Heart and Coronary Arteries: An Anatomical Atlas for Clinical Diagnosis, Radiological Investigation, and Surgical Treatment

233 Pages·1975·72.19 MB·English

by  Wallace A. McAlpine M.D.

McAlpine Heart and Coronary Arteries
Wallace A. McAlpine
Heart and
Coronary Arteries
An Anatomical Atlas for Clinical
Diagnosis, Radiological Investigation,
and Surgical Treatment
With 1098 Figures Mostly in Color
Springer-Verlag Berlin Heidelberg New York 1975
Wallace A. McAlpine, M.D.
F.A.C.S., F.R.C.S., Eng.: F.R.C.S. ED.
Cardiovascular and Thoracic Surgeon
Toledo, Ohio, USA
ISBN-13: 978-3-642-65985-0 e-ISBN-13: 978-3-642-65983-6
DOl: 10.1007/978-3-642-65983-6
The use of general descriptive names, trade marks. etc. in this
publication, even if the former are not especially identified, is not
to be taken as a sign that such names. as understood by the
Trade Marks and Merchandise Marks Act, may accordingly be used
freely by anyone.
Library of Congress Cataloging in Publication Data
McAlpine, Wallace A. 1920 - Heart and coronary arteries. Biblio·
graphy: p. Includes index. I. Heart-Atlases. 2. Coronary arteries
Atlases.·r. Title [DNLM: I. Biometry. 2. Coronary vessels-Atlases.
3. Heart-Atlases. WG 17 M 114 h] QM 181.M 32611'.12 74-20634
This work is subject to copyright. All rights are reserved. whether the
whole or part of the material is concerned, specifically those of trans
lation, reprinting, re-use of illustrations, broadcasting, reproduction by
photocopying, machine or similar means, and storage in data banks.
Under § 54 of the German Copyright Law where copies are made for
other than private use, a fee is payable to the publisher, the amount
to the fee be determined by agreement with the publisher.
iD by Springer-Verlag Berlin· Heidelberg 1975.
Softcover reprint of the hardcover I st edition 1975
Typesetting, printing and binding:
Universitiitsdruckerei H. Stiirtz AG, Wiirzburg
Type face: Monophoto-Times 9/1 r
Paper: Papierfabrik Zanders
Photography: W. McAlpine
Drawings: Paul Fairchild
Reproduction of the figures: Wiirttbg. Graph. Kunstanstalt G. Dreher
Dust cover: W. Eisenschink
Lay-out and Production:
J. Tesch. H. Matthies, and H. Schwaninger
Dedicated to my wife, Shirley,
who has sustained and encouraged
me throughout my surgical l(fe and,
particularl}; during the countless
added hours required in the prep
aration and photography the
(~f
specimens seen in these pages.
And to my children, Kim, Fraser,
Laurel and Leigh.
Foreword
The magnificent anatomic presentation in this book "The Heart and Cor
onary Arteries" has a unique importance for surgeons. It is a fundamental
contribution to the anatomy of the heart and great arteries as well, because
of the analytical, detailed, and imaginative anatomic approach of the
author.
While surgery from time to time is influenced by the development of new
physiologic principles and techniques, methods of intra- and post-operative
support, and new diagnostic methodology, the excellence of its results con
tinues to be related primarily to the precision and perfection of the opera
tive procedure itself. The operative procedure can be precise and perfect only
if it is based upon the surgeon's profound knowledge of normal anatomy,
his understanding of the alterations in this normal anatomy by the pathol
ogy with which he is dealing, and his ability to use this anatomic informa
tion in organizing and effecting his surgical procedure. The cardiac sur
geon, therefore, will find great rewards from intense study of this anatomic
atlas. The cardiologist, the pediatric cardiologist, the anatomist, the pathol
ogist, and students interested in cardiac disease will benefit to almost the
same degree from a careful study of this work.
May 1975 W. M.D.
JOHN KIRKLIN,
Professor and Chairman
Department of Surgery
University of Alabama
in Birmingham
Preface and Acknowledgements
The importance of gross anatomy in the com with the implicit reference to the anatomic
prehension, diagnosis, and surgical treatment position, and second, inspection from any
of disease was impressed on me by my first radiographic vantage point in the horizontal
teacher of anatomy, Professor Ian MacLaren plane; in the text, the radiographic view of
Thompson at the University of Manitoba. each photograph is specified. Finally, angled
Throughout my surgical training, in London or elevated views may be used. These are im
under Lord Brock and Professor Ian Aird, in portant clinically: In the definitive arter
Stockholm under Professor Crafoord, and in iographic visualization of the proximal parts
Ann Arbor under Professors John Alexander of the branches of the left coronary artery,
and Cameron Haight, the role of basic sciences the x-ray beam must be perpendicular to the
was always prominent in clinical consider axis of the vessels.
ations. To these, my teachers, this atlas is
presented as a tribute.
