INTRODUCTION

Coronary artery disease is one of the major cause of death in developed countries. The incidence of coronary artery disease is increasing today in developing countries as well, because of changing life style, urbanization, sedentary life style, hypertension, diabetes mellitus and increased type A personality. The increasing use of diagnostic and therapeutic interventional procedures necessitates that a sound, basic knowledge of the coronary artery pattern is essential. More progress has been made in the last few decades than in all foregoing medical history in management of cardiovascular disease. According to the World Health Organization (WHO), coronary heart diseases constitute the main cause of death in the industrial world. The main risk factors are lipid disorders, hypertension, diabetes, obesity, lack of physical activities and other disorders which cause functional impairment and damage to vascular cells. But, the risk factors dont explain the local distribution of atherosclerotic lesions. The pattern of this distribution corresponds to zones of disturbed flow with vortex formations and low velocity flow in coronary arteries. The anatomical details and

pathophysiological patterns of most coronary artery anomalies are presently well known. On the contrary, few data exist on the clinical relevance of the

variation of different coronary arteries, which necessitate a proper management and follow up protocol.1 Anatomy of coronary arteries and their variation is significant for proper interpretation of coronary angiographies, assessment of complexity and result of coronary insufficiency as well as surgical myocardium revascularization .2 The advances in the diagnosis of coronary heart diseases have brought to discussion the long forgotten studies in morphology and anatomy of coronary arteries.3&4 Knowledge of the normal and variant anatomy and anomalies of coronary circulation is an increasingly vital component in management of congenital and acquired heart disease.5 It is also established that the incidence of coronary artery disease is much higher in men than women until the 4th decade.6 The study of the mean lumen diameter of the vessels revealed that the luminal diameter in males was wider as compared to females. The heart weight and luminal diameter were studied by some workers. They concluded that relative to heart weight coronary arteries were found to be wider in females suggesting that better coronary flow in females. This could be one

of the factors contributing to lower incidence of coronary heart disease in women.7 A recent study was done on pulsatory power on coronary vessels. The author concluded that ratio between the volume of blood entering the lumen of left and right coronary arteries during each heart beat was equal to the ratio between the volume of blood entering the lumen of ascending aorta and pulmonary trunk during each heart beat.8 Several studies conducted on coronary arteries revealed that in coronary insufficiency the collateral circulation was more. The author has also found that anterior and posterior septal arteries, right superior septal artery and left superior septal artery may have a potential as a collateral route. By considering all disease spread.9 Cardia is from the Greek word Kardia, meaning heart. It is the heart that provides the motive force acting as a pump to move blood through the circulatory system. Heart receives its blood supply from the coronary vessels. It may seem like the heart has easy access to blood, however the blood passing through the chambers of heart does not actually supply it, instead special blood vessels, called coronary arteries deliver blood into heart muscle itself.The word coronary is derived from the Latin word co-ropattern and variations are important in influencing the

ne, Greek ko-ro-ne,means anything hooked or curved and coronary means encircling in a manner of crown.10 Arterial supply to heart is achieved by two arteries which are the only branches from ascending aorta. These arteries branch in such a manner that they occupy atrioventricular and interventricular groove in the shape of a crown. Hence they are called the coronary arteries.11 Their branches tend to form a subepicardial network like an inverted oblique crown. Vascular anomalies pose a great challenge to anatomists and surgeons. An American surgeon has said that the best way to avoid injury to blood vessels is to know all possible variations in course, distribution and branches. Any surgical trauma sustained by blood vessels is irrepairable leading to the necrosis of the part involved.5 Coronary arteries, as first branches of aorta, supply blood to myocardium. Coronary arteries, normally found impairs may vary in origin, distribution, number and size. These arteries emit several branches responsible for irrigation the whole surface and interior heart tissue.12 Knowledge of normal and variant anatomy and anomalies of coronary circulation is an increasingly vital component in the management of congenital and acquired heart diseases. Congenital, inflammatory, metabolic

and degenerative diseases may involve the coronary circulation and increasingly complex cardiac surgical repairs demand enhanced

understanding of the basic anatomy to improve the operative outcomes.13 Recently, coronary artery anomalies as a cause of coronary heart disease are gaining consideration in the diagnostic workup. One of the subsets of coronary artery anomalies is the anomalous origin. This subgroup has important clinical manifestations, including sudden death, especially in young athletes.14 Some authors have indicated the need to establish diagnostic screening protocols for athletes and other young individuals subjected to extreme exertion.15 It is desirable to determine the incidence of the variations, which are potentially capable of inducing sudden cardiac death, in order to analyze the value of screening.16 Since the 1960s when cineangiography and coronary arteriography were developed, imaging of the coronary circulation in many thousands of people has demonstrated that there is huge spectrum of variation in the disposition of the coronary arteries.11

Morphology
The right and left coronary arteries arise from the ascending aorta in its anterior and left posterior sinuses. The level of the coronary ostia are variable they are usually at or above cuspal margins. The two arteries, as indicated by their name, form an oblique inverted crown, in which on anastomotic circle in the atrioventricular groove is connected by marginal and interventricular (descending) loops intersecting at the cardiac apex.9 The main arteries and major branches are usually subepicardial. The caliber of coronary arteries, both main stems and larger branches based on measurements of arterial casts or angiograms, ranges between 1.5mm and 5.5mm for coronary arteries at their origin.17 Coronary arteries diameters increase up to the age of thirtieth year.18 Left coronary artery : Left coronary artery (a. coronaria sinistra)19 arises from the left posterior (left coronary) aortic sinus, the ostium is below the margin of the cusps in 15% and may be double, leading into major initial branches, usually the circumflex and anterior interventricular (descending) arteries.

The left coronary artery is larger in caliber than the right and supplies a great volume of myocardium, including almost all the left ventricle and atrium except, in so called right dominance, in which the right coronary artery partly supplies a posterior region of the left ventricle.9 Course : The artery lies between the pulmonary trunk and left auricle, emerging into the atrioventricular groove, in which it turns left. This part is loosely embedded in subepicardial fat and usually has no branches, but may give off a small atrial ramus and rarely, the Sinoatrial nodal artery.20 Branches and their course : Reaching the atrioventricular groove, the left coronary divides into two or three main branches. 1) Anterior interventricular (descending) artery 2) Circumflex artery 1. The anterior descending artery (Left anterior descending) is commonly described as its continuation. This artery descends obliquely forward and to the left in the interventricular groove, sometimes embedded by myocardial tissue.It reaches the apex and terminates there in 1/3rd of specimens.9 However, more often it turns round the apex into the posterior interventricular groove, and passes 1/3rd to 1/2 way along its length, and

meets with terminal twigs of the posterior interventricular branch of the right coronary artery. a) Left conus artery: A small left conus artery frequently leaves the anterior interventricular artery near its start and anastomose with counterpart from right coronary artery. b) Ventricular branches: The anterior interventricular artery gives of right and left anterior ventricular, anterior septal branches and a variable number of corresponding posterior branches. From 2 to 9 large anterior ventricular arteries branch at acute angles from the anterior interventricular artery. c) Left diagonal artery: Left diagonal artery is often large and may arise separately. This artery reported in 33-55% or more individuals, is sometimes duplicated. d) Septal branches: The anterior septal branches leave the anterior interventricular artery almost perpendicularly, and supply the ventral 2/3rd of the septum. Small posterior septal branches supply the posterior 1/3rd of the septum for a variable distance from the cardiac apex. 2. The circumflex artery, compairable to the anterior interventricular in caliber, curves left in the atrioventricular groove, continuing around the left cardiac border into the posterior part of the groove and ending left of the

crux in most hearts, but sometimes continuing as a posterior interventricular (descending) artery. a) Left marginal artery: In 90%, a large ventricular branch, the left marginal artery arise from the circumflex and ramifies over the rounded obtuse margin, supplying much of the adjacent left ventricle, usually to the apex. b) Ventricular branches: Anterior ventricular branches course parallel to the diagonal artery, when it is present and replace it when it is absent. Posterior ventricular branches are smaller and fewer. c) Atrial branches: It may supply the left atrium via anterior, lateral and posterior atrial branches. d) Sinoatrial Nodal, Atrioventricular Nodal branch: The artery to the Sinoatrial node is a branch in 35% usually from the anterior circumflex segment. The artery to the Atrioventricular node arises near the crux, in which case the circumflex usually supplies the posterior descending artery, an example of so called left dominance.21 e) Kugels artery: Kugel
22

described an atrial artery that arose from the

proximal left circumflex artery or from its branches, coursed through the lower part of the interatrial septum and in most of his cases (66%)

anastomosed directly or through its branches with the distal right coronary artery.

