Cardiovascular Pathology I

1. Cardiovascular Pathology I Laboratory Small Group Cases – November 6, 2008

2. Cardiovascular Pathology ICase 1 A 55-year-old man presents to the emergency room with chest pain radiating to his left arm and dyspnea for two hours. He rates the intensity of the chest pain at 10/10 and describes it as “crushing”. For several months prior to presentation he has had a few episodes of mild chest pain which developed while climbing stairs. The pain resolved within several minutes after resting. The patient smokes and has been told that his cholesterol is “on the high side”. On exam, the patient is obese. He is diaphoretic and is grabbing his chest. As part of his evaluation the ER physician orders an EKG, as well as serum myoglobin and troponin levels. Myoglobin 106 (0-75 ng/mL) Troponin 1.37 (<0.1 ng/mL)

3. CC: Chest Pain Differential: 5 Life-Threatening Causes of Chest Pain MI PE Tension Pneumothorax Aortic Dissection Esophageal Rupture

4. Pertinent Positives and Negatives Positives: Smoker Obese ST depression on EKG Crushing pain Myoglobin 106 (normal: 0-75 ng/mL) Non-specific Troponin 1.37 (normal: <0.1 ng/mL) Specific for myocardial injury (not necessarily MI)

5. Diagnosis Acute Myocardial Infarct Coronary Atherosclerosis/Thrombosis

6. Risk Factors Associated with atherosclerosis/ ischemic heart disease Nonmodifiable Potentially controllable Increasing age Male gender Family History Genetic abnormalities Hyperlipidemia Hypertension Cigarette smoking Diabetes Mellitus C-reactive protein

7. Describe the characteristic pathologic features in each organ Section of the left ventricle reveals transmural ischemic necrosis (emphasize staining difference between infarct and normal myocardium). The necrotic fibers have lost nuclei and cross striations. The interstitium contains neutrophils and congested blood vessels with some extravasation of RBCs. A cross section of the coronary artery reveals occlusion by a recent thrombus. The vessel wall shows modest atherosclerotic changes, including initimal fibrosis, few cholesterol clefts, focus of calcification and infiltrating macrophages.

8. Correlate the clinical findings with the pathology Typical clinical feature of acute myocardial infarction is crushing substernal pain with radiation. The several transient episodes of chest pain after walking up stairs represent angina.

12. Acute Myocardial infarction of the anterior left ventricle and septum is delineated by an area of dark, red-brown hemorrhage

13. Acute Myocardial infarction Cross section of the left ventricle shows an extensive, circumferential acute myocardial infarction. The asterix points out the non-infarcted myocardium.

15. Myocardial Infarction extending to the papillary muscle Asterix denotes mitral valve leaflet.

16. Myocardial rupture Longitudinal section of the heart. The thick arrow points to the site of rupture of the apex of the left ventricle. The rupture occured secondary to an acute transmural infarction. The thin arrows outline the pericardial sac which is filled with blood

17. Large Apical Ventricular aneurysm Longitudinal section of the heart “C” represents the inlet to the aneurysm which contains a laminated thrombus (*). Notice the thin fibrotic wall (arrow) of the aneurysm.

18. Ventricular aneurysm Longitudinal section of the heart through the (A ) Aortic valve  (B) Left ventricle (half of the left ventricle is folded back (*) (C) Arrows delineate the thin, fibrotic wall of the aneurysm, which contains red thrombus

21. Case 2 A 37-year-old Mexican male presents with fever and flank pain. Several weeks ago, he received treatment from a dentist for severe periodontal disease. He was not prescribed any medication for that procedure. His past medical history is significant for an episode of joint pains and fever when he was 10-years-old and still living in Mexico. He received some medication at that time but did not follow-up with any doctor after that. Physical exam revealed a low grade fever and a heart murmur.

22. Differential Endocarditis Glomerulonephritis Pylonephritis Renal Tumor

23. Pertinent Positives Low grade fever Joint Pain Heart Murmur Flank Pain ECHO shows vegetation

27. Describe the characteristic pathologic changes in each organ. Section of cardiac valve with attached vegetation. The valve is distorted (thickened) by fibrosis and chronic inflammation. Acute inflammation (necrosis) is superimposed on the old pathology. A large attached vegetation is composed of fibrin, RBC’s inflammatory cells and masses of blue bacteria. Section of the kidney demonstrates an ischemic infarct.

