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Adult Autopsy
Published in Cristoforo Pomara, Vittorio Fineschi, Forensic and Clinical Forensic Autopsy, 2020
Cristoforo Pomara, Monica Salerno, Vittorio Fineschi
The pulmonary valve and the aortic valve are viewed from above. Following palpation, a horizontal incision is made approximately 2 cm above each of the valves by using a pair of sharp-ended scissors. Observation of the right and left aortic sinuses is made by the identification of the origins of the two coronary arteries. Two sets of incisions are made at specific points of the ventricular walls of both the left and right sides of the heart using a blunt-ended scalpel, in order to create two flaps. One pair of incisions is made roughly 1 cm above the atrioventricular groove on the left side of the heart. The first cut is made approximately 1 cm to the left of the LAD and the second 1 cm to the right of the posterior interventricular sulcus. These two incisions are then extended to meet at a point approximating the apex. The same procedure is repeated for the right side of the heart. This time the first cut is made 2 cm to the right of the anterior interventricular sulcus, while the second one is made along the right marginal artery. In this way, two triangular flaps are created to reveal the underlying mitral and tricuspid valves on the left and right sides, respectively. Observation of muscular ridged (trabeculae carneae) is made. Papillary muscles and chordae tendineae are subsequently identified. The results of heart valve dissection reveal that the three semilunar cusps of the aortic valve are similar to, but thicker and stronger than, the pulmonary valve cusps. Muscular ridges, called trabeculae carneae, which characterize the right ventricle’s inner wall, are identified, and a few of them are ridges, while others bridge a small area of the ventricular surface. On observation, the three cusps of the tricuspid valve were identified: septal – recognized as having a medial orientation adjacent to the septum – anterior, and posterior. Meanwhile, on observation of the mitral valve (left atrioventricular valve), its two cusps are observed. Papillary muscles are seen to attach to the anterior and posterior cusps of this valve by means of chordae tendineae in a manner similar to that observed in the right ventricle (Figure 2.169a–e).
Autopsy Cardiac Examination
Published in Mary N. Sheppard, Practical Cardiovascular Pathology, 2022
The LCA originates in the left (anterolateral) aortic sinus and passes undivided for up to 2.5 cm as the left main stem coronary artery between the aorta and the left atrial appendage (Fig. 1.9). With the vessel wedged between the aorta, the pulmonary artery and the left atrial appendage, it may be difficult to visualize deep within fat. I usually identify the LAD vessel in the anterior interventricular groove first close to the apex and work my way back up to the dividing vessels and then to the left main stem. The left main stem generally bifurcates into LAD and Cx, 10–15 mm beyond the ostium (Fig. 1.9). In about one-third of individuals, it trifurcates. The branch between the anterior descending and circumflex branches is called the intermediate branch (Fig. 1.11). The LAD passes in the anterior interventricular sulcus towards the apex. During its course, it gives a variable number of branches (diagonal branches) to the left ventricle (Fig. 1.11). These often become intramural covered by muscle distally. These, together with LAD, are important for arterial and vein grafting. The first diagonal branch is a major vessel which originates in the proximal third of the LAD. It may reach the apex of the heart and is quite often submerged in muscle for part of its length. When the LCA trifurcates, this first diagonal branch is replaced by the intermediate branch. In addition to the diagonal branches passing to the left ventricle, there are smaller branches passing to the RV. These infundibular branches to the outflow component of the RV often anastomose with branches from the right coronary artery. In addition to the diagonal and right ventricular sprigs, the LAD gives a number of branches passing from its underside (epicardial aspect) vertically downwards into the anterior interventricular septum. These important arterial branches are the septal branches, sometimes also called the septal perforators. They are variable in number and site of origin, except for the first branch. The ‘first septal’ artery is a relatively large branch (1–2 mm in diameter), which originates from the LAD close to the origin of the first diagonal branch. This branch can become greatly enlarged in coronary artery disease. It is also the branch which is selectively occluded by alcohol injection to induce infarction in the upper septum in left ventricular outflow obstruction associated with hypertrophic cardiomyopathy. The LAD becomes smaller as it descends in the interventricular groove and identification may be impossible as it mingles with the diagonal branches in the lower half of the groove. Luckily, most pathology is in the proximal part of the vessel where assessment of stenosis is important. The 1 mm probe test cannot be done on the distal LAD below the midventricular slice as the vessel becomes small in diameter. Also, the distal vessels often have an intramural course, covered by strands of muscle in the normal heart.
Should we routinely assess coronary artery Doppler in daily echocardiography practice?
Published in Acta Cardiologica, 2022
Angela Zagatina, Nadezhda Zhuravskaya, Martin Caprnda, Haaris A. Shiwani, Katarina Gazdikova, Luis Rodrigo, Peter Kruzliak, Dmitry Shmatov
The possibility of ultrasound coronary artery imaging was demonstrated in the 1980s [7]. In the 80 s-90s and early 2000s, the visualisation of coronary arteries was challenging, and it was only feasible to assess small parts of arteries using high-frequency probes and the transoesophageal approach. However, in recent years using a new ultrasound system with multifrequency (1.7–3.5 MHz) transducer, second tissue harmonics provides a high quality of visualisation of the main coronary arteries in routine echocardiography [8–10]. Acquisition of the left anterior descending artery (LAD) is easiest, and, using the different non-classical views, it could be feasible for more than 90% of patients (Figures 1–2). Thus, complete imaging of the left main can be achieved in 98% of patients, the proximal, middle and distal segments of LAD were completely visible in 96%, 95% and 91% of patients respectively, for left circumflex complete views were achieved in 88%, 61% and 3%, and for right coronary artery in 40%, 28% and 54% of patients [10]. The anatomical course of the coronary arteries was investigated using colour Doppler mapping. With the patient in the supine or left lateral decubitus position, all standard and modified apical, parasternal and subcostal views were employed to follow the course of the main coronary arteries. In parasternal views, the left main and proximal segments of LAD and LCx were observed by focussing on the area adjacent to the left sinus of Valsalva cranial to the aortic valve, with the LAD and LCx further coursing in the anterior interventricular sulcus and lateral atrioventricular sulcus respectively. The middle segment of the LAD was interrogated in apical and parasternal views focussing on the anterior interventricular sulcus [10].