Coronary distribution: It has been observed that the distribution of the coronary arteries in the wall of the heart does not follow a uniform pattern in all hearts, and the patterns of coronary blood supply have been classified into three types viz balanced circulation, right coronary dominance and left coronary dominance.23 The term dominant coronary artery was introduced by Schlesinger (1940) who used it to indicate the areas of heart supplied by each artery.12 The heart with a balanced circulation suffer least, the left dominate most and right dominance occupy an intermediate status between the other two in coronary disease.23 Thus the morphological arterial patterns obtain considerable importance in clinical application. Coronary dominance is determined according to the overlap that either coronary artery makes into the generally assigned territory of the other. This

boundary zone, the sharing of whose supply determines dominance, is the posterior wall of the left and right ventricles adjacent to the inferior interventricular groove.23 Hence the term dominant is used to refer to the coronary artery that gives the posterior interventricular branch which supplies the boundary zone. This is usually the left coronary artery (70%) which is also invariably the larger of the two vessels.9 Coronary anastamosis : Anastomoses between the right and left coronary arteries are abundant during fetal life, but are much reduced by the end of first year of life. Anastomoses providing collateral circulation may become prominent in conditions of hypoxia and in coronary artery disease. An additional collateral circulation is provided by small branches from mediastinal, pericardial and bronchial vessels.9 Collateral circulation was divided into two types, homocoronary and intercoronary. Homocoronary anastomoses occur everywhere except in the immediate subepicardial layer, while intercoronary anastomoses are more usually subepicardial.The significance of this collateral circulation is that a potential exists for protecting the myocardium against the adverse effects of ischemia.23

It seems possible that factors additional to ischemia may be involved to redevelop the circulatory system which had been present at birth, but the natural history of the collateral circulation in man is still uncertain.23 The possibility of a non-coronary collateral circulation was postulated by Thebesius24 in 1708 in his description of openings in the atrial and ventricular walls.In addition, non-coronary collaterals sometimes develop in response to ischemia. They arise as tortuous vessels from the mediastinal, pericardial and bronchial vessels and enter the heart through the pericardial reflection surrounding the pulmonary and systemic veins. In a normal heart no communications exist among the large coronary arteries.But many anastomosis exist among the smaller arteries sized 20250 in diameter.25 When a sudden occlusion occurs in one of the larger coronary arteries, the small anastomosis dilate within a few seconds.But the blood flow through these minute collateral is usually less than one half that needed to keep alive the cardiac muscles that they supply; the diameter of the collateral vessels do not enlarge.Collateral flow does begin to increase, doubling reaching normal or almost normal coronary flow in the previously ischemic muscle with in one month. In fact, the flow is capable of increasing even further with increased metabolic loads. Because of these collateral channels, many

patients recover from various types of coronary occlusion.When the area of muscle involved is not too great.25 When atherosclerosis constricts the coronary arteries slowly over a period ofmany years rather than suddenly, collateral vessels can develop at the same time that the atherosclerosis does.Therefore the person may never experience an acute episode of cardiac dysfunction.25

Ontogeny
The vasculature begins to form early in the third week. The first evidence of blood vessel formation can be detected in the splanchnopleuric mesoderm of yolk sac, on day 11th as mesodermal aggregation called blood islands. The first evidence of coronary vessel development is the appearance at the beginning of 5th week of structures like blood islands just under the epicordium in the sulci of the developing heart. These vessels arise from cells of epicardium. During the late fifth and sixth weeks the capillary plexus developing from these foci form connections both with coronary veins sprouting from the coronary sinus and with coronary arteries growing from the aorta. In fact, the coronary arteries actually sprout not directly from the aorta but rather from a pair of special aortic branches,the left and right aortic

sinuses that emerge from the aorta just above the two cusps of the semilunar valve.26 It has been suggested that the developing capillary plexus in the sulci induce the sprouting of coronary arteries and veins.27 The coronary arteries almost always originate only from the right and left aortic sinuses of valsalva, since the structure and conditions appear to be the same for all six sinuses of the embryonic great arteries. It sought a possible mechanical explanation for the phenomenon by studying the development of the coronary vasculature in 351 staged, serially sectioned human embryos of Carnegie stages 9 through 23 from the Carnegie embryological collection. A plexus of blind epicardial capillaries appears on the heart in carnages stage 14 or 15 and acquires a coronary sinus connection in stage 15, 16 or 17. The connection of the proximal coronary arteries to the aorta does not appear until stage 18 and found no histological features of the cardiac nerves or any other component of the tissues to account for the consistent origin of coronary arteries from the right and left aortic sinus of the valsalva. However serial section reconstruction showed that the two sinues where coronary arteries developed acquire a positive transverse curvature and a negative longitudinal curvature, i.e. catinoidal or saddle-shaped

configuration before the appearance of coronary arteries. The four noncoronary sinues also have a positive transverse curvature, out longitudinally in contrast, they have a positive curvature or a straight. The result suggest that the coronary arteries originate from those sinuses of valsalva where wall tension is increased by catenoidal configuration.28

REVIEW OF LITERATURE
Study of left coronary artery has been made by various workers at various times. Here are some studies done by various workers. Baroldi G, Mantero O and Scomazzoni G(1956) studied the Collaterals of the Coronary Arteries in Normal and Pathologic Hearts. The normal heart possesses conspicuous coronary anastomoses.They found that maximum increase in collateral vessels was observed in cases of coronary narrowing; a less pronounced increase was found in conditions of chronic hypoxemia.29 Chander S and Indrajit (1957) stated that the occurrence of a single coronary artery is very rare. The artery took origin from the left posterior aortic sinus and had a diameter of 6 mm at the ostium. Hyrtl defined a case of single coronary artery as one in which only one artery supplies the entire heart and does not give any conspicuous, anomalous branches which may follow the distribution pattern of the other artery.30 Classification of single coronary artery is in three groups : 1) Those fulfilling the rigid criteria of Hyrtl in which a single coronary artery, supplying one ventricle, continues to supply the territory of the other artery. 2) Those in which both the arteries are present but arise from a common trunk.

3) Those in which the mode of branching of the arteries in grossly atypical and cannot be compared with that of the two arteries.30 Ayer AA and Rao YG.(1957) studied in the series of 25 adult hearts balanced circulation is found in 7, right coronary dominance in 11 and left dominance in 7. Among 20 foetal hearts balanced circulation has been seen in 10, right coronary dominance in 5 and left coronary dominance in 5. The frequency of left coronary dominance, viz 28% in adult and 25% in foetal materials is nearly the same, there seems to be a divergence in the frequency of the other two types of pattern. Balanced circulation is more frequent in foetuses, being 50% as compared with 28% in adults; while right coronary dominance is less in foetuses, being 25% compared with 44% in the adult.23 Singer R.(1958) done a survey of hearts from 83 Bantu, 109 cape coloured and 86 white south Africans indicates that the so called Bantu pattern is an individual variation noted in all three racial groups. Death due to coronary thrombosis among the Bantu speaking South African negroids is rare, this may be accounted for a distinctive pattern of distribution of the coronary arteries of the Bantu heart.31 Ogeden JA and Goodyer AVN.(1970)presented a comprehensive scheme for classification of left coronary artery after studying ten cases of single coronary artery (congenital variation) .Nine cases were found during autopsy

and one case was found during evaluation of coarctation of the aorta. The ages ranged from one day to eighty-four years. There were six males and four females. A single coronary artery was present in five cases and a single left coronary artery in five cases. The single left coronary artery in one case arose from the pulmonary artery rather than the aorta. Associated cardiovascular anomalies were found in three cases: truncus arteriosus (case 7) and transposition of the great vessels (cases 8,9). Case 3 had a unique variation. The heart was supplied by a single left coronary artery. A short proximal right coronary artery (dimple) was found in the right aortic sinus. This structure terminated shortly after the aortic origin, with a non patent, fibrous segment connecting the blindly ending proximal right coronary artery with the distal right coronary artery. The distal right coronary artery was a continuation of the left circumflex artery. Case 10 had an extremely unusual lesion. A single left coronary artery was present. However, this single artery arose from the left sinus of the pulmonary artery rather than the aorta. No coronary arteries originated from the aorta. The single coronary artery divided into three branches. The right coronary branch coursed between the aorta and pulmonary artery to reach the right atrioventricular groove, while the circumflex and anterior descending branches assumed their normal courses of distribution.32