28. List the potential manifestations of this disorder and correlate them with thepathology. Destruction of a valve causing a murmur Emboli to multiple organs such as the brain (stroke), intestinal tract (infarction/pain) and kidney (asymptomatic or flank pain).

29. Diagnosis Infective Endocarditis/Renal Infarct

30. Does the patient’s past medical history have any significance to his currentproblem? The patient may have had rheumatic fever as a ten year old with subsequent rheumatic valvular disease. During dental work he may have developed transient bacteremia which resulted in bacterial seeding of his deformed valve.

31. Case 3 A 27-year-old woman presents with shortness of breath, swelling of her feet and difficulty sleeping flat of 4-5 days duration. She has felt her heart beating in a “funny way” for the last two hours. She had a sore throat three weeks ago. On physical exam she has bilateral basilar lung crackles, hepatomegaly, mild ascites and pedal edema. Her heart rhythm is irregular and tachycardic.

32. Differential Heart Failure Right Sided Left Sided Dilated Cardiomyopathy Need chest X-ray and ECHO Myocarditis

33. Pertinent Positives Shortness of Breath Edema Congestion Ascites Sore Throat ECHO: Chamber Dilatation Palpatations / Arrhythmia

34. Diagnosis Lymphocytic myocarditis Preceding viral infections, such as Coxsackievirus and other enteroviruses, are the most common cause of lymphocytic myocarditis in the United States

37. Correlate the clinical finding with the pathology Inflammation/necrosis of the myocardium results in injury and weakens the myocardium causing less efficient contraction. The patient has symptoms and signs of left and right heart failure. Inflammation and heart chamber dilatation may also induce an arrhythmia.

38. Describe the characteristic pathologic changes Infiltration of the interstitium by mononuclear inflammatory cells, predominantly lymphocytes. Focal necrosis of myocardial fibers.

39. Case 4 A 63-year-old woman presents with a left-sided headache for 2 weeks. It is throbbing and is intermittently relieved by aspirin. Two days ago she developed blurred vision and diplopia in her left eye which prompted her to see a physician. On review of systems, the woman notes that she has malaise, occasional fevers and “achy joints”. On physical exam palpation reveals a thickened, nodular and tender temporal artery.

40. Differential Diagnosis Temporal Arteritis

41. Pertinent Positives Achy Joints Vision Changes Malaise Fever Older Age thickened, nodular and tender temporal artery

42. Diagnostic Plan Biopsy of temporal artery

43. Describe the characteristic pathologic features in the structure. Mononuclear inflammatory cells are found in the media and adventitia. Three to four multinucleated giant cells are in the wall of the artery.

44. Correlate the clinical findings with the pathology. The headache correlates with the inflammation of the temporal artery. Malaise, fever, and joint pain represents polymyalgia rheumatica syndrome which is often seen in a patient with temporal arteritis

45. Diagnosis and Treatment Plan Temporal Arteritis Treatment with corticosteroids

46. Case 5 A 78-year-old man presents with sudden onset of low mid-back pain. His past history is significant for coronary artery disease and coronary artery bypass surgery. On examination, a pulsatile mass can be felt in the lower abdomen.

47. Pertinent Positives Pulsatile mass in lower abdomen Need ultrasound History of coronary artery disease Old age

48. Differential Atherosclerotic Aneurysm of the Aorta

50. Describe the characteristic pathologic features of the specimen Complicated atherosclerotic plaques Dilatation (aneurysmal) of the aorta as a result of destruction/weakening of the media Mural thrombus may be present

51. List the possible clinical findings in this disorder and correlate with thepathology. Back pain – compression of nerves or early rupture “Pulsatile” abdominal mass reflects transmission of arterial pressure in the mass Abdominal bruits are auscultated and reflect turbulent flow A thrill is palpated and reflects turbulent flow

52. Cardiovascular Pathology II Laboratory Small Group Cases

53. Case 1 A 72-year-old man presents with progressive dyspnea, fatigue and pitting edema of the lower extremities. He has a history of multiple episodes of chest pain resulting in hospitalizations. He was offered coronary artery bypass surgery in the past but declined stating that “my father died on the table during heart surgery and I don’t want that to happen to me”. Physical Exam: Jugular venous pulse is elevated. (Right heart failure, inc intravascular volume) On cardiac exam the apical impulse is in the 5th intercostal space, lateral to the left midclavicular line (cardiomegaly). S3 is heard at the apex. (he cannot lay flat during the exam because of dyspnea)—when you lay down you increase preload and it will worsen—orthopnea. On lung auscultation there are bilateral crackles over 2/3 of the lower lung fields (pulmonary edema). There is dullness to percussion (could be pleural effusion too) . There is mild tender hepatomegaly (congestion of the liver b/c of RHF). His feet and legs are edematous (congestion of venous side due .

