Coronary circulation and

innervations of heart
Dr Yasrul Izad Abu Bakar
Faculty of Medicine, UniSZA
 Learning outcome
• Describe origin, course, branches, area of supply and
dominance of coronary arteries

• Discuss the venous drainage of heart

• Describe the innervations of the heart (sympathetic and

parasympathetic)

• Describe the conducting system of the heart

• Discuss the clinical applications. (Myocardial infarction,

angina pectoris, coronary bypass grafts)
 Introduction: Blood supply of heart
• Blood vessels of heart
comprise of coronary arteries
& cardiac veins, which carry
blood to & from the
myocardium & epicardium

• The endocardium receives O2

& nutrients by diffusion
directly from the heart
chamber
 Introduction: Blood vessels of heart
Blood vessels of heart:

• course across the surface

of heart just deep to
epicardium & usually
embedded in fat

• affected by sympathetic &

parasympathetic
innervation
 Orientation of heart

Left
Right
Right

Anterosuperior Posteroinferior
view view
 Coronary arteries (CA)
• Arteries supplying the heart Left coronary
artery
is called coronary arteries

• There are 2 coronary arteries

(CA):
1. Right coronary artery
2. Left coronary artery
Right coronary
artery
 Coronary arteries
Both:
Aorta
• First branches of aorta Left coronary
artery

• Arise from the aortic sinuses in the

initial portion of ascending aorta
(just superior to the aortic valve)

• Circle the heart in the coronary

sulcus (corona = crown)

• Usually embedded in fat

Right coronary
artery
• Supply both atria & ventricles
Anterosuperior
view
Coronary arteries

Coronary artery
embedded in fat
• Coronary arteries arise from the aortic sinuses in the initial portion of ascending
aorta (just superior to the aortic valve)

Opening of right Opening of left

coronary artery coronary artery

Left aortic
sinus

Right aortic
sinus
 Right coronary artery
• Smaller than left CA
• Origin: right aortic sinus of ascending aorta

Course:
• Emerges in between the right auricle and
pulmonary trunk

• Then it descends in the coronary sulcus (groove)

between right atrium & right ventricle Right CA

• At the inferior border of heart, it turns to the left

to reach the diaphragmatic surface of heart

• Runs in the coronary sulcus to reach posterior

interventricular groove

• Terminates by anastomosing with circumflex

branch of Left CA
Circumflex
branch
 Right coronary artery AV
nodal
Branches of Right coronary
artery:
Post
IV
a. Large branches
1. Right marginal (near inferior
border of heart) Right
2. Posterior interventricular Marginal
(lies in posterior IV sulcus)
SA
nodal
b. Small branches
1. Right atrial - SA Nodal (60%)
2. AV nodal (at the crux of the
heart) Right
atrial

• Crux of heart = the junction of septa Right

& walls of 4 heart chambers Marginal
 Right coronary artery
Area of supply:

1. Right atrium

2. Ventricles
- greater part of right ventricle
- part of left ventricle (diaphragmatic
surface)

3. Posterior part of IV septum (1/3)

4. SA node (60%)

5. AV node (80%)
 Left coronary artery
• Larger than right CA Left CA

• Origin: left aortic sinus of

ascending aorta Circumflex

Course:
• Emerges between pulmonary
trunk & left auricle
Ant.
IV
• Divides:
1. Anterior interventricular
branch (left anterior
descending: LAD)

2. Circumflex branch
 Left CA
Left coronary artery
1. Anterior interventricular
Ant.
branch IV

- runs downwards in anterior

IV groove towards the apex
Post IV
- turns around the inferior branch
border of heart &
commonly anastomoses
with posterior IV branch of
Right CA
Ant.
IV
 Left CA Circumflex
Left coronary artery
2. Circumflex branch

- runs in the coronary sulcus

- towards the
base/diaphragmatic surface Circumflex

of heart

- usually ends before reaching

the posterior IV sulcus
Right
coronary
- anastomoses with _______.
artery
 Left
marginal
Left coronary artery
Branches of Left coronary
artery:

a. Large branches IV septal

1. Anterior interventricular
2. Circumflex

Diagonal
b. Small branches Left
marginal
1. Diagonal
2. Left marginal
3. IV septal
4. Posterior left ventricular
Post. Left
ventricular
 Left coronary artery
Area of blood supply:
1. Left atrium

2. Left ventricle (most)

3. Anterior part of IV
septum (2/3)

4. AV bundle (of His)

5. SA node (40%)
 Cardiac dominance
• Dominance of coronary arterial
system is defined by which coronary
artery that gives rise to the posterior
IV branch (posterior descending
artery: PDA)

• Posterior IV branch supplies adjacent

areas of both ventricles & IV septum
(posterior)

• Heart with Right Dominant is more

common where the PDA is supplied
by the RCA (~85%)

• Dominant because it supplies the

inferior 1/3 of IV septum of the heart Post. IV branch of
right CA
 Variations of coronary arteries may occur

