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

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

Vessel wall calcification and proliferation of connective tissue in the artery lead to a narrowing of the lumen up to complete desolation of the artery, slowly progressive deformation and thereby cause chronic, slowly increasing insufficiency of blood supply to the organ fed through the affected artery.

What is the essence of stenting

For the prevention of diseases and the treatment of manifestations of varicose veins on the legs, our readers advise Anti-varicose gel "VariStop", filled with plant extracts and oils, it gently and effectively eliminates the manifestations of the disease, alleviates symptoms, tones, strengthens blood vessels.

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

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, the operation is performed, constantly recording the patient's cardiogram. The operation does not require any incisions and 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, a thin metal conductor is passed through it under the supervision of a monitor. This conductor is supplied with a can of the corresponding size of the narrowed area. A stent is mounted on the balloon in a compressed state, which is combined with human tissues and organs, elastic and flexible, able to adapt to the state of the vessel. The balloon inserted on the conductor is inflated, the stent expands and is pressed into the inner wall.

To ensure correct expansion of the stent, the balloon is inflated several times. The balloon is then deflated and removed from the artery along with the catheter and guidewire. In turn, the stent remains to preserve the lumen of the vessel. Depending on the size of the affected vessel, one or more stents may be used.

Cardiac stenting: reviews

Usually, according to numerous reviews, the results of the operation are good, the risk of complications after it is the smallest 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 hematomas at the site of arterial puncture. In order to prevent complications, the patient is left in the intensive care unit with the obligatory observance of bed rest. Some time later, after the wound heals at the puncture site, the operated patient is discharged from the hospital. The patient can return to his usual way of life and periodically be observed by a doctor at the place of residence.

The cost of stenting 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 heart vessels, patients get the opportunity to live a normal life.

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

CORONARY STENTING

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

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. Hypertrophy of the myocardium of the left ventricle. Violation of the processes of repolarization along the apical lateral wall of the left ventricle. It was because of the ECG, which the doctor did not like, that he was sent to cardiology.

Treadmill test - a negative test, with features.

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

Coronary angiography. The type of blood circulation in the myocardium is left. LCA barrel - without features. PNA: stenosis of the middle segment (after 1DA discharge) up to 60%. Orifice stenosis 1 DA up to 80%. In the distal segment - uneven contours, "muscular bridge" with stenosis during systole up to 30%. AO: no, PKA: no. Conclusion: Atherosclerosis of the coronary artery, Stenosis of the PNA, 1DA. "Muscular bridge" 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 pain in the heart (not acute) bothers, especially in stressful situations. The pressure is normally 130/80, sometimes it is 160/110.

I consulted with various cardiologists. Contradictory opinions:-

Why do you need a piece of iron in the heart, which sometimes has to be cut out and bypassed. Take your medicine and move on.

The stent must be placed until the coronary artery is clogged 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.

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

I dug through the Internet and found a lot of different horror stories for and against.

As to be, I will be glad to any advice of the professional.

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

But still my opinion - 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 the prognosis only if it is performed in the acute phase of myocardial infarction. In the case of a stable course of coronary artery disease, stenting does not reduce the risk of death or the development of myocardial infarction! With a stable course of coronary artery disease, stenting of the coronary arteries has one goal - to reduce the clinic 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 won't go into details because this is not your case.

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

According to the presented material, it seems that: at the present time, it is possible to refrain from stenting (why they began to do coronary angiography in the absence of a clinic and a negative load test - it is not clear from the description). Carry out full therapy aimed at reducing risk factors (statins, antihypertensive therapy, etc.). In case of deterioration of the condition, the appearance of an angina pectoris clinic, 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 the attending physician.

Cardiologist - a site about diseases of the heart and blood vessels

Cardiac surgeon online

conduction system of the heart

sinus node

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

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

If the sinus node is down, latent pacemakers in the atria, AV node, or ventricles turn on. 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 mouth of the coronary sinus.

Bundle of His and its branches

Excitation lingers 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. Autonomic 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. Conduct a comprehensive clinical examination of the patient, including echocardiography and selective coronary angiography determine the total rate of the coronary bed. At the same time, after the operation on days 3-8, using EchoCG, the dynamics of the left ventricular ejection fraction (LV EF), the dynamics of the left ventricular diastolic function (LV DF) and the dynamics of the left ventricular contractility (INLS), the number and nature of contractility of each segment. With the help of selective coronary angiography, the number of affected pools of the coronary arteries is determined, and after the operation, the degree of myocardial revascularization is determined, 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 if the degree of myocardial revascularization is greater than 80%, LV EF is greater than 50%, LV DF is greater than 1 and INLS equal to 1, the state of coronary blood flow is assessed as unsatisfactory if the degree of myocardial revascularization is less than 50%, LV EF is less than 50% , LV DF less than 1 and INLS more than 1. The method improves the accuracy of assessing the state of coronary blood flow after surgery. 1 z.p. 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 a coronary bypass or stenting operation and to select further treatment tactics.

Coronary or coronary heart disease (CHD) 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 surgeons - M., 1999, - pp. 3-6). The importance of coronary artery 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 common cause of death, disability, and economic loss in today's society than any other disease. Myocardial infarction (MI) with an outcome in cardiosclerosis occupies a special position in the general structure of IHD. When the coronary arteries are affected, the left ventricle is more likely to suffer. Since the LV is the main "working organ" of the heart (pump), any dysfunction of it affects the general condition of the body, leads to heart failure and other complications that lead to death.

One of the main treatments 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 coronary artery disease. 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 cardiopulmonary bypass surgery (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 changing clinical parameters, including echocardiography and selective coronary angiography, which allows you to accurately diagnose before surgery and determine the indications for surgical treatment.

For the prototype of the proposed invention, a well-known method for assessing the state of coronary blood flow after surgery was chosen by a comprehensive clinical examination of the patient, including performing echocardiography and selective coronary angiography with determining the total indicator of the coronary bed and comparing 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, - No. 17, - p.).

The known method lies 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 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 not had Q MI are distinguished. When analyzing the ECG, attention is also paid to rhythm disturbance, 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 undergo SCG through the right or left femoral artery. When analyzing the state of the coronary bed, determine: the type of blood supply to the heart - right, left, balanced; localization and extent of the lesion, distinguishing between localized and diffuse lesion; the presence or absence of collateral blood flow; allocate the degree of narrowing of the coronary arteries according to the classification of Yu.S. Petrosyan and L.S. 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, the method of summary assessment of the damage to the coronary bed is used (Petrosyan Yu.S., Shakhov B.E. Coronary bed in patients with postinfarction aneurysm of the left ventricle of the heart. - Gorky, g., - page .17-20), in which:

Consider the narrowing of the lumen of the vessels more than 50% and occlusion;

Take into account the type of coronary circulation;

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

First, the damage to each major artery of the heart is assessed according to the point system. The sum of points is a total indicator of damage to the entire coronary blood flow. For greater information content, the total rate of lesions of the arteries of the heart is expressed as a percentage of the maximum score. The number 240 is conventionally taken as the maximum score. This roughly corresponds to the amount of blood flowing through the coronary bed in 1 minute (), that is, 240 ml / min. And divided into the main arteries of the heart, depending on the type of blood circulation. For calculations, special maps-tables 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 extent of surgical intervention.

When conducting echocardiography, the following positions are used: parasternal along the long axis of the left ventricle, parasternal along the short axis of the left ventricle at the level of the mitral (MV) 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 (VTRV), posterior LV wall thickness (TZSLZh) in systole and diastole and diastolic function are evaluated, and segmental LV contractility.

However, today there is no consensus on what criteria reflect the effectiveness of surgical treatment, there is no analysis of myocardial changes in patients with coronary artery disease after surgery. Also, the tactics of further management of the patient 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, remodeling of the heart with the development of ischemic cardiomyopathy, disability and death of the patient. According to the authors of the present invention, a dual approach is needed 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 left ventricle. 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 invention is to improve the accuracy of the assessment and provide the possibility of predicting complications and planning subsequent treatment tactics.

