Professional Documents
Culture Documents
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Overview of Cardiac Pathology
Heart: two pumps PARTS OF THE HEART
1. bodyIVC/SVCRAtricuspid valve RV pulm valve pulm artery lungs (THAT GET DISEASE)
2. lungs pulm vein LAmitral valveLVaortic valveaortabody
1. coronary arteries*
2. valves
Coronary Arteries 3. conducting system
Normal Physiology 4. myocardium
2 main coronary arteries exit from aorta just above aortic valve (backflow pushes in) * most common
CA Major Branches Supplies
LAD: Left anterior descending LAD¨50% LV
Left main CA 70% LV
LCX: Left circumflex LCX: 20% / posterior LV
Right CA RV & 30% LV
Dominance: whoever gives rise to PDA (posterior descending) and PLA (posterior lateral) is “dominant”
Right-dominant: RCA (70-80% hearts)
Left-dominant: LCA (10%)
Co-dominant: shared (10-20%)
Heart Valves
Normal Physiology
Tricuspid(RA/RV)
Pulmonic (RV/PA)
Mitral (LA/LV, 2 leaflets, others 3)
Aortic (LV/aorta)
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Valvular Disease
Congenital (e.g. bicuspid aortic valve, most common, in 1-2% population) and acquired
Most significant disease is LEFT SIDE (mitral /aortic)
Regurgitation: blood flows in reverse through incompetent valve (aortic root dilation, floppy mitral valve changes)
Endocarditis: non-infectious or infectious (bacterial/fungal); plaques & vegetations can cause 2 problems:
impact valve function
risk to embolize (block artery stroke) & seed infection
Tx by replacement
mechanical: bileaflet used more often today; last longer but have to use antiplatelet drugs
bioprosthetic: e.g. part porcine or bovine; don’t last as long but no anticoagulant therapy needed
Conducting System
Normal Physiology
Myocardium
Normal Physiology Dimensions
Heart weight F: 200-300 g
Myocytes need lots of nutrients M: 230-420 g
Endocardium: endothelial cells LV thickness 1.0-1.4 cm
RV thickness 0.3-0.5 cm
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Myocarditis: most often after viral infection (coxsackie B virus);
can also be parasitic (Chagas dz; not in USA) or idiopathic (Giant
cell; deadly)
Results in poor contractility (lower ejection fraction)
Paradoxical outcome: typical myocarditis often have
sequelae; fulminant myocarditis often do very well
Cardiac transplant
Used in treatment of heart failure (secondary to many of these processes)
If heart can’t pump blood to lungs/body effectively Cardiac Transplant Facts
Indications: Heart failure with marked
Failure of transplanted hearts: limitations or bed rest (NYHA class III/IV)
Often from transplant vasculopathy (coronary vessels narrowed) 10-20/yr at JHH
o different from atherosclerotic CA dz: diffuse process / no 50% chance of 10 yr survival
way to do bypass Most transplant failures due to:
o Rejection (short-term)
o Transplant vasculopathy (long-term)
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Myocardial Infarction: (pathophysiology & pathology)
ISCHEMIA INFARCTION
Temporary imbalance: myocardial O2 supply & demands Happens when ischemia is severe enough and for long enough time
Complete reversibility of derangements Myocyte death
o cell metabolism, electrical, contractile Irreversible derangements (cellular, electrical, contractile)
“stunned myocardium”, full recovery can take weeks
Etiologies of MI
Coronary thrombosis: the primary cause of MI
Coronary artery embolus: most often from heart
Coronary vasospasm (Prinzmetal’s angina): vasoconstriction, will totally resolve with nitrates to vasodilate!
Ao Dxn (with coronary artery obstruction)
Coronary arteritis (inflammation)
Congenital coronary artery anomalies
Severe, prolonged hypotension
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Pathology of MI
Yellowish eccentric atherosclerotic plaque; can still have big lumen with no symptoms
Thrombosis:
Superficial thrombosis with endothelial erosion (turbulence & exposed substrate for
thrombosis; thrombus forms on surface of lumen)
Deep thrombosis with plaque disruption (rupture of plaque, blood hemorrhages
underneath to find substrate; plaque disrupted & pushes cap out into lumen)
Some can do both (push up from underneath & thrombus forms on surface as well)
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pH↓ with time (lactic acid building up)
K+↑ (efflux from cells), then plateaus
o then ↑ again (cells starting to die, release more K+)
Dx of MI
1. Symptoms:
“Typical” chest pain (substernal neck/jaw, etc, worse on
exercise, etc., etc.)