Right CA

Left CA

Right dominance Left dominance

 Mr. X
65 y.o man, heavy smoker, came to you with
complaint of:
• Sudden severe central chest pain
• Started after gardening

Associated with:
• Pain over the left arm
• Difficulty in breathing

Differential diagnosis???
 Mr. X
Coronary angiography:

• narrowing of the
proximal left
anterior descending
coronary artery

• Diagnosis:
ischaemic heart
disease

• Treatment option:
angioplasty /
coronary artery
bypass graft
 Clinical application:
Coronary artery disease (CAD)
• Result from reduced blood
supply to myocardial tissue
due to obstruction in coronary
artery e.g. IHD & MI

Ischaemic heart disease (IHD):

• due to narrowing of coronary
arteries
• Lead to reduced O2 supply to
myocardium
• Angina pectoris is a severe
pain due to IHD
 Clinical application:
Coronary artery disease (CAD)
Myocardial infarction (MI)
• commonly called heart
attack
• MI means death of area of
cardiac tissue due to total
blocked of coronary arteries

Common site of major arterial

occlusion:
1. Anterior IV (40-50%)
2. RCA (30-40%)
3. Circumflex (30-40%)
 Clinical application: CABG
Coronary artery bypass grafting (CABG)
surgery:

• Surgical treatment for some patient

with CAD

• A segment of artery/vein is connected

between ascending aorta & coronary
artery distal to the blockage

• The great saphenous vein is commonly

harvested for CABG

• CABG shunts blood from aorta to

increase blood flow distal to
obstruction
 Venous drainage of heart
The heart is drained: Coronary
sinus

1. Mainly, by veins that

empty into coronary
sinus

2. Partly, small veins that

empty directly into
heart chambers
Cardiac vein: coronary
sinus
Coronary
Coronary sinus: sinus
• Is the largest (main) vein
in the heart

• Situated in the posterior

part of coronary sulcus

• About 3cm long

• Finally empties into the

posterior wall of right
atrium
 Great cardiac v.

Coronary sinus
• Main tributaries of
coronary sinus:

1. Great cardiac vein

Oblique v. of Lt
2. Middle cardiac vein ventricle Small
cardiac v.

3. Small cardiac vein Great

cardiac
4. Posterior vein of left v.
ventricle
Posterior
5. Oblique vein of left atrium (of v. of Lt
Marshall) ventricle Middle
cardiac v.
 Great cardiac v.
Coronary sinus: tributaries
1. Great cardiac vein
• Main tributary of coronary sinus
• Accompanies the anterior IV branch &
circumflex branch of LCA
• Connected at left end of coronary
sinus
• Drains area supplied by LCA Great
cardiac
v.
2. Middle cardiac vein
• Accompanies posterior IV branch of
RCA
• Connected at right end of coronary
sinus Middle
cardiac v.
 Coronary sinus: tributaries
3. Small cardiac vein
• Accompanies right marginal branch of RCA
• Connected at right end of coronary sinus
• Together with middle cardiac vein drain the
area supplied by RCA Oblique
vein Small
cardiac v.
4. Posterior vein of left ventricle
• Accompanies posterior ventricular branch
• Connected at left end

5. Oblique vein of left atrium (of Marshall)

• Is a small vessel
• Relatively unimportant postnatally Post v. of
• Remnant of embryonic left SVC Left
ventricle
 Veins of heart
Small veins of heart include:

1. Anterior cardiac veins

• directly empty into right atrium

2. Smallest cardiac veins (venae

cordis minimae)
• are minute vessels begin in
capillary beds of myocardium
• directly open into chambers of Anterior
heart (mainly atria) cardiac
v.
 Nerve supply of heart
• Heart is supplied by autonomic nerve
fibres from the cardiac plexus

Sympathetic innervation:
• Derived from T1-T4/T5 segments of
spinal cord
• Cardio-acceletory (increases heart rate &
impulse conduction, increases force of
contraction, dilates coronary arteries)

Parasympathetic innervation:
• Derived from vagus nerves (CN X)
• Cardio-inhibitory (reduces heart rate &
force of contraction, constricts coronary
arteries)
Nerve supply Right Left
vagus n. vagus n.
of heart
• Parasympathetic:
from vagus nerves
(10th Cranial Nerve)

• Sympathetic: Thoracic
(sympathetic) Thoracic
from T1-T4/T5 cardiac (sympathetic)
segments of spinal branches
cardiac branches
cord
 Nerve supply of heart
• Both sympathetic &
parasympathetic nerves form the
cardiac plexuses

• Cardiac plexuses can be divided

into:
Deep
cardiac
1. Superficial cardiac plexus plexus
• Situated below arch of aorta

2. Deep cardiac plexus

• Lying on anterior surface of Superficial
bifurcation of trachea cardiac
• Posterior to ascending aorta plexus
 Nerve supply Right Left
of heart vagus n. vagus n.

