Flow rates in the descending coronary artery in patients with arterial hypertension and left ventricular hypertrophy. Stenosis pna what is it pna cardiology

To do this important work, the heart needs a considerable amount of oxygen, for the delivery of which the coronary artery system is responsible. Pathological changes in the state of blood vessels always lead to a deterioration in the blood supply to the heart and to the development of very serious cardiovascular diseases.

Calcification of the vessel wall and proliferation of connective tissue in the artery are brought to narrowing of the lumen until the artery is completely desolate, slowly progressing deformity, and thereby cause chronic, slowly increasing insufficiency of blood supply to the organ fed through the affected artery.

What is the essence of stenting

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A stent is a thin metal tube that consists of wire cells and is inflated with a special balloon. The balloon is introduced into the affected vessel, expanding, it is pressed into the walls of the vessel and increases its lumen. This is how the blood supply to the heart is corrected.

At the diagnostic stage, coronary angiography is performed, which allows you to determine the location, nature and degree of narrowing of the coronary vessels.

Then, in the operating room, under X-ray control, an operation is performed, constantly registering the patient's cardiogram. The operation does not require incisions; it is performed under local anesthesia.

A special catheter is inserted through the vessel on the arm or thigh at the mouth of the narrowed coronary artery, and a thin metal guide is passed through it under observation on a monitor. This conductor is provided with a balloon corresponding to the size of the constricted area. On the balloon, in a compressed state, a stent is mounted, which is compatible with human tissues and organs, elastic and flexible, able to adapt to the state of the vessel. The balloon is inserted on the guidewire, it inflates, the stent expands and is pressed into the inner wall.

To ensure the correct expansion of the stent, the balloon is inflated several times. Then the balloon is deflated and removed from the artery along with the catheter and guidewire. In turn, the stent is retained to preserve the vessel lumen. One or more stents can be used depending on the size of the affected vessel.

Stenting of the vessels of the heart: reviews

Usually, according to numerous reviews, the results of the operation are good, the risk of complications after it is the lowest and it is relatively safe. Nevertheless, in some cases, an allergic reaction of the body to a substance that is introduced during the operation for X-ray observation is likely.

There are also bleeding or bruising at the puncture site of the artery. In order to prevent complications, the patient is left in the intensive care unit with the obligatory adherence to bed regulations. After some time, after the wound at the puncture site has healed, the operated patient is discharged from the hospital. The patient can return to his usual way of life and periodically be observed by the doctor at the place of residence.

The cost of stenting of the heart vessels is quite high. This is explained by the fact that the operation uses expensive drugs and modern medical equipment. Thanks to stenting of the vessels of the heart, patients get the opportunity to live a normal life.

But nevertheless, it is worth remembering that even with the most impeccable methods of cardiac surgery, they do not cancel the need to take care of their health. We need systematic physical activity, commensurate with physical capabilities and age, balanced nutrition, fresh air, limiting the use of foods that contain cholesterol.

CORONARY STENTING

Age - 64 years old. After examination in the cardiology department, he received a referral for coronary artery stenting (TBCA PNA).

Now - all in thought - what to do?

Blood biochemistry - all indicators are within normal limits, almost in the middle of the interval: cholesterol (CHOL) - 3.67, KOEF. ATEROG - 2.78.

ECG - sinus bradycardia 54 per minute. Left ventricular myocardial hypertrophy. Violation of the processes of repolarization along the apical lateral wall of the LV. It was because of the ECG, which the doctor did not like, and was sent to cardiology.

Treadmill test - negative test, with peculiarities.

EchoCG - echo signs of aortic atherosclerosis, cardiosclerosis. Unsharp dilatation of the LA cavity.

Coronary angiography. The type of blood circulation in the myacardium is left. The trunk of the LCA is unremarkable. PNA: stenosis of the middle segment (after 1DA discharge) up to 60%. Oral stenosis 1 DA up to 80%. In the distal segment there is an unevenness of the contours, "muscle bridge" with stenosis during systole up to 30%. AO: b \ o, PKA: b \ o. Conclusion: Atherosclerosis of CA, Stenosis of PNA, 1DA. "Muscle bridge" of the PNA.

General condition - corresponds to age, I lead a fairly active life, I go fishing in winter. Sometimes I drink (in moderation). Shortness of breath - on the fourth floor. Sometimes pains in the heart (not acute) disturb, especially in stressful situations. The pressure is normal 130/80 sometimes 160/110.

Consulted with various cardiologists. Contradictory judgments: -

Why do you need a piece of iron in your heart, which sometimes you have to cut out and perform bypass surgery. Take your medicine and move on.

The stent must be placed before the coronary artery clogs completely. Miracles do not happen, and the process will only grow. Why live with the threat of a heart attack if the problem can be solved with stenting?

Here I found myself in such a situation - time for reflection - one week.

I dug up the Internet and found many different horror stories, both pros and cons.

How to be, I will be glad to any professional advice.

From the point of view of an endovascular surgeon, there is something to work with.

But still my opinion is - do not rush. Let me explain.

"Why live with the threat of a heart attack, if the problem can be solved with stenting." - this opinion is erroneous. Stenting improves prognosis only if it is performed in the acute phase of myocardial infarction. In the case of a stable course of ischemic heart disease, stenting does not reduce the risk of death or the development of myocardial infarction! In a stable course of coronary artery disease stenting of the coronary arteries has one goal - to reduce the clinical picture of angina pectoris with insufficient effectiveness of drug therapy (that is, to improve the quality of life). There are some other special situations, but I will not go into details as this is not your case.

You do not have a typical angina clinic and have a negative stress test. Thus, stenting will not improve your quality of life (since it is already good) and will not reduce the risk of heart attack (see above). But it will add at least one additional tablet to take. And even with endovascular interventions, there are complications, alas.

According to the presented material, one gets the impression that: at the present time it is possible to refrain from stenting (it is not clear from the description why coronary angiography was done at all in the absence of a clinic and a negative stress test). Complete therapy aimed at reducing risk factors (statins, antihypertensive therapy, etc.). In case of deterioration of the condition, the appearance of a clinic of angina pectoris, return to the issue of stenting.

I think, armed with knowledge, it makes sense to once again discuss the potential benefits and risks of the intervention with your doctor.

Cardiologist - site about diseases of the heart and blood vessels

Cardiac surgeon online

Conductive system of the heart

Sinus node

The sinus node is the driver of the sinus rhythm, it consists of a group of cells that have the property of automatism, and is located at the confluence of the superior vena cava into the right atrium.

Drawing. The conducting system of the heart and its blood supply. ZNV - posterior descending branch; LNPG - left bundle branch; OA - circumflex artery; RCA, right coronary artery; PNA - anterior descending artery; PNPG - right bundle branch; SU - sinus node

If the sinus node is not working, latent pacemakers in the atria, AV node, or ventricles are activated. The automatism of the sinus node is influenced by the sympathetic and parasympathetic nervous systems.

AV node

The AV node is located in the anteromedial part of the right atrium in front of the orifice of the coronary sinus.

A bunch of His and its branches

Excitation is delayed in the AV node for about 0.2 s, and then spreads along the bundle of His and its right and left legs. The left leg of the bundle of His is divided into two branches - anterior and posterior. Vegetative innervation has almost no effect on conduction in the His-Purkinje system.

Method for assessing the state of coronary blood flow after surgery

RU patent holders:

The invention relates to medicine, namely to cardiac surgery. A comprehensive clinical examination of the patient is carried out, including echocardiography and selective coronary angiography, the total indicator of the coronary bed is determined. At the same time, after the operation, on days 3-8, using echocardiography, the dynamics of indicators of the left ventricular ejection fraction (LVEF), the dynamics of indicators of left ventricular diastolic function (LV DF) and the dynamics of indicators of the contractility of the left ventricle (INLS), the number and nature of contractility of each segment. With the help of selective coronary angiography, the number of affected basins of the coronary arteries is determined, and after the operation, the degree of myocardial revascularization, according to the formula:

In this case, the revascularization index is determined by the formula:

The state of coronary blood flow is assessed as good when the degree of myocardial revascularization is more than 80%, LVEF is more than 50%, LV DF is greater than 1 and INLS is equal to 1, the state of coronary blood flow is assessed as unsatisfactory when the degree of myocardial revascularization is less than 50%, LVEF is less than 50%. , LV DF is less than 1 and INLS is greater than 1. The method increases the accuracy of assessing the state of coronary blood flow after surgery. 1 wp f-ly, 11 tab.

The invention relates to medicine, namely to cardiac surgery, and can be used to assess the state of coronary blood flow after coronary artery bypass grafting or stenting and the choice of further treatment tactics.

Coronary or ischemic heart disease (IHD) is the most common disease, the mortality rate from which in Russia has reached catastrophic values - 55% (see L.A. Bokeria. Modern society and cardiovascular surgery // Abstracts of the V All-Russian Congress of Cardiovascular hirugov. - M., 1999, - p. 3-6). The importance of coronary heart disease in modern society is determined by the number of people suffering from this disease, since the incidence of coronary disease is currently epidemic. IHD is a more frequent cause of death, disability and economic loss in modern society than any other disease. A special position in the general structure of ischemic heart disease is occupied by myocardial infarction (MI) with an outcome in cardiosclerosis. With the defeat of the coronary arteries, the LV is more often affected. Since the LV is the main "working organ" of the heart (pump), any of its dysfunction affects the general condition of the body, leading to heart failure and other complications leading to death.

One of the main methods of treatment for coronary artery disease is revascularization of the heart muscle by coronary artery bypass grafting (CABG) or balloon angioplasty and stenting, since the main cause of the disease is damage to the coronary arteries. The latter method is used more and more often, since it is a less invasive and more gentle method, which is not inferior in efficiency to an operation with artificial circulation (see Samko A.N. The use of intracoronary stents for the treatment of patients with coronary heart disease // Russian medical journal., - volume 6 , - No. 14, - p.).

Evaluation of the effectiveness of the operation is usually carried out by changes in clinical parameters, including the data of echocardiography and selective coronary angiography, which makes it possible to accurately diagnose before surgery and determine the indications for surgical treatment.

For the prototype of the present invention, a well-known method for assessing the state of coronary blood flow after the surgical intervention through a comprehensive clinical examination of the patient, including performing echocardiography and selective coronary angiography with the determination of the total indicator of the coronary bed and comparison of the data obtained (see Belenkov Yu.N. Left ventricular dysfunction in patients with coronary heart disease: modern methods of diagnosis, drug and non-drug correction // Russian medical journal., - volume 8, - №17, - p.).

The known method consists in the fact that the patient, in addition to clinical and biochemical studies, perform electrocardiography (ECG), echocardiography (EchoCG) and selective coronary angiography (SCG).

An objective sign according to the ECG data of the severity of postinfarction cardiosclerosis is the presence or absence of a pathological Q wave. Thus, patients with a history of Q myocardial infarction (MI) and patients who have had non-Q MI are distinguished. When analyzing the ECG, attention is also paid to disturbances in the rhythm, conduction, overload and hypertrophy of various parts of the heart.

To assess the nature of atherosclerotic lesions of the coronary bed and the degree of its severity, patients perform SCG through the right or left femoral artery. When analyzing the state of the coronary bed, the following is determined: type of blood supply to the heart - right, left, balanced; localization and prevalence of the lesion, highlighting localized and diffuse lesions; the presence or absence of collateral blood flow; allocate the degree of narrowing of the coronary arteries according to the classification of Y.S. Petrosyan and L.S. Zingerman (see Petrosyan Y.S., Zingerman L.S. Classification of atherosclerotic changes in coronary arteries // Abstracts of the 1st and 2nd All-Union symposia on modern methods coronary angiography and their use in the clinic. - M.g., - p.16). To obtain information about the state of the coronary bed as a whole, taking into account clinical indicators, use the method of total assessment of the lesion of the coronary bed (Petrosyan Yu.S., Shakhov B.E. Coronary bed in patients with postinfarction aneurysm of the left ventricle of the heart. - Gorky, g., - p. .17-20), in which:

The narrowing of the lumen of blood vessels by more than 50% and occlusion are taken into account;

The type of coronary circulation is taken into account;

Influence of centrally located narrowings on subsequent stenoses in the system of one artery.

First, the lesion of each major artery of the heart is assessed according to the scoring system. The sum of the points is the total indicator of the total coronary blood flow lesion. For more informational content, the total indicator of lesions of the arteries of the heart is expressed as a percentage of the maximum value of points. The number 240 is conventionally taken as the maximum value of points. This roughly corresponds to the amount of blood flowing through the coronary bed in 1 minute (), that is, 240 ml / min. And it is divided along the main arteries of the heart, depending on the type of blood circulation. For calculations, special table maps have been created. The total lesion of the coronary bed is calculated as a percentage of 240. This made it possible to determine different approaches to assessing the severity of the disease in seemingly similar patients, and to determining the indications and scope of surgical intervention.

During echocardiography, the following positions are used: parasternal along the long axis of the LV, parasternal along the short axis of the LV at the level of the mitral (MK) and aortic (AC) valves, papillary muscles, apex; apical - in the position of four and five-chamber images. When analyzing echocardiography at rest, systolic (end-diastolic volume (EDV), end-systolic volume (ESV), ejection fraction (EF), interventricular septal thickness (IVS), LV posterior wall thickness (LVDV) in systole and diastolic and diastolic function are assessed, as well as segmental LV contractility.

However, today there is no consensus on what criteria reflect the effectiveness of the performed surgical treatment; there is no analysis of myocardial changes in patients with coronary artery disease after surgery. Also, the tactics of further patient management remains unclear. The problem of left ventricular remodeling remains one of the most urgent and dynamically developing in modern cardiology. Chronic myocardial ischemia causes the development of diffuse cardiosclerosis, cardiac remodeling with the development of ischemic cardiomyopathy, disability and death of the patient. According to the authors of the present invention, a double approach is required to assess the effectiveness of the treatment: on the one hand, it is necessary to take into account the state of myocardial perfusion and its pumping function, on the other hand, the severity of left ventricular (LV) remodeling. Surgical correction is aimed not only at improving the clinic, but also at restoring the shape and geometry of the LV. In the presence of incomplete restoration of blood flow, it becomes necessary to more accurately assess the degree of restoration of coronary blood flow in order to decide on the choice of treatment tactics for this patient: perform another surgical intervention or continue drug treatment.

The objective of the present invention is to improve the accuracy of the assessment and ensure the possibility of predicting complications and planning the subsequent treatment tactics.