Liberthson RR, Dinsmore RE, Bharti S,Ruberstien JJ,Caulfield J,Wheeler EO,Hathrone JW and Lev M.(1974)found that left anterior descending and circumflex artery arose aberrantly from right sinus of Valsalva (RSV) of aorta in 6 patients.This variant with exertional sudden death in young

persons. Anomalous coronary pattern can be detected by selective coronary cineangiography and defect can be corrected by bypass surgery.33 Malhotra, Tewari and Pandey (1977) have studied Conus artery in 192 hearts. The conus artery is also named as third coronary artery. It was arising from the anterior aortic sinus left to the right coronary artery and was having its own ostium and was supplying the conus arteriosus of the heart.34 Meschan I. (1978) mentions that variations in the branching pattern of the coronary artery are frequent. In about 2/3rd of the cases, the right coronary artery is dominant, crossing the crux and supplying part of the left ventricular wall and the ventricular septum. In 15% of cases the left coronary artery is dominant and its circumflex branch crosses the crux, supplying the posterior interventricular branch. In 18% of cases both coronary arteries reach the crux and this is so called balanced coronary arterial pattern.35 Allwork SP.(1987) said that although the left coronary artery always supplies a greater mass of myocardium than does the right, it is not usually

dominant. The right coronary artery is dominant in approximately 70% of people. If the circumflex branch of the left coronary artery terminates in the posterior interventricular sulcus, left dominance is present. This occurs in about 15% of people. In hearts the circulation is said to be balanced if posterior interventricular branch is either bilateral or absent.He mentions that single coronary artery is rare in normal hearts but occurs with some frequency in congenitally malformed hearts. Single right arteries have greater morphological variability than left ones. Single coronary arteries are highly susceptible to atherosclerosis and of course, intercoronary collaterals are absent, so that possession of a single coronary artery is disadvantageous. The commonest is abnormal origin of the circumflex branch of the left coronary artery. This springs from the right coronary artery and usually crosses the posterior part of the aortic root and passes in the left atrioventricular sulcus. The anterior interventricular branch occasionally passes through muscle for much of its length and Geiringer coined the term intramural for this variant. An intramural left coronary artery surrounded by fibrous tissue has been found in babies who have succumbed to cot death.11 Reig J,Loncan MP,Martin S and Domenech JM.(1987) says that even though there exists a considerable similarity between the coronary pattern in

newborn and adult heart, important differences are evident, especially as regards the circumflex artery and posterior interventricular artery. As for the origin of the posterior interventricular artery, in the series the percentage of cases with right sided origin is 71%. These three points the type of coronary pattern, the relative length of the circumflex artery and the origin of the posterior interventricular artery, suggest some kind of regression of the circumflex artery with increasing age. In this way, with the decrease in the relative length of the circumflex artery, the posterior interventricular artery would be progressively taken over by the right coronary artery, and the percentage of double origin for the posterior interventricular artey would decrease in favour of the right sided origin.36 Bergmann RA, Afifi AK and Miyaucchi R.(1988) states that the left coronary artery is more variable than the right. In some cases, a single coronary artery serves the entire heart, either the right or the left coronary is absent. Coronary artery preponderance occurs in about 30% of cases, left coronary is preponderant in 12% of cases and right coronary in about 18%. Left coronary artery dominance is eight times more frequent in males (18.2%) than in females (2.6%), while right coronary artery preponderance is almost twice as common in females (23.1%) as in males (14.6%). The right coronary artery occasionally arise from the pulmonary trunk, usually

without adverse consequences. The anterior interventricular and terminal branches of the left coronary sometimes arise separately from the aortic sinus. One coronary artery may be larger than usual and the other correspondingly smaller. Very rarely, an extra coronary artery arises from the pulmonary artery.37 Puttman CE and Ravin CE. (1988) quotes that occasionally, the posterior descending artery will arise from right coronary artery at or proximal to the acute margin of the heart. This is referred to as early origin of the posterior descending artery. At the crux, a characteristic inverted U-shaped course of the right coronary artery is seen as it passes over the coronary sinus and continues in the posterior atrioventricular groove to send branches to the posterior wall of the left ventricle. When this anatomic situation occurs the right coronary artery is referred to as the dominant artery.38 Moffat DB. (1989) mentions that the anamalous origin of the coronary arteries are rare but well documented. Incidence of anomalous origin was 0.64% and the incidence of both coronary arteries arising from a single aortic sinus was 0.2%. The right and left coronary arteries arose in common from a single ostium in the wall of the anterior aortic sinus. The heart exhibited no other cardiac malformation and no obvious pathology, the patient died from bronchopneumonia. This is the oldest recorded case of an

anomalous origin of the coronary arteries, and this particular arrangement, with both a common ostial origin from the anterior aortic sinus and as anterior infundibular course by the left coronary artery, has not been described previously.39 Yamanaka O and Hobbs RE. (1990) observed that coronary artery anomalies were found in 1,686 patients (1.3% incidence) undergoing coronary arteriography at the Cleveland clinic foundation from 1960 to 1988. Of the 1,686 patients, 1,461 (87%) had anomalies of origin and distribution, and 225 (13%) had coronary artery fistulae.40 Baptista CA, DiDio LJ and Prates JC.(1991) The left coronary artery presented 3 types of division: bifurcation (54.7%), trifurcation (38.7%) and quadrifurcation (6.7%); the latter 2 patterns produced a diagonal artery. The ramus diagonalis was found in 45.3% of the hearts. The length of the ramus diagonalis varied from 20.1 to 50 mm (79.3%) and its relative length varied from 21 to 50% of the length of the left ventricle (75.3%). The ramus diagonalis was classified as short, medium and long types, the former 2 types were most frequent.41 Sim EK,Vanson JA,Edwards WD, Julsrud PR and Puga FJ.(1994) states that knowledge of the variations in coronary artery pattern is important in the arterial switch operation for complete transposition of the great arteries. The

origin of the coronary artery was defined as seen by an observer looking from the pulmonary artery toward the aorta. The usual pattern with the right coronary artery originating from the right sinus and left coronary artery from the left sinus (184 cases) and the circumflex coronary artery arising from the right artery (46 cases) accounted for 90% of the cases.42 Aharinejad S,Schreiner W and Neumann F(1998)provided new

experimental data on branching geometry of coronary artery. They suggest that analytical bifurcation law in CCO might be replaced by the bifurcation rule obeyed on a stochastic basis only.43 Basso C,Maron BJ, Carrado D and Theine G.(2000) quotes that the congenital coronary artery anomalies are not uncommonly associated with sudden death in young athletes, the catastrophic even probably provoked by myocardial ischemia. It is reported that 27 sudden death in young athletes identified solely at autopsy and due to either left main coronary artery arising from right aortic sinus or right coronary artery from the left sinus.14 Snell RS.(2000) mentions that the sinoartial node is usually supplied by the right but sometimes the left coronary artery. The atrioventricular node and the atrioventricular bundle are supplied by the right coronary artery.44

Dhall U, Chaudhary S and Sirohiwal BL.(2003) quotes that the mean lumen diameter of all the vessels (except LCA where it is equal) is more in males as compared to females.7 Ishizawa A, Tanaka O, Zhou M and Abe H. conducted dissection courses from 1999 to 2003 ,specimen was found to have left coronary artery with variant roots. It originates from right aortic sinus, then it pierces the upper part of the muscular interventricular septum and appeared on surface then divide into Anterior Interventricular Artery and Circumflex Artery.45 Kalpana R.(2003) found that 80% of ostia of left coronary arteries were below the sino-tubular junction. Left coronary artery showed bifurcation in 47%, trifurcation in 40%, quadrifurcation in 11%,pentafurcation in 1% and only one branch in 1%. There was right cardiac dominance in 89% and left cardiac dominance in 11%. She mentions that Harvey realised it earlier than any anatomist that Structure is the real guide to function. No physiological theory can be true unless it gives a complete and final explanation of all points of structure. The origin of posterior interventricular artery from right coronary artery is the commonest anatomy in man and referred to as right dominance, which occurred in 89% of the hearts and left dominance was observed in 11%. The Sinoatrial nodal artery was found originating in 56% of specimens from RCA, in 35% from LCA, and in 8% from both.13