My basic aim in this work is to provide photo
graphs of dissected, normal hearts for the study
In 1950, the surgical treatment of heart disease of the details and spatial disposition of anato
had entered its intracardiac phase and catheter mic structures. Photographs are the optimal
and improved radiologic techniques had medium of anatomic communication; how
become available. In response to this challenge, ever, if each photograph is to be a source of
I began a review of the related anatomic infor anatomic truth and to separate fact from
mation. The material was limited and often opinion, it must be free of distortion. To this
not readily transferable to the clinical problems end, considerable time and effort were expend
at hand. I then turned to the dissection of the ed: Finally, incorporating recent technical
normal heart. The answers to many questions advances in photography, the present tech
were readily available; however, it was appar nique was developed. In the photography, I
ent that comprehension of the relations found attempted, first, to manipulate external light -
in the operating room and the spatial anatomy ing to demonstrate the contours, delimit the
seen in radiographic studies required not only parts, and portray the relationships of the liv
a technique of fixation of the heart, which re ing heart and, second, to use interior lighting,
created the dimensions and form of the living not only to differentiate muscle and membrane,
organ, but also a technique of photography but also to delineate structures, such as the
that simulated radiographic investigations. aortic annuli.
In 1949, working in the department of surgery The physicians of this era are blessed, but also
at Sabbatsbergs Hospital, Stockholm, I besieged, by the mass of useful new informa
observed the pumping of fixative into lung spec tion confronting them and pressed by the need
imens for pathologic study. I was impressed to review facts once familiar. It is hoped, there
by the restoration of the form and dimension fore, that the format selected will facilitate the
of the functioning organ. It was a natural con use of this volume. Although this format occa
sequence to utilize this idea and to adapt the sionally involves repetition of material, page
apparatus of extracorporeal bypass in effecting turning is minimized by the assignment of
the perfusion-fixation of heart-lung specimens individual topics to two opposing pages on
a decade later. The importance of this type which the expository photographs and text
of fixation in the elucidation of the features appear. Although reference to valuable contri
of both normal and pathologic hearts has been butions of others is made, the format does not
attested by Dr. Maurice Lev and his colleagues. permit an encyclopedic account of the history
of anatomic knowledge of the heart. Color
A technique of photographic examination of coded drawings, made from the tracings of
the excised heart was developed to allow, first, photographs, are used to simplify orientation
the replication of normal in situ relationships of the photographs. In order to avoid reduction
IX
in the scale of the photographs and expedite rived therefrom, its mode of branching and the
their examination, abbreviations are used; precise area of supply of each of its branches.
these provide orientation and direct attention This elicitory exercise is salutary in the study
to structures being studied. The instructions of obliterative disease. The arrangement of the
to the reader should also facilitate the study section on the coronary arteries effects concor
of the material. dance with this fundamental anatomic method.
In any event, the primary purpose of this work
is to present photographs of hearts for study
In this presentation an anatomic method of
and I have attempted to ensure that conceptual
long-standing is used. A dominating structure
details and nomenclative changes clarify this
is first identified and studied; to it the remain
study.
ing parts are then applied sequentially. In this
instance, the dominating structure is composed
A complete knowledge of cardiac anatomy is de
of the aortic bulb, left ventricle, and the mem
rived from many investigative and clinical tech
brane connecting the two. This simple but
niques-gross dissection of normal hearts is one
eductive method clarifies relationships often
of these . This volume is presented as a broad
deemed complex, illumines the logic inherent
survey of this aspect. Gross dissection and, for
in cardiac design, and facilitates the acquisition
example, the injection-corrosion technique
of a detailed spatial knowledge of cardiac anat
exemplified by the works of James and Baroldi
omy. Although the index is planned to lessen
are not competitive-each has its own contri
the task of a random study of its parts, review
bution to make. I have made no attempt to
of the whole is recommended in the initial use
repeat the work of others. The location and
of this volume. This instruction may be incon
relations of the conduction system are indi
sistent with the subtitle of this work: The word
cated in many figures in this volume. These
atlas was selected to indicate both its pictorial
inferences stem largely from the works of Hud
nature and its nonencyclopedic aspect.
son, James, Lev, Rosenbaum, and Titus. All
1098 photographs and drawings are original.