The problem is solved by the fact that in a known method for assessing the state of coronary blood flow after surgery, including a comprehensive clinical examination of the patient, including echocardiography and selective coronary angiography with the determination of the total index of coronary lesion and comparison of the data obtained, before and after surgery by 3 -8 days with the help of EchoCG, the dynamics of the left ventricular ejection fraction (LV EF), the dynamics of the left ventricular diastolic function (LV DF) and the dynamics of the left ventricular contractility (INLS), the number and nature of contractility of each segment, using selective coronary angiography determine the number of affected pools 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 with the degree of myocardial revascularization> 80%, LV EF> 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 coronary artery 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 sources of patent and scientific and technical information that discredit the novelty of the method.

Studies conducted by the authors of the application have shown that the criteria: LV EF, LV DF and INLS are the most effective criteria that reflect the functional disorders of the left ventricle. The proposed method is applied in the Specialized Clinical Cardiosurgical Hospital of Nizhny Novgorod for 94 patients with coronary artery disease who underwent MI, who were hospitalized. In the study group, there were 80 men (88%), women - 14 (14%). The mean 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) according to the Jadkins method through the right or left femoral artery. The study was carried out in X-ray surgical operating rooms equipped with BI-ANGIOSCOP and Angioscop-3D X-ray surgical complexes (Siemens, Germany).

For the convenience of the analysis of 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 (ADA), circumflex artery (OA), right coronary artery (RCA), giving rise to other smaller branches. So, we consider the PNA basin to be a lesion not only of this artery, but also of the diagonal (DV) and septal (PV) branches extending from it. The OA pool - the defeat of the OA itself, as well as the obtuse marginal branch (OTC), the RCA basin - the defeat of the RCA, the posterior descending artery (PDA), the branch of the acute edge (VOA). In this regard, we have identified the following options for damage to pools (Table 1). There were no lesions of the LCA trunk in our patients.

The analysis of the obliterating lesions of the coronary arteries was carried out taking into account their division into three levels. Assessment of localization, the degree of damage to the artery 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 heart blood supply: right (70%), left (20%), balanced (10%); localization, degree and prevalence of the lesion, the 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 the contrasting of the coronary arteries under x-ray control with the introduction of RVC into the orifices of the arteries and recording the image on x-ray film, video camera. Increasingly, computer hard disks and CDs are being used, without compromising image quality.

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 treating coronary atherosclerosis and coronary artery disease as TBCA with stenting and CABG coronary angiography is used to assess the coronary bed (narrowing and their extent, severity and localization of atherosclerotic changes), determine treatment tactics and prognosis in patients with symptoms of CAD. It is also very useful for studying the dynamics of coronary tone, immediate and long-term results of PTCA, CABG and drug therapy. Briefly, the indications for coronary angiography can be formulated as follows:

insufficient effectiveness of drug therapy in patients with coronary artery disease and the issue of other treatment tactics (TBCA 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 suspected signs of coronary artery disease (pilots, astronauts, transport drivers);
AMI in the first hours of the disease for (intracoronary) thrombolytic therapy and / or angioplasty (TBKA) in order to reduce the area of necrosis; early postinfarction angina or recurrent MI;
assessment of the results of CABG (patency of aortocoronary and mammary coronary bypass grafts) or PCI in case of recurrence of angina attacks and myocardial ischemia.

Determination of the degree of stenosis and variants of coronary lesion

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

Hemodipamically significant, i.e., limiting coronary blood flow, is considered a narrowing of the vessel diameter by 50% or more (but this corresponds to 75% of the area). However, stenoses of less than 50% (the so-called non-obstructive, non-stenotic coronary atherosclerosis) can be prognostically unfavorable in case of plaque rupture, mural thrombus formation with the development of coronary circulation instability and AMI. Occlusions - complete overlap, blockage of the vessel according to the morphological structure - are cone-shaped (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 with AMI).

There are various options for quantifying the extent 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 lesion. Separately indicate the defeat of the LCA trunk. Significant proximal stenoses of the RA and OA can be considered the equivalent of a lesion of the LCA trunk. Large branches of the 3 main coronary arteries (intermedial, diagonal, obtuse margin, posterolateral and posterodescending) are also taken into account in assessing the severity of the lesion and, like the main ones, can be subjected to endovascular treatment (TBCA, stenting) or bypass.

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 layering of branches on the stenotic site of the vessel under study. This makes it possible to exclude underestimation of the degree of narrowing in the eccentric location of the plaque. This must be remembered in the standard analysis of angiograms.

Selective staining of venous aortocoronary and aortoarterial (internal thoracic artery and gastroepiploic artery) bypasses is often included in the plan of coronary angiography in patients after CABG to assess the patency and functioning of the bypasses. For venous bypasses starting on the anterior wall of the aorta about 5 cm above the RCA mouth, JR-4 and modified AR-2 coronary catheters are used, for the internal mammary artery - JR or IM, for gastroepiploic - Cobra catheter.

Who to contact?

Technique of coronary angiography

Coronary angiography can be performed both separately and in conjunction with catheterization of the right heart and left (less often right) VG, myocardial biopsy, when, along with an 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 contractility of the ventricles (see above). When conducting coronary angiography, constant monitoring of ECG and blood pressure should be ensured, a general blood test should be taken and biochemical parameters, composition of blood electrolytes, coagulogram, blood urea and creatinine, tests for syphilis, HIV, and hepatitis should be assessed. It is also desirable to have a chest x-ray and data from duplex scanning of the vessels of the iliac-femoral segment (if the femoral artery is punctured, which so far happens in most cases). Indirect anticoagulants are canceled 2 days before the planned coronary angiography with blood coagulation control. Patients with an increased risk of systemic thromboembolism (atrial fibrillation, mitral valve disease, a history of episodes of systemic thromboembolism) may receive intravenous unfractionated heparin or subcutaneously low molecular weight heparin during the coronary angiography procedure during the withdrawal of indirect anticoagulants. With planned CAG, the patient is taken 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 applied to 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 °. Upon reaching the blood stream from the pavilion, a 0.038 0.035 inch guidewire is inserted into the puncture needle, the needle is removed and the introducer is placed in the vessel. This is usually followed by a 5000 IU heparin bolus or a continuous flush with heparinized isotopic sodium chloride solution. A catheter is introduced into the introducer (different 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: catheters 6-8 F are used for the femoral one, and 6-8 F for the radial one. With the help of a syringe with a 5-8 ml RVC, the left and right coronary arteries are selectively contrasted manually in various projections, using cranial and caudal angulations, trying to visualize all segments of the artery and their branches.

In case of detection of stenosis, shooting is carried out in two orthogonal projections for a more accurate assessment of the degree and eccentricity of the 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 divides into the anterior descending (AD) and circumflex (OA) arteries. PNA goes along the anterior interventricular sulcus of the heart (it is also called the anterior interventricular artery) and gives diagonal and septal branches, blood supply to a vast area of the LV myocardium - the anterior wall, interventricular septum, apex and part of the side wall. OA is located in the left atrioventricular sulcus of the heart and gives rise to 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 left ventricle and (less often) the inferior wall of the left ventricle.

The RCA departs from the aorta from the right coronary sinus, goes along the right atrioventricular sulcus of the heart, in the proximal third gives branches to the cone and sinus node, in the middle third - the right ventricular artery, in the distal third - the artery of the sharp edge, posterolateral (a branch departs from it to atrioventricular node) and the posterior descending artery. The RCA supplies the pancreas, the pulmonary trunk and sinus node, the inferior wall of the left ventricle, and the adjacent interventricular septum.

The type of blood supply to the heart is determined by which artery forms the posterior descending branch: in approximately 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 accesses for 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, the coagulation status of the patient. The femoral approach is the most commonly used, safe and widespread (the femoral artery is quite large, does not collapse even during shock, is far from the 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 this occasion, in outpatients, a puncture of the arteries of the upper extremities (brachial, axillary, radial) is used.

