of an atrioventricular (atrial and ventricular) node (PZH) and a beam of Gis.
3 and P - rear and right sinuses Waltzalvy, A.Pu - Artery atrial-ventricular assembly, PJ and LV - right and left ventricles, LP - left atrium, T - three-rolled valve, P - penetrating part, B - branching part of the atrioventricular node .
Aorta, la - pulmonary artery, PSM - Front Popples Muscle, Ov - Enveling Branch, DV - Diagonal Branch, AOK - Artery Acute Territory.
an atrioventricular site of an atrioventricular node in 88-90% of cases is bustling from the system of the right-wing system (see Fig. 40, 42, 43), approximately 10% of cases - from the system of the left va and occasionally from a mixed source (V. V. Kovanov and T. N. Nikna, 1974; K.ANDERSON ETAL., 1979; G. Gensini, 1984).
According to T. James (1958), the interventricular partition and the conductive heart system is vascularized at two levels. The distal part of the atrioventricular node, a beam of Gis and its two legs are localized in various parts of the interhertiary partition. The first blood suite from the artery of an atrioventricular node, the legs of the Gis beam and the Purkinier's fibers are vascularized from the septal branches of the ZMZHV and the partition branches of the PMJ. According to W. McAlpine, the zone of occurring AT riovantricular node is partly in a comprehensive and right and left upper rearrangement arteries (Fig. 52, 53).
Rear interventricular branch
ZMZHV can be a direct continuation of the right va, but it is more often its branch. This is one of the largest branches in A, which in the back in the rear interventricular groove gives the rear septal branches, which, firstly, Ana1 is stomensized with the SMJ branches of the same name, and secondly, as already noted, we participate in the vascularization of terminal departments conductive Heart systems.
Approximately a quarter of patients with the right type of dominance there are significant variations in the exhaustion of the ZMZHV. These options include double ZMZHV, early exit ZMZHV (without reaching the head of the heart), etc.
Pymboke branch of the left ventricle
According to the materials of G. Gensini and P. Esente (1975), approximately 20% of the case of evi, the rights of the left ventricle forms the posterior branch. This terminal department of the right of V. V. V. Kovanov and T. N. Anikina (1974) is called the right envelope artery. We believe that the right envelope of the artery is the whole right in a and in the interval between the conical artery and the last descending branch of the right va. In some cases, the right BA may reach the branch of the stupid edge, and in these cases, the rear-bottom left ventricular branch is a branch of the right va.
With the left type of dominance, the right va, as a rule, does not reach the heart of the heart. With this variant of the distation of va, the rear interventricular branches (more often two-two) and the ZMZHV began the beginning of the left va. In this case, the artery atroventric of the Large node is also more often a branch of the left VA.
Left Crown Artery
The left cornese artery is departed from the left (2nd facial) aorta sinus (see Fig. 41-43, 48, 54) immediately below the synotombular connection line. The trunk of the left va in different hearts varies noticeably in length, but usually it is short and rarely transfers 1.0 cm. The left va, as a rule, leaves one barrel, envelope from behind Le Goshchi barrel, and at the level of nonless lung artery sinus is divided into branches , Chapter two: PMJ and OB.
As noted above, in 40-45% of cases, the left-wing branches may give an artery that feeds the sine node before division into masters. This artery can be branching and the left Va.
Front interventricular branch
The PMIV should be down along the front interventricular partition and reaches the top of the heart. Occasionally, there is a doubling of PMF and very rarely - self-escaped extension of the PMF from the 2nd facial aorta sinus. Less frequently, the PMWh does not reach the top of the heart, but approximately in 80% of cases it comes to the tops and, bent it, goes to the back surface of the heart.
Fig. 54. Corrosion preparation.
View of the coronary artery and mouth of the aorta (a) on the left. Left side effect.
The left cornese artery (LVA) departs from the 2nd facial sinus Aor you (2) and is divided into front interventricular (PMW) and envelope (s) branches. In this projection, PMIV occupies an extremely left for the front surface of the heart. Ei almost immediately (this is observed very often) gives a large branch - the branch of the stupid region (VTK). Further OH enives a mitral valve (M), located under a stupid angle to the plane of the base of the aorta. ZMZHV in this heart is the branch of the right corner artery. It is layered by the terminal surface branch.
Its permanent branches are diagonal (sometimes in the amount of two and three), septal branches and the right-handed branch.
A. On the front of the heart of the heart, the PMJ gives a non-permanently expressed Arte Ria - the right-hand branch.This artery is the residue from the fetal circle of the Visane and is becoming essential both at the UPU, and with IHD, especially with high occlusions of PMF.
