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Atrial Coronary Arteries: Anatomy

And Atrial
Perfusion Territories
Dr. Marco Tulio Mendoza Cabral
R1 Cardiologa Clnica
Hospital Cardiolgica Aguascalientes
Introduction
Atrial coronary circulation safety and efficacy of ablation
procedures, pathophysiology of atrial fibrillation itself
Atherosclerotic disease serves as a mechanism for AF

The blood supply to a tissue is often a key to the understanding


of pathological processes which may occur in the tissue.
M.A. Kugel
Atrial coronary anatomy, nomenclature
The sinus nodal artery (SNA) and the atrioventricular nodal artery
(AVNA): major atrial coronary branches

In 1907, Arthur Keith and Martin Flack were the first to describe atrial
coronary branches
SNA: Keith-Flack artery

Baroldi and Scomazzoni nomenclature: SNA as the main atrial


branch
55% arises from RCA
Right atrial branches
Right atrium (RA): RCA after the conus artery along the AV groove
Anterior: 1st branch, anterior RA ascends posteriorly anterior IA Groove
(RAO) projection: is slender, arises at a variable distance from the conus artery,
and courses to the left and superior both atria & IA septum. Main: SAN

intermediate/marginal
Acute margin, ascends AL of RA: surrounding atrial tissues. 13% SN (main)
Origin marked by small fatty excrescence or by a small cardiac vein.
Angiography: difficult (small, variability)

Posterior
arises on the posterior aspect of the RA and supplies the right posterior atrial
wall and left atrial (LA) posterior surface
Left atrial branches
Left atrium (LA): LCA (Cx). Along the AV groove:
Anterior: anterior LA upwards LA (anterior IA Groove)
(RAO) projection:early branch which ascends leftwards and upwards

intermediate/marginal

Posterior

Left atrial circumflex artery (LACX): Ascends LA and travels along its lower margin
parallel to the left AV groove left heart margin posterior wall of the LA.
Sometimes, across de crux right AV groove: right posterior branches
Rarely, supply SAN
Right and left atrial anastomoses and Kugels artery
small intra-atrial or atrioventricular branches, or as a single vessel.
LCX 66%
Kugels artery: the major transatrial pathway: right and left coronary
systems arteria anastomotica auricularis magna
vascular loop around the base of the SVC
Lies along the anterior atrial walls and travels into the interatrial septum
supplies the aortic cusp of the mitral valve (MV), aortic valve (AOV),
commissures, and aortic base lesions within these structures
Sinus nodal artery: origin, course, termination
55% the RCA within 2 cm of the coronary ostium (RAAB)
45%: first few mm of the LCA (LAAB)
95% proximal LCX
3% left main coronary trunk
2% Distal portion of the circumflex

Travels to reach the base of the SVC and circles before penetrating the
sinus node at the auriculocaval junction.
precaval (58%),
Retrocaval (36%),
and pericaval (6%)

Busquet et al.
S-Shaped Sinus Nodal Artery (SSNA)
In left-sided SNA patients= artery from Cx (below LAA): supply SNA
21.5% (111 patients studied)
Branch of Cx (13.5%)
Upper part of a divided LCX (5.4%)
Main continuation of the LCX (2.7%)

Larger than the normal SNA and follows the same course to the SAN

Feeds the LA, a large part of IA septum, RA, and part of the AV nodal
area

Nerantzis and Avgoustakis


Atrial coronary territories in sheep

29.5% 23.5% 29.5%


Right sinus nodal artery
AV Nodal Artery: origin, course, termination
Ramus septi fibrosi
supplies the membranous part of the interventricular septum
90%
10% LCX

Supply the posterior portion of the left branch of the bundle of His

Final: Tricuspid valve (TV), between the TV and MV, or closer to the
MV

Spirina and Soskin


AV nodal artery
Atrial venous system
Epicardial venous system coronary sinus
Thebesian venous system (drain directly into the cardiac chambers)

The left atrial veins


Posterolateral veins,
Posterosuperior veins,
Septal veins
The right atrial veins
small, large, short, or long intramyocardial tunnels and small intramural veins

Oblique vein (Marshall): descends lateral and inferior wall of LA:


left pulmonary veins and LAA great cardiac vein
Conclusions
Our understanding of atrial coronary anatomy is growing
But
Is limited by our technology
Development of smaller catheter tips capable of accessing narrower arteries

Needed to investigate its application to disease pathophysiology


Questions!