"In the description of the human body, all As I have done the photography and made the
terms are used in relation to the anatomic posi tracings for the drawings, the responsibility for
tion ". The descriptions of cardiac anatomy are the illustrative material and its design is mine.
often unique in their disregard for this cardinal In the belief that material is best studied in its
principle. The spatial examination of the heart complete and original form, the figures of
evinces the inaptness of some currently used others are not reproduced; rather, I have di
terms; these have been altered to effect their
rected the reader to contributions that I have
congruence with the anatomic position-a
found helpful.
necessity in their clinical use. In some instances,
terms familiar to workers in a narrow segment A definitive account of anatomy includes the
of cardiology, but not deducible by all physi statistical study of each structure examined.
cians, have been changed. For example, when In some areas, this statistical study has been ac
a branch of the left coronary artery supplies complished: Presenting this unpublished data,
the anterolateral or the lateral sector of the I express my thanks to two former colleagues,
left ventricular wall, the spatially correct terms, Dr. Axel Ehman, Michigan State Univer-
anterolateral and lateral, replace the ambig sity, and Dr. Toshiaki Kawakami, Univer-
uous terms in current use-the first and sity ofHokkaido, for their efforts in this attain
second diagonal branches. In other instances, ment. This has been largely a prospective
alteration is found in terms that have unfor study and many workers and a multitude
tunate connotations: For example, the tradi of specimens would be needed to gain the
tional terms, left anterior descending and cir desired statistical goal. In the discussion of
cumflex branches of the left coronary artery, specimens, features that are important but
are replaced by anterior and posterior divisions peripheral to the primary topic, are often de
of the left coronary artery. This may be deemed scribed; This results in repetition which may
quixotic or a mere attempt at innovation. The prove irksome to the reader; however, it is
suggested terms-eschewing the simplistic rele intended to compensate, in part, for the limited
gation of the arteries to the sulci-invite the statistical data. Specimens used in the
elicitation of the prime characteristics of an demonstrations of anatomic features have been
artery: its origin, its termination, its course selected carefully-the exceptional specimen
and relations and the arterial subdivision de- is not adduced in the depiction of the normal.
x
The index is intended to serve, not only as an sponse to all problems. The majority of the dis
aid when structures are seen in a dissection sections of the coronary arteries has been car
prior to their formal presentation, but also to ried out by my daughter, Kim; the precision of
enable the reader to examine most anatomic her work is evident. I am grateful to Springer
features in many specimens. The index also Verlag for their cooperation, attention to detail
represents a second approach to the study of and for the great efforts they have made in the
the material of this volume. This approach, production of this work. Eugen Jennewein and
antithetical to the format designed to minimize Kurt Soll of the Dreher Company, Stuttgart,
page-turning, affords a systematized review of have expended unusual effort in an attempt to
each anatomic structure. capture on these pages the information con
tained in the photographs. Generous support
The hearts seen in this work were from individ has been provided by the Andersons, the
uals who exhibited no clinical or gross evi Ransom Family Foundation, the Mary S.
dence of cardiac disease. During the past fifteen Ritter Foundation, the France Stone Foun
years, over I 000 human hearts, obtained from dation, Mary Stranahan, and the Institute of
hospitals over a wide area, have been studied. Medical Research of Toledo Hospital.
Over 300 hearts of domestic and wild animals
have been used in the study of the comparative Toledo, June 1975
anatomy; a few will be seen in these pages.
WALLACE A. McALPINE
Dr. Morris W. Selman and Dr. Hugh M. Fos
ter, Jr., my associates in the practice of cardio
vascular and thoracic surgery, have assumed
an increased clinical burden without com
plaint. This work would have been impossible
without them. Likewise, four of the nurses in
our office, Patricia Sheedy, Betty Nicolen, Dor
othy Fisher, and Janet Reynolds have added
to their travail, sharing in the typing of the
manuscript. Mr. Angus MacArthur of Kings
College Hospital, London, and Dr. Donald
Woodson of the Medical College of Ohio at
Toledo, both surgeons, Dr. Donnan Harding,
Chief of Pathology at Riverside Hospital,
Toledo, and Dr. Charles Schmidt, Chief of
Radiology at St. Luke's Hospital in Mil
waukee, have provided help in the arrangement
of the material. Without the support and
encouragement of Dr. Don N ouse, Chief of
Cardiology at Toledo Hospital, this work
would not have been possible. During the many
years of my anatomic study, the friendship and
encouragement of my minister, Dr. Robert
Hansen, were important. I am pleased to
express my great appreciation to the medical
artist, Paul Fairchild, who converted the
tracings into drawings. He was engaged in this
endeavor for five years; his meticulousness and
his skill are evident. My late friend, Richard
Jamieson, worked with me, late into the night,
for many months at the inception of my studies.