Keshaw K .(2003) , ratio obtained between pulse pressures of blood in left and right coronary arteries was equal to the ratio between pulse pressures of blood in ascending aorta and pulmonary trunk i.e. 3:1 which resembles the ratio between pulse pressures of blood in left and right ventricles. In the present study, ratio between volume of blood entering the lumen of left and right coronary arteries during each heart beat was equal to the ratio between the volume of blood entering the lumen of ascending aorta and pulmonary trunk during each heart beat i.e. 1:1 which resembles with the ratio between volume of blood entering the lumen of left and right ventricles during diastole of heart. Therefore ratio of 3:1 is existing between the structures related to systemic circulation (Left ventricle, ascending aorta, left coronary artery) and the structures related to pulmonary circulation (Right ventricle, pulmonary turnks, right coronary artery) as far as their wall thickness, pulse pressure and pulsatory power are concerned but in case of volume of blood entering the lumen during each heart beat, this ratio is 1 : 1 between the structures related to systemic and pulmonary circulations. In an individual not suffering from any cardiovascular disease these above mentioned ratios (3 : 1 and 1 : 1) remain always constant and may be known as Keshaw Constants. Any deviation/alteration in the Keshaw Constants in an individual is the indication of cardiovascular disease in that individual either

in the form of left/right sided cardiac failure or in the form of cardiac coronary inefficiency. Left coronary artery supplies left ventricle which is related to systemic circulation and right coronary artery supplies right ventricle which is related to pulmonary circulation. Coronary arteries are actually vasa-vasorum of arterial heart from which ventricles are developed.8 Reig J and Petit M. (2004) studied main trunk of the left coronary artery: anatomic study of the parameters of clinical interest. The objective of this study was to analyze in one single series all the characteristics of the main trunk of the left coronary artery that may be of use in the diagnosis and treatment of its pathologies. One-hundred human hearts from autopsies were used. The length of the main trunk, the luminal diameter of the main trunk at its midpoint, and the luminal diameter of the left coronary orifice were measured with a caliper. The angle of division between the anterior interventricular and circumflex branches was also measured, and the number of terminal branches originating from the main trunk was recorded. In four cases, there was no main trunk and the anterior interventricular and circumflex branches originated directly from the left aortic sinus. The average length of the main trunk was 10.8 +/- 5.52 mm (range = 2-23 mm); the average diameter at its midpoint was 4.86 +/- 0.80 mm; and there was no significant difference noted between the midpoint diameter of the main trunk

and the diameter of the left coronary orifice. The most frequent type of division of the main trunk was bifurcation (62%); in 38% of cases the main trunk divided into three or more branches. An average value of 86.7 +/- 28.8 degrees was obtained for the angle of division of the terminal branches of the main trunk (range = 40-165 degrees). There was a positive correlation between the length of the main trunk and the angle of division of its terminal branches, with the longest main trunk having the largest angle of division.46 Surucu HS, Karahan ST and Tanyeli E.(2004) This study was performed to assess the variations in the branching pattern and diameters of the terminal branches of the left coronary artery and discuss various names given to the third branch. Hearts of 21 autopsies and 19 cadavers were fixed with 10% formalin and their coronary arteries were examined by dissecting the epicardium. There were 2 branches in 19 hearts, 3 branches in 19 hearts, 4 branches in one heart and 5 branches in another. Diameter and length of these vessels were noted.Upon examination of the diameters and important variations of the branches of the left coronary artery, the importance of the median artery has been noted. Various names given to this artery in the literature should be replaced with the name "median artery". 47 Bhimalli S, Hukkeri VB and Potturi BR. (2005) said that 90% of the ostia of right coronary artery and 80% of the ostia of the left coronary were below

the supra-valvar ridge;No openings were found in non- coronary sinus. Right coronary orifice in majority was at a higher level than the left coronary orifice in majority was at a higher level than the left for coronary orifice.Left coronary artery showed bifurcation in 56.66%,trifurcation in 33.33%. Quadrifurcation in 8.33%, 1.66% of the cases had showed pentafurcation and 2.5% had two parallel anterior descending arteries. Right coronary artery dominance was found in 60%of cases, Left coronary artery dominance was found in 23.33% of cases and 16.66% cases had balanced distribution. 48 Lujinovic A,Ovcina F,Voljevica A,Hasanovic A.(2005) They study Branching of main trunk of left coronary artery and importance of her diagonal branch in cases of coronary insufficiency. In this study we have analyzed 100 coronary angiographies and dissected 20 human hearts from the Institute of Anatomy. By the method of the angiography we have found the bifurcation in 71% of cases while 65% of cases were proved by the dissection method. Trifurcation has been discovered in 29% of cases of analyzed angiographies i.e. 35% of cases of dissected hearts. We believe that third terminal branch of the left coronary artery should be marked as ramus diagonalis. This branch, including its anastomoses, presents important pattern of the collateral blood flow, which has special meaning, under conditions of coronary insufficiency.2

Ortale JR,Filho JM,Paccola AMF, Garcia Leal JGP, Sacranari CA.(2005) carried study on 50 hearts. He noted diameter of LCA varied from 3.3 to 7.4 (mean 5.0+/-0.9mm). In 50% of cases there was bifurcation of LCA into anterior interventricular artery and circumflex artery. In 46% cases there was trifurcation with anterior interventricular artery,circumflex artery and diagonal artery. In 4% cases there were four divisions with two diagonal branches. The diagonal branch was present in 25/50 (50%)cases,with one branch in 23/25 cases and two branches in 2/25 cases.49 Reddy JV, Subhakar RV and Sekhar R.(2005) Study on the Blood Supply of Human Hearts. They studied the origin, course, branching pattern, myocardial bridges and arterial anastomosis of coronary arteries in 80 human hearts. Single coronary ostium is observed in the left coronary sinus and more than one coronary ostia are seen in the right coronary sinus. The coronary ostia were observed above the level of free margin of aortic cusps in majority of cases. The myocardial bridges were observed in relation to left anterior descending branch of left coronary artery at a distance of 20 to 30 mms from its origin from the main trunk. The diameter of main trunk of left coronary artery is more than the right coronary artery. In 76.6% of cases, the Sinoatrial node is supplied by right coronary and in 23.3 by left coronary

artery. The Atrioventricular node is supplied by right coronary artery in 90% of cases and by left circumflex in 10% of cases. It is observed that 86.25% of hearts the right predominance is seen and in 11.25% left predominance is noted. Majority of anastomoses were observed between left anterior and posterior descending arteries.50 Bindu H and Devi S.(2006)mentions that Sinoatrial nodal artery arose from right coronary artery in 66% of hearts and from left coronary in 28% of hearts.51 Puri N, Syal M, Puri D,Singh B and Kapoor K. (2006) studied preoperative angiograms of 100 consecutive patients with coronary artery disease.The number of collateral developed was directly proportional to degree of obstruction.52

Richard A,Godart F, Breviere GM, Francart C, Foucher C and Rey C. (2007) studied to show the evolution of diagnostic techniques revealing an abnormal origin of the left coronary artery. Echocardiography with colour Doppler enabled the diagnosis of abnormal origin of 100 left coronary artery in 70% of cases.53

Apsara MP.(2007) quotes that the origin of circumflex artery from right coronary artery was detected in 1 patient in the left anterior oblique (LAO) cranial view of right coronary artery. Left coronary artery continued as left anterior descending artery without providing circumflex branch.54 Manju M, Kaur D and Nair N.(2007) reported of the cases in which the left coronary ostium was found arising below sino tubular junction in 84% of the cases, at the sino tubular junction in 10% of the cases and above the sino tubular junction in 6% of the cases.55 Bellesteros LE and Ramirez LM(2008) worked on the variation in left coronary artery and those of its branches in heart samples taken from 154 Colombian mixed race people injected with synthetic resin. Left coronary artery trunk presented 6.48 +/- 2.57 mm of length. Left coronary artery were bifurcated in 80 hearts(52%), trifurcated in 65 hearts (42.2%) and tetrafurcated in 9 hearts(5.8%). A short circumflex artery was observed in 143 hears (i.e 92.8%) finalizing as left marginal branch in 39 of them (25.3%). The inferior 3rd of posterior interventricular sulcus was most frequently occurring segment in anterior interventricular branch finalization (63.3%). The caliber of left coronary artery was 3.58 +/- 0.59mm, that of anterior interventricular branch 2.94 +/-0.5mm, and of circumflex artery