The problem is solved by the fact that in the known method for assessing the state of coronary blood flow after a surgical intervention, including a comprehensive clinical examination of the patient, including echocardiography and selective coronary angiography with determining the total indicator of coronary lesions and comparing the data obtained, before and after surgery, by 3 -8 days with the help of echocardiography, the dynamics of the left ventricular ejection fraction (LVEF), the dynamics of the left ventricular diastolic function (LV DF) and the dynamics of the left ventricular contractility (LVD) indices, the number and nature of contractility of each segment are investigated using selective coronary angiography determine the number of affected basins of the coronary arteries, and after the operation, the degree of myocardial revascularization, which is determined by the formula:

in this case, the revascularization index is determined by the formula:

and the state of coronary blood flow is assessed as good if the degree of myocardial revascularization is> 80%, LVEF> 50%, LV DF> 1 and INLS equal to 1, the state of coronary blood flow is assessed as unsatisfactory with the degree of myocardial revascularization<50%, ФВ ЛЖ<50%, ДФ ЛЖ<1 и ИНЛС>1, while in patients with ischemic heart disease with a history of myocardial infarction, the duration of ischemic heart disease is determined.

The proposed method meets the criteria of "novelty" and "inventive step", since the conducted patent information research did not reveal the sources of patent and scientific and technical information discrediting the novelty of the method.

The studies carried out by the authors of the application have shown that the criteria: LVEF, LV DF and INLS are the most effective criteria reflecting functional disorders of the left ventricle. The proposed method is applied in the Specialized Clinical Cardiac Surgery Hospital in Nizhny Novgorod for 94 patients with coronary artery disease who have had myocardial infarction and were in hospital. In the study group, there were 80 men (88%), women - 14 (14%). The average age of the patients was 54 ± 0.9 years (from 35 to 73 years).

To assess the nature of atherosclerotic lesions of the coronary bed and the degree of its severity, all patients underwent selective coronary angiography (SCG) using the Jadkins technique through the right or left femoral artery. The study was carried out in X-ray surgical operating rooms equipped with X-ray surgical complexes "BI-ANGIOSCOP" and "Angioscop-3D" (Siemens, Germany).

For the convenience of analyzing the coronary bed, the authors took into account not the number of affected coronary arteries (CA), but the number of basins. This approach is due to the fact that the myocardium is supplied with blood by three main arteries: the anterior descending artery (ANA), the circumflex artery (OA), and the right coronary artery (RCA), giving rise to other smaller branches. Thus, we consider the lesion of not only this artery to be the basin of the PNA, but also the diagonal (DV) and septal (PV) branches extending from it. Basin OA - lesion of the OA itself, as well as the branch of the blunt edge (BTK), the basin of the RCA - lesion of the RCA, posterior descending artery (PNA), branches of the acute edge (VOC). In this regard, we have identified the following options for the destruction of pools (table 1). Our patients had no lesions of the LCA trunk.

The analysis of obliterating lesions of the coronary arteries was carried out taking into account their division into three levels. The assessment of the localization, the degree of arterial lesion according to coronary angiography was carried out according to the classification of Yu.S. Petrosyan and L.S. Zingerman (1973). According to this classification, we determined the type of blood supply to the heart: right (70%), left (20%), balanced (10%); localization, degree and extent of the lesion, presence or absence of collateral blood flow.

Coronary angiography (coronary angiography)

Coronary angiography continues to be the "gold standard" for diagnosing coronary artery stenosis, determining the effectiveness of drug therapy, PCI and CABG.

Coronary angiography is a contrasting of the coronary arteries under X-ray control with the introduction of RVC into the mouth of the arteries and recording the image on an X-ray film, a video camera. Increasingly, the computer's hard disk and CD-disks are used, while the image quality does not deteriorate.

Indications for coronary angiography

In recent decades, indications for coronary angiography have been expanding all the time due to the spread of such methods of treatment of coronary atherosclerosis and coronary artery disease as PTCA with stenting and CABG coronary angiography is used to assess the coronary bed (narrowing and their length, severity and localization of atherosclerotic changes), to determine the treatment tactics and prognosis in patients with CHD symptoms. It is also very useful for studying the dynamics of coronary tone, immediate and long-term results of PTCA, CABG, and drug therapy. Briefly, indications for coronary angiography can be formulated as follows:

insufficient effectiveness of drug therapy in patients with coronary artery disease and the decision of the question of another treatment tactics (PTCA or CABG);
clarification of the diagnosis and differential diagnosis in patients with an unclear diagnosis of the presence or absence of coronary artery disease, cardialgia (difficult to interpret or questionable data from non-invasive and stress tests);
determination of the state of the coronary bed in representatives of professions associated with increased risk and responsibility, in cases of suspicion of the presence of signs of coronary heart disease (pilots, astronauts, transport drivers);
AMI in the first hours of the disease for (intracoronary) thrombolytic therapy and / or angioplasty (PTCA) in order to reduce the zone of necrosis; early postinfarction angina or recurrent myocardial infarction;
evaluation of the results of CABG (patency of aortocoronary and mammary-coronary shunts) or PCI in case of recurrence of angina attacks and myocardial ischemia.

Determination of the degree of stenosis and variants of coronary lesions

Stenoses of the coronary arteries are subdivided into local and diffuse (extended), uncomplicated (with smooth, even contours) and complicated (with uneven, irregular, undermined contours, flow of RVC into places of ulceration of the plaque, parietal thrombi). Uncomplicated stenoses usually occur with a stable course of the disease, complicated ones - in almost 80% of cases, occur in patients with unstable angina pectoris, ACS.

Hemodipamically significant, that is, limiting coronary blood flow, is considered to be a narrowing of the diameter of the vessel by 50% or more (but this corresponds to an area of 75%). However, stenoses of less than 50% (the so-called non-obstructive, non-stenotic coronary atherosclerosis) can be prognostically unfavorable in the case of plaque rupture, parietal thrombus formation with the development of coronary circulation instability and AMI. Occlusions - complete overlap, blockage of the vessel by morphological structure - are conical (slow progression of narrowing followed by complete closure of the vessel, sometimes even without myocardial infarction) and with a sharp break in the vessel (thrombotic occlusion, most often in AMI).

There are various options for quantifying the prevalence and severity of coronary atherosclerosis. In practice, a simpler classification is often used, considering the main three main arteries (PNA, OA and RCA) and highlighting one-, two- or three-vessel coronary lesions. Separately indicate the defeat of the trunk of the LCA. Proximal significant stenoses of the PNA and OA can be considered equivalent to the lesion of the LCA trunk. Large branches of the 3 main coronary arteries (intermediate, diagonal, obtuse margins, posterolateral and posterior descending) are also taken into account when assessing the severity of the lesion and, like the main ones, can be subjected to endovascular treatment (PTCA, stentonic) or bypass grafting.

Polypositional contrasting of the arteries is important (at least 5 projections of the LCA and 3 projections of the RCA). It is necessary to exclude the stratification of branches on the stenotic section of the studied vessel. This makes it possible to exclude underestimation of the degree of narrowing in the case of an eccentric location of the plaque. This must be borne in mind in the standard analysis of angiograms.

Selective contrasting of venous aortocoronary and aortoarterial (internal thoracic artery and gastroepiploic artery) shunts is often included in the plan of coronary angiography in patients after CABG to assess the patency and functioning of the shunts. For venous shunts starting on the anterior wall of the aorta approximately 5 cm above the RCA orifice, use coronary catheters JR-4 and modified AR-2, for the internal thoracic artery - JR or IM, for the gastroepiploic artery - a Cobra catheter.

Who to contact?

Coronary angiography technique

Coronary angiography can be performed both separately and in conjunction with catheterization of the right heart and left (less often right) GV, myocardial biopsy, when, along with the assessment of the coronary bed, it is additionally necessary to know the parameters of pressure in the pancreas, right atrium, pulmonary artery, minute volume and cardiac index , indicators of general and local ventricular contractility (see above). During coronary angiography, constant monitoring of ECG and blood pressure should be provided, a complete blood count should be provided and biochemical parameters, blood electrolyte composition, coagulogram, blood urea and creatinine parameters, tests for syphilis, HIV, hepatitis should be evaluated. It is also desirable to have a chest X-ray and duplex scanning of the vessels of the ilio-femoral segment (if the femoral artery is punctured, which is still the case in most cases). Indirect anticoagulants are canceled 2 days before the planned coronary angiography with blood clotting control. Patients with an increased risk of systemic thromboembolism (atrial fibrillation, mitral valve disease, history of episodes of systemic thromboembolism) during the withdrawal of indirect anticoagulants can receive intravenous unfractionated heparin or subcutaneous low molecular weight heparin during the coronary angiography procedure. With a planned CAG, the patient is delivered to the X-ray operating room on an empty stomach, premedication consists in the parenteral administration of sedatives and antihistamines. The attending physician must obtain written informed consent from the patient for the procedure, indicating the rare but possible complications of this technique.

The patient is placed on the operating table, ECG electrodes are placed on the limbs (precordial electrodes should also be at hand if necessary). After processing the puncture site and isolating it with sterile linen, local anesthesia is made at the puncture point of the artery and the artery is punctured at an angle of 45 °. When a stream of blood is reached from the pavilion, a 0.038 - 0.035 inch guidewire is inserted into the puncture needle, the needle is removed, and an introducer sheath is inserted into the vessel. Then usually 5000 U of heparin is administered as a bolus or the system is constantly flushed with heparinized isotopic sodium chloride solution. A catheter is inserted into the introducer (various types of coronary catheters are used for the left and right coronary arteries), it is advanced under fluoroscopic control to the aortic bulb and under the control of blood pressure from the coccyx of the catheter, the orifices of the coronary arteries are catheterized. The size (thickness) of the catheters varies from 4 to 8 F (1 F = 0.33 mm), depending on the access: with the femoral catheters 6-8 F are used, with the radial F. Using a 5-8 ml RKV syringe, selectively the left and right coronary arteries are manually contrasted in different projections using cranial and caudal angulation, trying to visualize all segments of the artery and their branches.

In case of detection of stenosis, a survey is carried out in two orthogonal projections for a more accurate assessment of the degree and eccentricity of stenosis: if in the LCA, we usually stand in the right anterior oblique projection or direct (this way the LCA trunk is better controlled), in the right (RCA) in the left oblique projection ...

The LCA originates from the left coronary) sinus of the aorta with a short (0.5-1.0 cm) trunk, after which it is divided into the anterior descending (PNA) and circumflex (OA) arteries. The PNA runs along the anterior interventricular sulcus of the heart (it is also called the anterior interventricular artery) and gives diagonal and septal branches, supplies a vast area of the LV myocardium - the anterior wall, the interventricular septum, the apex and part of the lateral wall. OA is located in the left atrioventricular groove of the heart and gives branches of the obtuse edge, the left atrial and, with the left type of blood supply, the posterior descending branch, supplies the lateral wall of the LV and (less often) the lower wall of the LV.

RCA departs from the aorta from the right coronary sinus, but goes but to the right atrioventricular groove of the heart, in the proximal third it gives branches a conical and sinus node, in the middle third - a right ventricular artery, in the distal third - an artery of an acute edge, posterolateral (a branch departs from it to atrioventricular node) and the posterior-descending artery. The RCA supplies the pancreas, the pulmonary trunk and the sinus node, the LV inferior wall and the interventricular septum adjacent to the ventricular septum.

The type of blood supply to the heart is determined by which artery forms the posterior-descending branch: in about 80% of cases it departs from the RCA - the right type of blood supply to the heart, in 10% - from the OA - the left type of blood supply, and in 10% - from the RCA and OA - mixed or a balanced type of blood supply.

Arterial approaches for performing coronary angiography

The choice of access to the coronary arteries, as a rule, depends on the operating physician (his experience and preferences) and on the condition of the peripheral arteries and the patient's coagulation status. The most commonly used, safe and widespread femoral approach (the femoral artery is large enough, does not collapse even in shock, is far from vital organs), although in some cases it is necessary to use other ways of introducing catheters (axillary, or axillary; brachial, or brachial; radial, or radial). So, in patients with atherosclerosis of the vessels of the lower extremities or previously operated on for this, in outpatients, puncture of the arteries of the upper extremities (brachial, axillary, radial) is used.

In the femoral, or femoral, method, the anterior wall of the right or left femoral artery is well palpated and punctured 1.5-2.0 cm below the inguinal ligament according to the Seldinger technique. Puncture above this level leads to difficulties in digital stopping of bleeding after removal of the introducer and to possible retroperitoneal hematoma, below this level - to the development of pseudoaneurysm or arteriovenous fistula.

With the axillary method, the right axillary artery is more often punctured, less often the left one. At the border of the distal region of the armpit, the pulsation of the artery is palpated, which is punctured in the same way as the femoral one, after local anesthesia with the subsequent installation of an introducer (for this artery, we try to take catheters no larger than 6 F for easier stopping bleeding and reducing the likelihood of hematoma development in this puncture site after examination). This method is now rarely used by us due to the introduction of radial access several years ago.

The brachial, or brachial, method has been used for a long time: back in 1958, Sones used it for selective catheterization of the coronary arteries, making a small skin incision and isolating the artery with a vascular suture at the end of the procedure. When the author performed this method, there was no big difference in the number of complications compared to puncture of the femoral artery, but his followers had a higher incidence of vascular complications (distal embolization, arterial spasm with impaired blood supply to the limb). Only in isolated cases is this access used because of the above-mentioned vascular complications and the difficulty of fixing the brachial artery during its percutaneous puncture (without a skin incision).

The radial method - puncture of the radial artery on the wrist - has become more and more often used in the last 5-10 years for outpatient coronary angiography and rapid activation of the patient, the thickness of the introducer and catheters in these cases does not exceed 6 F (usually 4-5 F), and when For femoral and brachial approaches, 7 and 8 F catheters can be used (this is especially important in complex endovascular interventions, when 2 or more wires and balloon catheters are needed, in the treatment of bifurcation lesions with stenting).

Before puncture of the radial artery, an Allen test is performed with clamping of the radial and ulnar arteries to detect the presence of collateralization in case of complication after the procedure - occlusion of the radial artery.

Puncture of the radial artery is performed with a thin needle, then an introducer is inserted into the vessel along the guidewire, through which a cocktail of nitroglycerin or isosorbide dipitrate (3 mg) and verapamil (2.5-5 mg) is immediately injected to prevent arterial spasm. For subcutaneous anesthesia, use 1-3 ml of 2% lidocaine solution.

With a radial approach, difficulties may arise with the passage of a catheter into the ascending part of the aorta due to the tortuosity of the brachial, right subclavian artery and brachiocephalic trunk, often other coronary catheters (not Judkins, as with femoral access) of the Amplatz type and multidisciplinary catheters are required to reach the orifices of the coronary arteries ...