B. Septal branchesThe PMWhv varies greatly in the size, number and distribution of the Research Institute. The large 1st septal branch (or the front septal branch) is determined more often, oriented vertically and disintegrating into several secondary vessels, which ramifying the front interventricular partition (Fig. 55). In some cases, the 1st septal branch is located in parallel to the most PMW. Rare cases of independent death (W. Mcalpine, 1975) are described. This artery also participates in the blood supply to the conductive system of the heart (Fig. 56). Therefore, in whether the treatment is guidance on the need for its independent shunting, it is especially in cases where its mouth is localized between two parts of the PMD stenosis
(B. V. Shabalkin and Yu. V. Belov, 1984; J. Moran et al., 1979).
The septum ischemia arising due to occlusion of the anterior septal artery (1st septal Branch of the PMJ) leads to the development of ventricular tachy
Fig. 55. The first septal naya branch (2) front interventricular vehicles (1) (according to R. Anderson and A. Becker, 1980).
Heart preparation (left) and an angiogram (right).
Fig. 57. The first (front) septal branch in dogs (by J. Tweedell et al., 1989) and its role in myocardial infarction.
LVA - left cornese artery, oh - envelope branch, PSA - front septal artery, PMJV - front interventricular branch.
1-5 - zones of infarction of the front interventricular partition on transverse sections of the heart from the base to the top.
Fig. 56. Scheme of septal branches of the front of the ventricular branch.
A view of the front interventricular partition (PMJD) in front, from the side of the output of the right ventricle (there is a rare wall of the right ventricle removed).
The first septal branch (1st SV) is most often the first Branch of the PMW. It is usually larger than the remaining piping branches of PMW. The PMWhs more often than other arteries are "rising".
The envelope branch (s) immediately after removal from the left Crown artery "is lost" in the thick layer of fatty fiber. Her intraoperative exposition is difficult and due to the authorities over it, the left atrium (ULP) (in the figure - cut-off). The figure shows the left artery of the sinus assembly (ACS), departing from the left corneous artery. Such a variant of the supply of the sinus node is found in 10-12% of cases.
LV - left ventricle, PP - right atrium, T - three clad valve, NG - Neckwarce comb, PSM - Front Popples Muscle, La Pulmonary Artery, A - Aor, HPV - Upper Vienna, LV - Pulmonary Vienna (in Figure - left).
cardia (J. Twedell et al, 1989), as a rule, from subendockar and, more often, - left ventricle (M.Debakker et al, 1983; L.harris et al, 1987; J.TWedell et al, 1989).Therefore, adequate protection of this region of the heart during open heart operations is important.
In dogs, this artery has an intervent of a daughter partition at 75-80% (Fig. 57). It is clear that the occlusion of this artery causes myocardial infarction.
W. Mcalpine (1975) highlights the so-called "Upper Septal Art Ria", although it notes that it is usually small in a person or is not at all. F. Rodriguez et al. (1961) also believe that people it meets only in 12-20% of cases. This artery is very important in some animals. For example, in a bullish heart, it can blood darke up to 50% of the partition area. But the person has its own discharge, it is not entirely justified to us, especially since in most cases it is represented
in the form of the branch of the first septal artery.
W. a person remaining septal branches of PMF ("front"), as a rule, have
smaller size (see Fig. 47) (D. Lewin and G.Gardiner, 1988).These branches communicate with similar branches of ZMZHV ("Lower"), forming a network of potential collateral vessels. And although the "efficiency" of such collaterals is not proven, the fact that the interventricular partition is the most vascularized region of the heart.
The man's "front" partition branches are larger than the "lower" (branches of ZMZHV), but can be equal to the caliber
Atrialia, part of the left ventricular wall (LV) and arterial vessels (at the level of the waltz sinus. "You) removed. Left cornese artery (LVA), who has been moving away from the aorta (a), gives an envelope branch (s), which follows the hide along atrioventricular furrows, rich mitral valve (M).
Fig. 58. Heart preparation.
(P.Fehn etal., 1968). And, on the contrary, - in Perelov "Lower" partition branches, the pain of "top". They have a large part of the Pickname ranks with the "lower" pennies of the picket arteries.
V. Diagonal (branch)
PMJ, following the left ventricle's front-lactoral surface, is usually one of those branches that feed the top (see Fig. 48, 54).
Medino artery
In 37% of cases, instead of bifurcation, there is a trifurkation (D. Lewin et al "1982). In these cases, the "diagonal branch" is the name of the median artery, and it is on the equal and PMZhV, from the trunk of the left VA. In these hearts, the median artery is equivalent to the diagonal branch, and it vasculizes the free wall of the left ventricle (D. Lewin and G. Gardiner, 1988).