2.71+/-0.54mm. Of the total sample 86 myocardial bridges were observed with 61 cases (70.9%) in the anterior interventricular branch, distributed amongst all segments proximal intermediate and distal average myocardial bridge length was 19.4 +/-10.7 mm and no gender difference were observed(p=0.20). the most frequently occurring location of myocardial bridges, on the anterior interventricular branch (proximal and intermediate) agreed with previous study.56 Bezerra FS, Nagato AC,Vieira CLJ,Reis LA,Novais L and Valenca SS. (2008)studied thirty hearts from adult individuals,15 from males and 15 from females. The domain was registered as right (in 80%), if right coronary branch irrigated the SAN(sinoatrial nodal artery). The same was listed for left coronary branch (in 20%). In addition,cases were both arteries irrigated Sinoatrial Node also were listed.57 Ottaviani G,Lavezzi AM, Matturri L.(2008) anomalous origin of the left coronary artery from the right aortic sinus of Valsalva, anomalous location of the right coronary ostium within proper aortic sinus of Valsalva, hyperacute myocardial infarction, and myocardial fibrosis. They convinced that the cardiovascular evaluation of young athletes needs to be focused on the identification of individuals at high risk of sudden cardiac arrest, paying

attention to suggestive symptoms and to a family history of sudden death due to cardiac arrest, particularly at an early age. In addition, enquiry should be made into the concomitant presence of a smoking habit or of passive smoke exposure.15 Loukas M, Groat C, Khangura R, Owens DG and Anderson RH. ( 2009) studied the normal and abnormal anatomy of the coronary arteries.16 Gajbe UL,Gosavi S,Meshram S,Gajbhiye VM.(2010) the anamolous origin of multiple coronary ostia from single coronary sinus is very rare finding. In 30 hearts, they found origin of multiple ostia of coronary arteries from single coronary sinus. The courses of arteries arising from these anomalous ostia were also studied and findings were correlated with clinical findings and pathophysiological conditions. There study help cardiologist during routine diagnostic work up for cardiac diseases and in management of these diseases.1 Fazliogullari Z, Karabulut AK, Unver Dogan N, Uysal l. (2010) examined the routes and variations of the left coronary artery (LCA), the right coronary artery (RCA), and their branches, as well as the frequency of a median artery in cadaver hearts.The LCAs branched out of the aortic sinus and had an average diameter of 4.44 +/ 1.79 mm. They gave rise to two

branches (bifurcation) in 46 percent, three branches (trifurcation) in 44 percent and four branches (quadrifurcation) in ten percent of the hearts. The median artery was identified in 27 hearts, with a mean diameter of 2.00 mm (standard deviation 0.67). Right dominance was observed in 42 percent, left dominance in 14 percent, and equal dominance in 44 percent of the hearts. Myocardial bridges were found on the LCA branches in 22 of the 27 hearts in which the median artery existed.They came to Conclusion that there is a close relationship between the existence of the median artery and myocardial bridges. This suggests that the median artery might be important in myocardial bridges, which exist in embryos but do not result in any clinical symptoms for many years in a large number of people.58 Joshi S, Joshi SS and Athavale SA. (2010) said that anomalous coronary origins may cause potentially dangerous symptoms, and even sudden death during strenuous activity. One hundred and five heart specimens were dissected. No openings were present in the pulmonary artery or the noncoronary sinus. The number of openings in the aortic sinuses varied from 2-5 in the present series; multiple ostia were mostly seen in the anterior sinus. The majority of the ostia lay below the sinutubular ridge (89%) and at or above the level of the upper margin of the cusps (84%). Left ostial openings were mainly centrally located (80%), whereas the right coronary ostia were

often shifted towards the right posterior aortic sinus (59%). The preferential location of the ostia was within the sinus and above the cusps, but below the sinutubular ridge. On occasion, normal variants like multiple ostia, vertical or circumferential shift in the position, and slit-like ostia may create confusion in interpreting the images and pose a difficulty during procedures like angiography, angioplasty, and coronary artery bypass grafting.59

Aims and objectives

All the cases have been studied having following aims and objectives.
1.

To study the origin and branching pattern of left coronary artery.

2.

To study morphometric parameters of left coronary artery at its origin and after giving its first branch and establish their relation if any.

3.

To study morphometry of first branch of Left Coronary Artery at its origin.

4. 5.

To study anastomoses of right and left coronary artery. To study area of distribution of left coronary artery.

Materials and methods

The 25 specimens (cadaveric hearts) were obtained from department of Anatomy GMC Patiala. The specimens were collected without any age, sex, socio-economic status, religion, educational or pathological basis. The specimens were serially numbered from 1 to 25. These were fixed in 10% formalin solution. The visceral pericardium was removed to expose the coronary arteries. The left coronary artery was dissected out carefully to avoid damage to small branches. The diameter of artery was noted at origin,before and after giving its first branch. The variations in branching pattern of left coronary artery were noted at subepicardial level. A drawing

of each artery was made and each specimen was photographed. The data was collected, finalized,analysed and compared with available data.

OBSERVATION
The present study was carried on 25 specimens (cadaveric hearts) which were obtained from department of Anatomy Govt.Medical College and Rajendra Hospital, Patiala. The specimens were collected without any age, sex, socio-economic status, religion, educational or pathological basis. The specimens were serially numbered from 1 to 25. These were fixed in 10% formalin solution. The fat and visceral pericardium was removed to expose the coronary arteries. The left coronary artery was dissected carefully to avoid damage to small branches and to see the continuation of its branches. The left coronary artery was followed from origin to termination. The branching pattern of left coronary artery along with any variation were observed in all the specimens.The diameter of artery was noted at its origin,

before and after giving its first branch and the diameter of its first branch was also noted. The variations in branching pattern of left coronary artery were noted at subepicardial level.

Origin-:The ostium for LCA was found in the left posterior aortic sinus in all the specimens. There was single ostium for LCA in all the specimens. TABLE NO.1 SHOWING ORIGIN OF LEFT CORONARY ARTERY
Parameter Aortic Sinus( From Left Posterior Aortic Sinus) Right Coronary Artery From any Other

Number 25 0 0

Percentage (%) 100 0 0

Origin of branches of left coronary artery -: TABLE NO. 2 SHOWING ORIGIN OF ANTERIOR INTERVENTRICULAR BRANCH OF LEFT CORONARY ARTERY.
Parameter From Left Coronary Artery From any other Number 25 0 Percentage (%) 100% 0%

In all cases,Anterior Interventricular Artery arises from left coronary artery.

TABLE NO.3 SHOWING ORIGIN OF CIRCUMFLEX ARTERY BRANCH OF LEFT CORONARY ARTERY.
Parameter From Left Coronary Artery From any other Number 25 0 Percentage (%) 100% 0%

In all cases, Circumflex Artery arises from left coronary artery.

TABLE NO.4 SHOWING ORIGIN OF DIAGONAL ARTERY BRANCH OF LEFT CORONARY ARTERY.
Parameter From Left Coronary Artery From any other Number 25 0 Percentage (%) 100% 0%

In all cases, Diagonal Artery arises from left coronary artery.

TABLE NO.5 SHOWING ORIGIN OF LEFT MARGINAL ARTERY BRANCH OF LEFT CORONARY ARTERY.
Parameter From Left CoronaryArtery From any other Number 25 0 Percentage (%) 100% 0%

In all cases, Left Marginal Artery arises from left coronary artery.

TABLE NO.6 SHOWING VARIATION IN ORIGIN OF POSTERIOR INTERVENTRICULAR ARTERY BRANCH.

Parameter From Left Coronary Artery From Right CoronaryArtery Number 4 21 Percentage (%) 16% 84%

In 4 cases, Posterior Interventricular Artery is branch of Left Coronary Artery and in 21 cases, Posterior Interventricular Artery is branch of Right Coronary Artery . So the Right cardiac dominance was present in 84% and the Left cardiac dominance was present in 16% of the specimens.