The importance of his contribution cannot be
measured. Richard Serrick, a good engineer
and fine friend, designed the mount for the
heart. My friend Keith McKenney provided
unwavering encouragement and a positive re-
XI
Contents*
Foreword VII
Preface and Acknowledgements IX
Instructions to the Reader XV
Section I General Information
1. Technique 1
Section II The Normal Heart
2. An Introduction to the Aorto-Ventricular Unit 9
3. The Left Ventricle-General Considerations 27
4. The Mitral Valve 39
5. The Left Atrium 57
6. The Right Ventricle 65
7. The Right Atrium 87
8. An Attitudinal Review of the Heart-
an Introduction to Spatial Clinical Investigations 101
9. The Great Vessels and the Pericardium 123
Section III The Coronary Arteries
10. The Origin of the Coronary Arteries 133
11. The Arteries to the Atria and the A.V. Node 151
12. The Branches of the Coronary Arteries 163
13. The Course and Relations of the Coronary Arteries 179
14. The Five Modes of Termination of the Posterior Division
of the Left Coronary Artery 197
References 211
Subject Index 215
Abbreviations 224
* A detailed table of contents will be found at the beginning of each chapter.
XIII
Instructions to the Reader
1. (myocardial aneurysm [1] and calcification
The Designation of Figures: In most instan [2]).
ces, six figures (photographs, drawings,
x-rays, or tables) appear on each page; the 4.
figures are assigned numbers in the manner The vantage point of each figure will be not
depicted below: The numeration proceeds ed. Usually, traditional radiographic views
from the left to the right of the reader in each are used. Each of the four classic radiogra
row, upper, middle and lower. This system phic planes has two aspects which are re
applies when fewer or more than six figures ferred to as radiographic views. With the
appear. In the text, the figures are indicated exception of the anteropo~terior plane, the
by Arabic bold face numbers (1-6). If the terms used in this atlas, listed here, are in ac
figure referred to is found on the same page, cord with current usage in radiology. The
the single sequence number is used (e.g. 4); if advantages of numerical designations are dis
the figure is found on a different page, both cussed on page 8.
its page number and its sequence number will
be used (e.g. 154-4).
Radiographic Views:
Abbreviations and Numerical Designations
1 2 3 1 2
Antero-posterior: A.P. 0°
Postero-anterior: P.A. 180°
4 5 6 3 4 Left Anterior Oblique: L.A.O. 45°
Right Posterior Oblique: R.P.O. 225°
5 6 Right Lateral: R.Lat. 270°
Left Lateral: L.Lat. 90°
Right Anterior Oblique: R.A.O. 315°
Left Posterior Oblique: L.P.O. 135°
2.
The Presentation of Material: At the begin
When a specimen is viewed from above, de
ning of each chapter, the reader will find a
tailing the spatial disposition of structures in
detailed table of contents. Turn to Page 9 and
the horizontal plane, the term superior view
note that in Chapter 2, there are four anatom
is used. When the postero-inferior aspect of
ic topics, A, B, C, and D. Topic C, the Aor
the heart is seen with the interventricular sul
tic Sinuses and its three SUbtopics (designated
cus disposed vertically, the term inferior view
by Roman numerals I, II, and III) comprise
will be used.
the opposing pages 20 and 21. Topic B, the
Ostium of the Left Ventricle and its four sub
topics occupy the two pairs of opposing pages 5.
16 and 17, and 18 and 19. The mode of dissection of the specimen will
be described. The heart may be separated
3. into two segments either by a transection or
The Specimens: (a) Their differentiation: On an incision; the former, in contradistinction
each pair of opposing pages, specimens are to the latter, is precisely in a single plane.
assigned a capital letter. For example, on An incision may have multiple components
pages 14 and 15, six specimens (A-F) are which are positioned to separate but still
found; one of these (Specimen E: 15-1-4) is preserve the integrity of structures, e.g., the
shown in four figures. (b) Their origin is indi left and right aortic leaflets. Transections in
cated in the text. Over 200 specimens are most instances are made either in the classi
used-19 are animal hearts-the remainder cal radiographic planes of examination or in
are human, only three of which show disease the planes which are customarily used in
xv