With 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 method. Puncture above this level leads to difficulty in digitally stopping 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. At the border of the distal armpit, a pulsation of the artery is palpated, which is punctured in the same way as the femoral one, after local anesthesia, followed by the installation of an introducer (for this artery, we try to take catheters no larger than 6 F to more easily stop bleeding and reduce the likelihood of developing a hematoma in this artery). puncture site after examination). This method is currently 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: even Sones in 1958 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 great difference in the number of complications compared with puncture of the femoral artery, but in his followers the frequency of vascular complications (distal embolization, arterial spasm with impaired blood supply to the limb) was higher. Only in isolated cases is this access used because of the above 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 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 with 7 and 8 F catheters can be used in femoral and shoulder approaches (this is especially important for complex endovascular interventions, when 2 or more guidewires 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 a 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, 1-3 ml of a 2% lidocaine solution is used.

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

Abbreviations in cardiology

The abbreviations that patients encounter in discharges, when describing cardiac ultrasound, in medical records, often puzzle them. The most common abbreviations found in cardiac patients are deciphered in this section.

BPVR - blockade of the anterior-upper branching - blockade of the heart.

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.;
Grade 3 - pressure from 180/100 mm. rt. Art. and higher.

Hypertension (AH) stage 1 implies the absence of changes in the "target organs" (heart, retina, kidneys, brain, peripheral arteries).

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

Left ventricular hypertrophy:

Ultrasound evidence of arterial wall thickening (carotid artery >0.9 mm) or atherosclerotic plaques.

Slight increase in serum creatinine µmol/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

Hypertension (AH) 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; congestive heart failure.

Determining the degree of 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 years old.

Women over 65.

Total cholesterol is above 6.5 mmol/l.

Lowering high-density lipoprotein cholesterol levels.

Increased low-density lipoprotein cholesterol levels.

Pna heart it

Cardiac ischemia

LCA - left coronary artery

ME - metabolic equivalent

OA - circumflex artery

RCA - right coronary artery

ANA - anterior descending artery

Every year, about a million Americans die from coronary artery disease. In addition, a significant

part of the population, coronary artery disease causes LV dysfunction and arrhythmias, is a frequent

reason for hospitalization. Clinical manifestations of CAD 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 coronary artery disease, 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 ischemia threshold), new-onset angina and unstable angina (progressive angina, rest angina, post-infarction angina). In addition, painless ischemia is observed in CAD, 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 complete.

Diagnosis Chest pain is one of the most common reasons for seeking medical attention. Pain that resembles angina is not necessarily caused by pathology of the coronary arteries. It occurs in many conditions - in the pathology of the gastrointestinal tract, musculoskeletal system, lungs, central nervous system and some heart diseases. In such cases, overdiagnosis of coronary artery disease is possible. On the other hand, coronary artery disease may have atypical manifestations (shortness of breath, sweating, weakness). Bayes' conditional probability theorem helps to choose the optimal diagnostic sample in terms of efficiency and cost. The a priori probability of a disease (prevalence in a given group), the sensitivity and specificity of a diagnostic test allow us to estimate the posterior probability (the probability of a disease according to the test data). The diagnostic scheme (see below) shows 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 diagnosis of coronary artery disease itself is secondary.

Chest pain: a probabilistic analysis in the diagnosis of coronary artery disease Characteristics 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 men 60-69 years women 30-39 years women 60-69 years > Angina-like (A or B) men 30-39 years men 60-69 years women 30-39 years 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 60mg%, then the number of risk factors is reduced by one.

Pain in the heart area occurs in many conditions, so the list of diseases with which IHD needs to be differentiated is very extensive: esophageal reflux (Bernstein test - injection of 0.1 N hydrochloric acid into the esophagus, x-ray of the stomach, trial treatment with antacids), esophageal dysmotility (manometry), peptic ulcer (gastroduodenoscopy, trial treatment with H, blockers), pancreatitis (amylase and lipase activity), gallbladder disease (ultrasound), diseases of the musculoskeletal system (trial treatment with NSAIDs), PE (ventilation perfusion lung scintigraphy), pulmonary hypertension (Echocardiography, cardiac catheterization), pneumonia (chest x-ray), pleurisy (chest x-ray, NSAID trial);

pericarditis (Echocardiography, trial treatment with NSAIDs), mitral valve prolapse (EchoCG, trial treatment with adrenergic blockers), psychogenic pain (trial treatment with sedatives, psychiatrist's consultation), cervicothoracic sciatica (neurologist's consultation).

Methods of diagnosis Stress testing has the greatest diagnostic value when the average prior probability of coronary artery disease (for example, in 50-year-old men with chest pain resembling angina pectoris, or 45-year-old women with typical angina pectoris).

When the a priori probability of coronary artery disease is low (eg, in 30-year-old women with atypical chest pain for angina), exercise tests give too many false positive results, which limits their diagnostic value.

When the a priori probability of CAD is high (eg, in 50-year-old men with typical angina), exercise tests are used more to assess the severity of coronary artery disease than to diagnose CAD.

Method Criteria for a strongly positive test (high risk of complications) Remarks Stress test ECG test (treadmill, bicycle ergometry) Failure to achieve oxygen consumption > 6.5 IU, heart rate > 20 min1.

ST segment depression > 2 mm.

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

ST segment depression in several leads.

BPc under load almost does not change or decreases.

Elevation of the ST segment in leads that do not have an abnormal Q wave.

Occurrence of VT Effective and relatively inexpensive screening method.

Diagnosis of angina pectoris;

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 not possible (for example, with paresis of the legs and arthritis), then pharmacological tests or manual ergometrine are performed) myocardial scintigraphy C201T (treadmill, bicycle ergometry) The appearance of accumulation defects against the background of low load (

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

60%) than with lesions of the PNA or RCA (

The sensitivity of the test against the background of low load is also higher than the ECG test.

The most common causes of a false positive result are obesity (poor image quality), large breasts, and a high position of the diaphragm (overlapping artifacts). Defects in accumulation may persist for several weeks despite restoration of perfusion with BKA.

The cost of the study is high myocardial scintigraphy with 99mTc isonitrile (treadmill, bicycle ergometry) The appearance of accumulation defects against the background of low load (

Signs and treatment of coronary artery occlusion

Occlusion is a sudden obstruction of blood vessels. The reason is the development of pathological processes, clogging with a thrombus, 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 two main vessels - the left and right coronary arteries.

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

Causes

The processes that occur during the formation of coronary type occlusion largely determine the morphology. Most often, chronic occlusion begins to form from the moment of formation of an intraluminal fresh 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 location of the large lateral branches in relation to the occluding plaque.

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

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

Atherosclerosis plaque formation on the coronary artery

Why do such processes 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 to become chronic, some factors must act on the heart, coronary arteries. Indeed, normal blood flow is hindered by several reasons.

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. An air embolism is a condition where an air bubble enters the blood vessels. This often happens with serious damage to the respiratory organs or an incorrectly performed injection. There is also a fat embolism, which can be traumatic, or result from deep metabolic disorders. When small fat particles accumulate in the blood, they are able to combine into a fat clot, which causes occlusion. Arterial embolism is a condition in which the vascular lumen is blocked by mobile blood clots. They usually form in the valvular apparatus of the heart. This happens with various pathologies of cardiac development. This is a very common cause of occlusion of arteries located in the heart.
Thrombosis. It develops if a blood clot appears and begins to grow. It is attached to the venous or arterial wall. Thrombosis often develops in atherosclerosis.
Vascular aneurysm. This is the name given to the pathology of the walls of arteries or veins. There is their expansion or protrusion.
Injuries. Tissues that have been damaged due to external causes begin to put pressure on the vessels, which disrupts blood flow. This causes the development of thrombosis or aneurysm, after which occlusion occurs.

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

Symptoms

The manifestation of symptoms is directly dependent on the work of the heart, because it is precisely his defeat. 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 is drastically weakened. He can grab the heart area with his right or left hand. As a result, this situation often leads to loss of consciousness. It should 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. To do this, give an anesthetic. Well, if it is possible to inject papaverine. If a person has heart medicine with him, it must be given in the correct dose.

After being treated by ambulance medical specialists, the victim is taken to the hospital. There is an examination of the patient. An ECG is available in any medical institution. When it is deciphered, the depth and height of the teeth, the deviation of the isoline and other signs are taken into account.

Also, an 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 carry out coronary angiography of the heart vessels with the introduction of a contrast agent.

Treatment of acute manifestations of occlusions is a complex matter. Its success depends on the timely detection of the first signs of coronary artery disease. Basically, one has to resort to surgical intervention in order to clean the internal cavities of the arteries, to remove the affected areas. Carry out arterial shunting.

