The coronary circulation consists of the coronary arteries and veins, together with the

lymphatics of the heart. Because the lymphatics, apart from the thoracic duct, are of
very limited significance to operative anatomy, they will not be discussed at any length
in this chapter. The veins, relatively speaking, are similarly of less interest. In this
chapter, therefore, we concntrate upon those anatomical aspects of arterial
distribution that are pertinent to the surgeon, concluding with a brief discussion of the
cardiac venous drainage and the cardiac lymphatics

THE CORONARY ARTERIES

The coronary arteries are the first branches of the ascending portion of the aorta. They
take their origin from the sinuses within the aortic root, immediately above its
attachment to the heart (Figure 4.1). There are three sinuses within the aortic root, but
only two coronary arteries. The sinuses can be named, therefore, according to whether
they give rise to an artery, the normal arrangement being a right coronary, left
coronary, and non-coronary aortic sinus (Figure 4.2). When described in this fashion,
the terms right and left refer to the aortic sinuses giving rise to the right and left
coronary arteries, rather than to the position of the sinuses relative to the right-to-left
coordinates of the body (Figure 4.3). In the normal heart, the aortic root is situated
obliquely, while in malformed hearts, the root is frequently positioned abnormally.
Whatever the position of the aortic root, however, the two coronary arteries, when two
are present, almost always take origin from those aortic sinuses that are adjacent to
the sinuses of the pulmonary trunk. Because of this, it is more convenient, and more
accurate, to consider these sinuses as being to the left-hand and the right-hand side of
the observer standing, figuratively speaking, within the non-adjacent sinus and looking
towards the pulmonary trunk (Figure 4.4). This approach to distinguishing the aortic
sinuses giving rise to the coronary arteries, introduced by the group from Leiden 1, holds
true irrespective of the relationships of the arterial trunks. It is now conventional to
describe the right-hand sinus as no. 1, and to distinguish the left-hand sinus as no. 2.
The convention becomes particularly valuable when considering coronary arterial
origins in malformed hearts (see Chapter 8).

Irrespective of the specific sinus from which they arise, the coronary arteries usually
take their origin beneath the sinutubular junction (Figure 4.5). The junction is the
discrete transition between the aortic root and the tubular component of the ascending
aorta, and is the most obvious annular structure within the aortic root. Deviations of
origin of the coronary arteries relative to the junction are not uncommon2. They are
considered abnormal, in adults, when arising more than one centimetre distal to the
sinutubular junction, a feature said to occur in almost one-twentieth of normal hearts 3.
The arterial opening can be deviated either towards the ventricle, so that the artery
arises deep within the aortic sinus, or towards the aortic arch, so that the origin is
outside the sinus (Figure 4.6). The displacement is of greater significance when
combined with the artery taking an oblique course through the aortic wall and
originating above or within an inappropriate aortic sinus. This arrangement, now known
as an anomalous aortic origin of a coronary artery4, is typically associated with the
proximal part of the artery crossing the attachment of the zone of apposition between
adjacent leaflets, and is also considered to represent one variant of the intramural
arrangement (Figure 4.7). It can involve either the right coronary artery arising from
the left coronary aortic valvar sinus (Figures 4.7, 4.8), an arrangement which occurs in
one of every 500 individuals, or the left coronary artery arising from the right coronary
aortic valvar sinus, found in one of 2000 individuals5. Both variants introduce the
potential for luminal narrowing, and may provoke disturbances in myocardial perfusin.

The left coronary artery almost always takes origin from a single orifice within the left-
hand facing sinus. In contrast, in about half of all hearts, there are two orfices within
the right coronary aortic sinus (Figure 4.9). In such instances, the orfices are unequal
in size, the larger giving rise to the main trunk of the right coronary artery, while the
considerably smaller second orifice usually gives rise to an infundibular artery, or rarely
to the artery supplying the sinus node. In one large series7, two orfices were found in
the right-hand facing sinus in almost half the cases, three orifices in 7%, and four
orifices in 2%. In contrast, multiple orifices in the left coronary aortic sinus (Figure 4.10)
are considerably more rare7. If unrecognised, they may crate problems in the
interpretation of coronary angiograms. The presence of dual orfices in the same sinus,
of course, is of far greater significance in the setting of an anomalous aortic origin of a
coronary artery, when one of the orifices gives rise to an artery taking an intra-arterial
and intramural course, as shown in Figures 4.7 and 4.8.

Although rare, the coronary arteries, on occasion, can arise from a solitary orifice in the
aortic root. This is usually within the right coronary aortic sinus. The artery originating
from the solitary orifice can take one of two patterns. It can divide immediately into
right and left coronary arteries. The left artery then passes either in front of the
pulmonary trunk (Figure 4.11), between it and the aorta, or behind the arterial pedicle,
before dividing into anterior interventricular and circumflex branches. The solitary
artery can also arise from the left coronary aortic sinus, branching so that the right
coronary artery passes in front of the pulmonary trunk (Figure 4.12), runs between the
arterial trunks, or extends behind the arterial pedicle, running through the transverse
sinus. It is the variants involving a course between the great arterial trunks that are of
most significance, as they can be harbingers of sudden cardiac death6,8.