Abbreviations in cardiology

Abbreviations that patients encounter in discharge notes, when describing ultrasound of the heart, in medical records, often puzzle them. The most common abbreviations found in cardiac patients are deciphered in this section.

BPVR - blockade of the anterior-superior branching - heart block.

Essential hypertension 2 degrees, 3 stages, risk 4. What does this mean?

1 degree - pressure within / 90-99 mm. rt. Art .;
Grade 2 - pressure within / mm. rt. Art .;
3 degree - pressure from 180/100 mm. rt. Art. and higher.

Hypertension (HD) stage 1 assumes no changes in the "target organs" (heart, retina, kidneys, brain, peripheral arteries).

Hypertension (HD) stage 2 is established when there are changes on the part of one or more "target organs" (that is, when there are already objective consequences of hypertension):

Left ventricular hypertrophy:

Ultrasound signs of thickening of the artery wall (carotid artery> 0.9 mm) or atherosclerotic plaques.

Slight increase in serum creatinine mole / L for men or μmol / L for women

Microalbuminuria: mg / day; urine albumin / creatinine ratio> 22 mg / g (2.5 mg / mmol) for men and> 31 mg / g (3.5 mg / mmol) for women

Changes in the vessels of the fundus

Hypertensive heart disease (HD) stage 3 is established in the presence of associated clinical conditions:

Cerebrovascular diseases: ischemic stroke; hemorrhagic stroke; transient cerebral ischemia.

Heart disease: myocardial infarction; angina pectoris; congestive heart failure.

Determination of the risk of developing cardiovascular complications (heart attack and stroke) in the next 10 years.

Main risk factors:

Systolic blood pressure above 140 mm Hg. Art., diastolic above 90 mm Hg. Art.

Men over 55.

Women over 65.

Total cholesterol is above 6.5 mmol / L.

Reducing high density lipoprotein cholesterol.

Increased low-density lipoprotein cholesterol levels.

Nah heart it

Cardiac ischemia

LCA - left coronary artery

ME - metabolic equivalent

OA - circumflex artery

RCA - right coronary artery

PNA - anterior descending artery

About a million Americans die from coronary artery disease every year. In addition, a significant

part of the population ischemic heart disease causes LV dysfunction and arrhythmias, is a frequent

the reason for hospitalization. Clinical manifestations of coronary artery disease include sudden death,

MI, HF and angina pectoris. Angina pectoris, the most common symptom of coronary artery disease, is pain in

chest, usually behind the sternum, lasting 5-10 minutes, with irradiation to the arms, neck,

lower jaw, back and epigastrium. The pain is usually not sharp, but pressing or

Angina pectoris is caused by transient myocardial ischemia resulting from damage to the coronary arteries, both atherosclerotic (> 90%) and non-atherosclerotic (spasm, anatomical abnormalities, etc. - see p. 98).

Angina pectoris is an integral part of several clinical syndromes that differ both in treatment methods and in prognosis. These include exertional angina (with a constant or changing threshold of ischemia), new-onset angina and unstable angina (progressive angina, rest angina, postinfarction angina). In addition, with ischemic heart disease, painless ischemia is observed, which serves as a poor prognostic sign.

With the accumulation of knowledge about the causes of these conditions and their mechanisms, the possibilities of diagnosing and treating coronary artery disease have improved. This allows in many cases to increase life expectancy and make it more fulfilling.

Diagnosis Chest pain is one of the most common reasons for seeking medical attention. Pain that resembles angina is not necessarily caused by coronary artery disease. It occurs in many conditions - with pathology of the gastrointestinal tract, musculoskeletal system, lungs, central nervous system and some heart diseases. In such cases, overdiagnosis of ischemic heart disease is possible. On the other hand, IHD can have atypical manifestations (shortness of breath, sweating, weakness). Bayes' Conditional Probability Theorem helps to select the optimal diagnostic sample in terms of efficiency and cost. The prior probability of disease (prevalence in this group), sensitivity and specificity of the diagnostic test allow us to estimate the posterior probability (the probability of disease according to the test data). The diagnostic scheme (see below) presents an example of a formalized approach to the recognition of coronary artery disease. It should be noted that functional (stress) tests are currently used mainly to determine the risk of cardiovascular complications, while their role in the very diagnosis of ischemic heart disease is secondary.

Chest pain: a probabilistic analysis in the diagnosis of coronary artery disease Nature of pain A priori probability of coronary artery disease,% Posterior probability of coronary artery disease depending on the magnitude of ST segment depression during exercise 0-0.5 mm 1-1.5 mm 2-2.5 mm Typical for angina pectoris (A and B) men 30-39 years old men 60-69 years old women 30-39 years old women 60-69 years old> Reminiscent of angina pectoris (A or B) men 30-39 years old men 60-69 years old women 30-39 years old women 60 -69 years Not typical for angina pectoris (neither A nor B) men 30-39 years old men 60-69 years old women 30-39 years old women 60-69 years old 60 mg%, then the number of risk factors decreases by one.

Pain in the heart area occurs in many conditions, therefore the list of diseases with which IHD must be differentiated is very extensive: esophageal reflux (Bernstein's test - the introduction of a 0.1 N solution of hydrochloric acid into the esophagus, gastric X-ray, trial treatment with antacids), impaired esophageal motility (manometry), peptic ulcer (gastroduodenoscopy, trial treatment with H, blockers), pancreatitis (amylase and lipase activity), gallbladder disease (ultrasound), musculoskeletal diseases (trial NSAID treatment), PE (ventilation perfusion lung scintigraphy), pulmonary hypertension (Echocardiography, cardiac catheterization), pneumonia (chest x-ray), pleurisy (chest x-ray, trial NSAID treatment);

pericarditis (EchoCG, trial treatment of NSAIDs), mitral valve prolapse (EchoCG, trial treatment with b adrenergic blockers), psychogenic pain (trial treatment with sedatives, psychiatric consultation), cervicothoracic sciatica (consultation with a neuropathologist).

Diagnostic Methods Exercise tests have the greatest diagnostic value with an average prior probability of coronary artery disease (for example, in 50-year-old men with chest pain resembling angina pectoris, or in 45-year-old women with typical angina pectoris).

With a low prior probability of CHD (for example, in 30-year-old women with chest pain atypical for angina pectoris), exercise tests give too many false-positive results, which limits their diagnostic value.

With a high prior probability of coronary artery disease (for example, in 50-year-old men with typical angina pectoris), exercise tests are used to a greater extent to assess the severity of coronary artery disease than to diagnose coronary artery disease.

Method Criteria for a sharply positive test (high risk of complications) Notes Exercise tests ECG test (treadmill, bicycle ergometry) Failure to achieve a level of oxygen consumption> 6.5 ME, heart rate> 20 min 1.

ST segment depression> 2 mm.

Depression of the ST segment within 6 minutes after the termination of the load.

Multiple ST segment depression.

ABP under load hardly changes or decreases.

ST segment elevation in leads that do not have an abnormal Q wave.

Onset of VT An effective and relatively inexpensive screening method.

Diagnosis of exertional angina;

Assessment of the risk of complications;

Evaluation of the effectiveness of treatment.

ME = oxygen consumption under basal metabolic conditions (

If the load on the treadmill or bicycle ergometer is impossible (for example, with paresis of the legs and arthritis), then pharmacological tests or manual ergometrine are performed) myocardial scintigraphy s201T (treadmill, veloergometry) The appearance of accumulation defects against a background of low load (

The diagnostic value is higher than that of the stress ECG test (90% versus 70%). The method is good for diagnosing a single-vessel lesion, although with OA lesions the sensitivity is lower (

60%) than with PNA or RCA lesions (

The sensitivity of the sample against the background of a low load is also higher than that of the ECG sample.

The most common causes of a false positive result are obesity (poor image quality), large breasts, and a high diaphragm (overlap artifacts). Accumulation defects can persist for several weeks, despite the restoration of perfusion with the help of BCA.

Cost of examination High myocardial scintigraphy with 99mTc isonitrile (treadmill, veloer geometry)

Signs and treatment of coronary artery occlusion

Occlusion is a sharp obstruction of blood vessels. The reason is the development of pathological processes, clogging with a blood clot, traumatic factors. By localization, different types of occlusion are distinguished, for example, it can affect the arteries of the heart. It is supplied with blood by the two main vessels, the left and right coronary arteries.

Due to their obstruction, the heart does not receive the required amount of oxygen and nutrients, which leads to serious disorders. Often there are minutes, sometimes hours, to take emergency measures, so it is necessary to know the causes and symptoms of occlusion.

Causes

The processes that occur during the formation of a coronary occlusion largely determine the morphology. Most often, chronic occlusion begins to form from the moment of the formation of a fresh intraluminal thrombus. It is he who fills the lumen - after the fibrous capsule of an unstable atherosclerotic plaque ruptures in acute coronary syndrome.

Thrombus formation occurs in two directions from the plaque. The length of the occlusion is determined by the position of the large lateral branches in relation to the occlusive plaque.

There are several stages in the formation of structures of chronic occlusion of the heart arteries.

1 stage lasting up to two weeks. There is a sharp inflammatory reaction to acute thrombosis, rupture of an unstable plaque. Vascular microtubules are formed. Infiltration of thrombotic material with inflammatory cells and myofibroblasts occurs. In the arterial lumen of a fresh thrombus, there are platelets and erythrocytes in the fibrin framework. Almost immediately, they begin to infiltrate inflammatory cells. Endothelial cells also migrate in the fibrin mesh and participate in the formation of fine structures, microscopic tubules inside the thrombus, which begins to organize. At this stage, structured tubules are not formed in thrombotic occlusion.
The duration of the next, intermediate stage is 6-12 weeks. Negative remodeling of the arterial lumen occurs, that is, the cross-sectional area is reduced by more than 70%. The elastic membrane ruptures. Microscopic tubules are formed in the thickness of the occlusion. Thrombotic material continues to form. Other pathological processes also occur. Active inflammation develops, the number of neutrophils, monocytes, macrophages increases. The formation of the proximal occlusion capsule begins, which contains almost only dense collagen.
The stage of maturity lasts from 12 weeks. Inside the occlusion, soft tissues are almost completely displaced. There is a decrease in the number and total area of the tubules in comparison with the previous period, but after 24 weeks it does not change.

Atherosclerosis plaque formation on the coronary artery

Why do such processes begin to develop? Of course, in a healthy person with good blood vessels, the above does not happen. In order for the vessels to become sharply impassable or the occlusion becomes chronic, some factors must act on the heart, the coronary arteries. Indeed, there are several reasons for preventing normal blood flow.

Embolism. Emboli or clots can form inside arteries and veins. This is the most common cause of arterial obstruction. There are several types of this condition. Air embolism is a condition when a bubble of air enters the vessels. This often happens when the respiratory system is severely injured or the injection is not performed correctly. There is also a fatty embolism, which can be traumatic in nature, or result from profound metabolic disorders. When small fatty particles accumulate in the blood, they are able to join into a fat clot, which causes occlusion. Arterial embolism is a condition in which the vascular lumen is clogged with mobile blood clots. They usually form in the valve apparatus of the heart. This happens with various pathologies of cardiac development. This is a very common cause of occlusion of the arteries in the heart.
Thrombosis. It develops when a blood clot appears and begins to grow. It is attached to the venous or arterial wall. Thrombosis often develops with atherosclerosis.
Vascular aneurysm. This is the name of the pathology of the walls of arteries or veins. Their expansion or protrusion occurs.
Injuries. Tissues, damage of which occurred due to external reasons, begin to press on the vessels, which disrupts blood flow. This causes the development of thrombosis or aneurysm, after which occlusion occurs.

If you start living this way from a young age, serious problems can arise. Unfortunately, they are observed even in those who once led an incorrect lifestyle, of course, the degree of the disease is not so acute. If negative factors are eliminated from your life as early as possible, the likelihood of developing occlusion will be much less.

Symptoms

The manifestation of symptoms is in direct proportion to the work of the heart, because it is precisely its defeat that is going on. Since, as a result of occlusion, it ceases to receive nutrition and oxygen, this cannot go unnoticed by a person. The work of the heart suffers, and this manifests itself in the soreness of this area. The pain can be very intense. The person begins to have difficulty breathing. As a result of oxygen starvation of the heart, flies may appear in the eyes.

The person weakens sharply. He can grab the heart area with his right or left hand. As a result, this situation often leads to loss of consciousness. It must be borne in mind that pain can be given to the arm, shoulder. The signs are very pronounced. In any case, it is necessary to provide first aid.

Treatment

It is necessary to relieve pain, spasm. For this, an anesthetic should be given. It is good if you can get an injection of papaverine. If a person has a heart medicine with them, they must be given the correct dose.

After assistance by ambulance medical specialists, the victim is taken to the hospital. The patient is examined there. An ECG is available in any medical institution. When it is deciphered, then the depth and height of the teeth, the deviation of the isoline and other signs are taken into account.

Also, ultrasound of the heart and blood vessels, arteries is performed. This study helps to identify the consequences of occlusion, impaired blood flow. It is useful to conduct coronary angiography of the vessels of the heart with the introduction of a contrast agent.

The treatment of acute manifestations of occlusions is difficult. Its success depends on the timely detection of the first signs of coronary artery disease. Basically, you have to resort to surgical intervention in order to clean the internal cavities of the arteries, remove the affected areas. Arterial bypass is performed.

In order not to bring the body to this, it is necessary to maintain the cardiovascular system in a normal state. To do this, a number of preventive measures should be taken:

You need to monitor the level of blood pressure. It is best to be wise about drinking strong tea, coffee, salty and spicy foods.
It is important to eat right. This means that you need to reduce the consumption of fatty foods, which contain a lot of cholesterol. After forty years, it is necessary to be tested for cholesterol levels at least once every six months. Every day, you should eat natural products that are rich in vitamins and essential trace elements.
It is necessary to get rid of excess weight, as it puts a serious strain on the heart and blood vessels.
You should give up bad habits. This applies to smoking and alcoholic beverages. In medical practice, there have been cases when a sharp spasmodic occlusion occurred, which was caused by alcohol or nicotine.
It is necessary to avoid stress and mental shock.

With such simple measures, you can protect yourself from dangerous consequences. It is important to understand that occlusion poses a real threat to human health and life. It is necessary to prevent it or provide first aid!

Blood biochemistry - all indicators are within normal limits, almost in the middle of the interval: cholesterol (CHOL) - 3.67, KOEF. ATEROG - 2.78.

Treadmill test - negative test, with peculiarities.