Enveling branch
OS is the following large branch of the left VA and in some cases can be separated from
aortic sines alone. It follows along the left atrioventricular furrow (see Fig. 43) and, having encouraged the mitral valve (Fig. 54, 58) and the left (stupid) edge of the heart, goes to its diaphragmal surface.
As already noted, more often (in 90% of cases) it is uncommentary and it vary in size and length, which is mainly determined by the most long-term law-to-face. It is clear that the defense of such states as hypoplasia
inappropriate.
Usually, the OS gives the left fragment of the artery of Kyugel (see Fig. 56), and although it does not reach the sinus node more often, at 10-12% of the seas of the artery of the sinus node may be about the branch.
OV gives 1-3 large branches of the stupid edge, following the book from the atrioventricular grooves (Fig. 59), and very often the system of the OI is generally represented by a large VTK and the Neva of the wrenched s.
A. Branch of the Artery of the Dull Territory (left
the edge branch) is the largest ve |
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interior view (see Fig. 54, 60) and can go like |
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Fig. 59. Heart preparation. |
from the beginning of the OS and at the level of the stupid edge. |
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This is a very important branch participating in Piet. |
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Atrium and arterial vessels (at the level of blue |
free Wall Research Institute (its front and rear |
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waltasalva) removed. |
surfaces) lzh along its lateral |
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Envelope branch (s), giving the largest |
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the edges. In general, a number of hearts in general |
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branch - a branch of a stupid region (VTK) - and rebuilding mit |
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the rally valve usually gives one or more |
putting a branch of a stupid edge (Fig. 60). |
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rear left left branches and le |
Either, in addition, can give rise to |
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in the blood supply type of the heart ends in |
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the critical branch feeding the side and |
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the form of the rear interventricular branch (ZMZHV). |
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PZH and L W - right and left ventricles. |
the back surface of the left atrium. |
Fig. 60. Anatomy of crown arteries, blood supplying side and rear walls of the left ventricle (LV).
LK - Pulmonary Valve, HPV and NPV - Upper and Lower Vienna, M - Mitral Valve, COP - Coronary SI NUS, L and 3 - Left and Rear Sinuses Aorts, PVa - Right Self Artery, A.Pu - Arterypreservative of the node, PP is the right atrium.
B. Terminal branch OS is more often posterior (left vehicles) branch,but the destruction of this vehicle, as well as the ZMZHV and the arteries of the atrioventricular node from the left VA, is determined by the dominance of the right or left VA.
With a balanced type of blood supply of the heart ZMZHV vasculums from the systems of both VA (and the right and left).
Thus, the epicardial trunks of the right-wing system are involved in the vascularization of the right atrium, the interpresentation partition, the free wall of the right ventricle, the posterior wall of the interventricular partition, the puffy muscles of the right ventricle and partly - the rearbed group from the solar muscles of the left ventricle.
The sine node is more often (in 55-60% of cases) is a zone of blood supply to the right va. Atrioventricular node in preferential pain
the supervision of observation (up to 90% of cases) is also bloodtained from the system of the right va. The blood supply zone of the left VA includes the left atrium, the front, bog, and most of the rear wall of the left ventricle, the front intergustrial partition and the front-flying group of the porcelain muscles of the left ventricle. Given the significant variability of BA branching, the study of the variant
W. Grossman, 1986). In addition, the anatomy of each of the main epicardial arthrium has a number of features, and the role of their branches in the blood supply to myocardium in each particular case is ambiguous.
The study of these features is dedicated to this section of work. We believe that with an increase in interest in the operations of the Aorticoronary shunting, the knowledge of these countries not set out in domestic guidelines would be useful.
Our ideas about the surgical anatomy of VA will be incomplete if we do not dwell on the relationship of WA with atrioventricular valves. Further successes in prosthetics or plastic reconstruction of atrioventricular valves are largely due to the exact knowledge of the topographic-anatomical relationships of these valves with adjacent heart structures and in cha and a heart vessels.
According to G. I. Zuckerman et al. (1976), the most dangerous areas are areas of outdoor and internal mitral valve commissioners, in which the envelope branch of the left Va is as close as possible to its fibrous ring. As shown by the following by the following by V. I. Shumakov (1959) and L. G. Monastic (1965), the projection of fibrosis ring of the mitral valve is located below the envelope branch of the left va on the front wall and below venous sinus - on the rear, but in hearts with a small size (up to 12 cm in length) on the front wall, this discrepancy does not exceed 1-6 mm in half. The intimate adjacent of the mitral valve to the specified structure creates objective prerequisites for their nuclear damage (D. Miller et al., 1978), fraught with the development of irreversible changes in myocardium and even the death of patients (G. I. Zuckerman et al., 1976; S. S. Sokolov, 1978).Envelope ligation
the branches of the left va is a dangerous complication and during prosthetics of the mitral valve occurs in 1.2-3.1% of cases (G. I. Zuckerman et al., 1976).The real possibility of ligation of the envelope branch of the left va exists and when the MK annulhoplastics in the case of deep firmware of the fibrous ring (V. A. Prelov, 1985).