There are subtle variations in the course taken by the artery as it passes between the
trunks9. There are three possibilities (Figure 4.13). In the first, the artery runs between
the aorta and the pulmonary trunk at the level of the aortic sinutubular junction, as
shown in Figures 4.7 and 4.8.
The second possibility is for the artery to extend deeply within the musculature of the
ventricular septum (Figure 4.14). The third possibility is for the artery to track within
the tissue plane between the pulmonary infundibular sleeve and the aortic root (Figure
4.15). This course is below the level of the hinges of the pulmonary valvar leaflets, yet
not buried within the muscular ventricular septum.

The fact that the artery is not within the septummay not readily be appreciated when
seen from the lateral aspect (Figure 4.16). It is likely that compression on the arterial
lumen will be greatest when the artery is buried within the musculature of the septum,
an important consideration when assessing the need for surgical correction of the
anomalous course. A still further alternative course for a solitary coronary artery,
although less frequent, is when the single artery initially follows the path of the normal
right coronary artery. It then continues beyond the crux, encircling the left
atrioventricular junction through the territory usually supplied by the circumflex artery,
before terminating as the anterior interventricular coronary artery.
The right and left coronary arteries, having taken origin from the aortic root, extend
subepicardially within the atrioventricular and interventricular grooves, the left-sided
artery giving rise to two major branches. The right coronary artery emerges from the
right aortic sinus and immediately enters the right atrioventricular groove (Figure 4.17).
It then encircles the tricuspid orifice, running in the right atrioventricular groove (Figure
4.18). In approximately nine-tenths of cases, the right coronary artery gives rise to an
inferior interventricular artery at the crux, albeit that the artery is usually said to be
posterior. Computed tomographic images now leave no doubt that the artery is inferior
and interventricular (Figure 4.19).
In a good proportion of these cases, the artery continues beyond the crux, where it
supplies downgoing branches to the diaphragmatic surface of the left ventricle (Figure
4.20). This is right coronary arterial dominance. As the artery encircles the tricuspid
orifice, it is most closely related to the origin of the leaflets of the tricuspid valve near
the take-off of its acute marginal branch. Other important branches also take origin
from this encircling segment of the artery.

Immediately after its origin, the artery lies within the rightward extent of the transverse
sinus, with the adjacent muscular wall representing the ventriculoinfundibular fold of
the supraventricular crest. In this course, the right coronary artery gives rise to
downgoing infundibular branches, which may also arise by separate orifices within the
right aortic sinus. In just over half the cases, the right coronary artery gives rise to the
artery supplying the sinus node (Figure 4.21). This artery typically arises from the
proximal part of the right coronary artery, but on occasion the nodal artery can arise
more distally, coursing over the lateral margin of the appendage to reach the terminal
groove.
This is of major surgical significance (Figure 4.22)10.
The left coronary artery has a short confluent stem, usually called the left main artery
by the surgeon. It emerges from the left coronary aortic sinus, and enters the left
margin of the transverse sinus, being positioned behind the pulmonary trunk and
beneath the left atrial appendage. It is a very short structure, rarely extending beyond
one centimetre in length before bifurcating into its anterior interventricular and
circumflex branches (Figure 4.23). In some hearts, the left main artery trifurcates, with
an intermediate branch present between the two major branches (Figure 4.24). The
intermediate branch supplies the pulmonary surface and obtuse margins of the left
ventricle. The anterior interventricular or descending artery runs inferiorly within the
anterosuperior interventricular groove, giving off diagonal branches to the pulmonary
surface of the left ventricle (Figure 4.25), and the important perforating branches that
pass inferiorly into the septum (Figures 4.26, 4.27). The first septal perforating branch
(Figure 4.26) is particularly important, as it is at major risk when the pulmonary valve is
removed for use as a homograft. The interventricular artery then continues towards the
apex, frequently curving under the apex onto the diaphragmatic surface of the
ventricles.

The circumflex branch of the left coronary artery passes backwards to run in relation to
the mitral orifice. Its relationship to the orifice is most extensive when it gives rise to
the inferior interventricular artery at the crux. In this circumstance, the left coronary
artery is said to be dominant (Figures 4.28, 4.29). A dominant left coronary artery,
however, is found in only about one-tenth of cases. When the left coronary is not
dominant, the circumflex artery usually terminates by supplying branches to the obtuse
margin of the left ventricle. In almost half of normal individuals, the circumflex artery
also gives rise to the artery that supplies the sinus node.
Throughout much of their epicardial course, the arteries and their accompanying veins
are encased in epicardial adipose tissue. In some hearts, the myocardium itself may
form a bridge over segments of the artery (Figure 4.30). The role of these myocardial
bridges in the development of coronary arterial disease is not clear. They certainly can
be an impediment to the surgeon in efforts to isolate the artery.