EchoCG - echo signs of aortic atherosclerosis, cardiosclerosis. Unsharp dilatation of the LA cavity.

Consulted with various cardiologists. Contradictory judgments: -

Why do you need a piece of iron in your heart, which sometimes you have to cut out and perform bypass surgery. Take your medicine and move on.

The stent must be placed before the coronary artery clogs completely. Miracles do not happen, and the process will only grow. Why live with the threat of a heart attack if the problem can be solved with stenting?

Here I found myself in such a situation - time for reflection - one week.

I dug up the Internet and found many different horror stories, both pros and cons.

How to be, I will be glad to any professional advice.

From the point of view of an endovascular surgeon, there is something to work with.

But still my opinion is - do not rush. Let me explain.

I think, armed with knowledge, it makes sense to once again discuss the potential benefits and risks of the intervention with your doctor.

sstanovleniya_kroobrasheniya / it is said that if there is left ventricular hypertrophy, then they do not perform stenting. And, this is in Germany, where our people go for treatment with money. And, it turns out, our doctors do it. I respect our doctors, but in this situation I doubt their higher qualifications.

There is more than enough information on endovascular manipulations. It is strange that you could not find the answers to your questions.

Another question arose: is there a certain critical value of occlusion (stenosis) of the LCA (50, 60, 70%), at which stenting becomes mandatory?

Cardiologist - site about diseases of the heart and blood vessels

Cardiac surgeon online

Conductive system of the heart

Sinus node

AV node

The AV node is located in the anteromedial part of the right atrium in front of the orifice of the coronary sinus.

A bunch of His and its branches

Cardiologist - site about diseases of the heart and blood vessels

Cardiac stenting surgery: what is important to know about it?

The heart is a powerful pump that circulates blood in our body. Oxygen and nutrients are supplied with blood to tissues and organs, without which, in turn, their vital activity would be impossible.

One of these is atherosclerosis, the most advanced chronic disease that affects the arteries. Gradually growing atherosclerotic plaques on the inner lining of the vascular wall, multiple or single, are cholesterol deposits.

Many cardiologists have many advanced surgical procedures. But before there were intravascular therapies, coronary artery bypass grafting was the only surgical treatment for coronary artery disease. Currently, many patients manage to avoid surgical intervention due to the use of low-traumatic and effective methods, such as stenting of the heart vessels of the heart vessels of the heart.

What is the essence of stenting

For the prevention of diseases and treatment of the manifestations of varicose veins on the legs, our readers advise the spray "NOVARIKOZ", which is filled with plant extracts and oils, therefore it cannot harm health and has practically no contraindications

At the diagnostic stage, coronary angiography is performed, which allows you to determine the location, nature and degree of narrowing of the coronary vessels.

Stenting of the vessels of the heart: reviews

Comments (1)

Coronography showed LCA-stenosis 25%, PNA-stenosis 90%, OA-stenosis 35%, VTK-50%, RCA-occlusion. Is it possible for me to have stenting? Or is bypass surgery necessary?

Andrey, only a cardiac surgeon can answer this question, and the one who will directly deal with your case. Only he, having assessed your condition and the degree of vascular lesions, will be able to choose the most effective method of treatment.

After stenting, the attending physician prescribed the drug Monosan, 10 mg twice a day,

from which the head hurts. What to do and what can replace monosan?

Boris, all appointments must be coordinated with your doctor. You cannot change the treatment on your own. Unfortunately, drugs in this group (nitrates) often cause headache, which is associated with a powerful vasodilator effect. Possible replacement for Kordinik. The drug is new, has a similar effect. Or you can use a proven product called Sydnopharm. Discuss this with your cardiologist. You can soften the effect of Monosan by taking a caffeine pill.

Is it possible to pass the X-ray with the stents installed?

Any kind of X-ray examination with the installed coronary stents is quite possible. Stenting is not a contraindication for chest x-rays, fluoroscopy, or computed tomography, as stents are made with materials that are not altered by x-rays. Some types of coronary stents have limitations on magnetic resonance imaging (MRI) due to the fact that the material from which they are made tends to heat up and deform under the influence of a magnetic field. But MRI and X-ray are fundamentally different research methods, so X-rays with stents are allowed.

But nevertheless, before any examination (even X-ray), you need to consult the cardiac surgeon who performed the stent operation, because only the attending physician knows all the features of the patient's clinical case, and also knows all the characteristics of the installed stent.

Hello! 3.5 years ago, my mother underwent heart stenting surgery, recently she began to complain that after a fall, something was interfering in her chest. She feels very bad, it is very difficult to see a doctor, she is not in the city.

Your mom cannot feel the coronary stent because there are no nerve endings inside the vessels. Unpleasant sensations behind the sternum can be psychological in nature (suspicious patients think that it is the stent that interferes with them) or be symptoms that cardiac pathology is progressing (for example, restenosis develops, i.e. repeated narrowing of the lumen of the coronary vessels at the site of stent placement, or appears a new focus of narrowing in other branches of the cardiac arteries). It is imperative that your mother be shown to a cardiologist, and it is better to do this in the hospital where stenting was performed, since only the cardiac surgeon who operated on her can fully assess her state of health.

We wish your mother a successful treatment.

My husband was substituted with one stent at the beginning of September, a week later they substituted five more, in a month another one is needed. He is undergoing rehabilitation in a sanatorium. His condition is average. I would like to know, can I insert so many stents?

The number of stents that need to be installed in the coronary vessels of the heart must be such that it is possible to restore normal blood supply to the myocardium. If cardiac surgeons installed 1 stent and saw that there was no effect, and also saw during angiography that there are five more problem areas in the coronary arteries, then doctors will insist on installing five more stents. Etc. The only important point that you need to clarify with your doctors (or consult with other specialists to get a second medical opinion) is that it is possible in the case of your husband to do coronary artery bypass grafting once, rather than stenting many times. The efficiency of CABG surgery is higher than that of stent placement, but the percentage of complications is also higher.

We wish your husband a successful treatment.

Hello, I am interested in this question: is it possible to carry out professional hygiene using the ultrasound method. A person who underwent stenting or vascular bypass surgery?

Ultrasonic cleaning of the oral cavity is not prohibited in patients who have undergone stenting or coronary artery bypass grafting. A contraindication for this procedure is the presence of a pacemaker. It is also advisable not to resort to professional oral hygiene using ultrasound in cases where, against the background of constant intake of antiplatelet agents and anticoagulants (which are prescribed to thin the blood and reduce blood clots in the coronary vessels), the patient has manifestations of severe bleeding of the gums.

We wish you and your loved ones good health.

Hello, please tell me My daughter has a metochondrial disease and has a low blood pressure of 90/60 and below (which we constantly raise) with elecampane root and coffee. Where can we go, what examinations to do, or how to raise blood pressure

It is difficult to give a substantive answer to your question, since it is not clear what kind of mitochondrial disease (there are many of them) your daughter has, and what specific health disorders besides low blood pressure: are there any concomitant problems with the heart, kidneys, etc. treatment of hypotension. Contact your pediatrician (if your daughter is less than 18 years old) or therapist so that the doctor, after reviewing all the medical records you have, can recommend treatment for low blood pressure.

Generally speaking, blood pressure of 90/60 mm Hg should be corrected in cases where there is a real deterioration. Many children and young girls tolerate such pressure well; there is no need to try to increase it. If there are frequent fainting, dizziness, then for a start, treatment with herbal remedies (ginseng, elecampane) and a coffee drink is prescribed. If there is no effect, they switch to drugs for increasing pressure based on heptaminol, ephedrine, midodrine in tablets or drops. In severe cases of pressure reduction, intravenous injections of adrenaline, cordiamine and their derivatives are used.

We wish your daughter successful treatment and well-being for many years to come.

My mom got a stent in November 2015, she still has constant pain on the left side of her side. Could this be or is it something else? I am very worried about her.

The installed stent does not cause pain in the heart, therefore, the pain in your mother's left side cannot be directly related to the stent. If this pain sensation is the same as it was before stenting (i.e., angina pectoris due to poor blood supply to the heart), then during control coronary angiography it should have been seen that the stent did not bring the expected improvement in coronary blood flow, and then the issue had to be resolved about repeated manipulations or another type of heart surgery (coronary artery bypass grafting). Constant pain in the left side may not be associated with the heart, it can be caused by osteochondrosis or intercostal neuralgia, chronic pancreatitis and other diseases. As you can see, it is difficult to establish the source of pain without seeing the patient. In any case, your mother needs to see a cardiologist and tell about the complaints that bother her; if necessary, the doctor will refer her to related specialists.

We wish your mother a speedy recovery from unpleasant symptoms.

I am 59 years old. In October, I got two stents, but I needed four. A month later, I was scheduled to receive another stent. I felt good, I started to work out in the gym and gradually increased the load. Two months later, I had a heart attack at home. A fourth stent was installed. It turned out that the first stent was clogged by 60%. ... In a month they will try to inflate the stent. I heard that contrast solution is very harmful to health. Is it so? Now I sometimes feel feminine in my throat and pressure in the chest area. It feels like stents are pressing. This is at rest. In the gym on the ellipsoid and on the treadmill, there is no shortness of breath and no pain during exercise. Sore throat may be due to a clogged stent? After a heart attack, there was a feeling of fear that this could happen again

The harm of contrast solution to the body is minimal, especially when comparing the effects of contrast administration and the consequences of refusal (due to fear of contrast) from the treatment of angina pectoris. Coronary stents are not felt by the body in any way, because the inner walls of the vessels do not have sensitive nerve endings. Therefore, all your symptoms are subjective experiences about stents as a foreign body. It is also possible to associate a burning sensation in the throat and behind the sternum with the progression of angina pectoris and the ineffectiveness of stents. If, according to the results of coronary angiography, poor blood flow through the stented vessels is determined, then the question of further treatment tactics will be decided - washing the stents, stenting other parts of the coronary vessels or coronary artery bypass grafting.

Cardio loads (simulators, treadmill) must be postponed until good parameters of cardiac blood flow are obtained, otherwise there is a high likelihood of repeated heart attacks.

We wish you a successful treatment.

I am 56 years old. In 2010, the thyroid and parathyroid glands were removed, stage 3 hypertension, risk 4, ischemic heart disease, type 2 diabetes mellitus since 2010. Tension angina pectoris 2fk. CKG from 05/30/2016: stenosis up to 90% of the middle segment, up to 25% of the apical segment and 50-75% of 1 DV PNA. The stent was installed in June 2016. All was good. The blood pressure returned to normal. The pains are gone. About a month ago I started to hurt in the area of my heart, I can't lie on my left side. When walking in frost and windy weather in the neck region, sensations such as nausea. Will everything be the same again as before stenting? Before him, I could not get to work without pressing pains and nausea, which seemed to pass under the jaw and in the hands. Go to cardiology again?

50 years. A month ago, a covered stent was placed in the RCA due to 70% narrowing, after which he continued his recovery in the hospital (2 weeks) and rehabilitation center (3 weeks); I am planning to transfer to a sanatorium. At the same time, I continue to feel periodic discomfort in the left half of my chest even at rest, while walking about 5-5.5 km / h, pressing sensations appear in the heart. What could be the reason for this? Does it make sense to increase the load? Are additional rehabilitation measures possible in my situation? I do not receive clear answers from the attending physicians; "Arrows" smoothly transfer to other stages of rehabilitation. Or is everything already clear that stenting for some reason did not achieve a result?

Hello! My dad had CABG. 4 shunts were installed. Everything was good for 3-4 months. Then the seizures began. 6 months after the operation, he went to the hospital for examination. It turned out that all 4 shunts had closed. None of the doctors know how this could have happened. At a meeting of doctors, dad was offered to do stenting. Do you think this makes common sense? Or is it better to go to another clinic in Moscow or St. Petersburg for a second operation?

Hello, we are now in the hospital with a diagnosis of angina pectoris, they did an antiography and say to do bypass surgery please tell me about this we are told there are 3 different springs 5 12 and 24 thousand are there any significant differences in them? They say that for 5 they say it will be necessary to observe it every half a year, and those that are more expensive are much better. ... the question is, does the sum make sense or not? And you can do it for 5 and live well?

hello, I have such a question, my father had heart problems at first they said that they needed to have a bypass, but then they said that his arteries are too narrow, the shunt cannot be done, we will do stenting later and they refused the stent, they say and it is dangerous veins are too narrow, in short, they refused to do operation, please tell me besides the operation, can there be a medicine for the treatment of at least traditional medicine? I don’t know what to do. His heart hurts badly.

The information provided on the site should not be used for self-diagnosis and treatment. Specialist consultation required

Anatomy of the coronary arteries of the heart

SURGICAL ANATOMY OF THE CORONARY ARTERIES.

The widespread use of selective coronary angiography and surgical interventions on the coronary arteries of the heart in recent years has made it possible to study the anatomical features of the coronary circulation of a living person, to develop the functional anatomy of the heart arteries in relation to revascularizing operations in patients with coronary heart disease.

Interventions in the coronary arteries for diagnostic and therapeutic purposes place increased demands on the study of vessels at different levels, taking into account their variants, developmental anomalies, caliber, angles of discharge, possible collateral connections, as well as their projections and relationships with surrounding formations.

When systematizing these data, we paid special attention to information from the surgical anatomy of the coronary arteries, based on the principle of topographic anatomy as applied to the plan of surgery with dividing the coronary arteries of the heart into segments.

The right and left coronary arteries were conventionally divided into three and seven segments, respectively (Fig. 51).

In the right coronary artery, three segments are distinguished: I - a segment of an artery from the mouth to the branch branch - an artery of the acute edge of the heart (length from 2 to 3.5 cm); II - a section of the artery from the branch of the acute edge of the heart to the divergence of the posterior interventricular branch of the right coronary artery (length 2.2-3.8 cm); III - posterior interventricular branch of the right coronary artery.

The initial section of the left coronary artery from the ostium to the site of division into the main branches is designated as segment I (length from 0.7 to 1.8 cm). The first 4 cm of the anterior interventricular branch of the left coronary artery are separated

Rice. 51.Segmental division of coronary

A- the right coronary artery; B- left coronary artery

into two segments of 2 cm each - II and III segments. The distal part of the anterior interventricular branch was segment IV. The enveloping branch of the left coronary artery to the point of origin of the branch of the obtuse edge of the heart - V segment (length 1.8-2.6 cm). The distal part of the circumflex branch of the left coronary artery was more often represented by the artery of the blunt edge of the heart - segment VI. And finally, the diagonal branch of the left coronary artery - segment VII.