Due to the fact that with a sharp integrity of the valve and the distribution of calcium on the fibrous ring (and sometimes on the wall of the atrium and ventricle), there is a sharp of myocardium, in order to prevent damage to the envelope of the branch of the levie Va V. Zuckerman et al. (1976) They advise not to resort to complete decalcinization of the valve and the fibrous ring, strengthening (for the prevention of calcinates chipping) these sections of the Teflon seams on the side of the atrium and ventricle. In addition, due to the danger of the formation of a fistula between the coronary sine and the bands of the left ventricle D. Miller et al. (1978) Recommended when re-infracted about theses, pay attention to the preservation of the integrity of the rear wall of the left ventricle.
In this section of the work, we did not stop at the surgical anatomy of rare disheavals, following and branching VA. Not described by the surgical features of the VA at the UPU. These materials are set out in more detail in the corresponding sections.
Surgical anatomy of atrial crown arteries
The description of the arterial blood supply to the atrium until recently will not be paid due attention. In classical works on anatomy, there are only references to the fact that atrial arterys depart from the right or left coronary artery (S. S. Mikhailov, 1987; N. Gray, 1948; W. SpaLholz, 1924).Meanwhile, all utensy capabilities of cardiac surgery allowed us to expand the sphere of surgery interventions at the atrial complex. The safety of such interventions in many times is determined by the preservation of the coronary arteries (VA), blood supply to the most important elements of the conductive heart system - the arteries of the sinus-atrial node (SPU) and the atrocadic assemblies (PZH) (B. A. Konstantinov et al., 1981; S. Marcelletti, 1981).Due to the smallness of messages illuminating the variant anatomy of these VA, we present these results of their own studies of the variant anatomy of the Armeration of SPU and PGU in comparison with the data of the literature.
Despite the fact that another W. Spatelholz (1924) has developed the regional atrial regional scheme, at present the existence of anterior, intermediate, rear-rail and left-handed arteries (described by this author) is not confirmed. From this group, the only, more or less permanent atrief of the coronary artery is the so-called right intermediate atrial artery. It departs from the right corn-free artery (PVA) in the area of \u200b\u200bthe acute edge, the faith is sent ticulously up and feeds myocardium relevant zone of the right atrium. It usually anatomizes with the arteries surrounding the mouth of the upper hollow vein (HPV), and therefore its damage is not associated with the fatal consequences.
The most permanent atrial coronary arteries are arteries that feed the sinus-atrial and atrial and ventricular nodes. The first from go first, and the last - the last branches of the right or left (or both) va.
The blood supply to the sinus-atrial node is carried out mainly by the array of SPU (Fig. 61), the damage of which, despite the abundance of additional sources of blood supply, leads to irreversible violations of the heart rhythm. According to A. A. Travin et al. (1982), there are two types of severity of the Armeration of SPU. With the right type of blood supply to the heart of the HP SPU begins from PVA (61.4% of cases), and at the left - from the left corneous artery (LVA) (38.6% of cases). As long as the studies of the indicated authors, in 47.5% of cases of the artery envelopes the mouth of the EPV to the right, in 37.5% - to the left and in 15% of cases, the mouth of the EHF is covered in the form of a ring. According to T. James and G. Burch (1958), the Archild of SPU moves away from PVA in 6 1% of cases, and from the left - in 39% of cases. Approximately the same data leads S. Marcelletti (1981): in
Fig. 61. Options for fattening and distributing the artery of the sinus-atrial node (SPU).
A - the extinguishing of the Armeration of SPU (1) from the right corvene artery (PVA); B - Detection of the Armeration of SPU (2) from the left Crown artery (LVA). In both cases, the Archilding of SPU is located on the front surface of the atrial complex.
B, G - the debit of two sprigs of the artery of SPU from PVA and LVA. In both cases, one artery of SPU (departing from PVA) spreads along the anterior surface of the atrial complex, the other (which is the branch of the LVA) is a spread along the rear surface of the atrial complex.
D, E - ARTERE SPU (1), which is the terminal branch of PVA, envelopes the atrial complex from behind, then moves to its reserved surface (shown by the dotted line) and envelopes the mouth of the EHF behind (E).