PIE CHART SHOWING CARDIAC DOMINANCE IN PERCENTAGE

Mean diameter and S.D. of Left Coronary Artery at origin is 4.87 +/0.80mm, just before giving first branch 4.87 +/- 0.80mm, just after giving first branch 4+/-0.79mm and first branch is 3.34+/-0.66mm .

TABLE NO.7 SHOWING MEASUREMENT OF LEFT CORONARY ARTERY

Parameter At origin

Mean Diameter ( in mm) 4.87

Standard deviation 0.80

before giving first branch after giving first branch first branch

4.87 4 3.34

0.80 0.79 0.66

DETAIL OF EACH SPECIMEN ON THE BASIS OF BRANCHING PATTERN OF LEFT CORONARY ARTERY IS GIVEN BELOW :A) CASES SHOWING BIFURCATION PATTERN I) Specimen NO : 1 Left Coronary Artery : LCA was seen dividing into 2 after a short course. 1) Anterior Interventricular Artery was seen to be continued in anterior interventricular groove and crossed the apex and had reached lower 1/3rd of Posterior IV groove. On sternocostal surface it was seen giving acute branches to left ventricle. 2) Left Circumflex Artery was seen giving anterior ventricular branches , branch to left atrium and then it was seen giving a Left marginal branch which was having a tortous course and terminated into two to three terminal

branches along the left margin was seen,then the Left Circumflex Artery crossed left border continued in atrioventricular groove and terminated as Posterior Interventricular (Descending) Artery in posterior interventricular groove. It was seen giving AV nodal artery before becoming Posterior Interventricular (Descending) Artery. II) Specimen NO : 2 Left Coronary Artery : LCA was seen dividing into 2 after a short course. 1) Anterior interventricular artery : was seen to be continued in anterior interventricular groove, after crossing the apex and reached lower 1/3rd of posterior interventricular groove. On sternocostal surface was seen giving acute branches to left ventricle. Diagonal artery was also observed. 2) Left circumflex Artery immediately branch ,which was running was seen giving a ventricular

parallel to the Diagonal artery branch of

Anterior interventricular artery and then it continued in atrioventricular groove ,it was seen giving a left marginal branch and atrial branches , it was crossing the left border and was seen giving 2-3 posterior ventricular

branches which supply the posterior aspect of left ventricle and terminated as Posterior Interventricular (Descending) Artery in posterior

interventricular groove. It was seen giving AV nodal artery before becoming Posterior Interventricular (Descending) Artery.

III) Specimen NO : 3 Left Coronary Artery : After a short course was seen dividing into 2 branches. 1. Anterior interventricular artery was seen giving off ventricular

branches and was continued in anterior interventricular IV groove. One of it branch was seen large named left diagonal branch. 2) Left circumflex artery was seen giving off atrial branches which supply left atria and ventricular branches, Main ventricular branch continued along left border was left marginal artery and winded around the left border after supplying posterior surface of left ventricle it terminated.

IV)Specimen NO: 4 Left Coronary Artery : LCA was seen dividing into 2 after a short course. 1) Anterior interventricular artery: LAD was seen giving off Acute ventricular branches and then had crossed apex and reached lower 1/3rd of posterior interventricular groove. 2) ) Left circumflex Artery was seen giving a ventricular branch

immediately which was running parallel to the ventricular branches of Anterior interventricular artery and few atrial branches was seen ,then it

continued in Atroventricular groove and was seen giving a left marginal branch, crossed the left border, was seen giving 2-3 posterior ventricular branches which supply the posterior aspect of left ventricle and terminated as Posterior Interventricular (Descending) Artery in posterior

interventricular groove. It was seen giving AV nodal artery before becoming Posterior Interventricular (Descending) Artery.

V) Specimen NO : 5 Left Coronary Artery : LCA was seen dividing into 2 after a short course. 1) Anterior interventricular artery was seen running in anterior interventricular groove , was seen giving off Acute ventricular branches and then was crossing apex to reach upto lower 1/3rd of posterior interventricular groove. 2) ) Left circumflex artery was seen giving left marginal artery immediately which was tortuous, was seen giving two terminal branches. During its course in Atrioventricular groove it was seen giving off atrial branch which supply left atrium and then it winded around the left border and it terminated after giving posterior ventricular which supply posterior surface of left ventricle.

VI) Specimen NO : 10 Left Coronary Artery : LCA was seen dividing into 2 after a short course. 1) Anterior interventricular artery was seen running in anterior interventricular groove and immediately was seen giving Diagonal branch and also it was seen giving off acute ventricular branches to right and left ventricle, crossed apex and ends in lower 1/3rd of posterior interventricular groove. 2) Left circumflex branch was seen giving off atrial, anterior ventricular branches ,left marginal artery along the left border of heart and it was continued in the atrioventricular groove and was seen giving posterior ventricular branches to posterior surface of left ventricle and then continued as Posterior interventricular Artery in posterior interventricular groove and anastomoses with Anterior interventricular artery. It was seen giving AV nodal artery before it terminated as Posterior interventricular Artery. VII) Specimen NO : 11 Left Coronary Artery : LCA was seen dividing into 2 after a short course. 1. Anterior interventricular artery which was soon duplicates, one branch was running in anterior interventricular groove and it was crossing apex and was reaching the lower 1/3rd of posterior interventricular groove. Other branch was seen giving off acute ventricular branches.

2. Left Circumflex Artery which was observed having short course in Atrioventricular groove and terminated as Left marginal artery. VIII) Specimen NO : 13 Left Coronary Artery : LCA was seen dividing into 2 after a short course. 1) Anterior interventricular artery ran in anterior interventricular groove and was seen giving off acute ventricular branches. It was giving Left diagonal branch which was further divided into two branch . 2). Left circumflex artery was seen giving left marginal artery which was running along the left border and then just after crossing the left border in Atrioventricular groove it was ramified on the posterior of left ventricle. IX) Specimen NO : 14 Left Coronary Artery : LCA was seen dividing into 2 after a short course . 1) Anterior interventricular artery: it was seen running in anterior interventricular groove and was seen giving off ventricular branches. Two Diagonal branch were seen of large caliber. 2) Left circumflex :continued as Left Marginal Artery which was running at obtuse margin. X) Specimen NO : 16 Left Coronary Artery : LCA was seen dividing into 2 after a short course.

1) Anterior interventricular artery. it was seen running in anterior interventricular groove and was seen giving off ventricular branches, after crossing apex and it was ended in lower 1/3rd of posterior interventricular groove. 2) Left Circumflex Artery was seen giving left marginal artery along the left border of heart and continued in the Atrioventricular groove to posterior ventricular surface of left ventricle and ended by anastomosing with RCA. XI) Specimen NO : 17 Left Coronary Artery : LCA was seen dividing into 2 after a short course . 1) Anterior interventricular artery: It was running in anterior interventricular groove and was seen giving off ventricular branches,

diagonal branches were observed and ended at lower 1/3rd of posterior interventricular groove. 2) Left circumflex Artery was seen giving off a Left marginal branch which was running till apex along left border and then Left circumflex Artery was seen running in Atrioventricular groove and was supplying posterior aspect of left ventricle and was ended by anastomosing with ventricular branches of RCA. XII) Specimen NO : 18 Left Coronary Artery : LCA was seen dividing into 2 after a short course .

1) Anterior interventricular artery: was duplicated soon and was running in the anterior interventricular groove and was seen giving off ventricular branches and ends at lower 1/3rd of posterior interventricular groove. 2) Left Circumflex Artery was seen giving off a large anterior ventricular branch immediately which had replaced the diagonal artery,branch to left atrium and then had crossed left border and ventricular branches observed which were supplying posterior aspect of left ventricle and anastomosed with Right Coronary Artery. XIII)Specimen NO : 19 Left Coronary Artery : LCA was seen dividing into 2 after a short course . 1) Anterior interventricular artery:it was running into anterior interventricular groove. It was seen giving off acute ventricular branches. Diagonal branch was observed which was divided into two and supplied sternocostal surface of left ventricle. 2)Left Circumflex Artery : Diagonal branch arised from it immediately and it was running in Atrioventricular groove towards left border It was seen giving off Left Marginal Artery and ventricular branch which was ramified on the posterior surface of left ventricle. XIV)Specimen NO : 20

Left Coronary Artery : LCA was seen dividing into 2 after a short course. 1) Anterior interventricular artery(AIV) immediately was seen giving off a left conus artery and then it was running in anterior interventricular groove and supplied the left ventricle by giving acute ventricular branches. Diagonal branch was observed which arised from AIV. 2) Left Circumflex Artery was seen giving off a branch to left atrium and then coursed to posterior aspect along Atrioventricular groove and was seen giving off ventricular branches and ended by becoming Left marginal

branch which ran along the left margin of heart. XV) Specimen NO : 22 Left Coronary Artery : LCA was seen dividing into 2 after a short course 1) Anterior interventricular artery: It was running in the anterior interventricular groove and was seen giving off acute ventricular branches to left ventricle,then ended before apex. Diagonal branch was observed. 2) Left Circumflex Artery run in atrioventricular groove at left border was seen giving off a atrial branch and reached posterior aspect of left ventricle. One of the its branch is Left Marginal Artery and afterward it ended after it had supplied the posterior ventricle.