The use of segmental division of the coronary arteries, as our experience has shown, is advisable in a comparative study of the surgical anatomy of the coronary circulation according to the data of selective coronary angiography and surgical interventions, to determine the localization and spread of the pathological process in the arteries of the heart, is of practical importance when choosing the method of surgical intervention in the case of coronary artery disease. hearts.

Rice. 52. Right coronal type of coronary circulation. The posterior interventricular branches are well developed

The beginning of the coronary arteries . The aortic sinuses, from which the coronary arteries depart, James (1961) suggests calling the right and left coronary sinus. The mouths of the coronary arteries are located in the bulb of the ascending aorta at the level of the free edges of the semilunar valves of the aorta or 2-3 cm above or below them (V.V. Kovanov and T.I. Anikina, 1974).

The topography of the sections of the coronary arteries, as indicated by A.S. Zolotukhin (1974), is different and depends on the structure of the heart and chest. According to M. A. Tikhomirov (1899), the orifices of the coronary arteries in the aortic sinuses can be located below the free edge of the valves "abnormally low", so that the semilunar valves pressed against the wall of the aorta close the orifices, either at the level of the free edge of the valves, or above them, at the wall of the ascending part of the aorta.

The level of the mouth is of practical importance. With a high location at the time of left ventricular systole, the mouth is

under the blow of a stream of blood, without being covered by the edge of the semilunar valve. According to A. V. Smolyannikov and T. A. Naddachina (1964), this may be one of the reasons for the development of coronary sclerosis.

The right coronary artery in most patients has a main type of division and plays an important role in the vascularization of the heart, especially its posterior diaphragmatic surface. In 25% of patients in the blood supply of the myocardium, we revealed a predominance of the right coronary artery (Fig. 52). NA Javakhshivili and MG Komakhidze (1963) describe the beginning of the right coronary artery in the region of the anterior right sinus of the aorta, indicating that its high discharge is rarely observed. The artery enters the coronal groove, located behind the base of the pulmonary artery and under the right atrial appendage. The section of the artery from the aorta to the sharp edge of the heart (segment I of the artery) is adjacent to the wall of the heart and is completely covered with subepicardial fat. The diameter of the I segment of the right coronary artery ranges from 2.1 to 7 mm. Along the course of the artery trunk on the anterior surface of the heart in the coronary sulcus, epicardial folds filled with adipose tissue are formed. Abundantly developed adipose tissue is noted along the artery from the sharp edge of the heart. The atherosclerotic trunk of the artery along this length is well palpated in the form of a cord. Detection and isolation of the I segment of the right coronary artery on the anterior surface of the heart is usually not difficult.

The first branch of the right coronary artery - the arterial cone artery, or fatty artery - departs directly at the beginning of the coronary sulcus, continuing to the right at the arterial cone downward, giving branches to the cone and the wall of the pulmonary trunk. In 25.6% of patients, we observed its common origin with the right coronary artery, its mouth was located at the mouth of the right coronary artery. In 18.9% of patients, the mouth of the cone artery was located next to the mouth of the coronary artery, located behind the latter. In these cases, the vessel began directly from the ascending aorta and was only slightly inferior in caliber to the trunk of the right coronary artery.

Muscular branches extend from segment I of the right coronary artery to the right ventricle of the heart. Vessels in the amount of 2-3 are located closer to the epicardium in the connective tissue couplings on the layer of adipose tissue covering the epicardium.

The other most significant and permanent branch of the right coronary artery is the right marginal artery (a branch of the acute edge of the heart). The artery of the acute edge of the heart, a permanent branch of the right coronary artery, departs in the region of the acute edge of the heart and descends along the lateral surface of the heart to its apex. It supplies blood to the antero-lateral wall of the right ventricle, and sometimes to the diaphragmatic part of it. In some patients, the diameter of the lumen of the artery was about 3 mm, but more often it was equal to 1 mm or less.

Continuing along the coronary sulcus, the right coronary artery bends around the sharp edge of the heart, passes to the posterior diaphragmatic surface of the heart and ends to the left of the posterior interventricular sulcus, not reaching the blunt edge of the heart (in 64% of patients).

The terminal branch of the right coronary artery - the posterior interventricular branch (segment III) - is located in the posterior interventricular sulcus, descending along it to the apex of the heart. VV Kovanov and TI Anikina (1974) distinguish three variants of its distribution: 1) in the upper part of the furrow of the same name; 2) along the entire length of this groove to the apex of the heart; 3) the posterior interventricular branch extends to the anterior surface of the heart. According to our data, only in 14% of patients it reached

the apex of the heart, anastomosing with the anterior interventricular branch of the left coronary artery.

From the posterior interventricular branch into the interventricular septum at a right angle from 4 to 6 branches, supplying blood to the conducting system of the heart.

With the right-sided type of coronary blood supply, 2-3 muscle branches extend from the right coronary artery to the diaphragmatic surface of the heart, running parallel to the posterior interventricular branch of the right coronary artery.

To access the II and III segments of the right coronary artery, it is necessary to raise the heart upward and take it to the left. The II segment of the artery is located superficially in the coronary sulcus; it can be found and selected quickly and easily. The posterior interventricular branch (segment III) is deeply located in the interventricular groove and is covered with subepicardial fat. When performing operations on the II segment of the right coronary artery, it must be remembered that the wall of the right ventricle in this place is very thin. Therefore, it should be manipulated carefully to avoid its perforation.

The left coronary artery, participating in the blood supply to most of the left ventricle, the interventricular septum, and the anterior surface of the right ventricle, dominates the blood supply to the heart in 20.8% of patients. Starting in the left sinus of Valsalva, it goes from the ascending aorta to the left and down along the coronary groove of the heart. The initial section of the left coronary artery (segment I) before the bifurcation has a length of at least 8 mm and no more than 18 mm. Isolation of the main trunk of the left coronary artery is difficult, since it is hidden by the root of the pulmonary artery.

The short trunk of the left coronary artery with a diameter of 3.5 to 7.5 mm turns to the left between the pulmonary artery and the base of the left ear of the heart and is divided into the anterior interventricular and circumflex branches. (II, III, IV segments of the left coronary artery) is located in the anterior interventricular groove of the heart, along which it goes to the apex of the heart. It can end at the apex of the heart, but usually (according to our observations, in 80% of patients) it continues on the diaphragmatic surface of the heart, where it meets the terminal branches of the posterior interventricular branch of the right coronary artery and participates in vascularization of the diaphragmatic surface of the heart. The diameter of the II segment of the artery ranges from 2 to 4.5 mm.

It should be noted that a significant part of the anterior interventricular branch (II and III segments) lies deep, covered with subepicardial fat, muscle bridges. Isolation of the artery in this place requires great care because of the danger of possible damage to its muscular and, most importantly, the septal branches leading to the interventricular septum. The distal part of the artery (segment IV) is usually located superficially, is clearly visible under a thin layer of subepicardial tissue and is easily distinguished.

From the II segment of the left coronary artery deep into the myocardium, 2 to 4 septal branches depart, which are involved in the vascularization of the interventricular septum of the heart.

Throughout the anterior interventricular branch of the left coronary artery, 4-8 muscle branches extend to the myocardium of the left and right ventricles. The branches to the right ventricle are smaller in size than to the left, although they are the same in size as the muscle branches from the right coronary artery. A much larger number of branches branch off to the anterolateral wall of the left ventricle. In functional terms, diagonal branches are especially important (there are 2 of them, sometimes 3), extending from the II and III segments of the left coronary artery.

When searching for and isolating the anterior interventricular branch, an important landmark is the large vein of the heart, which is located in the anterior interventricular groove to the right of the artery and is easily found under the thin layer of the epicardium.

The enveloping branch of the left coronary artery (V-VI segments) departs at right angles to the main trunk of the left coronary artery, located in the left coronary groove, under the left ear of the heart. Its constant branch - the branch of the blunt edge of the heart - descends over a considerable length at the left edge of the heart, somewhat posteriorly, and in 47.2% of patients reaches the apex of the heart.

After branching out of the branches to the blunt edge of the heart and the posterior surface of the left ventricle, the enveloping branch of the left coronary artery in 20% of patients continues along the coronary sulcus or along the posterior wall of the left atrium in the form of a thin trunk and reaches the confluence of the inferior ps-loy vein.

The V segment of the artery is easily detected, which is located in the fatty membrane under the left atrial appendage and is covered by a large vein of the heart. The latter sometimes has to be crossed to gain access to the trunk of the artery.

The distal part of the circumflex branch (segment VI) is usually located on the posterior surface of the heart and, if surgery is required, the heart is lifted and retracted to the left while simultaneously pulling the left ear of the heart.

The diagonal branch of the left coronary artery (segment VII) goes along the anterior surface of the left ventricle down and to the right, then plunging into the myocardium. The diameter of its initial part is from 1 to 3 mm. With a diameter of less than 1 mm, the vessel is poorly expressed and is often considered as one of the muscular branches of the anterior interventricular branch of the left coronary artery.

Anatomy of the coronary arteries

Coronary arteries

Right coronary artery

The right coronary artery departs from the right sinus of Valsalva and passes in the coronary (atrioventricular) groove. In 50% of cases, immediately at the place of discharge, it gives off the first branch - the branch of the arterial cone (conus artery, conus branch, CB), which feeds the infundibulum of the right ventricle. Its second branch is the artery of the sinus-atrial node (S-A node artery, SNA). extending from the right coronary artery back at a right angle into the interval between the aorta and the wall of the right atrium, and then along its wall - to the sinus-atrial node. As a branch of the right coronary artery, this artery occurs in 59% of cases. In 38% of cases, the artery of the sinoatrial node is a branch of the left circumflex artery. And in 3% of cases there is a blood supply to the sino-atrial node from two arteries (both from the right and from the envelope). In the anterior part of the coronary sulcus, in the region of the acute edge of the heart, the right marginal branch (branch of the acute edge, acute marginal artery, acute marginal branch, AMB) departs from the right coronary artery, usually from one to three, which in most cases reaches the apex of the heart. Then the artery turns back, lies in the posterior part of the coronary groove and reaches the "cross" of the heart (the intersection of the posterior interventricular and atrioventricular grooves of the heart).

Left coronary artery

Anterior interventricular branch

Circumflex artery

Anatomy of the coronary arteries.

Professor, Dr. med. Sciences Yu.P. Ostrovsky

At the moment, there are many options for the classifications of the coronary arteries adopted in different countries and centers of the world. But, in our opinion, there are certain terminological differences between them, which creates difficulties in the interpretation of coronary angiography data by specialists of different profiles.

We analyzed the literature on the anatomy and classification of the coronary arteries. Literature data are compared with our own. A working classification of coronary arteries has been developed in accordance with the nomenclature accepted in the English-language literature.

Coronary arteries

From an anatomical point of view, the coronary artery system is divided into two parts - right and left. From the standpoint of surgery, the coronary bed is divided into four parts: the left main coronary artery (trunk), the left anterior descending artery or anterior interventricular branch (LAD) and its branches, the left circumflex coronary artery (OB) and its branches, the right coronary artery (RCA) ) and its branches.

Large coronary arteries form an arterial ring and a loop around the heart. The left circumflex and right coronary arteries are involved in the formation of the arterial ring, passing along the atrioventricular sulcus. The anterior descending artery from the system of the left coronary artery and the posterior descending artery from the system of the right coronary artery, or from the system of the left coronary artery - from the left circumflex artery with the left dominant type of blood supply, are involved in the formation of the arterial loop of the heart. The arterial ring and loop are functional devices for the development of collateral circulation of the heart.

Right coronary artery

The right coronary artery (right coronary artery) departs from the right sinus of Valsalva and passes in the coronary (atrioventricular) groove. In 50% of cases, immediately at the place of discharge, it gives off the first branch - the branch of the arterial cone (conus artery, conus branch, CB), which feeds the infundibulum of the right ventricle. Its second branch is the artery of the sinus-atrial node (S-A node artery, SNA). extending from the right coronary artery back at a right angle into the gap between the aorta and the wall of the right atrium, and then along its wall - to the sinus-atrial node. As a branch of the right coronary artery, this artery occurs in 59% of cases. In 38% of cases, the artery of the sinoatrial node is a branch of the left circumflex artery. And in 3% of cases there is a blood supply to the sino-atrial node from two arteries (both from the right and from the envelope). In the anterior part of the coronary sulcus, in the region of the acute edge of the heart, the right marginal branch (branch of the acute edge, acute marginal artery, acute marginal branch, AMB) departs from the right coronary artery, usually from one to three, which in most cases reaches the apex of the heart. Then the artery turns back, lies in the posterior part of the coronary groove and reaches the "cross" of the heart (the intersection of the posterior interventricular and atrioventricular grooves of the heart).

With the so-called right type of blood supply to the heart, observed in 90% of people, the right coronary artery gives off the posterior descending artery (PDA), which runs along the posterior interventricular sulcus at different distances, giving branches to the septum (anastomosing with similar branches from the anterior descending artery, the latter usually longer than the first), the right ventricle and branches to the left ventricle. After the posterior descending artery (PDA) has departed, the RCA continues beyond the cross of the heart as the right posterior atrioventricular branch along the distal part of the left atrioventricular sulcus, terminating in one or more posterolateral branches feeding the ventricle diaphragm ... On the posterior surface of the heart, immediately below the bifurcation, at the junction of the right coronary artery into the posterior interventricular sulcus, an arterial branch originates from it, which, piercing the interventricular septum, goes to the atrioventricular node - the artery of the atrioventricular node (AVN).

The branches of the right coronary artery vascularize: the right atrium, part of the anterior, the entire posterior wall of the right ventricle, a small area of the posterior wall of the left ventricle, the interatrial septum, the posterior third of the interventricular septum, the papillary muscles of the right ventricle and the posterior papillary muscle of the left ventricle.

Left coronary artery

The left coronary artery (left coronary artery) starts from the left posterior surface of the aortic bulb and extends to the left side of the coronary sulcus. Its main trunk (left main coronary artery, LMCA) is usually short (0-10 mm, diameter varies from 3 to 6 mm) and is divided into anterior interventricular (left anterior descending artery, LAD) and an envelope (left circumflex artery, LCx) branches ... In% of cases, the third branch departs here - the intermediate artery (ramus intermedius, RI), which obliquely crosses the wall of the left ventricle. LAD and OM form an angle with each other, which varies from 30 to 180 °.