Additive prognostic value of high baseline coronary flow velocity to ejection fraction during resting echocardiography: 3-year prospective study
Published in Acta Cardiologica, 2023
Angela Zagatina, Olesya Guseva, Elena Kalinina, Fausto Rigo, Martin Caprnda, Jan Masan, Katarina Gazdikova, Peter Firment, David Ullrich, Ludovit Gaspar, Peter Kruzliak, Dmitry Shmatov
As the most simple for echocardiographic methods left side coronary artery flows were scanned in addition to conventional echocardiography. We used the manufacturer preset ‘Coronary’. The transducers were multifrequency phased-array sector scan probes with second harmonic technology. The anatomical course of the coronary arteries was investigated using colour Doppler mapping. With the patient in the supine or left lateral decubitus position, all standard and modified apical, parasternal and subcostal views were employed to follow the course of the main coronary arteries. The entire left main coronary artery (LM) was visualised, while LAD and left circumflex artery (LCx) were scanned in their proximal and middle segments. In parasternal views, the LM and proximal segments of LAD (pLAD) and LCx (pLCx) were observed by focussing on the area adjacent to the left sinus of Valsalva cranial to the aortic valve, with the pLAD and pLCx further coursing in the anterior interventricular sulcus and lateral atrioventricular sulcus, respectively. Examples of pLAD are shown in Figure 1. The middle segment of the LAD (mLAD) was interrogated in apical and parasternal views focussing on the anterior interventricular sulcus, while the same LCx segment (mLCx) was visualised in parasternal and subcostal views focussing on the lateral and inferior atrioventricular sulci as described in the publications of Vegsundvåg et al. [6]. The initial colour Doppler scanning was at a Nyquist limit of 0.20 m/s. If necessary, subsequently the Nyquist limit was adjusted up to 0.46 m/s to provide optimal imaging of the aliased zone, so the Nyquist limit was 0.20–0.46 m/s. Pulsed-wave Doppler registered blood flow velocity using a sample volume (2–3.0 mm) placed on the colour signal. If there was an aliasing effect, the sample volume of pulsed-wave Doppler was placed on this zone (Figure 1). The maximal diastolic velocity was used for analysis. Knowing that Doppler methods are angle-dependent, the maximal diastolic velocity of all loops went into the analysis. The scanning was performed in the same manner as in our previous studies [18,21].
Prognostic value of Doppler echocardiographic coronary flow velocity assessment at rest in elderly patients
Published in Acta Cardiologica, 2023
Angela Zagatina, Elena Kalinina, Martin Caprnda, Ludovit Gaspar, Katarina Gazdikova, David Ullrich, Robert Prosecky, Luis Rodrigo, Peter Kruzliak
Left-side coronary artery flows were scanned in addition to conventional echocardiography. We used the manufacturer preset ‘Coronary’. The transducers were multifrequency phased-array sector scan probes with second harmonic technology. The anatomical course of the coronary arteries was investigated using colour Doppler mapping. With the patient in the supine or left lateral decubitus position, all standard and modified apical, parasternal, and subcostal views were employed to follow the course of the main coronary arteries. The entire LM was visualised, while LAD and LCx were scanned in their proximal and middle segments. In parasternal views, the LM and proximal segments of LAD and LCx were observed by focussing on the area adjacent to the left sinus of Valsalva cranial to the aortic valve, with the LAD and LCx further coursing in the anterior interventricular sulcus and lateral atrioventricular sulcus respectively. In the short-axis view the proximal LAD could be seen leaving the left main and turning slightly towards the transducer. The origin and proximal part of the LCx was found by using the same view, passing from the transducer. Adjusting the transducer position, the ultrasound beam was aligned in parallel to vessel flow as much as possible. Examples of proximal LAD are shown in Figure 1. The middle segment of the LAD was interrogated in apical and parasternal views focussing on the anterior interventricular sulcus – Figure 1, while the same LCx segment was visualised in parasternal and subcostal views focussing on the lateral and inferior atrioventricular sulci as described in the publications of Vegsundvåg et al. [4]. The initial colour Doppler scanning was at a Nyquist limit of 0.20 m/s. If necessary, the Nyquist limit was subsequently adjusted up to 0.46 m/s to provide optimal imaging of the aliased zone, so the Nyquist limit was 0.20–0.46 m/s. Pulsed-wave Doppler registered blood flow velocity using a sample volume (2–3.0 mm) placed on the colour signal. If there was an aliasing effect, the sample volume of pulsed-wave Doppler was placed on this zone (Figure 2). The maximal diastolic velocity was used for analysis. The scanning was performed in the same manner as in our previous studies [10,12,16]. A persistent flow velocity of ≥70 cm/s was considered pathological based on our previous experience and recent scientific data [10,12,16,17].