XVI) Specimen NO 23 :

Left Coronary Artery : LCA was seen dividing into 2 after a short course. 1) Anterior interventricular artery: It was running in the anterior interventricular groove and was seen giving off acute ventricular branches to left and right ventricle and crossed apex and terminated in lower 1/3rd of posterior interventricular groove.One of ventricular rami was Diagonal Artery. 2) Left Circumflex Artery: Ran in AV groove was seen giving off a Left Marginal Artery and crossed the left border and terminated on the posterior aspect of left ventricle after giving many posterior ventricular branches. B) CASES SHOWING TRIFURCATION PATTERN I) Specimen NO : 6 Left Coronary Artery : it was seen into three branches 1) Anterior interventricular artery Coursed in anterior IV groove and many ventricular branches were seen. 2) Diagonal artery was seen as a direct branch and supplied the sternocostal surface of left ventricle . 3) Left circumflex artery was seen giving off a left marginal and a atrial branch,after crossing left border in atiovenrtcular groove. It was seen giving off terminal posterior ventricular branches which had supplied posterior aspect of left ventricle .

II) Specimen NO : 7 Left Coronary Artery : it was seen into three branches 1) Anterior interventricular artery was seen in anterior interventricular groove and was seen giving off acute ventricular branches crossed apex and reached lower 1/3rd of Posterior IV groove. 2) Left Diagonal Artery was seen which further duplicates immediately supply sternocostal surface. 3) Left Circumflex Artery was seen giving atrial branch and then crossed left border in Atrioventricular groove and terminated as artery. III) Specimen NO : 8 Left Coronary Artery : it was seen into three branches 1) Anterior interventricular artery : It was seen running in anterior interventricular groove and was seen giving off acute ventricular branches and ended in lower 1/3 of posterior interventricular groove. 2) Diagonal artery was a direct branch from LCA and supplied the sternocostal surface of left ventricle . 3) Left circumflex artery continued in the atriventricular groove and gave a Left Marginal artery and then was turning around left border and ended by giving posterior ventricular branch which was supplying left ventricle. Left marginal

IV) Specimen NO : 9 Left Coronary Artery : Left coronary artery was seen divided into 3 branches1) Anterior interventricular artery : It was seen running in anterior

interventricular groove and was seen giving off acute ventricular branches out of which one was large and was running parallel to Diagonal artery. Then AIV ended in lower 1/3 of posterior interventricular groove. 2) Diagonal Artery was a direct branch from LCA and supplied the sternocostal surface of left ventricle . 3) Left Circumflex Artery was seen giving off atrial branch and was moving in atrioventricular groove along left border of heart was seen giving two branches at margin,Left marginal artery which run parallel to each other and then the left circumflex ended by supplying posterior surface of left ventricle. V) Specimen NO: 15 Left Coronary Artery branches1) Anterior interventricular artery was seen running in the anterior interventricular groove and was soon duplicates , which was seen giving off : After short course divided was seen into 3

ventricular branches and

crossed

apex to reach upto lower 1/3rd of

posterior interventricular groove. 2) Left diagonal branch arised directly from LCA. 3) Left circumflex Artery was seen giving off atrial branches, ventricular branches one of which was large ie Left Marginal Artery and then

continued in atrioventricular groove, terminated by supplying posterior surface of left ventricle .

VI) Specimen NO : 21 Left Coronary Artery : After a short course was seen divided into three branch1) Anterior interventricular artery : was seen running in the anterior groove and gave off acute branches to the left ventricle. It crossed the apex and terminated at lower 1/3rd of posterior IV groove. 2)Left Diagonal Artery was given off by LCA which terminates into two branches . 3) Left Circumflex Artery was seen running in atrioventricular groove crossed left border ,gave Left marginal which was running along the left border of heart. VII) Specimen NO : 24

Left Coronary Artery : After a course of it divided was seen into three branches1) Anterior interventricular artery : After its origin was seen giving a diagonal branch. Anterior interventricular artery ran in the anterior

interventricular groove and terminated after crossing the apex at lower 1/3rd of posterior interventricular groove. 2) Diagonal Artery was observed it come directly from LCA and run parallel to the Diagonal Artery of LAD. 3) Left Circumflex Artery :.It was seen giving a Left Marginal Artery and after running in atrioventricular groove it terminated by supplying the posterior aspect of left ventricle. Small branch supplied left auricle. VIII) Specimen NO : 25 Left Coronary Artery LCA : After a short course it was seen divided into 3 branches 1. Anterior interventricular artery was seen giving off ventricular

branches and continued in anterior interventricular groove terminated before apex. One of it branch was large named left diagonal branch. 2) Left circumflex artery was seen giving off atrial branches which supply left atria and ventricular branches, Main ventricular branch continued along

left border was left marginal artery and winded around the left border after supplying posterior surface of left ventricle it ended. 3) Diagonal Artery was seen arising directly from LCA.

C) CASES SHOWING TETRAFURCATION PATTERN I) Specimen NO : 12 Left Coronary Artery : It was seen divided into four branches after a short course 1) Anterior interventricular artery soon duplicates and ran in anterior interventricular groove crossed apex to reach upto lower 1/3rd of posterior interventricular groove. 2) Left Diagonal Artery was a branch to the sternocostal surface of left ventricle. 3) Left Diagonal Artery 4) Left Circumflex Artery continued in atrioventricular groove ,was seen giving a branch along the left border of heart ,the left marginal artery and supplied posterior surface of left ventricle ,ended by anastomosing with ventricular branches of RCA.

TABLE NO. 8 SHOWING THE BRANCHING PATTERN OF LCA IN PERCENTAGE(%)

Branching pattern Bifurcation Trifurcation Tetrafurcation

No. of specimens 16 8 1

Percentage (%) 64 32 4

The main trunk of Left Coronary Artery was bifurcated in 16 specimens (64%),trifurcated in 8 specimens (32%) and quadrifurcated in 1 specimens (4%) .

TABLE NO. 9 SHOWING TERMINATION OF ANTERIOR INTERVENTRICULAR ARTERY

Termination of AIV Before apex After apex

No. of Specimens 2 23

Percentage(%) 8 92

The anterior interventricular branch crossed over the apex to reach upto few cms up the posterior inter-ventricular sulcus in 23 specimens( 92%), upto the anterior apex in 2 specimens (8%).

TABLE NO. 10 SHOWING TERMINATION OF CIRCUMFLEX ARTERY

Termination Of Circumflex Artery At obtuse margin Between obtuse margin and crux After crux

No. of specimens 7 14 4

Percentage(%) 28 56 16

The circumflex branch terminated at obtuse margin in 7 specimens(28%), between the obtuse margin and the crux in 14 specimens( 56%), after crux in 4 specimens( 16%).

Out of 25 heart studied LCA was seen arising from left posterior aortic sinus In 4 cases (figure no.1,2,4,10) the circumflex artery branch of left coronary artery has shown an inverted loop at crux and then it was terminated as posterior inter-ventricular artery which was running in upper part of posterior inter-ventricular groove . In rest of 21 cases, circumflex artery terminates before the crux . In two cases,7 and 17 the circumflex branch of left coronary artery it just end as left marginal artery so the area of posterior surface of ventricle was supplied by right coronary artery. Therefore in 4 cases left dominance is present and in 21 cases right dominance is present. The main trunk of LCA bifurcated in 64%,trifurcated in 32% and quadrifurcated in 4% of specimens.