Anterior interventricular branch

The anterior interventricular branch is located in the anterior interventricular groove and goes to the apex, giving along the anterior ventricular branches (diagonal, diagonal artery, D) and anterior septal branch) branches. In 90% of cases, from one to three diagonal branches are determined. The septal branches extend from the anterior interventricular artery at an angle of approximately 90 degrees, pierce the interventricular septum, feeding it. The anterior interventricular branch sometimes enters the thickness of the myocardium and again lies in the groove and along it often reaches the apex of the heart, where in about 78% of people it turns posteriorly to the diaphragmatic surface of the heart and at a short distance (10-15 mm) rises up along the posterior interventricular groove. In such cases, it forms a posterior ascending branch. Here she often anastomoses with the terminal branches of the posterior interventricular artery - the branch of the right coronary artery.

The circumflex branch of the left coronary artery is located in the left part of the coronary sulcus and in 38% of cases gives the first branch the artery of the sinus-atrial node, and then the obtuse marginal artery (obtuse marginal branch, OMB), usually from one to three. These critical arteries feed the free wall of the left ventricle. In the case when there is a right type of blood supply, the circumflex branch gradually becomes thinner, giving branches to the left ventricle. With a relatively rare left type (10% of cases), it reaches the level of the posterior interventricular sulcus and forms the posterior interventricular branch. With an even rarer, so-called mixed type, there are two posterior ventricular branches of the right coronary and from the circumflex arteries. The left circumflex artery forms the important atrial branches, which include the left atrial circumflex artery (LAC) and the large anastomosing artery of the auricle.

The branches of the left coronary artery vascularize the left atrium, the entire anterior and most of the posterior wall of the left ventricle, part of the anterior wall of the right ventricle, the anterior 2/3 of the interventricular septum, and the anterior papillary muscle of the left ventricle.

Types of blood supply to the heart

The type of blood supply to the heart is understood as the predominant spread of the right and left coronary arteries on the posterior surface of the heart.

The anatomical criterion for assessing the predominant type of coronary artery spread is the avascular zone on the posterior surface of the heart, formed by the intersection of the coronary and interventricular grooves, crux. Depending on which of the arteries - right or left - reaches this zone, the predominant right or left type of blood supply to the heart is distinguished. The artery reaching this zone always gives up the posterior interventricular branch, which runs along the posterior interventricular groove towards the apex of the heart and supplies blood to the posterior part of the interventricular septum. Another anatomical feature is described to determine the predominant type of blood supply. It is noticed that the branch to the atrioventricular node always departs from the predominant artery, i.e. from the artery, which is of greatest importance in supplying blood to the back of the heart.

Thus, with the predominant right type of blood supply to the heart, the right coronary artery provides nutrition to the right atrium, right ventricle, posterior part of the interventricular septum and posterior surface of the left ventricle. In this case, the right coronary artery is represented by a large trunk, and the left circumflex artery is poorly expressed.

With a predominantly left type of blood supply to the heart, the right coronary artery is narrow and ends in short branches on the diaphragmatic surface of the right ventricle, and the posterior surface of the left ventricle, the posterior part of the interventricular septum, the atrioventricular node and most of the posterior surface of the ventricle receive blood from the well-defined large left circumflex artery.

In addition, a balanced type of blood supply is also distinguished. in which the right and left coronary arteries make approximately equal contributions to the blood supply to the posterior surface of the heart.

The concept of "predominant type of blood supply to the heart", although conditional, is based on the anatomical structure and distribution of the coronary arteries in the heart. Since the mass of the left ventricle is significantly larger than the right, and the left coronary artery always supplies blood to most of the left ventricle, 2/3 of the interventricular septum and the wall of the right ventricle, it is clear that the left coronary artery is predominant in all normal hearts. Thus, in any of the types of coronary blood supply, the left coronary artery is predominant in the physiological sense.

Nevertheless, the concept of "predominant type of blood supply to the heart" is valid, is used to assess anatomical findings in coronary angiography and is of great practical importance in determining the indications for myocardial revascularization.

For topical indication of lesions, it is proposed to divide the coronary bed into segments

Segments of the coronary arteries are marked with dashed lines in this diagram.

Thus, in the left coronary artery in the anterior interventricular branch, three segments are distinguished:

1.proximal - from the place of origin of the LAD from the trunk to the first septal perforator or 1DV.

2. Medium - from 1DV to 2DV.

3. distal - after 2DV discharge.

In the circumflex artery, it is also customary to distinguish three segments:

1.proximal - from the mouth of the OM to 1 ITC.

3.Distal - after the discharge of 3 VTC.

The right coronary artery is divided into the following main segments:

1.proximal - from the mouth to 1 VOK

2.medium - from 1 WOK to the sharp edge of the heart

3. distal - up to RCA bifurcation to the posterior descending and posterolateral arteries.

Coronary angiography

Coronary angiography (coronary angiography) is an X-ray imaging of the coronary vessels after a radiopaque contrast agent has been injected. The X-ray image is simultaneously recorded on 35 mm film or digital media for further analysis.

At the moment, coronary angiography is the "gold standard" for determining the presence or absence of stenosis in coronary disease.

The purpose of coronary angiography is to determine the coronary anatomy and the degree of narrowing of the lumen of the coronary arteries. Information obtained during the procedure includes the determination of the localization, length, diameter and contours of coronary arteries, the presence and degree of coronary obstruction, characteristics of the nature of the obstruction (including the presence of an atherosclerotic plaque, thrombus, dissection, spasm, or myocardial bridge).

The obtained data determine the further tactics of the patient's treatment: coronary artery bypass grafting, intervention, drug therapy.

To carry out high-quality angiography, selective catheterization of the right and left coronary arteries is required, for which a large number of diagnostic catheters of various modifications have been created.

The study is carried out under local anesthesia and NLA through arterial access. The following arterial approaches are generally recognized: femoral arteries, brachial arteries, radial arteries. Transradial access has recently gained solid ground and has become widely used due to its low trauma and convenience.

After puncture of the artery, diagnostic catheters are inserted through the introducer, followed by selective catheterization of the coronary vessels. The contrast agent is dosed using an automatic injector. Shooting is performed in standard projections, catheters and an intraducer are removed, a compression bandage is applied.

Basic angiographic views

During the procedure, the goal is to obtain the most complete information about the anatomy of the coronary arteries, their morphological characteristics, the presence of changes in the vessels with an accurate determination of the localization and nature of the lesions.

To achieve this goal, coronary angiography of the right and left coronary arteries is performed in standard projections. (They are described below). If it is necessary to conduct a more detailed study, surveys are performed in special projections. One or another projection is optimal for the analysis of a certain section of the coronary bed and allows the most accurate identification of morphological features and the presence of pathology in this segment.

Below are the main angiographic views, indicating the arteries for which these views are optimal.

The following standard views exist for the left coronary artery.

1. Right anterior oblique with caudal angulation.

RAO 30, caudal 25.

2. Right anterior oblique view with cranial angulation.

RAO 30, cranial 20

LAD, its septal and diagonal branches

3. Left anterior oblique with cranial angulation.

LAO 60, cranial 20.

The mouth and distal portion of the LCA trunk, the middle and distal segment of the LAD, septal and diagonal branches, the proximal segment of the OS, the VT.

dollars, 400 thousand coronary angioplasty and 1 million coronary angiography. In the CIS countries - no more than 2 thousand CABG per year.

The need for CABG is 500 operations per 1 million population per year.

ETIOLOGY

Other reasons - 5% (nonspecific aortoarteritis, aneurysms of the ascending aorta, specific aortitis, etc.)

PATHOGENESIS AND PATHOLOGICAL ANATOMY

In the angiospatic period, there is no hemodynamically significant stenosis of the coronary arteries. The cause of myocardial ischemia is a spasm of the coronary arteries or their inability to expand according to an increase in myocardial oxygen demand (physical activity). This is associated with a decrease in the production of ERF (endothelium relaxant factor) by the coronary endothelium, which is facilitated by even the initial atherosclerotic changes in the arterial wall.

In the period of inadequate blood supply, there is always hemodynamically significant stenosis of the coronary arteries. The following factors play a role in the development of myocardial ischemia: stable stenosis, collateral insufficiency and coronary spasm.

Prolonged myocardial ischemia (even without a heart attack) leads to ischemic cardiomyopathy (hypo, dyskinesia of ischemic zones), and then to cardiosclerosis with the development of heart failure, arrhythmias, and dysfunction of the valve apparatus. If more than 15% of the LV myocardium undergoes cicatricial changes, the expulsion fraction begins to decrease, if more than 40%, refractory heart failure develops.

Developed myocardial infarction in the acute period can lead to the development of acute heart failure and cardiogenic shock, to acute postinfarction aneurysm, rupture of the interventricular septum, avulsion of papillary muscles and acute mitral valve insufficiency. In the long term, postinfarction anerism, VSD and dysfunction of the papillary muscles (usually posterior) with mitral insufficiency may also develop. Endocardial necrosis and arrhythmias in the acute period of myocardial infarction are often accompanied by thromboembolism of the great circle arteries.

For the branches of the LCA (LAD and OA), stenosis of more than 70% of the diameter is hemodynamically significant, for the main trunk of the LCA - more than 50%, for the RCA - more than 30%.

On the 1st place in terms of the frequency of damage for any type of blood supply is the LAD (the anterior wall of the LV, the anterior part of the interventricular parum, the anterior pedicle of the His bundle). In 2nd place - RCA (the pancreas, the posterior and part of the lateral wall of the LV, the posterior part of the interventricular septum, sinus and atrioventricular nodes, the posterior part of the His bundle). RCA is usually involved in the process with the right and middle right type of blood supply. On the 3rd place is OA (the lateral wall of the LV, and with the left type of blood supply - the posterior wall of the LV and the atrioventricular node). The LCA trunk is affected least often (in 8%), but the prognosis is the most unfavorable.

In the compensation of coronary circulation, both intrasystem and intersystem anastomoses play an important role, the main of which are apical anastomoses (between the LAD and RCA).

CLASSIFICATION

1. Chronic ischemic heart disease (stable angina at rest, variant angina at rest, arrhythmic variant of ischemic heart disease).

2. Unstable angina.

3. Myocardial infarction.

4. Cardiac complications of coronary artery disease (postinfarction LV aneurysm, postinfarction VSD, postinfarction mitral valve insufficiency).

For each of the forms, it is necessary to indicate the FC CHF.

INSTRUMENTAL DIAGNOSTICS OF CHD

A screening method for determining the presence of myocardial ischemia, foci of necrosis and scarring, allows approximately localizing the affected area.

Standard 12-lead ECG (sensitivity - 75%) - detects acute myocardial ischemia (angina pectoris attack or heart attack), postinfarction scar and rhythm disturbances.

Daily (Holter) monitoring (sensitivity - 90%) - records daily transient ischemic changes and rhythm disturbances.

Exercise ECG: veloergometry and thermomill test (sensitivity 50-85%) - reveals latent coronary insufficiency.

Transesophageal pacing (sensitivity is the same as for exercise tests) - an alternative to exercise ECG in patients with chronic arterial insufficiency, cardiopulmonary insufficiency.

ECG with pharmacological tests: nitroglycerin - positive dynamics on the ECG after taking it confirms the diagnosis of ischemic heart disease; a test with ergometrine in an amount of up to 0.5 mg stepwise in / in (provokes a spasm of coronary arteries) - reveals myocardial ischemia caused by coronary spasm (spontaneous angina at rest).

Allows to diagnose hypo- and dyskinesia of ventricular segments, wall thickness and dimensions of the ventricular cavity.

Allows you to diagnose complicated forms of ischemic heart disease: aneurysms, mitral valve insufficiency, VSD.

In recent years, methods have been developed for ultrasound imaging of the main trunk of the LCA and the proximal part of the LAD.

Doppler mode allows you to detect turbulent flow in the heart cavities with organic damage to the valve apparatus, VSD, turbulent blood flow along the LCA and LAD.

Color-kinesis - color mapping of myocardial ischemia and cardiosclerosis zones.

Currently, this is the main method for verifying the diagnosis and determining the indications for surgical treatment or angioplasty.

In coronary ventriculography, 45 ml of a contrast agent (OMNIPAK, VIZIPAK) is injected into the cavity of the left ventricle and 5-8 ml at the mouth of the coronary arteries. X-ray photography is necessary to obtain good serial images and assess the LVEF. Digital digital angiography allows, with a single injection of a contrast agent, to obtain a high-quality image of the entire coronary bed and to assess the contractility of LV, as well as the kinetics of its individual segments.

For catheterization of LV and coronary arteries, two methods are used: the transfemoral Judkins method (catheters are different for the LCA and RCA) and the Sones transaxillary method (the catheters are the same for the LCA and RCA)

Coronoventriculography determines the type of blood supply to the heart: in 85%, the right type (the posterior wall of the LV and IVS is supplied by the RCA), in 10% - the left type (the posterior wall of the LV and IVS is supplied by the OA), and in 5% - balanced (RCA and LCA equally participate in the blood supply to the posterior wall of the LV).

Indications for coronary angiography: stable angina pectoris refractory to conservative therapy; unstable angina; a history of myocardial infarction; to clarify the diagnosis of ischemic heart disease, when the data of non-invasive methods are in doubt; suspicion of anerism of the heart; multifocal atherosclerosis.

Scanning with isotope 201 Waist (accumulates in the capillaries of the myocardium) - with ischemia and cicatricial changes, the ability to concentrate decreases.

After the introduction of the color-kinesis technique, it fades into the background.

CHRONIC ISCHEMIC HEART DISEASE

The main clinical signs of chronic ischemia: periodically developing anginal status, arrhythmias, signs of heart failure.

There are two forms of chronic coronary artery disease: stable exertional angina and spontaneous rest angina.

With stable exertional angina, the anginal status is characterized by retrosternal pain radiating to the left half of the trunk, face and neck. The pain is clearly associated with physical activity and after its termination disappears no later than 15 minutes (usually after 1-2 minutes). Chest pain is easily relieved by taking nitroglycerin. Stable exertional angina is characterized by a stable clinical picture (the same physical activity, the same duration and frequency of seizures, the same subjective characteristics of seizures, and identical doses of nitroglycerin required to stop an attack).

The most frequent rhythm disturbances in patients with ischemic heart disease: ventricular premature beats and conduction disturbances, less often atrial fibrillation, paroxysmal tachycardia.

Functional classes of stable exertional angina (Canadian Association of Cardiology): I - anginal status occurs only during intense physical exertion; II- when walking at a distance of more than 500 m or when climbing more than 1 floor; III- when walking a distance of meters or when climbing less than 1 floor; IV - when walking at a distance of less than 100 m, as well as the appearance of exertional rest angina.