Also syncope, dyspnea, orthopnea (SOB on laying down), cough
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Total CK and CK-MB peak early (first 48 hrs)
o draw multiple times early in hosp to capture
CA INFARCT COMPLICATIONS
Shock
Anterior
LAD BBB
Septum
VSD
Posterior papillary
LCX Lateral
muscle rupture MR
Posterior papillary
Inferior
muscle rupture MR
Right Right
AV block
Ventricle
VSD
Collaterals:
normally not too many / tiny in everybody
o if you have gradual stenosis of CA (e.g. long-term angina) you can develop collaterals (protective!)
o Can have virtually complete occlusion with collateral: but occlude second artery massive MI
Collateral flow highest in outer layer of myocardium
o If enough collateral flow: won’t get a transmural infarct regardless of duration!
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Morphologic Stages of MI (Inflammatory Response & Repair)
Aneurysmal Thinning: when a scar forms after a transmural infarct, the previously infracted
area can become very thin: predispose to aneurysm in that area
Reperfusion Therapy:
1. Thrombolytics
2. Mechanical (Stent and/or balloon angioplasty, usually both) reperfusion
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Remember: TIME IS MUSCLE with reperfusion therapy
Wait 0-1 hours: save 35 extra lives per 1000 patients
Wait 2-3h: save 25
Wait 13-24h: only save 5 (big drop)
Killip class: can be used to grade (no heart failure = I, cardiogenic shock = IV): worse outcome with ↑ class
Mural thrombus
LV aneuyrism & thrombus: need a large transmural infarct
1. Infarct thins, elongates (expansion) LV volume ↑, EF↓, heart failure
2. LV remodeling can be prevented (reduce infarction size, restore patency, reduce afterload with ACE inhibitors)
3. Can be nidus for thrombus formation (dilation stasis) embolization
Arrhythmias
Arrythmia Characteristics Treatment
Ventricular premature beats (VPBs) Common None
Accelerated idioventricular rhythm (AIVRs) Common with reperfusion None
Ventricular tachycardia / fibrillation (VT/VF) Cause of sudden death Shock
Drugs
Block 1,2,3°, can be permanent or temporary ± Pacer
Mechanical complications
1. Free wall rupture (hemopericardium; burst through wall of heart blood into pericardium)
a. Usually fatal: hemopericardium + cardiac tamponade
b. Rarely: leads to pseudoaneurysm
i. Rupture contained by adherent pericardium
ii. See narrow neck / wide body aneuyrism on echo / acth
Treatment of Acute MR
iii. Need urgent cadiac surgery
Aggressive use of diuretics & inotropes
Vasodilator therapy
2. Papillary muscle rupture mitral regurgitation Intraaortic balloon counterpulsation
a. Can occur with either ST or non-ST segment elevation MI (balloon pump)
b. Usually an inferior MI (posteromedial papillary muscle Emergent cath to
supplied only by RCA; anterolateral has dual supply) o Confirm dx
c. Causes pulmonary congestion ± hypotension; can o Define anatomy
sometimes be heard as MR (systolic murmur at apex) Repair/replace with immediate surgery
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Treatment of VSD (a lot like MR Tx)
3. Septal rupture VSD, blood flows back into RV instead of aorta Aggressive use of diuretics & inotropes
a. Anteroseptal or inferior MI Vasodilator therapy
b. Frequently at first MI (no collaterals) Intraaortic balloon counterpulsation
c. Causes pulmonary congestion ± hypotension (balloon pump)
d. ± systolic murmur + thrill at L. sternal border) Emergent cath to
o Confirm dx
o Visualize VSD
o Define anatomy
Fix with immediate surgery
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Pathology of Heart Muscle Disease
Myocarditis
Key feature: Myocarditis Leukocytes Why?
Type of WBC helps you ID the etiology Chagas Dz / T. cruzi T-cell rich mononuclear Intracellular parasite
Coxsackievirus B3 Lymphocitic Virus (or autoimmune after)
Myocarditis: leukocytic infiltration of Rheumatic fever Anitschkow cells Autoimmune post-strep
heart muscle associated with myocyte (weird histiocytes) (won’t see PMNs, etc)
necrosis. (Aschoff bodies too)
Fungal No WBC Seen in immunocompromised pts
(Generally excludes MI-related inflammation) Drugs (cocaine, etc) Eosinophils Hypersensitivity
Various causes: idiopathic, infectious - hypersensitivity
(parasitic, viral, bacterial, fungal),
rheumatic fever (infectious autoimmune), drugs Clinical features of myocarditis
• Acute presentation:
heart failure, arrhythmia or death
Infectious Myocarditis • ↑ ESR
• Leukocytosis
Chagas’ Disease (trypanosoma cruzi): parasitic • ↓LV function with ↓ EF
South America: transmitted by reduvid bug
16-18M infected; 3M have Chagas’ dz of heart Pathologic findings
• Pale, flabby hearts
See T-cell-rich mononuclear cell infiltrate: parasite • WBC infiltrate + myocyte necrosis
takes over cytoplasm (by definition)
• WBC infiltrate: may be patchy
Coxsackievirus: picornavirus, fecal-oral or resp trans
Most common cause in USA
Coxsackievirus B3 is #1
Biphasic course:
o initially URI / GI illness; sensitization of immune system
o 7-14d later myocarditis (but virus no longer detectable –
IMMUNOLOGIC RESPONSE is to blame)
Lymphocitic infiltrate + myocyte necrosis
Why does Coxsackie B3 myocarditis happen? Various theories (may all play a role)
1. Immune system overdoes it while trying to kill virally-infected cardiomyocytes
o Lots of proinflammatory cytokines; persistent infiltration (can be detrimental to remote heart areas too)
2. Autoimmune-mediated destruction (molecular mimicry / similar host-viral epitopes)
o May be immune response against self-antigens, or
o maybe virus injures cells, exposing normally hidden antigenic epitopes to immune system (not recognized as “self”)
3. Direct virus-induced cardiomyocyte injury
In any case immune system is key: immunosuppressive therapy can be used to treat viral myocarditis!