Discussion
Branches of coronary arteries may vary in origin, distribution, number and size. The name and nature of a coronary artery or a branch is defined by that vessels distal vascularization pattern or territory, rather than by its origin.The location, level and size of the ostium is very important in the successful performance of a coronary angiogram.In present study the left coronary ostia were present at the left posterior aortic sinus respectively in all the specimens studied and there were no variations in the location of the ostia which was in contrast to previous study(59)where two cases were observed having double openings in the left posterior sinus, one in each of the two branches of the left main coronary artery. In our study, the main trunk of LCA showed 64% cases of bifurcation,32% cases of trifurcation and 4% tetrafurcation. Previous studies have reported wide variation in LCAT branching and have found a greater prevalence of bifurcated expression. Our results (64%of this type) coincided with previous reports indicating 4070%
(2,13,41,46,47,48,49,56,58)

, although this was greater than

that reported by

(3)

.The trifurcated division (with the addition of a Diagonal

Branch) observed in this work (32%) was in an intermediate range in relation to previous reports giving a frequency of 2050% (2,13,41,46,47,48,49,56,58 ). Such a wide range can be explained by the different approaches used for defining the Diagonal Branch . For some authors, the Diagonal Branch is the artery located in the angle formed by the Anterior Interventricular Branch and Circumflex Branch
(41,49)

,other authors use a broader approach

and consider that the Diagonal Branch originates in the vertex of the angle formed by the terminal branches of the Left Coronary Artery or in the initial millimetres of the Anterior Interventricular Branch and Circumflex Branch (20). The frequency of LCAT tetrafurcation in our study was 4%, similar to that reported by previous studies (411%) by
(2,13,41,46,47,48,49,56,58 )

.Diagonal

branch length variations have special importance in heart surgery because their external portion is frequently used for an autogenous bypass implant (41). The presence of collateral irrigation in the obtuse face of the heart, with Circumflex Branch or Anterior Interventricular Branch diagonals or

collaterals, could respond to vascular compensation for a greater territorial demand in irrigation because of deficiency in the larger arteries.

Beginning usually as a direct continuation of main Left Coronary Artery, the anterior interventricular (descending) branch gently curves around the base of pulmonary artery to enter the anterior interventricular sulcus to reach the apex of the heart. It reaches the apex almost always terminating there in one of specimens, but more often turning around the apex into the posterior inter-ventricular sulcus, in which it traverses a third to half its length, to meet the twigs of the corresponding right coronary ramus in case of Right Cadiac Dominance or left coronary ramus Dominance. The heart apex has traditionally been singled out as the place where anterior interventricular branch conclude with greatest frequency; the in case of Left Cadiac

interventricular posterior sulcus being the most frequent place for finalisation , once it has supplied the apex with numerous collaterals. Anterior interventricular branch finalisation before the apex has anterior interventricular branch been described as having an 8% frequency although James
(20) (13)

has reported a slightly higher rate (17%). This was in

contrast to our study which was 8% before apex. Our study was more in agreement with study (56) which was 1.3% before apex.

After apex, in the posterior interventricular sulcus being the most frequent place for finalisation of Anterior Interventricular Branch. In our study

anterior interventricular terminated after apex in 92% of specimens.

TABLE NO. 12 SHOWING COMPARISON OF TERMINATION OF ANTERIOR INTERVENTRICULAR BRANCH WITH PREVIOUS STUDY IN PERCENTAGE(%): Termination Before Apex After Apex James(1961) 17 83 Kalpana(2003) 8 92 Present Study 8 92

TABLE NO. 13 SHOWING COMPARISON OF TERMINATION OF CIRCUMFLEX ARTERY WITH PREVIOUS STUDY IN PERCENTAGE(%): Termination Before obtuse margin At obtuse margin Between obtuse margin and crux At crux Beyond crux Not present James (1961) 1 20 60 9 9 1 Kalpana(2003) 3 13 67 6 11 ----Present Study -----28 56 ----16 ------

The incidence of the termination of Circumflex artery before obtuse margin found in previous work ranges 1-3%,at obtuse margin ranges 13-20%

,between obtuse margin and crux it ranges between 60-67% , at crux 6-9%

and beyond crux 9-11%[13,20]. It has been observed in many cases that the marginal branches, besides irrigating segments of the obtuse face of the heart through collateral branches positioned in horizontal or oblique way. In the present study of the termination of Circumflex artery before obtuse margin was not seen in our work, at obtuse margin 28% ,between obtuse margin and crux it ranges between 56% and beyond crux in 16% cases.

TABLE NO. 14 SHOWING COMPARISON OF CARDIAC DOMINANCE WITH PREVIOUS STUDY IN PERCENTAGE(%):

Cardiac dominance Left Right Balanced

Ayer (1957) 28% 44% 28%

Meschan (1978) 15% 67% 18%

Allwork (1987) 15% 70% 15%

Kalpana (2003) 11% 89% ----

Reddy (2005) 11.25% 86.25% 2.5%

Bhimalli (2006) 23.33% 60% 16.66%

Fazliogullari (2010) 14% 42% 44%

Present study 16% 84% ----

In our study,Posterior Interventricular Artery arises from Left Coronary Artery in 16% of the specimens. The A.V. Nodal arterty (AVNA) arises commonly from the inverted loop said to characterise the LCA at the crux where the Posterior Interventricular artery (PIVA) arises.The AVNA arose from LCA in 16% of the specimens. The Posterior Interventricular artery

(PIVA) arose from Right Coronary Artery in 84%and from Left Coronary Artery in 16% of the specimens.

In our study we recorded the Mean diameter and Standard Deviation of Left Coronary Artery Trunk
1. 2. 3. 4.

At Origin : 4.87 +/- 0.80 mm Before Giving First Branch : 4.87 +/- 0.80 mm After Giving First Branch : 4+/-0.79 mm First Branch : 3.34+/-0.66 mm .

In Previous research mean diameter and Standard Deviation of Left Coronary Artery
1. 2. 3.

5.0+/-0.9 mm

(49)

4.44 +/ 1.79 mm (58) 3.58 +/- 0.59 mm (56)

The high degree of variability of the coronary arteries and their branches must be carefully observed and studied from anatomical, pathophysiological, diagnostic and therapeutic viewpoints.

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MASTER CHART

Specimen no.

Origin Of LCA from

Orig in of Bran ches AIV

DA

CA

LMA

Diamet er Of (mm) LCA LCA (at (before

LCA (after

Ist Branch

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25

LPAS LPAS LPAS LPAS LPAS LPAS LPAS LPAS LPAS LPAS LPAS LPAS LPAS LPAS LPAS LPAS LPAS LPAS LPAS LPAS LPAS LPAS LPAS LPAS LPAS

LCA LCA LCA LCA LCA LCA LCA LCA LCA LCA LCA LCA LCA LCA LCA LCA LCA LCA LCA LCA LCA LCA LCA LCA LCA

LCA LCA LCA LCA LCA LCA LCA LCA LCA LCA LCA LCA LCA LCA LCA LCA LCA LCA LCA LCA LCA LCA LCA LCA LCA

LCA LCA LCA LCA LCA LCA LCA LCA LCA LCA LCA LCA LCA LCA LCA LCA LCA LCA LCA LCA LCA LCA LCA LCA LCA

LCA LCA LCA LCA LCA LCA LCA LCA LCA LCA LCA LCA LCA LCA LCA LCA LCA LCA LCA LCA LCA LCA LCA LCA LCA

origin) 3.75 4.5 4 4.5 5.5 4.5 5.5 4.5 5.5 5.5 5 5 6 5.5 4.5 5.25 5 5 6.5 6 5 3.5 4.5 3.5 4

division) Division) 3.75 3.25 4.5 4 4 3.5 4.5 3.5 5.5 4.5 4.5 3.75 5.5 5.5 4.5 3.75 5.5 4 5.5 5.25 5 4 5 4 6 5 5.5 4 4.5 4 5.25 4.25 5 5 5 3.25 6.5 5 6 5 5 3.5 3.5 2 4.5 3.75 3.5 3.5 4 3.25

2.75 3.5 2.5 3 3.5 2.75 4 4 3.75 4 4 4 3.5 3.5 3.5 3.25 3.5 2.75 4.25 3.5 4 2 3.5 3.25 2.75