HPV and NPV - Upper and lower hollow veins, PP and LP - right and left atrium, pzh and lz - right and left lugs, aorta, la - pulmonary artery, m - mitral valve, ks - coronary sinus, PMZhV - The front of the ventricular branch, the DV - the diagonal branch, the rich branch, ZMZHV - the rear interventricular branch.
I am% of cases of HTU leaves from PVA. Regardless of the source of bloodsmith, the Arteriya SPU reaches an emergency in front or behind or (less often) surrounds her mouth
(K.anderson and S. But, 1979).
According to W. Mcalpine (1975), the Archilder of SPU in 48% of cases is the branch of the PVA, in 30% of the LVA branch, in 22% of cases - the rear branch of the right or left VA. In 1968, A. Moberg noted that atrial va can be out from extracardial vessels. W. Mcalpine (1975) leads one such case in its atlas, described by N. Nathan et al. (1970). It is the branch of the right bronchial artery (Fig. 62) in it.
Having studied more than 500 hearts, we did not find any such incident. But in one heart with an inexistan one, an independent debit of spa from aorta was discovered (Fig. 63). In this heart, we found the second artery that feeds the SPU and is the branch of the PVA equivalent. The rarity of our observation is that in this heart there was a single PVA, from which the branches of the Raily and Lev Va. The only vessel from the 2nd facial sinus of aorta was the left artery of SPU. However, the presence of the second (right) artery of SPU and in this rare on the observation approved us in the opinion that the power of the SPU is carried out, as a rule, by many branches of the right and left va. Therefore, the selection of arteries that feed the node is equal
Fig. 62. Dispatching the artery of the sinus-subnedentiary assembly (SPU) from the bronchial artery.
Designations are the same as in Fig. 61.
Fig. 63. Disposition of the Armeration of SPU (2) by an independent mouth from the 2nd facial aorta sinus (a).
A, B, B - the Arterium (2) is the equivalent of a branch that departs from the LVA. It spreads ahead of the pulmonary artery (LA) (fragment a), it takes place under the level of the left atrium (y) (fragment b) and extends along the rear surface of the atrial complex.
The ventricular complex is bloodshed in the uni-in-law (1), departing from the 1st facial aorta sinus.
M - the second artery of SPU is the equivalent of a branch departing from PVA. It applies to the front surface of the ventricular complex, envelopes the ear of the right atrium in front and it can be seen that she fell into the seam (white arrow) in the cannulating area.
Seen the destruction of the uni-in-law from the 1st facial aorta sinus.
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The main source of blood supply to the heart is crown artery (Fig. 1.22).
The left and right corveric arteries are branched off from the initial part of the ascending aorta in the left and right sinus. The location of each coronary artery varies both in height and around the aortic circumference. The mouth of the left corneous artery can be at the level of the free edge of the semi-lounge flap (42.6% of observations), above or below its edge (in 28 and 29.4%, respectively).
For the mouth of the right corverity artery, the location is above the free edge of the semi-lounge flap (51.3% of observations), at the level of the free edge (30%) or below it (18.7%). The displacement of the estate of the corpusal arteries up from the free edge of the separation sash is up to 10 mm for the left and 13 mm - for the right corn-free artery, down - up to 10 mm for the left and 7 mm - for the right corveric artery.
In single observations, there are more significant vertical shifts of the mouth of the Vernal arteries, up to the beginning of the aorta arc.
Fig. 1.22. Heart blood supply system: 1 - ascending aorta; 2 - top hollow vein; 3 - Right Crown Artery; 4 - la; 5 - left cornese artery; 6 - Big Vienna Heart
In relation to the middle line of the sinus, the mouth of the left coronary artery in 36% of observations is shifted to the front or rear edge. A significant displacement of the beginnings of the corneal arteries in the circumference of the aorta leads to the disheem of one or both of the coronary arteries from the aorta sinus unusualities, and in rare cases, both corvene arteries come from one sinus. The change in the location of the mouth of the coronary arteries in height and the circumference of the aorta does not affect the blood supply to the heart.
The left cornese artery is located between the beginning of the pulmonary trunk and the left ear ear and is divided into envelope and the front interventricular branches.
The latter follows to the top of the heart, located in the front interventricular furrow. The envelope branch is heading under the left ear in the corrosive furrow on the diaphragmal (rear) surface of the heart. Right Crown Artery after leaving the aorta lies under the right ushko between the beginning of the pulmonary trunk and the right atrium. Next turns along the cornerwort to the right, then - back, reaches the rear longitudinal furrow, which goes to the top of the heart, called the rear interventricular branch. Curve arteries and their large branches lie on the surface of myocardium, located at different depths in the epi cardiac tissue.