54. Test Study Notes Notes on CXR: Full fuzzy hilum—venous vessels engorged, sign of pulmonary edema Heart size should be not more than ½ of the total chest size on X-Ray more than ½ size think cardiomegaly Pleural effusion-fluid in pleural space around the lung Pulmonary edema-fluid in alveoli inside lung (increases diffusion distance for oxygen) Butterfly pattern on xray—patchy, diffuse, bilateral infiltrates

55. Pertinent Positives Old age progressive dyspnea Fatigue pitting edema of the lower extremities history of multiple episodes of chest pain Family History of heart problems Jugular venous pulse is elevated. S3 at apex bilateral crackles over 2/3 of the lower lung fields with dullness mild tender hepatomegaly

66. Describe the characteristic pathologic features in each organ. Section of the heart reveals irregular fibrosis replacing myocardium. Our patient has a healed myocardial infarct! Section of the lung shows severe, chronic passive congestion. Vessels, including alveolar capillaries, are congested. Alveoli contain numerous hemosiderin laden macrophages- “heart failure cells” Our patient has some type of left heart failure, backup of fluid into lung Section of the liver shows centri-lobular sinusoidal congestion. Hepatocytes (are in cords) around the central vein show degeneration and atrophy. Students should be able to describe changes in healing, from necrosis to granulation tissue to formation of scar. Patient may have elevated bilirubin and alkaline phosphatase on labs b/c of compression of biliary ductules (due to swelling of liver with blood) , also elevated AST/ALT due to necrosis

67. Correlate the clinical findings with the pathology. Clinical findings are due to congestive heart failure (CHF, both sides) Dyspnea correlates with severe congestion. Enlarged, sometimes tender, liver correlates with hepatic congestion. Pitting edema correlates with elevated venous pressure. Fatigue correlates with poor muscle perfusion.

68. Diagnosis Healed Myocardial Infarction Eccentric hypertrophy to compensate for increased preload (volume overload) Over time the left ventricular wall fatigues (increased fetal proteins, fibrosis) Dilation of the heart—systolic heart failure Chronic Passive Congestion of the Lung and Liver (CHF).

69. Does this patient have signs/symptoms of left sided heart failure, right sided heart failure, or biventricular heart failure? Left Heart Failure Right Sided Heart Failure Left sided heart failure Pulmonary congestion Pulmonary edema Hepatic enlargement and congestion Peripheral edema Jugular venous distention elevated systemic congestion

70. Case 2 A 29-year-old male presents with exertional dyspnea. He has no history of joint pains, fever, previous heart disease, or previous lung disease. Physical examination: Lungs are clear to auscultation and normal to percussion. On cardiac exam a harsh crescendo-decrescendo systolic ejection murmur is heard best at the apex and lower left sternal border. Aortic stenosis (but not typical location) or HOMI Try manuevers like Valsalva (gets louder because of increased afterload) HOMI murmur is over abnormal mitral valve, “sub-aortic” obstruction S4 is present. Decrease in compliance of left ventricle for some reason The heart rhythm is irregular. Arrythmia or a-fib (but not with S4) There is no peripheral edema. Not fluid overloaded Despite physician recommendations against strenuous activity, one week later, he plays basketball, collapses and dies.

71. The photograph shows an enlarged heart. The free wall of the left ventricle and the septum are markedly hypertrophied

73. Describe the characteristic pathologic features  Grossly, the myocardium is thickened, especially the interventricular septum and left ventricular wall. On transverse section, the thickened septum impinges on the ventricle producing a “banana shaped” chamber. Microscopically, the muscle fibers are hypertrophied, disorganized and haphazard in arrangement, with fibrosis between the fibers.

74. Correlate the clinical findings with the pathology. The hypertrophied wall is less compliant and less blood fills the ventricle. Diastolic dysfunction These changes cause decreased stroke volume (less preload) and cardiac insufficiency leading to exertional dyspnea. Septal hypertrophy may lead to stenotic systolic murmur which radiates to the apex. Atrial fibrillation is common. Atria stretches due to inc. Pressure in LV Anytime the Atria stretches we can see A-Fib!