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

You need to monitor your blood pressure. It is best to be sensible 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 that contain a lot of cholesterol. After forty years, it is necessary to take tests 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.
Bad habits should be abandoned. This applies to smoking and alcoholic beverages. In medical practice, there were cases when there was a sharp spasmodic occlusion, which was caused by alcohol or nicotine.
Stress and mental shocks should be avoided.

Thanks to 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 - a negative test, with features.

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

I consulted with various cardiologists. Contradictory opinions:-

Why do you need a piece of iron in the heart, which sometimes has to be cut out and bypassed. Take your medicine and move on.

The stent must be placed until the coronary artery is clogged 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.

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

I dug through the Internet and found a lot of different horror stories for and against.

As to be, I will be glad to any advice of the professional.

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

But still my opinion - 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 the attending physician.

sstanovleniya_kroobrasheniya/ states that if there is left ventricular hypertrophy, then they do not perform stenting. And, this is in Germany, where our people with money go to be treated. And, our doctors, it turns out, are taken. 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 answers to your questions.

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

Cardiologist - a site about diseases of the heart and blood vessels

Cardiac surgeon online

conduction system of the heart

sinus node

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

If the sinus node is down, latent pacemakers in the atria, AV node, or ventricles turn on. 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 mouth of the coronary sinus.

Bundle of His and its branches

Cardiologist - a 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 throughout our body. With blood, tissues and organs receive oxygen and nutrients, without which, in turn, their vital activity would be impossible.

One of them is atherosclerosis - this is 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 methods of surgical treatment. But before the advent of intravascular therapies, the only surgical treatment for coronary heart disease was coronary artery bypass grafting. 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 vessels.

What is the essence of stenting

For the prevention of diseases and the treatment of manifestations of varicose veins on the legs, our readers advise the NOVARIKOZ spray, 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.

Cardiac stenting: reviews

Comments

Coronography showed - LCA - stenosis 25%, PNA stenosis 90%, OA stenosis 35%, VTK-50%, RCA occlusion. Can I have stenting? Or is bypass necessary?

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

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

which causes a severe headache. What to do and what can replace monosan?

Boris, all appointments must be coordinated with the attending physician. It is impossible to change the treatment on your own. Unfortunately, drugs in this group (nitrates) often cause headaches, which is associated with a powerful vasodilating effect. Possible replacement for Cordinic. The drug is new, has a similar effect. Or you can use a proven tool called Sidnopharm. Discuss this with your cardiologist. You can soften the effect of Monosan by taking a caffeine tablet.

Can X-rays be taken with stents in place?

Carrying out any kind of x-ray examination with coronary stents in place is quite possible. Stenting is not a contraindication for x-rays, fluoroscopy, or computed tomography of the chest, because stents are made of materials that do not change in any way under the influence of x-rays. Some types of coronary stents are limited in 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-rays are fundamentally different research methods, so X-rays with stents are allowed.

But still, before any examination (even X-ray), you need to consult a cardiac surgeon who performed the stenting 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 a heart stenting operation, recently she began to complain that after a fall, something was blocking her chest. Could the stent come off when it fell from the artery? She feels very bad, it is very difficult to get to the doctor, she is not in the city.

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

We wish your mother successful treatment.

My husband had one stent inserted at the beginning of September, a week later another five were inserted, a month later he needs another one.

The number of stents that need to be installed in the coronary vessels of the heart should be such that it is possible to restore normal blood supply to the myocardium. If cardiac surgeons put 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 check with your doctors (or consult other specialists for a second medical opinion) is that it may be more appropriate in the case of your husband to do coronary artery bypass surgery once rather than many times stenting. The effectiveness of CABG is higher than the placement of stents, but the complication rate is also higher.

We wish your husband successful treatment.

Hello, I’m interested in the following question: is it possible to carry out professional hygiene using the ultrasound method. For a person who underwent stenting or vascular bypass surgery?

Ultrasonic cleaning of the oral cavity is not prohibited for patients who have undergone stenting or coronary bypass surgery. 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 gum bleeding.

We wish you and your loved ones good health.

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

It is difficult to answer your question in detail, because 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. The appointments for treatment of hypotension. Talk to your pediatrician (if your daughter is under 18 years old) or a GP so that the doctor, after reviewing all the medical records you have, can recommend treatment for low blood pressure.

Generally speaking, a blood pressure of 90/60 mm Hg should be corrected in cases where there is a real deterioration in the condition. 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 are prescribed. In the absence of effect, they switch to drugs to increase pressure based on heptaminol, ephedrine, midodrine in tablets or drops. In severe cases of pressure reduction resort to intravenous injections of adrenaline, cordiamine and their derivatives.

We wish your daughter successful treatment and good health for many years to come.

My mother had a stent placed in November 2015, and she still has constant pain on her left side from her side. Could this be the case or is there another reason? I'm very worried about her.

The installed stent does not give pain in the heart, so the pain in your mother's left side cannot be directly related to the stent. If these pain sensations are the same as they were before stenting (i.e., angina pectoris pain due to poor blood supply to the heart), then with 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 should have been resolved about repeated manipulations or another type of heart surgery (coronary bypass grafting). Constant pain in the left side may not be related to the heart, it can be caused by osteochondrosis or intercostal neuralgia, chronic pancreatitis, and other diseases. As can be seen, 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 her 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 had two stents put in, but I needed four. A month later, I was scheduled to have another stent placed. I felt good. I started to work out in the gym. I gradually increased the load. Two months later, I had a heart attack at home. A fourth stent was placed. It turned out that the first stent clogged by 60%. . In a month I will be trying to inflate the stent. I heard that the contrast solution is very harmful to health. Is it so? Now I sometimes feel zhennie in the throat and pressure in the chest area. It feels like the stents are pressing. It is at rest. In the gym on an elliptical and a treadmill during exercise, there is no shortness of breath and no pain. Can the pain in the throat be due to clogged stent? After a heart attack, there was a feeling of fear that it might happen again

The harmfulness of the contrast solution for the body is minimal, especially if we compare the consequences of the introduction of contrast 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 burning 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) should be postponed until good parameters of cardiac blood flow are obtained, otherwise the likelihood of repeated heart attacks is high.

We wish you successful treatment.

I am 56 years old. In 2010, the thyroid and parathyroid glands were removed, hypertension stage 3, risk 4, coronary artery disease, diabetes mellitus type 2 since 2010. Angina pectoris 2fc. KCG dated May 30, 2016: stenosis up to 90% of the middle segment, up to 25% of the apical segment and 50–75% of the 1st DV of the AIA. In June 2016, a stent was placed. Everything was fine. The pressure returned to normal. The pains are gone. About a month ago I began to get sick in the heart area, I can’t lie on my left side. When walking in cold weather and in windy weather in the neck feeling like nausea. Will everything be the same again as it was before the stenting? Before him, I could not get to work without pressing pains and nausea, which seemed to pass under the jaw and into the hands. Go back to cardiology?

50 years. A month ago, a coated stent was placed in the RCA due to a 70% narrowing, after which he continued his recovery in the hospital (2 weeks) and the rehabilitation center (3 weeks); I plan to transfer to a sanatorium. At the same time, I continue to feel periodic discomfort in the left half of the chest, even at rest, when walking at about 5-5.5 km / h, there are pressing sensations in the region of 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 don’t get clear answers from the attending physicians; "Arrows" smoothly transfer to other stages of rehabilitation. Or is it already clear that stenting for some reason did not achieve a result?

Hello! My dad got CABG. Installed 4 shunts. Everything was fine for 3-4 months. Then the seizures started. 6 months after the operation, he went to the hospital for examination. It turned out that all 4 shunts were closed. None of the doctors know how this could happen. At a meeting of doctors, dad was offered a stent. Do you think there is common sense in this? Or is it better to go to another clinic in Moscow or St. Petersburg for a second operation?

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

hello, I have such a question, my father had heart problems, at first they said that it was necessary to do a bypass, but then they said that his arteries were too narrow; the bypass cannot be done; 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 a lot.