The branching of the main trunks of the coronary arteries is divided into three types - a trunk, loose and transitional. The main type of branching of the left corneous artery is observed in 50% of cases, loose - at 36% and transition - at 14%. The latter is characterized by dividing its main barrel on 2 permanent branches - envelope and front interventricular. The scattered type includes cases when the main arterial barrel gives the interventricular, diagonal, added diagonal and envelope branches on one or almost at one level. From the front interventricular branch, as from the envelope, 4-15 branches depart. The angles of dishelling both primary and subsequent vessels are different and range from 35-140 °.
According to the international anatomical nomenclature adopted at the Congress of Anatoms in Rome in 2000, the following vessels differ, blood supplying heart:
Left Crown Artery (ARTERIA CORONARIA SINISTRA)
Front interventricular branch (r. Interventricularis Anterior)
Diagonal branch (r. Diagonalis)
Branch of arterial cone (R. CONI ARTERIOSI)
Lateral branch (r. Lateralis)
Partitioning interventricular branches (RR. Interventricularis Septales)
Envelope branch (r. Circumfl exus)
Anastomotic atrial branch (r. Atri Alis Anastomicus)
Atrial and ventricular branches (RR. Atrioventricularis)
Left edge branch (r. Marginalis Sinister)
Intermediate atrial branch (R. atrialis intermedius).
Rear branch of lz (r. Posterior Ventriculi Sinistri)
Branch of the preservative node (r. Nodi atrioventricularis)
Right Crown Artery (ARTERIA CORONARIA DEXTRA)
Branch of arterial cone (Ramus Coni Arteriosi)
The branch of the sinus-atrial node (R. Nodi SinoAtrialis)
Atrial branches (RR. Atriales)
Right Edge Branch (R. Marginalis Dexter)
Intermediate atrial branch (r. Atrialis intermedius)
Rear interventricular branch (r. Interventricularis Posterior)
Partitioned interventricular branches (RR. Interventriculares Septales)
The branch of the preservation node (r. Nodi atrioventricularis).
By 15-18 years, the diameter of the coronary arteries (Table 1.1) is approaching adult indicators. At the age of 75, some increase in the diameter of these arteries is observed, which is associated with the loss of the elastic properties of the arterial wall. Most people have the diameter of the left cornen artery more right. The number of arteries derived from the aorta to the heart can decrease to 1 or increase to 4 due to additional coronary arteries, which are not normal.
Left coronary artery (LKA) originates in the assholes of the Bulb of Aorta, passes between the left atrium and la and about 10-20 mm shared on the front interventricular and envelope branches.
The front interventricular branch is a direct continuation of the LKA and passes in the corresponding head of the heart. Diagonal branches are deployed from the front interventricular branch (1 to 4), which are involved in the blood supply to the side wall of the LV and can anatomize with the envelope branch of LV. LKA gives from 6 to 10 partition branches, which blood supply to the front two thirds of the interventricular partition. The front interventricular branch itself reaches the top of the heart, providing it with blood.
Sometimes the front interventricular branch passes to the diaphragmal surface of the heart, anathematizing with the rear interventricular artery artery, carrying out collateral blood flow between the left and right coronary arteries (with the right or balanced type of blood supply to the heart).
Table 1.1.
The right edge branch used to be called the artery of the sharp edge of the heart - Ramus Margo Acutus Cordis. The left edge branch is the branch of the stupid edge of the heart - Ramus Margo Obtusus Cordis, as a well-developed myocardium of the hearts makes its edge rounded, stupid).
Thus, the front interventricular branch of the LKA is blood supply to the front-winding wall of the LV, its top, most of the interventricular partition, as well as the front papillary muscle (due to the diagonal artery).
The envelope branch, departing from the LKA, located in AV (Vernoy) Borozde, goeshes the heart to the left, reaches an intersection and rear interventricular furrow. The envelope branch can end with the stupid edge of the heart, and continue in the rear interventricular furrow. Passing in ancient furrow, the envelope branch sends large branches to the side and rear walls of LV. In addition, important atrial arteries are departed from the envelope of the branch (among them - R. Nodi Sinoatralis). These artery, especially the artery of the sinus node, are abundantly anastomized with the branches of the right coronary artery (PKA). Therefore, the branch of the sinus node has a "strategic" value in the development of atherosclerosis in one of the main arteries.
PKA begins in the direction of the Aorta Bulbs Sinus. Returning from the front surface of the aorta, the PKA is located in the right-hand side of the cornerwort, suitable for the acute edge of the heart, envelopes it and goes to Crux and further to the rear interventricular furrow. In the area of \u200b\u200bintersection of the rear interventricular and coronary, PKA gives the rear interventricular branch, which goes towards the distal part of the front interventricular branch, anatomosing with it. Rarely PKA ends at the sharp edge of the heart.