We have already emphasised the significance of the origin of the important artery
supplying the sinus node. This, the largest of the atrial arteries, originates from the
right coronary artery in just over half of individuals, and from the circumflex artery in
the remainder (Figure 4.31). There are, however, rare variants that must also be
recognised when present10. A lateral origin from the right coronary artery, with a course
across the appendage, is an obvious potential danger for the standard atriotomy
(Figure 4.22). The artery to the sinus node, rarely, may also take a lateral or terminal
origin from the circumflex artery (Figure 4.31). Although rare in normal individuals, our
experience suggests that these variants are more frequent in congenitally malformed
hearts11. In addition, the artery to the sinus node takes a variable course relative to the
cavoatrial junction.
There are three possibilities (Figure 4.31). Usually, the artery courses anterocavally
across the crest of the appendage to reach the node. Alternatively, it runs deeply
within Waterstons groove, and passes retrocavally. It is thus intimately related to the
superior rim of the oval fossa.
The third possibility is for the artery to branch, forming a circle around the cavoatrial
junction.
The arterial supply to the ventricular conduction tissues is also of surgical significance.
The atrioventricular nodal artery arises from the dominant coronary artery at the crux,
usually from a U-turn of this artery beneath the floor of the coronary sinus. The nodal
artery then passes towards the central fibrous body, running within the fibrofatty plane
forming the meat in the atrioventricular muscular sandwich.

Having traversed the node in some hearts, it perforates the fibrous atrioventricular
junction to supply a good part of the branching atrioventricular bundle. The septal
perforating arteries from the anterior interventricular artery (Figures 4.26, 4.27) always
supply the anterior parts of the ventricular bundle branches. Occasionally, they also
supply the greater part of the inferior ventricular conduction tissues.

THE CORONARY VEINS

The coronary veins drain blood from the myocardium to the right atrium. The smaller
anterior, and the smallest cardiac veins, drain directly to the cavity of the atrium. They
are not of surgical significance. The larger veins accompany the major arteries, and
drain into the coronary sinus (Figure 4.32). The great cardiac vein runs alongside the
anterior interventricular artery. It becomes the coronary sinus as it encircles the mitral
orifice to enter the inferior and leftward margin of the atrioventricular groove. The
coronary sinus then runs within the groove (Figure 4.33), lying between the left atrial
wall and the ventricular myocardium (Figure 4.34), before draining into the right atrium
between the sinus septum and the sub-Eustachian sinus. At the crux, the sinus receives
the middle cardiac vein, which has ascended with the inferior interventricular artery,
and the small cardiac vein, which has encircled the tricuspid orifice in company with
the right coronary artery. Occasionally, these latter two veins drain directly to the right
atrium. The orifice of the coronary sinus is guarded by the Thebesian valve (Figure
4.35), which, on very rare occasions, may be imperforate. A prominent valve is also
found in the great cardiac vein where it turns around the obtuse margin of the left
ventricle. This is the valve of Vieussens12. Some consider that the valve marks the
transition from the great cardiac vein to the coronary sinus. An alternative view is that
the coronary sinus commences at the site of drainage of the oblique vein of the left
atrium (Figure 4.36).

THE CARDIAC LYMPHATICS

Little is known about the surgical implications of the lymphatic drainage of the heart
itself, although lymphatic structures exist as superficial, myocardial, and
subendocardial networks13. The most important lymphatic channel within the thorax,
however, is both well recognised and of particular importance. This is because, on
occasion, the surgeon may need to ligate this vessel, the thoracic duct, in patients
suffering with problems in lymphatic drainage subsequent to their conversion to the
Fontan circulation. The thoracic duct originates within the abdomen in the confluence
of lymphatic channels known as the cysterna chyli, this structure lying on the second
lumbar vertebra. It enters the right paravertebral gutter of the thorax through the
aortic opening of the diaphragm, and runs within the gutter to the level of the fourth
thoracic vertebra. Within the lower part of the thorax, it lies on the vertebral column
between the descending thoracic aorta and the azygos vein. Crossing the midline
obliquely at the level of the fourth thoracic vertebra, it enters the left paravertebral
gutter, running beneath the arch of the aorta (Figure 4.37). It then continues superiorly
and anteriorly, curving over the aortic arch between the left common carotid and
subclavian arteries, to terminate in either the left subclavian or internal jugular vein as
these structures join to form the left brachiocephalic vein. The duct has a fibromuscular
coat, and contains several valves along its course, with a bifoliate valve
characteristically present at its termination in the brachiocephalic vein.