The information provided on the site should not be used for self-diagnosis and treatment. Need expert advice

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 in recent years has made it possible to study the anatomical features of the coronary circulation of a living person, to develop a functional anatomy of the arteries of the heart in relation to revascularization operations in patients with coronary heart disease.

Interventions on the coronary arteries for diagnostic and therapeutic purposes impose increased requirements on the study of vessels at different levels, taking into account their variants, developmental anomalies, caliber, angles of departure, 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 in relation to the operation plan with the division of the coronary arteries into segments.

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

Three segments were distinguished in the right coronary artery: I - a segment of the artery from the mouth to the outlet of the branch - the artery of the sharp edge of the heart (length from 2 to 3.5 cm); II - section of the artery from the branch of the sharp edge of the heart to the discharge 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 mouth to the place 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 is divided

Rice. 51. Segmental division of the coronary

A- right coronary artery; B- left coronary artery

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

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 selective coronary angiography and surgical interventions, to determine the localization and spread of the pathological process in the arteries of the heart, and is of practical importance when choosing the method of surgical intervention in the case of ischemic disease hearts.

Rice. 52. Right-wing type of coronary circulation. Well developed posterior interventricular branches

Beginning of the coronary arteries . Sinuses of the aorta, from which the coronary arteries depart, James (1961) proposes to call the right and left coronary sinus. The orifices of the coronary arteries are located in the bulb of the ascending aorta at the level of the free edges of the aortic semilunar valves 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 A. S. Zolotukhin (1974) points out, 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, by wall of the ascending aorta.

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

under the blow of a stream of blood, not 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 to the myocardium, we revealed the predominance of the right coronary artery (Fig. 52). N. A. Javakhshivili and M. G. 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 coronary sulcus, located behind the base of the pulmonary artery and under the auricle of the right atrium. 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 by subepicardial fat. The diameter of segment I of the right coronary artery ranges from 2.1 to 7 mm. Along the artery trunk on the anterior surface of the heart in the coronary sulcus, epicardial folds are formed, filled with adipose tissue. Abundantly developed adipose tissue is noted along the artery from the sharp edge of the heart. The atherosclerotically altered trunk of the artery along this length is well palpated in the form of a cord. Detection and isolation of segment I 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 artery of the arterial cone, or the fatty artery - departs directly at the beginning of the coronary sulcus, continuing down to the right at the arterial cone, giving branches to the cone and the wall of the pulmonary trunk. In 25.6% of patients, we observed its common beginning 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 conus artery was located next to the mouth of the coronary artery, located behind the latter. In these cases, the vessel originated directly from the ascending aorta and was only slightly inferior in size to the trunk of the right coronary artery.

Muscular branches depart from the I segment 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 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 sharp edge of the heart). The artery of the acute edge of the heart, a constant 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 anterior-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 1 mm or less.

Continuing along the coronary sulcus, the right coronary artery goes 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 final branch of the right coronary artery - the posterior interventricular branch (III segment) - is located in the posterior interventricular groove, descending along it to the apex of the heart. V. V. Kovanov and T. I. Anikina (1974) distinguish three variants of its distribution: 1) in the upper part of the furrow of the same name; 2) throughout this groove to the top of the heart; 3) the posterior interventricular branch enters the anterior surface of the heart. According to our data, only in 14% of patients it reached

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 right angles, from 4 to 6 branches depart, supplying blood to the conducting system of the heart.

With a right-sided type of coronary blood supply to the diaphragmatic surface of the heart, 2-3 muscular branches extend from the right coronary artery, 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 lift the heart up and take it to the left. II segment of the artery is located superficially in the coronary sulcus; it can be easily and quickly found and selected. The posterior interventricular branch (III segment) is located deep in the interventricular groove and is covered by 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 handled carefully to avoid perforation.

The left coronary artery, participating in the blood supply to most of the left ventricle, the interventricular septum, as well as 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 the coronary sulcus of the heart. The initial section of the left coronary artery (I segment) before the bifurcation has a length of at least 8 mm and not 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, 3.5 to 7.5 mm in diameter, turns to the left between the pulmonary artery and the base of the left auricle of the heart and divides 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 the vascularization of the diaphragmatic surface of the heart. The diameter of segment II of the artery ranges from 2 to 4.5 mm.

It should be noted that a significant part of the anterior interventricular branch (segments II and III) lies deep, covered by subepicardial fat and muscle bridges. The isolation of the artery in this place requires great care because of the danger of possible damage to its muscular and, most importantly, septal branches leading to the interventricular septum. The distal part of the artery (IV segment) 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, from 2 to 4 septal branches extend deep into the myocardium, 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 depart to the myocardium of the left and right ventricles. The branches to the right ventricle are smaller in caliber than to the left, although they are the same in size as the muscular branches from the right coronary artery. A significantly larger number of branches extend to the anterior-lateral wall of the left ventricle. In functional terms, the 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 reference point 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 a thin layer of the epicardium.

The circumflex branch of the left coronary artery (V-VI segments) departs at a right angle to the main trunk of the left coronary artery, located in the left coronary sulcus, under the left auricle of the heart. Its permanent branch - the branch of the blunt edge of the heart - descends over a considerable distance at the left edge of the heart, somewhat backwards, and in 47.2% of patients reaches the apex of the heart.

After the branches depart to the blunt edge of the heart and the posterior surface of the left ventricle, the circumflex 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 posterior vein.

The V segment of the artery is easily detected, which is located in the fatty membrane under the ear of the left atrium 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 section of the circumflex branch (VI segment) is usually located on the posterior surface of the heart and, if necessary, surgical intervention on it, the heart is lifted and retracted to the left while pulling the left ear of the heart.

The diagonal branch of the left coronary artery (VII segment) 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 little expressed and is more 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 (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 origin, 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 sinoatrial node (S-A node artery, SNA). leaving 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 sinoatrial 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 circumflex). In the anterior part of the coronary sulcus, in the region of the acute edge of the heart, the right marginal branch departs from the right coronary artery (the branch of the acute edge, acute marginal artery, acute marginal branch, AMB), more often from one to three, which in most cases reaches the apex of the heart. Then the artery turns back, lies in the back of the coronary sulcus and reaches the "cross" of the heart (the intersection of the posterior interventricular and atrioventricular sulcus 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 classification of 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 have analyzed the literature on the anatomy and classification of the coronary arteries. Data from literary sources are compared with their own. A working classification of the coronary arteries has been developed in accordance with the nomenclature adopted in the English literature.

coronary arteries

From an anatomical point of view, the coronary artery system is divided into two parts - right and left. From a surgical standpoint, the coronary artery 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 (OC) and its branches, the right coronary artery (RCA) ) and its branches.

The large coronary arteries form an arterial ring and loop around the heart. The left circumflex and right coronary arteries are involved in the formation of the arterial ring, passing through the atrioventricular sulcus. The formation of the arterial loop of the heart involves 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. The arterial ring and loop are a functional device 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 origin, 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 sinoatrial node (S-A node artery, SNA). leaving 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 sinoatrial 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 circumflex). In the anterior part of the coronary sulcus, in the region of the acute edge of the heart, the right marginal branch departs from the right coronary artery (the branch of the acute edge, acute marginal artery, acute marginal branch, AMB), more often from one to three, which in most cases reaches the apex of the heart. Then the artery turns back, lies in the back of the coronary sulcus and reaches the "cross" of the heart (the intersection of the posterior interventricular and atrioventricular sulcus 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 groove for a different distance, 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) originates, 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 diaphragmatic surface of the left ventricle. . On the posterior surface of the heart, immediately below the bifurcation, at the point of transition of the right coronary artery to 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 artery (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 portion 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 goes 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 envelope (left circumflex artery, LCx) branches . In % of cases, the third branch departs here - the intermediate artery (ramus intermedius, RI), which crosses obliquely the wall of the left ventricle. LAD and OB form an angle between them, which varies from 30 to 180°.