The nerve fibres from

cardiac plexus are
distributed along the
coronary vessels &
supply:

1. Coronary vessels Thoracic

(sympathetic) Thoracic
cardiac (sympathetic)
2. The conducting branches
cardiac branches
system
(particularly SA
node)
T1-T5 segments
of spinal cord
 Mr. X
• Why pain over the left arm???
 Clinical importance
Cardiac referred pain:
• In IHD or MI, pain fibres are
stimulated

• These visceral sensory fibres

follow the course of
sympathetic fibres (T1 – T4)

• T1 – T4 spinal segment also

have somatic innervation on
skin (dermatome)

• Referred pain may also felt at

chest & left upper limb
 Conducting system of heart
Cardiac conduction system:
• initiates & coordinates the contraction of
atrium & ventricle

• can be affected by coronary artery disease

• consists of nodes & network of specialized

cardiac muscle cells (conducting fibres)
organized into 4 basic components:

1. Sinu-atrial (SA) node

2. Atrioventricular (AV) node

3. Atrioventricular (AV) bundle (with right &

left branches)

4. Purkinje fibres (subendocardial branches)

 Conducting system of heart
In general,

• Cardiac excitation begins in SA

node

• Impulse travels through both atria

& AV node

• Then enters AV bundle (bundle of

His)

• Then enters right & left bundle

branches

• Purkinje fibres (terminal branches

of bundle branches) conduct the Nodal tissue initiates heart beat &
impulse to apex & ventricular
myocardium coordinate contractions of hearts
chamber
 Sinuatrial (SA) node
Consists of small collection of SVC
nodal tissue, specialized cardiac
muscles fibres & fibroelastic Crista
connective tissue terminalis

• Located anterolaterally deep to

the epicardium at the junction
between SVC & right atrium
(near the upper part of sulcus terminalis)

• Initiates & regulates impulse

for contraction (rate of 70/min) SA node

• The impulse travels through

both atrial wall (myogenic
conduction) to reach AV node
 SA node
SA node
• Is the natural pacemaker of
heart
SA nodal
• Stimulated by sympathetic artery
innervation to accelerate heart
rate

• Inhibited by parasympathetic
to return to basal rate

• Supplied by SA nodal artery

(branch of right coronary
artery)
 Atrioventricular (AV) node
• Smaller than SA node

• Located in the postero-inferior part

of atrial septum (near the opening of
coronary sinus)

• Generates impulses at rate of 60/min

• Distributes impulse to ventricles

through the AV bundle

• Sympathetic speeds up conduction Coronary

sinus AV node
• Parasympathetic slows down
conduction opening
 AV bundle (of His)
Begins as the AV node Left
branch
crosses AV ring Right
branch

• Descends along the

membranous part of
interventricular septum
(IVS)

• At the upper part of the

muscular part of septum, it Right AV
fibrous ring bundle
divides into right & left of tricuspid
branches valve
 AV bundle (of His)
• Is the only
myocardium
connection
between atrial
& ventricles

AV
bundle
 Bundle branches
• Right & left bundle Left
bundle
Right
branches proceed on each bundle
side of muscular IVS deep
to endocardium

• Then ramify into

subendocardial branches
(Purkinje fibres) which
extend into the walls of Subendocardial branches
(Purkinje fibres)
respective ventricles
 Right Bundle branch
• Pass down the right side of IVS

• Mostly enters the Right

septomarginal trabeculae bundle
(moderator band) to reach
anterior wall of right ventricle

• Divides into Purkinje fibres

(subendocardial branches)

• Stimulates muscle of IVS,

anterior papillary muscle Moderator
(through moderator band) & wall of band
right ventricle
Moderator band
- is found in right
ventricle

- extends from IV
septum to the base of
anterior papillary
muscle

- important because of
the presence of Right
Bundle Branch

- facilitate conduction
time thus allowing
coordinated
contraction of the
anterior papillary
muscle
 Left Bundle branch
• Descends on left side of IVS

• Divides into approximately 6

smaller tracts

• Distributed to left ventricle after

dividing into Purkinje fibres
(subendocardial branches)

• Subendocardial branches
stimulates muscle of IVS,
anterior & posterior papillary
muscles, & wall of left ventricle
 Purkinje Fibres
• Form
subendocardial
plexus
• Terminal branch of
conducting system

Under light
microscope:
• Large pale fibres
• Usually posses
double nuclei
 Clinical application: Heart block
• Damage to conducting
system of heart may result
from ischaemia caused by
CAD (coronary artery disease)

• Occlusion of RCA (supplies SA &

AV node) or anterior IV branch
(supplies AV bundle) may cause
heart block or bundle branch
block

• In some patient with heart

block, an artificial cardiac
pacemaker is inserted
subcutaneously
 Clinical application: cardiac arrythmias
Cardiac arrhythmias:
Defects in normal rhythm of
cardiac contraction

• Due to defects in conducting

system

• Vascular lesions of heart

may also cause arrhythmias

• The passage of impulses

over the heart from SA node
can be recorded as
electrocardiogram (ECG)
 Thank you

Emel: yasrulizadh@unisza.edu.my
Ext: 5557