Rheumatic Fever:
Acute, recurrent, multisystem inflammatory disease
Autoimmune complication: 1-5 wks post-infection with group A strep (pharyngitis)
o (common epitope with cardiac myosin M protein; Ab formed)
o Treat strep pharyngitis to prevent it!
Path features:
Aschoff bodies (perivascular round / oval foci of fibrinoid necrosis surrounded by lymphocytes and Mϕ)
Anitschkow cells: weird looking (like little caterpillers) – modified histiocytes
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Fungal myocarditis
Rare; generally seen in immunocompromised pts
Aspergillus and cryptococcal infection (candida too)
NO WBC (because of patient – immunosuppresed!)
Hypersensitivity myocarditis
Various drugs (incl cocaine, e.g. Len Bias)
Cardiomyopathies
Pathology doesn’t help in determining etiology, but genetics can help with prognostication
Dilated Cardiomyopathy:
Clinical features of DCM
Big, flabby, hypocontracting hearts • Chronic progressive heart failure with ↓LVEF
Boxcar nuclei (hypertrophy of myocytes themselves) • Arrhythmia, embolic episodes
• Mitral/ tricuspid regurgitation
Presentations • CXR: cardiac enlargement and pulmonary
vascular congestion
Alcoholic cardiomyopathy:
ETOH & acetaldehyde Pathologic findings of DCM
interfere with calcium • Biventricular hypertrophy & 4-chamber
transport; relationship to dilation
cardiomyopathy unknown • Mural thrombi
• Myocyte hypertrophy
Beer drinkers’ • Interstitial fibrosis
cardiomyopathy (Canadians
put cobalt in beer to stabilize head, toxic to heart)
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Peripartum cardiomyopathy:
onset of CHF in 3rd trimester or 1st 6 mo post-partum
Risks: multiparity, eclampsia, twins, mom > 30yo, poor nutrition, exact etiology unknown, non-specific biopsy
Outcome: about 50% pts have heart return to normal size within 6 mo
Hypertrophic Cardiomyopathy:
Clinical features of HCM
Heavy hypercontracting hearts Exertional angina
Dyspnea, fatigue, syncope
Wide septum (top), myocytes in Sudden death
disarray (bottom)
Pathologic findings of HCM
Classic: young athletes! • Asymmetric septal hypertrophy
• Catenoidal configuration to the septum
Genetic mutations are important in HCM • Disarray of the myoctyes
(like in DCM) • Systolic anterior motion of the
anterior leaflet of the mitral valve
β -myosin heavy chain gene • Endomyocardial plaque on the
1/3 of all HCM outflow tract of the left ventricle
50% families with HCM have (where MV anterior leaflet keeps
identifiable mutation (can make in bumping against it)
all family members)
Mutations that change charge of altered AA have shorter survival
Good prognostic indicator: test family members; take precautions or treat before sudden death occurs
Restrictive Cardiomyopathy:
LV contracts normally but rigid (ventricle filling is impaired)
Very rare
Endomyocardial fibrosis in Africa (fibrosis of ventricular endocardium);
Lofler’s syndrome (myocyte necrosis + eosinophilic infiltrate)
Note fibrous ring around LV; RV hypertrophy
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Infiltrative processes
Amyloid
Various proteins can be the cause; deposited in tissues & form β-pleated sheets abnormally
Immunocyte-derived disease (AL): from light chains (from plasma cell disorders!)
Senile cardiac amyloid: from transthyretin (prealbumin)
Path findings:
heart is enlarged & firm
amorphous eosinophilic hyaline deposits in blood vessels / within
interstitium
stain with Congo red (see picture to right; would see greenish
bands if polarized)
Others:
hemochromotosis: can get iron deposits in heart
glycogen storage disease: congenital; myocytes filled with glycogen
Heart transplants
Remember autograft / isograft / allograft / xenograft (diagram)
Xenograft: risk of transmission of new disease to humans!