Anterior interventricular branch

The anterior interventricular branch is located in the anterior interventricular sulcus and goes to the apex, giving off the anterior ventricular branches (diagonal, diagonal artery, D) and the anterior septal (septal branch)) along the way. In 90% of cases, one to three diagonal branches are determined. Septal branches depart from the anterior interventricular artery at an angle of approximately 90 degrees, perforate the interventricular septum, feeding it. The anterior interventricular branch sometimes enters the thickness of the myocardium and again lies in the groove and often reaches the apex of the heart along it, where in about 78% of people it turns back to the diaphragmatic surface of the heart and for a short distance (10-15 mm) rises up along the posterior interventricular groove. In such cases, it forms a posterior ascending branch. Here it often anastomoses with the terminal branches of the posterior interventricular artery, a 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 to the artery of the sinoatrial node, and then the artery of the obtuse marginal artery (obtuse marginal artery, obtuse marginal branch, OMB), usually from one to three. These fundamentally important 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 important atrial branches, which include the left atrial circumflex artery (LAC) and the large anastomosing auricular artery.

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 distribution of the right and left coronary arteries on the posterior surface of the heart.

The anatomical criterion for assessing the predominant type of distribution of the coronary arteries is the avascular zone on the posterior surface of the heart, formed by the intersection of the coronary and interventricular sulci, - 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 off a posterior interventricular branch, which runs along the posterior interventricular sulcus 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 noted that the branch to the atrioventricular node always departs from the predominant artery, i.e. from the artery, which is of the greatest importance in the supply of blood to the posterior surface of the heart.

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

With a predominant 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 a 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 contribute approximately equally to the blood supply to the posterior surface of the heart.

The concept of "primary 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 much 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 type 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, it is used to assess anatomical findings during coronary angiography and is of great practical importance in determining indications for myocardial revascularization.

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

Dotted lines in this scheme highlight the segments of the coronary arteries.

Thus, in the left coronary artery in the anterior interventricular branch, it is distinguished by three segments:

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 the discharge of 2DV.

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

1. proximal - from the mouth of the OB to 1 VTK.

3. distal - after the departure of 3 VTK.

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

1. proximal - from the mouth to 1 wok

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

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

Coronary angiography

Coronary angiography (coronary angiography) is an X-ray visualization of the coronary vessels after the introduction of a radiopaque substance. The x-ray image is immediately recorded on 35 mm film or digital media for further analysis.

Currently, 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 determining the location, extent, diameter and contours of the coronary arteries, the presence and degree of coronary obstruction, characterization of the nature of the obstruction (including the presence of an atherosclerotic plaque, thrombus, dissection, spasm or myocardial bridge).

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

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

The study is performed under local anesthesia and NLA through arterial access. The following arterial accesses are generally recognized: femoral arteries, brachial arteries, radial arteries. Transradial access has recently gained a strong position 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, the catheters and intraduser are removed, and a compression bandage is applied.

Basic angiographic projections

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 location and nature of the lesions.

To achieve this goal, coronary angiography of the right and left coronary arteries is performed in standard projections. (Their description is given below). If it is necessary to conduct a more detailed study, shooting is carried out in special projections. This or that projection is optimal for the analysis of a certain section of the coronary bed and allows you to most accurately identify the features of the morphology and the presence of pathology in this segment.

Below are the main angiographic projections with an indication of the arteries for visualization of which these projections are optimal.

For the left coronary artery, the following standard projections exist.

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.

Orifice and distal segment of the LCA trunk, middle and distal segment of the LAD, septal and diagonal branches, proximal segment of the OB, VTK.

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

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

ETIOLOGY

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

PATHOGENESIS AND PATHOLOGICAL ANATOMY

In the angiospathic 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 in response to an increase in myocardial oxygen demand (exercise). This is associated with a decrease in the production of ERF (endothelium relaxing factor) by the coronary endothelium, which is facilitated even by initial atherosclerotic changes in the arterial wall.

In the period of inadequate blood supply, there is always a 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 areas), and then to cardiosclerosis with the development of heart failure, arrhythmias, and valvular dysfunction. If more than 15% of the LV myocardium undergoes cicatricial changes, the ejection 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 post-infarction aneurysm, rupture of the interventricular septum, detachment of papillary muscles and acute mitral valve insufficiency. In the long term, postinfarction anerism, VSD and papillary muscle dysfunction (usually posterior) with mitral insufficiency may also develop. Necrosis of the endocardium and arrhythmias in the acute period of infarction are often accompanied by thromboembolism of the arteries of a large circle.

For the branches of the LCA (LCA 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 with any type of blood supply is the LAD (the anterior wall of the LV, the anterior part of the interventricular septum, the anterior leg of the bundle of His). In 2nd place - RCA (RV, posterior and part of the lateral wall of the left, posterior part of the interventricular septum, sinus and atrioventricular nodes, posterior part of the bundle of His). RCA is usually involved in the process with the right and middle-right type of blood supply. The 3rd place is occupied by 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 trunk of the LCA is affected the least (in 8%), but the prognosis is the most unfavorable.

Both intrasystemic and intersystemic anastomoses play an important role in coronary circulation compensation, the main of which are apical anastomoses (between the LAD and RCA).

CLASSIFICATION

1. Chronic ischemic heart disease (stable angina pectoris, variant angina pectoris, arrhythmic variant of coronary artery disease).

2. Unstable angina.

3. Myocardial infarction.

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

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

INSTRUMENTAL DIAGNOSIS OF IHD

The screening method for determining the presence of myocardial ischemia, foci of necrosis and scarring, allows you to approximately localize the affected area.

A standard 12-lead ECG (sensitivity - 75%) - reveals acute myocardial ischemia (angina attack or heart attack), post-infarction scar and rhythm disturbances.

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

ECG with physical activity: bicycle ergometry and terdmil test (sensitivity 50-85%) - reveals hidden coronary insufficiency.

Transesophageal pacing (same sensitivity as exercise tests) is 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 coronary artery disease; a test with ergometrine in an amount of up to 0.5 mg in steps i.v.

It allows diagnosing hypo- and dyskinesia of ventricular segments, wall thickness and dimensions of the ventricular cavity.

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

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

The Doppler mode makes it possible to detect turbulent flow in the heart cavities with organic damage to the valvular apparatus, VSD, turbulent blood flow through the LCA and LAD.

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

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

With 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. To obtain good serial images and evaluate LV EF, X-ray telephotography is necessary. Digital digital angiography allows, with a single injection of a contrast agent, to obtain a high-quality image of the entire coronary bed and evaluate LV contractility, as well as the kinetics of its individual segments.

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

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

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

Scanning with the isotope 201Thalium (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, 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 after 15 minutes (usually after 1-2 minutes). Retrosternal pain is easily stopped by taking nitroglycerin. Stable exertional angina is characterized by a stable clinical picture (the same physical activity, the same duration and frequency of attacks, the same subjective characteristics of attacks, the same doses of nitroglycerin required to stop an attack).

The most frequent rhythm disturbances in patients with coronary artery disease: ventricular extrasystole and conduction disturbances, less often - atrial fibrillation, paroxysmal tachycardia.

Functional classes of stable angina pectoris (Canadian Heart Association): 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 stress-rest angina pectoris.

Spontaneous rest angina is characterized by the occurrence of anginal status without regard to physical activity. At the same time, load tolerance is either not changed or even increased. The duration of the attack is 5-15 minutes (up to a maximum of 30 minutes). Spontaneous angina is caused by transient spasm of the coronary arteries. Quite rarely occurs in isolation and in 90% is combined with exertional angina (IV FC). Spontaneous angina that accompanies ST elevation is called variant angina (Prinmetal's angina).

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

Ultrasound, coronary ventriculography - verification of the diagnosis, evaluation 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, the prevention of thrombosis in the coronary arteries, the treatment of concomitant arterial hypertension and diabetes mellitus.

The main drugs in the conservative treatment of coronary artery disease: nitrates, -blockers and calcium antagonists.

NITRATES - improve coronary perfusion, especially in ischemic areas (there is 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 (the most powerful vasodilator and antiaggregant). For the relief of anginal status, nitrates of fast, but short-acting are used. The effect occurs most quickly after sublingual administration of nitroglycerin (beginning - after 1-2 minutes, duration - up to 30 minutes. Nitrosorbide preparations (isosorbide dinitrate, cardiket -20) are characterized by a slower onset of the effect (after 10 minutes), but a longer duration of action (3 -4 hours). Long-acting nitropreparations are used to prevent angina attacks. The speed of the onset of the effect is in minutes, and the duration of action is an hour. These include prolonged forms of nitroglycerin (sustak, nitrong, Deponit patch, Nitro-Mac Retard) and prolonged forms of isosorbide dinitrate (cardiquet-40, cardiquet-60, isoket, Mono-Mac Depot, Efox).The drug cardiquet-120 contains two fractions - instant (effect after 20 minutes) and slowly soluble - effect after 1 hour with a duration of 15 hours.