Spontaneous angina pectoris at rest is characterized by the onset of anginal status without regard to physical activity. At the same time, the load tolerance is either not changed or even increased. The duration of the attack is 5-15 minutes (maximum up to 30 minutes). Spontaneous angina is caused by transient spasm of the coronary arteries. It is quite rare in isolation and in 90% is combined with exertional angina (IV FC). Spontaneous angina pectoris associated with ST elevation is called variant angina (Prinmetall angina).

ECG, Holter monitoring and stress tests: diagnostic criteria - horizontal ST displacement by more than 1 mm from the isoline, T wave reversal, the appearance of arrhythmia (the latter is taken into account during stress tests).

Ultrasound, coronary ventriculography - diagnosis verification, assessment of indications for surgery (EF<40% - операция противопоказана).

The main directions of conservative therapy: improving myocardial perfusion and reducing its oxygen demand. In addition, conservative therapy necessarily provides for the normalization of lipid metabolism, prevention of thrombus formation in the coronary arteries, treatment of concomitant arterial hypertension and diabetes mellitus.

The main drugs in the conservative therapy of ischemic heart disease: nitrates, β-blockers and calcium antagonists.

NITRATES - improve coronary perfusion, especially in ischemic areas (no “steal syndrome”) + reduce preload and, to a lesser extent, afterload. The main mechanism of action is that in the wall of blood vessels (mainly arterioles) they degrade to NO (organic nitrates require the presence of sulfhydryl groups), which is nothing more than ERF (a powerful vasodilator and antiplatelet agent). To stop the anginal status, nitrates of a quick but short action are used. The most rapid effect occurs after sublingual administration of nitroglycerin (onset - after 1-2 minutes, duration - up to 30 minutes. Nitrosorbide preparations (isosorbide dinitrate, cardiket-20) differ in a slower speed of onset of the effect (after 10 minutes), but longer duration of action (3 -4 hours). Long-acting nitro drugs are used for the prevention of angina attacks. The speed of the onset of the effect in this case in a minute, and the duration of action in an hour. dinitrate (kardiket-40, kardiket-60, isoket, Mono-Mac Depot, Efoks.) The drug kardiket-120 contains two fractions - fast-dissolving (effect after 20 minutes) and slowly dissolving - effect after 1 hour with a duration of 15 hours.

NON-SELECTIVE -ADRENO BLOCKERS. They decrease the heart rate while increasing their strength, reduce afterload, promote the redistribution of myicardial blood flow in favor of ischemic zones and improve oxygen delivery to ischemic tissues. Contraindicated with a tendency to bradycardia. Short-acting drugs: propranolol (anaprilin, obzidan), whiskey. Long-acting drugs - korgard, trazikor.

CALCIUM ANTAGONISTS. They reduce the force of myocardial contraction, improve coronary perfusion, and reduce afterload. Drugs: verapamil (isoptin, finoptin), nifedipine (corinfar). Verapamil has a more pronounced antiarrhythmogenic effect (slows down AV conduction, inhibits the function of the sinus node), and nifedipine has more pronounced peripheral vasodilation.

Normalization of lipid metabolism: mevacor, zocor.

Prevention of thrombus formation: tiklid, aspirin.

The annual mortality rate with conservative therapy is 3-9% per year.

Exertional angina FC III-IV.

History of myocardial infarction even without angina pectoris clinic.

Stenosis of the trunk of the LCA is more than 50% even without angina pectoris clinic (very often it immediately begins with a massive MI).

RCA stenosis is more than 30% in patients with angina pectoris of any FC.

First performed by Grüntzig in 1977.

Principle: a balloon dilatation catheter is inserted into the coronary artery, under the control of the screen, the balloon is inserted into the stenosis site, after which the pressure in the balloon is brought to the atmosphere for up to 3 minutes, as a result of which the plaque is crushed. At the end of the procedure, it is necessary to measure the pressure of the artery below the stenosis and control coronary angiography. The angiographic success criterion is a reduction in the degree of stenosis by more than 20%. Often, balloon dilatation is completed by stenting the vessel (stents 2-4.5 mm). 24 hours before the manipulation, the patient begins to take antiplatelet agents, at the time of angioplasty heparin and nitroglycerin are administered intracoronary.

Angioplasty is performed with an expanded cardiovascular operating room and with constant ECG monitoring (complications - acute artery occlusion, intimal stratification, acute myocardial ischemia).

New technologies of angiopastics: laser recanalization - with the help of "cold" laser radiation (at the end of the fiber), a canal is made in the lumen of the occluded artery, then balloon angioplasty is performed; rotary recanalization - a canal is drilled in the occluded artery using a rotating half-moon blade with a diamond coating; rotational atherectomy - an atherosclerotic plaque is cut using an atherectomy catheter with a container and a knife inside.

Indications for angioplasty: single stenoses of any of the coronary arteries (except for the main trunk of the LCA), single stenoses of no more than 2 coronary arteries, multiple stenoses in one coronary artery, chronic occlusions less than 3 months old and no more than 2 cm long.

Mortality - 1.2%, the nearest positive result - in 90%, within 1 year, 40% develop restenosis. The incidence of complications requiring emergency surgery is no higher than 6%.

Cost: 5-10 thousand dollars, coronary angiography - 3-5 thousand dollars.

The CABG was first performed by Michael De-Becky in 1964, and the CABG was performed by V.I. Kolesov also in 1964.

Indications: stenosis of the main trunk of the LCA (even with EF< 40%), стенозы или окклюзии более 2 коронарных артерий, множественные стенозу коронарных артерий.

Basic principles: the operation is carried out only in conditions of infrared on a "dry heart", preferably with the use of optics (magnification 2-4 times); all arteries with hemodynamically significant stenosis are shunted (no more than 7 arteries with a diameter of more than 1 mm can be shunted at once), however, no more than 4 anastomoses are applied to the aorta (therefore, jumping, sequential and bifurcation shunts are used); first, permanent resident is shunted, then OA and PKA; usually apply first coronary anastomoses, then aortic (Yu.V. Belov - in reverse order); during the operation, the shunt function is monitored with a flowmeter (blood flow through the shunt is at least 50 ml.min). Currently, it is considered optimal to apply no more than 4 shunts (stealing the rest).

Contraindications to CABG are severe damage to the distal bed and LVEF< 40%.

Cost of AKshtys. dollars excluding the cost of a bed-day.

After CABG due to the high risk of developing acute heart failure (especially in patients with EF< 50%) должны быть предусмотрены трансаортальная баллонная контрпульсация, либо искусственый левый желудочек.

Mortality after CABG - 5.7%; in persons under 75 years of age - 1.4%, in patients with angina pectoris without a history of myocardial infarction - 0.5%.

Five-year survival rate after CABG is 96%, with conservative treatment of the same category of patients - 60%. The frequency of MI after CABG is 1% per year, without CABG> 3%.

During the first year, the patency of CABG remains in 80% of patients, then the frequency of shunt occlusions is 2% per year, and after 5 years - 5% per year. The results are better after CABG (therefore, at present, CABG and CABG are combined). In women, the results are 2.5 times worse.

With 1 CA lesion (excluding the LCA trunk), the results of CABG are comparable to those of conservative therapy. When 2 or more coronary arteries are affected with FC I-II angina, surgical treatment improves the quality of life, relieves the patient of angina attacks and constant intake of antianginal drugs, without significantly affecting long-term survival. In FC III-IV CABG, surgical treatment also increases long-term survival.

Principle: with the help of a "cold" laser, tubules are created in the myocardium either transmyocardially (on a beating heart) or endomyocardially (with a catheter).

It is an alternative to CABG in patients with severe distal lesions and low LV ejection fraction.

UNSTABLE STENOCARDIA

Changes in the nature of anginal attacks (especially lasting over 15 minutes and the need to use large doses of nitroglycerin to stop them), to a lesser extent in their frequency and intensity.

The appearance of resting angina attacks against the background of existing exertional angina;

First-onset angina pectoris (up to 1 month old).

Rest angina in the early period (first 2 weeks) after MI.

The duration of unstable angina pectoris is up to 30 days, after which it should be called refractory to conservative therapy for severe stable angina pectoris.

Unstable angina is always associated with an unstable atherosclerotic plaque. In this case, ulceration, plaque rupture, and hemorrhage into the plaque occur. All of the above leads to the development of parietal thrombus formation and prolonged coronary spasm with a sharp decrease in the lumen of the coronary artery, as well as to arterioarterial embolism of the distal vessels.

Clinic. ECG with obligatory Holter monitoring.

Normal levels of MV-fraction CPK, AST, LDH (as opposed to MI).

Coronary angiography: pronounced coronary spasm, poor contrasting of the distal bed, a floating thrombus in the lumen of the coronary artery.

In case of unstable angina, the patient should be admitted to the intensive care unit for 48 hours (acute period), where intensive therapy should be carried out in full, as in myocardial infarction. It includes intravenous administration of 0.1% nitroglycerin (perlinganite), oral administration or intravenous administration (isoket) of prolonged forms of nitrates, β-blockers, calcium antagonists. In addition, powerful antithrombotic therapy should be carried out: heparin IV, aspirin or ticlide. With the development of acute heart failure, it is imperative to prescribe cardiac glycosides and diuretics. In severe cases, intra-aortic balloon counterpulsation should be considered.

If the effect of the treatment is obtained, then in the future - planned coronary angiography, followed by a decision on a possible method of interventional treatment.

If there is no effect of treatment, then emergency coronary angiography is performed, followed by intracoronary fibrinolytic therapy and angioplasty (usually against the background of TABA). If it is impossible to perform the latter, an emergency CABG is performed.

Mortality during planned operations in NS is 4%, in emergency operations - 10%.

ACUTE MYOCARDIAL INFARCTION

In the overwhelming majority of cases, the cause of myocardial infarction is coronary artery thrombosis; a lesser role is attributed to prolonged coronary spasm and arterioarterial embolism.

During the first two hours (the most acute period or the period of acute ischemia), thrombus lysis is possible, then myocardial necrosis will not occur. By the end of the first day (acute period), the zone of myocardial necrosis is histologically and macroscopically determined, the processes of inflammation and lysis of necrotic cardiomyocytes begin, after 10 days (subacute period) scarring processes develop and a soft scar of granulation tissue is formed by the end of 4-8 weeks, by the end 6 months a dense post-infarction scar is formed.

The area of acute ischemia and necrosis determines the possibility of developing cardiogenic shock.

Angina status for more than 30 minutes, not stopped by taking nitroglycerin and non-narcotic analgesics.

Signs of acute heart failure (cardiogenic shock, pulmonary edema) and severe rhythm disturbances.

ECG: ST dislocation, T wave inversion, pathological Q wave (pathognomonic sign), arrhythmias.

An increase in the MV fraction of CPK, AST, LDH1 and 5 with obligatory normalization by 2-3 days (CPK), by 4-5 days (AST and days (LDH)).

Fever and leukocytosis by the end of the first day and during the first week, and within a month - increased ESR.

In the postinfarction period, rhythm disturbances and chronic heart failure usually develop.

Conservative treatment is the same as for unstable angina. Obligatory -blockers and calcium antagonists (reduce the ischemic zone), adequate analgesia with narcotic analgesics. With the development of cardiogenic shock - TABA. The period of stay in the intensive care unit is 10 days (the risk of developing severe complications).

Emergency intracoronary fibrinolytic and antithrombotic therapy followed by balloon angioplasty is effective if no more than 6 hours have passed since the moment of myocardial infarction.

CABG is performed no earlier than 4 months after MI. Indications for emergency CABG are: coronary artery thrombosis during angioplasty or coronary angiography, cardiogenic shock, transmural myocardial infarction no more than 6 hours old, early relapse of angina pectoris after myocardial infarction.

Mortality in CABG within 6 hours is 5%, at a later date - 10%. 5-year survival rate after angioplasty and CABG is 90%, with conservative treatment - 80%.

SURGICAL TREATMENT OF IHD COMPLICATIONS

1. Postinfarction aneurysm

It is formed both in the acute period of a heart attack and in the long-term. Frequency - every fifth after transmural infarction.

In 85%, it is formed from the anterior or anterolateral wall of the LV. 5-year survival rate - 20% (death from ruptured aneurysm).

Diagnosis: a history of myocardial infarction, chronic left ventricular failure, angina pectoris, apex systolic murmur, cardiomegaly, echocardioscopy, ventriculography.

Tactics: an absolute indication for surgical treatment (usually in combination with CABG, which precedes resection of anerisma). Methods - anerism resection, anerismorrhafia and aneurysmoplication (with small anerisma).

It usually develops in the acute period, while 30% of patients survive. Frequency - up to 2%.

Diagnosis - as congenital VSD, the main syndrome is progressive heart failure.

Tactics - surgical treatment (plastic VSD after CABG).

It develops either as a result of a papillary muscle infarction with their subsequent rupture (acute mitral insufficiency), less often as a result of papillary muscle ischemia (chronic mitral insufficiency).

With rupture of the papillary muscles, pulmonary edema and cardiogenic shock develop, with chronic mitral insufficiency - chronic left ventricular failure.

Tactics - emergency or planned CABG + mitral valve replacement.

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st. Vorovskogo, 64, Chelyabinsk, Chelyabinsk region,

Educational bases of the department of CHOKB № 1, st. Vorovskogo, 70 Clinic SUSMU, st. Cherkasskaya, 2 MBUZ GB No. 6, st. Rumyantseva, 24 FSBI "FC SSH", Ave. Hero of Russia Rodionova E. N., 2

Department of Hospital Surgery, South Ural State Medical University - postgraduate education of doctors in the specialties: general surgery, cardiovascular surgery (angiosurgery, cardiac surgery).

The information on this site is intended for professionals and cannot be used as a guide to self-medication. The site administration is not responsible in cases of harm associated with the use of information posted on this site.

Rectal stenosis 90

danaFebruary 2016

It all depends on the clinical picture of the disease. You can't rely on numbers alone.

danaFebruary 2016

Diagnosis: ischemic heart disease, angina pectoris 2 FC. Atherosclerosis of the coronary arteries. RCA stenosis up to 75%. Chronic heart failure 2 А Functional class 3. Hypertensive heart disease 3 tbsp, arterial hypertension 1 tbsp. MTR risk 4 tbsp.

I did not find anything about sugar and cholesterol in the extract.

On November 7, my husband had a widespread myocardial infarction with teeth. Stenosis 90% LAD. It is advised to put a stent.

what do you mean "take off"? A stent is a special reinforced tube that is inserted into the vessel and prevents it from narrowing. where can it fly out of the vessel? "Expensive drugs" are statins that prevent the formation of cholesterol plaques inside the vessel. these drugs should be taken by all people over 50 years of age. and they are not that expensive. during the period of postoperative rehabilitation, you will have to take more expensive drugs that prevent the formation of blood clots in the vessels. this is about six months.

the land in the cemetery, the coffin and the funeral supplies are not much cheaper, believe me.