Rejection: by the time it’s clinically apparent, irreversible damage may have
been done to the myocardium – use heart biopsy to detect before Sx start!
If you see myocarditis starting (e.g. lymphs) – titrate your
immunosuppresion!
Accelerated graft arteriosclerosis is a problem too (after initial complications of rejection, still 50% lose heart by 13yrs)
diffuse, concentric process, not a localized eccentric plaque like normal atherosclerosis
Can’t treat with CABG or stent (because it’s not just in one place)
Endomyocardial biopsy
Allows histologic diagnosis of myocarditis in living patients!
Serial biopsys can document natural history of cardiac disease
Can improve therapy: better response by titrating doses, etc.
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Pathology of Heart Valves
Normal Valves
Normal histology:
Bland & unremarkable (No
inflammatory cells or blood
vessels)
Zona spongiosa, zona fibrosa,
zona ventricularis
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Stenotic Valve Disease
Stenosis: valve becomes rigid, obstructs blood flow
Results in severe pressure gradient across the valve
Aortic Stenosis
Most common valve to be stenotic
2 2
Normal valve: 3-4cm , critical stenosis at 0.75 cm
Mitral Stenosis
Post-Rheumatic fever almost exclusively (don’t see too much anymore in US)
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Carcinoid heart disease
Aortic Regurgitation
Mitral Regurgitation
Etiologies:
1. Cusp disease
2. Ring abnormalities (dilated or rigid)
3. Chordae Tendineae
(short vs long/broken)
4. Papillary muscle injury (MI, CM)
Note: MV prolapse isn’t uncommon in young women, but only some develop true regurgitation / floppy valves
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Floppy Mitral Valve Myxoid Degeneration Rheumatic Mitral Regurgitation
Floppy cusp (top) won’t make Normal zona fibrosa but myxoid Crazy shortened thickened chordae tendininae,
a good seal (lots of mucousy stuff )mixed in definitely won’t let valve close
Tricuspid Regurgitation
Pretty rare
Can get from old rheumatic fever, carcinoid heart disease, bacterial endocarditis, or dilated annulus (from
right-sided CHF; like MV problems in left CHF)
Endocarditis
The “door stopper” – has two main problems
1. Stops leaflets from closing (regurgitation)
2. Thrombus formation (seeds infection; can embolize)
Non-infectious endocarditis
NBTE Histology:
Fibrin, platelets, fibroblasts, vegetations
(some Mϕ and Fe too)
No acute inflammatory cells
(PMNs, etc.) or bacteria
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Libman-Sacks Endocarditis
4% of patients with lupus (SLE)
Often doesn’t cause disease
Infectious endocarditis
More common in:
INFECTIOUS CAUSES OF ENDOCARDITIS
IV drug users (usually RIGHT SIDED)
o shoot up in veins R heart, hit damaged valve #1 is STAPH AUREUS
o Others are in left side valves Viridans group strep, enterococci, coag-
Pts w/ prosthetic heart valves neg staph, HACEK organisms fungi,
Pts w/ structural heart disease others (pretty much everything)
HACEK: common board question, group
Complications: valve dysfunction & thromboemboli of Gram (-)s, grow slowly (watch
culture 2-3 wks)
Gross view: friable (can break off), growing on line of closure (regurgitation)
Some can actually eat away at valve leaflet (S. aureus)
Histology:
Large view: see vegetation overlying valve (arrow)
Ulceration, some normal valve, colonies with acute inflammation
(PMNs, lymphs, etc)
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Artificial Valves
Bioprosthetic or Mechanical?
Material? Anticoagulants? Lifespan?
Bioprosthetic Bovine, pig valve in prosthetic strut No anticoagulants Limited life / need replacement
Mechanical Carbon alloys Need warfarin Last 20+ years
Mechanical: cage & ball was loud & drove you crazy, Poe-style tilting disk (leaked) bileaflet / St. Jude (used today)
Earlier designed – more turbulence more thrombus formation
Valvuloplasty:
• Severe mitral (and rarely tricuspid) regurgitation or stenosis
Review questions
1. Which of the following is a major cause of aortic 3. This picture is an example of? (shows picture of big
valvular stenosis? root with taut leaflets)
a. Carcinoid heart disease a. Aortic regurgitation due to root
b. Marfan enlargement
c. Syphilis
d. Calcified congenital bicuspid valve 4. The most common infectious cause of
endocarditis is?
2. What is the order most frequently noted for a. Staph aureus
affected valves by chronic rheumatic valve disease
a. Mitral > mitral & aortic > aortic
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