NON-SELECTIVE -ADRENOBLOCKERS. They reduce the heart rate while increasing their strength, reduce afterload, contribute to the redistribution of myocardial blood flow in favor of ischemic zones and improve oxygen delivery to ischemic tissues. Contraindicated in patients with a tendency to bradycardia. Short-acting drugs: propranolol (anaprilin, obzidan), whisken. Long-acting drugs - corgard, trazikor.

CALCIUM ANTAGONISTS. Reduce the force of myocardial contraction, improve coronary perfusion, reduce afterload. Preparations: verapamil (Isoptin, Finoptin), nifedipine (Corinfar). Verapamil has a more pronounced antiarrhythmic effect (slows down AV conduction, inhibits the function of the sinus node), while nifedipine has more pronounced peripheral vasodilation.

Normalization of lipid metabolism: mevacor, zocor.

Prevention of thrombus formation: tiklid, aspirin.

Annual mortality with conservative therapy is 3-9% per year.

Angina pectoris FC III-IV.

Postponed MI in history, even without a clinic of angina pectoris.

LCA trunk stenosis more than 50% even without an angina clinic (very often immediately begins with extensive MI).

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

First performed by Gruntzig in 1977.

Principle: a balloon dilation 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 atmosphere for up to 3 minutes, as a result, the plaque is crushed. At the end of the procedure, it is obligatory to measure the pressure in 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 vessel stenting (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 arterial occlusion, intimal dissection, acute myocardial ischemia).

New angioplasty technologies: laser recanalization – with the help of “cold” laser radiation (at the end of the light guide), a channel is made in the lumen of the occluded artery, then balloon angioplasty is performed; rotary recanalization - a canal is drilled in the occluded artery with the help of a rotating crescent-shaped blade with a diamond coating; rotational atherectomy - atherosclerotic plaque is cut off using an atherectomy catheter with a container and a knife inside.

Indications for angioplasty: single stenosis of any of the coronary arteries (except for the main trunk of the LCA), single stenosis 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.

Lethality is 1.2%, the nearest positive result is in 90%, during the 1st year 40% have restenoses. The frequency of complications requiring emergency surgery is not higher than 6%.

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

The AKSH was first performed by Michael De-Becky in 1964, and the MKSH 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 performed only under IR conditions on a "dry heart", preferably with the use of optics (2-4 times magnification); 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 the same time), however, no more than 4 anastomoses are applied to the aorta (therefore, jumping, sequential and bifurcation shunts are used); first, LAD is shunted, then OA and RCA; usually impose first coronary anastomoses, then - aortic (Yu.V. Belov - in reverse order); during the operation, the function of the shunt is monitored with a flowmeter (the blood flow through the shunt is not less than 50 ml.min). Currently, no more than 4 shunts are considered optimal (stealing the rest).

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

The 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 younger than 75 years - 1.4%, in patients with angina pectoris without a history of myocardial infarction - 0.5%.

Five-year survival 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 1st year, the patency of CABG remains in 80% of patients, then the frequency of bypass occlusions is 2% per year, and after 5 years - 5% per year. Outcomes are better after MKSH (which is why CABG and MKSH are currently combined). In women, the results are 2.5 times worse.

In case of damage to 1 CA (excluding the LCA trunk), the results of CABG are comparable with the results of conservative therapy. When 2 or more CAs are affected in FC I-II angina pectoris, surgical treatment improves the quality of life, saves the patient from angina attacks and the constant use 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 (by a catheter).

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

UNSTABLE ANGINA

Changing the nature of anginal attacks (especially the duration of more than 15 minutes and the need to use large doses of nitroglycerin for their relief), to a lesser extent their frequency and intensity.

The appearance of attacks of angina pectoris against the background of existing angina pectoris;

First-time angina pectoris (prescription up to 1 month).

Angina at rest in the early period (the first 2 weeks) after MI.

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

Unstable angina is always associated with atherosclerotic plaque instability. In this case, ulceration, tearing of the plaque, hemorrhage into the plaque occurs. All of the above leads to the development of parietal thrombosis and prolonged coronary spasm with a sharp decrease in the lumen of the coronary artery, as well as to arterioarterial embolism of the vessels of the distal bed.

Clinic. ECG with obligatory Holter monitoring.

Normal levels of the MB-fraction of CPK, AST, LDH (unlike MI).

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

With unstable angina, the patient should be hospitalized in the intensive care unit for 48 hours (acute period), where he should be given full intensive care as in MI. 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: intravenous heparin, aspirin or ticlid. 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 the 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, emergency CABG is performed.

Mortality in elective surgeries for NS is 4%, for emergency surgeries - 10%.

ACUTE MYOCARDIAL INFARCTION

In the vast majority of cases, the cause of MI is coronary artery thrombosis, a smaller role is assigned 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), a zone of myocardial necrosis is determined histologically and macroscopically, processes of inflammation and lysis of necrotic cardiomyocytes begin, after 10 days (subacute period) scarring processes develop and a soft scar from granulation tissue is formed by the end of 4-8 weeks, by the end of 6 months a dense post-infarction scar is formed.

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

Anginal 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 arrhythmias.

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

An increase in the MB-fraction of CPK, AST, LDH1 and 5 with mandatory normalization by 2-3 days (CPK), by 4-5 days (AST and x-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. Mandatory -alrenoblockers and calcium antagonists (reduce the zone of ischemia), adequate anesthesia with narcotic analgesics. With the development of cardiogenic shock - TABA. The period of stay in the intensive care unit is 10 days (danger of developing severe complications).

Emergency intracoronary fibrinolytic and antithrombotic therapy followed by balloon angioplasty are effective if no more than 6 hours have passed since MI.

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 MI less than 6 hours old, early recurrence of angina pectoris after MI.

Mortality in CABG up to 6 hours - 5%, at a later date - 10%. 5-year survival 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 a transmural infarction.

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

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

Tactics: absolute indication for surgical treatment (usually in combination with CABG, which precedes resection of the aneurysm). Methods - anerism resection, anerismoraffia and aneurysm plication (for small anerisms).

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

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

Tactics - surgical treatment (VSD plastic surgery after CABG).

It develops either due to infarction of the papillary muscles with their subsequent rupture (acute mitral insufficiency), less often due to ischemia of the papillary muscle (chronic mitral insufficiency).

With a 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.

← previous
Cardiac surgery: modern stage
Violation of blood flow in the coronary arteries
next →

st. Vorovskogo, d. 64, Chelyabinsk, Chelyabinsk region,

Educational bases of the department CHOKB No. 1, st. Vorovskogo, d. 70 Clinic of SUSMU, st. Cherkasskaya, d. 2 MBUZ GB No. 6, st. Rumyantseva, 24

Department of Hospital Surgery South USMU - postgraduate education of physicians in the following specialties: general surgery, cardiovascular surgery (angiosurgery, cardiac surgery).

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

Stenosis of the pca 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 A Functional class 3. Hypertensive heart disease 3 tbsp, arterial hypertension 1 tbsp. The risk of CCO 4 tbsp.

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

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

what does "take off" mean? A stent is a special reinforced tube that is inserted into the vessel and does not allow it to narrow. 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 still expensive drugs that prevent the formation of blood clots in the vessels. it's about six months.

the land in the cemetery, the coffin and funeral accessories 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 don't delay making a decision.

Recanalization of chronic RCA occlusion.

06/22/11 Patient No. 30253. Age: 55 years old. Enrolled in NPTsIK with a diagnosis of coronary artery disease: angina pectoris 2 FC. Hypertension stage II.