The PKA with its branches is blood supply to the right atrium, a part of the front and the entire back surface of the LV, the interpidential partition and the back of the interventricular partition. From the important branches of the PKA, it should be noted the branch of the cone of the pulmonary trunk, the branch of the sinus node, the branch of the right edge of the heart, the rear interventricular branch.
The branch of the mole branch cone often anastomoses with a conical branch, which departs from the front interventricular branch, forming the Ring of Visane. However, approximately half of the cases (Schlesinger M. et al., 1949), the artery of the Cone of the pulmonary trunk departs from the aorta on its own.
The branch of the sinus node in 60-86% of cases (Aryev M.Ya., 1949) departs from PKA, but there is evidence that in 45% of cases (James T., 1961) it can move away from the envelope of the LKA branch and even from the LKA itself . The branch of the sine node is located along the wall of the PJ and reaches the place of imposition of the upper hollow vein into the right atrium.
The acute edge of the heart of the PKA gives a pretty constant branch - the branch of the right edge, which goes along the sharp edge to the top of the heart. Approximately at this level, the branch of the right atrium, which supplies the front and side surface of the right atrium with blood.
At the place of the transition of the PKA to the rear interventricular artery, the branch of the AV-node is departed, which bloodsink this node. From the rear interventricular branch, branches are perpendicular to PJ, as well as short branches to the rear third of the interventricular partition, which is anastomosed with similar branches, separating from the front interventricular artery of the LKA.
Thus, the PKA supplies the front and rear walls of the PJ, partly - the rear wall of the LV, the right atrium, the upper half of the interpresentation partition, sine and AV nodes, as well as the back of the interventricular septum and the rear papilla muscle.
V.V. Brother, A.S. Gavrish "Structure and functions of a cordic-vascular system"
Artery hearts out from lukovitsa aorta,bulbils. aortae., - The initial expanded department of the ascending part of the aorta and like the crown is surrounded by the heart, in connection with which they are called the corned arteries. Right Crown Artery begins at the level of the right sine aorta, and the left cornese artery is at the level of its left sinus. Both arteries depart from the aorta below the free (upper) edges of the semi-luncture dampers, so during the reduction (systole) ventricles of the valve cover the holes of the arteries and almost do not let the blood to the heart. When relaxing (diastole), sinuses are filled with blood, covering her the path from the aorta back to the left ventricle, and at the same time open blood access in the heart vessels.
Right Crown Artery,a.. corondria dextra., it goes to the right under the ear of the right atrium, falls into the cornese furrow, goes to the right pulmonary surface of the heart, then follows its back surface to the left, where it anastomes with the envelope branch of the left cornoe artery. The largest branch of the right cornese artery is rear interventricular branch, G.interventrlculdris posterior., which is heading over the same name of the head of the heart towards its top. The branches of the right corveric artery are bloodtained the wall of the right ventricle and atrium, the back of the interventricular partition, the puffy muscles of the right ventricle, the rear puffy muscle of the left ventricle, the sinus-atrial and atreservantic nodes of the conductive heart system.
Left Crown Artery,a.. corondria sinistra., somewhat thicker. Located between the beginning of the pulmonary trunk and the left atrium ear, it is divided into two branches: front interventricular branch, g.interventriculdrls. anterior., and envelope branch, g.circumFlexus.. The latter, which is a continuation of the main trunk of the coronary artery, envelopes the heart on the left, located in his Vernoy Barrout, where the rear surface of the organ anastomoses with the right corveric artery. The front interventricular branch follows the same name of the head of the heart towards its top. In the field of heart clipping, it sometimes passes to the diaphragmal surface of the heart, where he anastomoses with the terminal department of the rear ^ of the interior branch of the right corveneous artery. The branches of the left corneous artery are blood supply to the wall of the left ventricle, including the puffy muscles, most of the interventricular partition, the front wall of the right ventricle, as well as the wall of the left atrium.
The branches of the right and left corneous arteries, connecting, form, are in the heart of both two arterial rings: a transverse, located in the Vornechniki Borozde, and the longitudinal, whose vessels are located in the front and rear interventricular furrows.
The branches of the coronary arteries provide the blood supply to all layers of the walls of the heart. In myocardium, where the level of oxidative processes is the highest, anastomosing microsudes repeat the move of the bunches of muscle fibers of its layers.