It is more realistic to knock out a quota for an operation at the end of the year than at the beginning. so do not delay making a decision.

Recanalization of chronic RCA occlusion.

06/22/11, Patient No. 30253. Age: 55 Was admitted to the NPTSIK with a diagnosis of ischemic heart disease: angina pectoris 2 FC. Hypertension stage II.

From the anamnesis: A fluctuation in blood pressure was detected in 2007, with a max of 180/120 mm Hg, adapted to / 75-80 mm Hg. Art. In 2007, an ECG revealed cicatricial changes without a coronary history, since that time, with heavy loads, he began to notice pressing pains in the precardial region passing at rest (before that he did not pay attention to painful s-m). On 31.03.11, while accelerating the step, he noted a prolonged painful attack - he was hospitalized at the 50th hospital with progressive heart failure. Examined: VEM - doubtful (decrease in blood pressure during exercise with ST depression up to max. 0.7 mm). HM-ECG: 5 episodes of ST depression up to 3.3 mm.

Performed procedures: 24.06.11, the CAG was performed in a planned manner, in which: The type of coronary circulation is right. The trunk of the LCA is short, practically absent. LAD moderate diffuse changes in all areas without hemodynamically significant stenosis. The circumflex branch is represented by the developed VTK, in the middle / 3 it is stenotic by 90%. RCA: occluded in media / 3, collateral filling of the distal bed through intersystem collaterals is good. Syntax score - 18.

Completed: The first step was direct stenting of the middle segment of the OS with a 3.5 x 20 mm stent with a good immediate angiographic result. The second stage was a mechanical conduction recanalization of media occlusion / 3 RCA followed by PTCA with a good result. A 2.5 x 38 mm stent was delivered, positioned and implanted into the residual stenosis zone. At control RCA angiography, the stent is fully deployed, positioning is adequate, and the main blood flow is restored.

Arteriography of the LCA. 90% stenosis of media / 3 OS is visualized.

Arteriography of the LCA (RAO / LAO 0; CAUD 30). 90% stenosis of media / 3 OS.

RCA arteriography (RAO 45; CRAN / CAUD 0). Medium occlusion / 3 RCA.

Stent implantation into the affected OS segment.

Control angiography of the LCA. Good stenting result.

The stage of conduction recanalization of media occlusion / 3 RCA.

PTCA of the occluded segment with a balloon.

Control angiography after predilation. Residual stenosis in the previously occluded segment and a distal parietal contrast defect are visualized.

Stent implantation in media / 3 RCA with extension to the border of media / 3 and dist / 3.

Control angiography (LAO 10-20; CRAN 30). Adequate positioning of the stent, restoration of the main blood flow.

Control angiography (LAO 40; CRAN / CAUD 0). Good angiographic result.

Rectal stenosis 90

Man, 69 years old, suffered the first heart attack of the posterior wall in 2006, concomitant diseases: hypertension. For almost 20 years he has been suffering from hypertension, blood pressure is over 200. He is constantly taking drugs that regulate blood pressure (diroton), as well as some heart drugs (cardiket, and some others, until I can write for sure, as well as American aspirin). I do not smoke. Physically very active, health complaints are extremely rare.

In early 2013, he began to complain of pronounced angina pectoris and high uncontrollable blood pressure. Was in the hospital, was discharged with improvement, with a new drug regimen selected, but the pressure was sharply reduced, began to suffer from hypotension, switched to his usual regimen, and the situation stabilized. Attacks of angina pectoris by the winter of 2013 resumed and became pronounced, without nitrospray he did not leave the house.

On January 5, 2014, with a heart block, he was taken to the hospital, where on January 12, 2014, in the morning there was a second myocardial infarction of the anterior wall. After analyzing the situation with the medical care provided in a pre-infarction state, the relatives transferred the patient to the regional Volgograd cardiac center. The condition has stabilized. After three days in intensive care, the patient was transferred to the ward. At the moment, he feels fine.

The results of coronary angiography performed in the intensive care unit of the regional cardiac center on January 13, 2014 (the next day after the heart attack)

Directional diagnosis: ischemic heart disease. Exertional angina FC4.

Final diagnosis: ischemic heart disease. Atherosclerosis of the coronary arteries: two RCA stenoses in the n / W 90%, in the D / W 65%. Stenosis of OS in d \ W 90%, in d \ W 50%. Stenosis of VTK1 in the n / H is more than 50%. LAD stenosis in the n / H up to 50%.

We agree to the operation. The question is about time. The doctor argues that for my dad (the patient is my father, I have only one left), surgery is not indicated now, no one in Russia operates after a heart attack. I need at least two months of rehabilitation, and I'm afraid to be late. Please forgive me for the scanty important information and the abundant unnecessary information. Ready to fight to the last. Dad has four grandchildren, three of whom are my little kids. I really want him to live as long as possible.

(I understand that you are requesting the protocol or recording of the CAG study, but I have only this so far)

Comments on the post:

Abugov Sergey Alexandrovich.

Russian Scientific Center of Surgery named after Academician B.V. Petrovsky.

How are we to be? And how to argue?

Dad was discharged from the hospital. I am attaching an extract. Feels satisfactory, moderately active, tunes in for surgery. My question to respected doctors consulting here on the forum:

Disturbed by pain under the scapula on the left. Sometimes there is a burning sensation. Pain not after physical activity can occur at rest. Nitrosprey seizures do not stop at all. The pain is relieved with analginum (in the hospital with tramadol). The interval is at least every other day. About once a day. With such pains, an ECG was done in the hospital - it was reported that there was no deterioration. The doctor explained that it was osteochondrosis. Is it true??

Where can I go with my illness?

Arterial stenosis

Normal blood circulation ensures optimal functioning of all internal organs of the body. It is through the blood that they receive oxygen in the required volume, nutrients. In other words, vascular damage inevitably leads to damage to all organs.

A fairly serious vascular disease is stenosis of the coronary arteries. Bifurcation stenoses of the coronary arteries are quite common in medical practice. Arterial stenosis is a significant narrowing of the lumen of the arteries. This leads to the development of their complete or partial obstruction.

Classification of arterial stenosis

SLKA affects many arteries. Lesions differ from each other in symptoms and possible consequences. It is worth considering them in more detail.

Stenosis of the trunk of the right coronary artery

The vessels located in the heart are called coronary vessels. Their other name is coronal. They are responsible for normal blood supply and myocardial function.

The RCA, in turn, is responsible for providing oxygen to the sinus node. Damage to the right coronary artery can lead to disturbances in the rhythm and rate of ventricular contractions.

The consequences of not providing timely medical care can be very serious. Due to stenosis of the RCA trunk, the following ailments can rapidly develop:

Ischemia.
Angina pectoris.
Myocardial infarction.
Arrhythmia.
Rapid increase or decrease in blood pressure, etc.

But in medical practice, this ailment is quite rare.

Stenosis of the left trunk of the coronary artery

Unlike the previous ailment, stenosis of the left trunk of the coronary artery is much more common. But it is also a more dangerous ailment.

The greatest health risk is that the left ventricle is responsible for virtually the entire circulatory system. In case of violations in its work, the rest of the internal organs suffer.

Symptoms of stenosis of the left coronary artery

With STLK, a person feels a breakdown. First, its general condition worsens, inoperability, drowsiness are observed.

With the development of the disease, the following symptoms may appear:

Shortness of breath.
Frequent headaches and migraines.
Discomfort in the chest area.
Attacks of angina pectoris during physical exertion and emotional stress.
Nausea, etc.

Consequences of STLKA

Significant narrowing of the left coronary artery is largely caused by the formation of plaques in its thickness. Their formation is due to the high percentage of low-density lipoproteins in the patient's body.

Similar vascular conditions, as in the case of stenosis of the right coronary artery, can lead to the following consequences:

The development of ischemic diseases and their consequences.
Preinfarction conditions.
Myocardial infarction, etc.

Tandem stenosis of the coronary arteries

This type of stenosis is quite rare. It is characterized by damage to both the left and right coronary arteries. The diagnosis is very negative.

If only one ventricle in the heart is damaged, the second can take over the main work of pumping blood. In this case, the disease develops much more rapidly.

In the absence of timely medical intervention, the consequence of tandem stenosis is only one - death. To get rid of this ailment, surgical intervention is necessary to replace or repair damaged coronary arteries.

Vertebral artery stenosis

The vertebral arteries are no less important than the coronary arteries. PA disorders can lead to serious changes in the human body.

PA stenosis can be caused by intervertebral hernias, inflammatory processes, tumors, congenital disorders of the vertebrae, etc. Narrowing of the PA lumen leads to a complete or partial cessation of the flow of blood into the brain and, accordingly, oxygen.

Symptoms of vertebral artery stenosis

The main symptoms of PA stenosis are:

Violent headaches, which often turn into migraines.
Nausea and vomiting.
Severe dizziness.

Pain sensations can be given to other parts of the body. The nature of the pain can be completely different. It increases with sharp turns of the head, shaking or fast driving, etc.

Consequences of vertebral artery stenosis

The most common consequence of advanced PA stenosis is stroke. The blood supply to the brain is significantly blocked. There is a pronounced lack of oxygen.

Lack of timely medical care for stroke or advanced vertebral artery stenosis can be fatal.

Femoral artery stenosis

The next type of stenosis is femoral artery stenosis. In this case, stenosis and occlusion of the lower extremities are interrelated and interchangeable concepts. Blood flow to the legs significantly deteriorates, swelling is observed. Swelling can lead to a point of no return, when the condition of the arteries and their tissues deteriorates so much that it will be impossible to correct the situation.

Symptoms of femoral artery stenosis

The main symptoms of this ailment include:

Lameness.
Severe pain in the lower limbs.
Cramping.
Complete cessation of hair growth in certain areas of the legs.
Changes in the color and shade of the skin of the lower extremities. Cyanosis or, conversely, redness may be observed.
Changes in the temperature of the lower extremities, which indicates the development of inflammatory processes.

Consequences of femoral artery stenosis

Like all previous types of stenosis, this one requires immediate intervention. Otherwise, the patient will face negative consequences for his health.

In the absence of medical intervention, inflammatory processes will rapidly develop and increase. This will lead to the formation of gangrene.

With advanced inflammatory processes, edema and tumors, immediate limb amputation is required. This is to prevent the risk of enlarging the affected area.

Iliac artery stenosis

The iliac artery is the second largest artery in the human body. Disturbances in the work of the iliac artery can lead to very serious consequences.

Symptoms of iliac artery stenosis

Among the main signs of ailments and lesions of the iliac artery are:

Increased fatigue and inability to work.
Drowsiness.
Lameness.
Loss of sensation in the limbs.
Cyanosis or redness of the skin.
Swelling of the lower extremities.
Impotence syndrome, etc.

Consequences of the disease

With stenosis of the iliac artery, tissue exchange is significantly slowed down. Excretion of unnecessary substances from the body worsens.

Those begin to accumulate in large quantities in the plasma. This inevitably leads to an increase in its density and viscosity. Such changes in the composition of the blood always end in the formation of blood clots in the walls of blood vessels. This interferes with normal blood circulation and oxygen supply to the internal organs of the human body.

Critical stenosis

The acute form of stenosis is critical. It begins to develop if the thickness of the vessels increases by more than 70 percent.

This form requires immediate surgical intervention. This is the only treatment for this form of the disease.

Critical stenosis increases the patient's risk of complete cardiac arrest or myocardial infarction. This can happen at any time, which is why if the condition worsens, you should immediately contact a specialist.

What is the essence of stenting

Stenting of the vessels of the heart: reviews

CORONARY STENTING

Cardiologist - site about diseases of the heart and blood vessels

Cardiac surgeon online

Conductive system of the heart

Sinus node

AV node

A bunch of His and its branches

Method for assessing the state of coronary blood flow after surgery

Coronary angiography (coronary angiography)

Indications for coronary angiography

Determination of the degree of stenosis and variants of coronary lesions

Who to contact?

Coronary angiography technique

Arterial approaches for performing coronary angiography

Abbreviations in cardiology

Nah heart it

Signs and treatment of coronary artery occlusion

Causes

Symptoms

Treatment

Cardiologist - site about diseases of the heart and blood vessels

Cardiac surgeon online

Conductive system of the heart

Sinus node

AV node

A bunch of His and its branches

Cardiac stenting surgery: what is important to know about it?

What is the essence of stenting

Stenting of the vessels of the heart: reviews

Related articles: It is important for everyone to know! Signs of heart diseaseWhat is important to know about the vessels of the brainHeart aneurysm - is surgery always needed?Bypass grafting of the vessels of the heart: important about the operation

Comments (1)

Anatomy of the coronary arteries of the heart

SURGICAL ANATOMY OF THE CORONARY ARTERIES.

Anatomy of the coronary arteries

Coronary arteries

Right coronary artery

Left coronary artery

Anterior interventricular branch

Circumflex artery

Anatomy of the coronary arteries.

Coronary arteries

Right coronary artery

Left coronary artery

Anterior interventricular branch

Types of blood supply to the heart

Coronary angiography

Basic angiographic views

ETIOLOGY

PATHOGENESIS AND PATHOLOGICAL ANATOMY

CLASSIFICATION

INSTRUMENTAL DIAGNOSTICS OF CHD

CHRONIC ISCHEMIC HEART DISEASE

UNSTABLE STENOCARDIA

ACUTE MYOCARDIAL INFARCTION

SURGICAL TREATMENT OF IHD COMPLICATIONS

Rectal stenosis 90

On November 7, my husband had a widespread myocardial infarction with teeth. Stenosis 90% LAD. It is advised to put a stent.

Recanalization of chronic RCA occlusion.

Rectal stenosis 90

Arterial stenosis

Classification of arterial stenosis

Stenosis of the trunk of the right coronary artery

Stenosis of the left trunk of the coronary artery

Symptoms of stenosis of the left coronary artery

Consequences of STLKA

Tandem stenosis of the coronary arteries

Vertebral artery stenosis

Symptoms of vertebral artery stenosis

Consequences of vertebral artery stenosis

Femoral artery stenosis

Symptoms of femoral artery stenosis

Consequences of femoral artery stenosis

Iliac artery stenosis

Symptoms of iliac artery stenosis

Consequences of the disease

Critical stenosis

Related articles:
It is important for everyone to know! Signs of heart disease
What is important to know about the vessels of the brain
Heart aneurysm - is surgery always needed?
Bypass grafting of the vessels of the heart: important about the operation