From the anamnesis: Fluctuations in blood pressure were detected in 2007, with a max of 180/120 mm Hg, adapted to / 75-80 mm Hg. Art. In 2007, ECG revealed cicatricial changes without a coronary anamnesis, since that time, under heavy loads, he began to notice pressing pains in the precardiac region, passing at rest (before that, he had not paid attention to pain syndrome). On March 31, 2011, when accelerating his pace, he noted a prolonged pain attack - he was hospitalized in the 50th City Clinical Hospital with progressive heart failure. Examined: VEM - doubtful (decrease in blood pressure on exercise with ST depression max. up to 0.7 mm). XM-ECG: 5 episodes of ST depression up to 3.3 mm.

Procedures performed: 24.06.11, CAG was performed in a planned manner, in which: The type of coronary circulation is right. The barrel of the LKA is short, practically absent. LAD moderate diffuse changes in all departments without hemodynamically significant stenosis. The circumflex branch is represented by a developed VTC, in media/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.

Accomplished: The first stage was direct stenting of the middle segment of the OB with a 3.5 x 20 mm stent with a good immediate angiographic result. The second stage was 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 in the area of residual stenosis. At the control angiography of the RCA, the stent deployment was complete, positioning was adequate, and the main blood flow was restored.

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

LCA arteriography (RAO/LAO 0; CAUD 30). 90% media stenosis/3 RH.

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

Stent implantation in the affected segment of the OB.

Control angiography of LCA. Good result of stenting.

Stage of conduction recanalization of media occlusion/3 RCA.

PTAP of the occluded segment with a balloon.

Control angiography after predilatation. Residual stenosis is visualized in the previously occluded segment and a parietal contrast defect distally.

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.

Stenosis of the pca 90

A 69-year-old man, suffered his first posterior wall infarction in 2006, concomitant diseases: hypertension. For almost 20 years she has been suffering from hypertension, her blood pressure is over 200. She constantly takes drugs that regulate blood pressure (Diroton), as well as some heart drugs (cardiitis, and some others, I can’t write for sure yet, 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 uncontrolled blood pressure. He was in the hospital, discharged with improvement, with a new drug regimen selected, but the pressure was sharply reduced, he began to suffer from hypotension, switched to his usual regimen, and the situation stabilized. By the winter of 2013, angina pectoris attacks resumed and became pronounced; he did not leave the house without nitrospray.

On 01/05/2014, with a heart block, he was taken to the hospital, where on 01/12/2014 in the morning there was a 2nd 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 Cardiology 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 cardiocenter on January 13, 2014 (on the next day after a heart attack)

Directional diagnosis: coronary artery disease. Angina pectoris FC4.

Final diagnosis: coronary artery disease. Atherosclerosis of the coronary arteries: two stenoses of the RCA in n\W 90%, in d\W 65%. Stenosis of OB in s\W 90%, in d\W 50%. Stenosis of VTK1 in n\W more than 50%. LAD stenosis in n\W up to 50%.

We agree to the operation. Question about time. The doctor argues that the father (the patient is my father, I was left alone.) Now the operation is not indicated, no one in Russia operates after a heart attack. I need at least two months of rehab, and I'm afraid of being late. Please forgive me for the meager important information and abundant unnecessary. Ready to fight to the last. Dad has four grandchildren, three of which are my little kids. I really want him to live as long as possible.

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

Post comments:

Abugov Sergey Alexandrovich.

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

How can we be? And how to argue?

Dad was released from the hospital. I am attaching the extract. He feels satisfactory, moderately active, ready for surgery. My question to the respected doctors consulting here on the forum:

Disturbed by pain under the shoulder blade on the left. Sometimes a burning sensation is felt. Pain not after physical activity, may occur at rest. Nitrospray attacks are not stopped at all. The pain is relieved with analgin (tramadol in the hospital). Interval at least every other day. Approximately once a day. With such pains in the hospital, they did an ECG - they said that there was no deterioration. The doctor explained that it was osteochondrosis. Is it true??

Where should 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, damage to blood vessels inevitably leads to damage to all organs.

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

Classification of arterial stenoses

SLCA 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

Vessels that are located in the heart are called coronary. 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 disruption of the rhythm and rate of contractions of the ventricles.

The consequences of delayed medical care can be very serious. Due to stenosis of the RCA trunk, the following ailments can rapidly develop:

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

But in medical practice, this disease is quite rare.

Stenosis of the trunk of the left coronary artery

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

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

Symptoms of stenosis of the left coronary artery

With STLC, a person feels a breakdown. First, his general condition worsens, inoperability, drowsiness are observed.

As the disease progresses, the following symptoms may appear:

Breathlessness.
Frequent headaches and migraines.
Discomfort in the chest.
Attacks of angina pectoris during physical exertion and emotional overstrain.
Nausea, etc.

Consequences of STLKA

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

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

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

Tandem coronary artery stenosis

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 affected, the second one 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 - a lethal outcome. To get rid of this disease, you need surgery to replace or restore damaged coronary arteries.

Stenosis of the vertebral arteries

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

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

Symptoms of stenosis of the vertebral arteries

The main symptoms of VA stenosis are:

Severe headaches that often turn into migraines.
Nausea and vomiting.
Strong dizziness.

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

Consequences of stenosis of the vertebral arteries

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

The lack of timely medical care for a stroke or advanced stenosis of the vertebral artery can be fatal.

Femoral artery stenosis

The next type of stenosis is stenosis of the femoral artery. In this case, stenosis and occlusion of the lower extremities are interrelated and interchangeable concepts. The flow of blood to the legs is significantly worsened, swelling is observed. Edema 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 disease include:

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

Consequences of stenosis of the femoral artery

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, swelling and tumors, immediate amputation of the limb is required. This is necessary to prevent the risk of an increase in the affected area.

Stenosis of the iliac artery

The iliac artery is the second largest artery in the human body. Violations 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 inoperability.
Drowsiness.
Lameness.
Loss of sensation in the limbs.
Blueness or redness of the skin.
Swelling of the lower extremities.
Impotence syndrome, etc.

The consequences of the disease

With stenosis of the iliac artery, tissue metabolism slows down significantly. The 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 prevents 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 risk of complete cardiac arrest or myocardial infarction in the patient. 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

Cardiac stenting: reviews

CORONARY STENTING

Cardiologist - a site about diseases of the heart and blood vessels

Cardiac surgeon online

conduction system of the heart

sinus node

AV node

Bundle 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 lesion

Who to contact?

Technique of coronary angiography

Arterial accesses for coronary angiography

Abbreviations in cardiology

Pna heart it

Signs and treatment of coronary artery occlusion

Causes

Symptoms

Treatment

Cardiologist - a site about diseases of the heart and blood vessels

Cardiac surgeon online

conduction system of the heart

sinus node

AV node

Bundle of His and its branches

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

What is the essence of stenting

Cardiac stenting: reviews

Related articles: It's important for everyone to know! Signs of heart diseaseWhat is important to know about the vessels of the brainAneurysm of the heart - is surgery always necessary?Cardiac bypass surgery: important about the operation

Comments

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 projections

ETIOLOGY

PATHOGENESIS AND PATHOLOGICAL ANATOMY

CLASSIFICATION

INSTRUMENTAL DIAGNOSIS OF IHD

CHRONIC ISCHEMIC HEART DISEASE

UNSTABLE ANGINA

ACUTE MYOCARDIAL INFARCTION

SURGICAL TREATMENT OF IHD COMPLICATIONS

Stenosis of the pca 90

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

Recanalization of chronic RCA occlusion.

Stenosis of the pca 90

arterial stenosis

Classification of arterial stenoses

Stenosis of the trunk of the right coronary artery

Stenosis of the trunk of the left coronary artery

Symptoms of stenosis of the left coronary artery

Consequences of STLKA

Tandem coronary artery stenosis

Stenosis of the vertebral arteries

Symptoms of stenosis of the vertebral arteries

Consequences of stenosis of the vertebral arteries

Femoral artery stenosis

Symptoms of femoral artery stenosis

Consequences of stenosis of the femoral artery

Stenosis of the iliac artery

Symptoms of iliac artery stenosis

The consequences of the disease

critical stenosis

Related articles:
It's important for everyone to know! Signs of heart disease
What is important to know about the vessels of the brain
Aneurysm of the heart - is surgery always necessary?
Cardiac bypass surgery: important about the operation