75. Diagnosis Hypertrophic cardiomyopathy Usually die of a lethal arrythmia (ventricular)

76. What is a common genetic defect that is associated with this disorder? In about 60% of patients, hypertrophic cardiomyopathy is familial. In lecture she said it was 100% genetic (can be de novo mutations too, not all familial) Autosomal dominant transmission with variable expression. Genetic defects comprise mutations of any one of four genes that encode proteins of the sarcomeres (cardiac contractile elements): Beta-myosin heavy chain (most common defect) cardiac troponin T Alpha-tropomyosin myosin binding protein C. Note that there are great variability in symptoms of pts with HCM—clinical diversity reflects broad spectrum of underlying molecular causes!

77. Case 3 A 43-year-old female presents after fainting while getting out of bed. She has no previous history of syncope. She has hyperlipidemia for which she has been taking medication for the past 15 years. On examination there is a cardiac murmur that develops with changes in the patient’s position. Take a look on echo to see (“TTE”: Transthoracic Echo Finding) Our results show a well-encapsulated mass in the left atrium Most common mass would be myxoma (benign) in adults If it was an abscess the patient would be very, very ill! DDX: orthostatic hypotension, arrythmia, MI, anemia, neurologic (seizure, stroke)…huge differential here!

82. Describe the characteristic pathologic features  Single globular neoplasm growing in atrium (usually left). May be pedunculated. Microscopically, a mixture of cells is embedded in a loose connective tissue background. The cells include primitive mesenchyme, smooth muscle and inflammatory cells. Blood vessels are noted (disorganized)

83. Correlate the clinical findings with the pathology. A pedunculated myxoma may have a “ball-valve” effect, creating turbulence of blood flow (murmur) when the patient is in one position versus another. If it gets stuck in the mitral valve orifice patients can have syncope! What other symptoms besides syncope? Thrombosis, embolic phenomenon from tumor itself, secrete IL-6 so pts can present with fever, malaise MC place is LEFT side--atria The tumor impedes blood flow between the atrium and ventricle (positional).

84. Diagnosis Atrial myxoma

85. Case 4 A 37-year-old women presents with tiredness. She had gained weight in the past several months. Swelling in her legs and feet made it difficult to walk. She had a complete physical examination two years ago which was unremarkable except for an abnormal Pap smear for which she had followed up with her gynecologist. What are we thinking? Endocrine (Thyroid), Pregnancy, Depression Physical exam: On cardiac exam: the apical impulse is in the 5th intercostal space, lateral to the left midclavicular line. S3 is heard at the apex. There is a II/VI holosystolic murmur at the apex which radiates to the axilla. Mitral regurgitation-like sound On lung auscultation there are bilateral crackles over 2/3 of the lower lung fields. There is mild tender hepatomegaly. Her feet and legs having pitting edema. After physical exam it kind of seems like heart failure—we can’t r/o pregnancy

86. Pathological FindingsDilated Cardiomyopathy (MC Type) Grossly the heart is markedly enlarged and flabby on chest x-ray More than ½ the total size of the chest cavity Usually all four chambers are dilated. Stretches out the valve—mitral ring stretched Mural thrombi are frequent.

87. Cardiomyopathy The photograph shows an enlarged, expanded heart without atria. The left ventricle is markedly enlarged.

88. Diagnosis Dilated Cardiomyopathy The weakened myocardium fails to pump blood efficiently.

89. What are the possible etiologies of cardiomyopathy? Viral myocarditis Coxsackie virus A/B Alcohol Peripartum cardiomyopathy End of third trimester Drugs (i.e., doxorubicin for breast cancer or other cancers, chronic cocaine use-vasospasm) Familial Idiopathic

90. What are the possible etiologies of her heart murmur in this patient? Mitral regurgitation Holosystolic murmur at the apex which radiates to the axilla Left ventricular dilatation distorts the mitral valve annulus and tendinous cords leading to failure of the valve to close completely and regurgitation Valve leaflets themselves are normal!

91. Cardiovascular Pathology Review and Quiz LUMEN SLIDES

92. 55 y/o male with crushing chest pain, radiating to the left shoulder. What is this organ, and what are the characteristic pathological features seen here? Section of the left ventricle reveals transmural ischemic necrosis (emphasize staining difference between infarct and normal, myocardium). The necrotic fibers have lost nuclei and cross striations. The interstitium contains neutrophils and congested blood vessels with some extravasation of RBCs.