There are various options for the distribution of branches of coronary arteries, which are called blood supply types. The main ones are as follows: the legal, when most of the heap departments are branched by the branches of the right corner artery; Levover, when most of the heart receives blood from the branches of the left cornen artery, and medium, or uniform, in which both corvene arteries are evenly involved in the blood supply of the walls of the heart. Alsaces the transition types of blood supply to the heart - medium right and middle. It is believed that among all types of blood supply to the heart, the average right type is predominant.
Options and abnormalities of the position and branching of the coronary arteries are possible. They manifest themselves in changes in the points of the beginning and number of coronary arteries. Thus, the latter can move away from AOPFBI directly above the semi-short valves or significantly higher - from the left connector artery, and not from the aorta. The corona artery may be the only one, that is, the unpaired, there may be 3-4 corn-free artery, and not two: two arterys are moving on the right and to the left of the aorta or two from the aorta and two from the left connector artery.
Along with Vienna. The arteries to the heart (especially by Pericarda) are inconsistent (additional) arteries. These can be mediastinal-pericardial branches (upper, average and lower) inner chest artery, branches of pericardian-fraggmal artery, branches that depart from the concave surface of the chub of aorta, etc.
Vienna hearts more numerous than arteries. Most of the major heart veins are going to one common wide venous vessel - vented sinus,sinus. corondrius. (residue of embryonic left overall cardinal veins). Sinus is located in the cornese furrow on the back surface of the heart and opens into the right atrium below and the Kepened from the hole of the lower hollow vein (between its damper and the interdudal partition). The tributaries of the corona sine are 5 veins: 1) Big Vienna Hearts,v.. cORDIS [ cardLDCA.] magna., which begins in the field of the top of the heart on its front of its surface, lies in the front interventricular furrow next to the front interventricular branch of the left corner artery, then at the level of the corn-free groove turns to the left, passes under the envelope branch of the left corvering artery, falls into the corneous furrow on the back surface of the heart, Where continues to the bellows sinus. Vienna collects blood from the veins of the front surface ^ of both ventricles and the interventricular partition. In the large vein of the heart, the veins of the rear surface of the left atrium and the left ventricle are puzzled; 2) middle vein heartsv.. cORDIS [ cardidca.] media., it is formed in the region of the back surface of the heart of the heart, rises up on the rear interventricular furrow (inserts to the rear interventricular branch of the right-wing artery) and flows into the bellows sinus; 3) small Vienna Heartsv.. cORDIS [ cardidca.] pDRVA., it begins on the right pulmonary surface of the right ventricle, rises up, falls into the corneous furrow on the diaphragmal surface of the heart and flows into the bellows sinus; She collects blood mainly from the right half of the heart; four) rear vein left ventricle,and.posterior. ventriculi. sinistri. [ v.. ventriculi. sinistri. posterior.], it is formed from several veins on the back surface of the left ventricle, closer to the top of the heart, and flows into a bemark sinus or in a large vein of the heart; five) oblique vein left atriumv.. obliqua. dtrii. sinistri., it should be topped down on the back surface of the left atrium and flows into the bemark sinus.
In addition to the veins, flowing into the bemark sinus, the heart has veins that open directly to the right atrium. it front Vienna HeartsuV.. cORDIS [ cardidCae.] anteriorcs., gathering blood from the front wall of the right ventricle. They are heading up to the base of the heart and open in the right atrium. The smallest veins of the heart(Tebrieyev Vienna), vV. cORDIS [ cardidCae.] minimae., total 20-30, begin in the thicker of the walls of the heart and fall directly into the right atria and partially in the ventricles and left atrium through holes of the smallest veins,foraMina. vendrum minimdrum.
Lymphatic directionthe walls of the heart consists of lymphatic capillaries located in the form of networks in endocardium, myocardium and epicardium. Lympha from endocardium and myocardium reaches the surface network of lymphatic capillaries located in Epicard and the plexus of lymphatic vessels. Connecting among themselves, the lymphatic vessels are enlarged and about "the two main vessels of the heart, along which the lymph is subject to regional lymph nodes. Left lymphatic vesselhearts are formed from the fusion of the lymphatic vessels of the front surfaces of the right and left ventricles, the left pulmonary and rear surfaces of the left ventricle. It follows from the left ventricle to the right, passes behind the pulmonary trunk and falls into one of the lower tracheobronchial lymph nodes. Right lymphatic vesselthe heart is formed from the lymphatic vessels of the front and rear surfaces of the right ventricle, it is directed to the right to left along the anterior semi-ray of the pulmonary barrel and flows into one of the front mediated lymph nodes located at the arterial ligament. Small lymphatic vessels, according to which lymphs from the sservation walls, fall into nearby front mediocked lymph nodes.