93. 55 y/o male with crushing chest pain, radiating to the left shoulder. What is this organ, and what are the characteristic pathological features seen here? A cross section of the coronary artery reveals occlusion by a recent thrombus. The vessel wall shows modest athrosclerotic changes, including, initimal fibrosis, few cholesterol clefts, focus of calcification and infiltrating macrophages.

94. 55 y/o male with crushing chest pain, radiating to the left shoulder. Given the pathology, what is the diagnosis? Typical clinical feature of acute myocardial infarction is crushing substernal pain with radiation. Diagnosis: Acute Myocardial Infarct Coronary Atherosclerosis/Thrombosis.

95. Acute Myocardial infarction Right Ventricle  Left Ventricle  Anterior surface The left ventricular wall contains an acute myocardial infarction. The mixture of pale myocardium (thin arrow) and hemorrhage (thick arrow) highlight the infarcted tissue. The asterix points out the non-infarcted myocardium.

96. Acute Myocardial infarction The infarction of the left ventricle is delineated by an area of dark, red-brown hemorrhage. (P) is posterior.

97. Acute Myocardial infarction Cross section of the left ventricle shows an extensive, circumferential acute myocardial infarction. The asterix points out the non-infarcted myocardium.

98. Acute Myocardial infarction The section demonstrates coagulation (ischemic) necrosis of the myocardium. Thin bands of neutrophils (arrows) infiltrate the interstitium.        

99. Acute Myocardial Infarction The section reveals "ghost -like" remnants of myocardial fibers. Cellular detail (cross striations and nuclei) is lost. Abundant neutrophils infiltrate the interstitium between dead myofibers.        

100. Myocardial Infarction extending to the papillary muscle The arrow points to a partial rupture of the muscle. Asterix denotes mitral valve leaflet.

101. Coronary artery disease A cross section of the coronary artery reveals an atherosclerotic plaque (P) which has ruptured into the lumen (black arrows). Two blue arrows point to slit like spaces (cholesterol cleft). (F) Fibrous tissue (I) Inflammatory cells        

102. 37 year old male with fever, cardiac murmur and flank pain. What is this organ, and what are the characteristic pathological features seen here? Section of cardiac valve with attached vegetation. The valve is distorted (thickened) by fibrosis and chronic inflammation. Acute inflammation (necrosis) is superimposed on the old pathology. A large attached vegetation is composed of fibrin, RBC's inflammatory cells and masses of blue bacteria.

103. 37 year old male with fever, cardiac murmur and flank pain. What is this organ, and what are the characteristic pathological features seen here? ischemic infarct of the kidney

104. 37 year old male with fever, cardiac murmur and flank pain. What is the potential manifestations of this disorder and what are the characteristic cardiovascular clinical findings in patients who have the aortic or mitral valves involved by this pathologic process? What is the diagnosis? Destruction of a valve causing a murmur. Emboli to multiple organs such as the brain (stroke), intestinal tract (infarction/pain) and kidney (asymptomatic or flank pain). Diagnosis: Infective Endocarditis/Renal Infarct

105. Infective Endocarditis Vegetations (arrow) adhere to the cusps of the aortic valve.

106. Infective Endocarditis The Vegetations (arrows) adhere to the atrial (A) side of the mitral valve.

107. Infective Endocarditis Left atrium  Mitral valve  Left Ventricle The Vegetations (arrows) adhere to the atrial  side of the mitral valve leaflets, which are thickened because of chronic rheumatic valvular disease.

108. Viral Myocarditis Lymphocytes infiltrate the interstitium.  

109. Viral Myocarditis

110. 63 year old woman with a headache of the left temporal region. The woman has malaise and states, "my joints ache." What should be your next step? Biopsy the temporal artery

111. 63 year old woman with a headache of the left temporal region. The woman has malaise and states, "my joints ache." Describe the pathology seen in this section. Section of temporal artery with inflammation. Mononuclear inflammatory cells are found in the media and adventitia. Three-four multinucleated giant cells are in the wall of the artery.

112. 63 year old woman with a headache of the left temporal region. The woman has malaise and states, "my joints ache." Given the history and pathology, what is the diagnosis? The headache correlates with the inflammation of the temporal artery. Malaise, fever, and joint pain represents polymyalgia rheumatica syndrome which is often seen in a patient with temporal arteritis. Diagnosis: Temporal Arteritis

113. 78 year old man with sudden onset of low, mid-back pain. On physical exam there is a pulsatile mass and a bruit. What is causing his signs and symptoms? The back pain is caused by the compression of nerves or early rupture. Diagnosis: Atherosclerotic Aneurysm of the Aorta

114. 72 year old woman with progressive dyspnea, fatigue and pitting edema of the lower extremities. Describe the characteristic pathologic features seen here. Section of the heart reveals irregular fibrosis replacing myocardium.

115. 72 year old woman with progressive dyspnea, fatigue and pitting edema of the lower extremities. Describe the characteristic pathologic features seen here. Section of the lung shows severe, chronic passive congestion. Vessels, including alveolar capillaries, are congested. Alveoli contain numerous hemosiderin laden macrophages.

116. 72 year old woman with progressive dyspnea, fatigue and pitting edema of the lower extremities. Describe the characteristic pathologic features seen here. Section of the liver shows centri-lobular sinusoidal congestion. Hepatocytes around the central vein show degeneration and atrophy. Students should be able to describe changes in healing, from necrosis to granulation tissue to formation of scar.

117. 72 year old woman with progressive dyspnea, fatigue and pitting edema of the lower extremities. Given the pathology, what is the diagnosis? Clinical findings are due to congestive heart failure. Dyspnea correlates with severe congestion. Enlarged, sometimes painful liver correlates with hepatic congestion. Fatigue correlates with poor muscle perfusion. Pitting edema correlates with elevated venous pressure. Diagnosis: Healed Myocardial Infarction/Chronic Passive Congestion of the Lung and Liver (CHF).

118. Healed myocardial Infarction Cross section of the Heart (two halfs):     Right Ventricle      Left Ventricle. Arrows point to healed myocardial infarction.

119. Healed Myocardial Infarction Much of the left ventricular wall and septum are thin and fibrotic (white). The asterix denotes non-infarcted myocardium.

120. Healed Myocardial infarction The section reveals myocardium replaced by scar. The scar is composed of homogenous, pink fibrous tissue. Small bundles of myocardial fibers (arrows) are scattered throughout the scar.        

121. 37 year old female dies of heart failure. This is what you see at autopsy. Describe the pathology and determine the cause of her heart failure. Grossly the heart is markedly enlarged and flabby. Usually all four chambers are dilated. Mural thrombi are frequent. The weakened myocardium fails to pump blood efficiently. Diagnosis: Dilated cardiomyopathy

122. Cardiomyopathy The photograph shows an enlarged, expanded heart without atria. The left ventricle is markedly enlarged.

123. Dilated Cardiomyopathy The photograph depicts the large, globular heart of dilated cardiomyopathy.

124. 29 year old male presents with exertional dyspnea, apical systolic murmur and bisferiens carotid pulse. He later dies suddenly. This is the gross specimen at autopsy. Why was he short of breath on exertion? The hypertrophied wall is less compliant and less blood fills the ventricle. These changes cause decreased stroke volume and cardiac insufficiency leading to exertional dyspnea.

125. 29 year old male presents with exertional dyspnea, apical systolic murmur and bisferiens carotid pulse. He later dies suddenly. This is the gross specimen at autopsy. Given the pathology, why did he have abnormal heart sounds? Septal hypertrophy may lead to stenotic a murmur which radiates to the apex. The character of the peripheral pulse also changes, creating a double impulse with each beat. Atrial fibrillation is common. 

126. 29 year old male with exertional dyspnea, apical systolic murmur and bisferiens carotid pulse. What is the diagnosis and what would you expect to see microscopically? Diagnosis: Hypertrophic cardiomyopathy

127. Hypertrophic Cardiomyopathy The photograph shows an enlarged heart. The free wall of the left ventricle the septum are markedly hypertrophied

128. 43 year old female with cardiac murmur changing with patient's position. Describe the pathology seen below. Single globular neoplasm growing in atrium (usually left). May be pedunculated.Microscopically, a mixture of cells is embedded in a loose connective tissue background. The cells include primitive mesenchyme, smooth muscle and inflammatory cells. Blood vessels are noted.

129. 43 year old female with cardiac murmur changing with patient's position. Given the pathology, and gross specimen seen below, why is she experiencing a murmur and what is the diagnosis? A pedunculated myxoma may have a "ball-valve" effect, creating turbulence of blood flow (murmur) when the patient is in one position versus another. The tumor impedes blood flow between the atrium and ventricle. Diagnosis: Atrial myxoma

130. OTHER CARDIOVASCULAR PATHOLOGIES

131. Fibrinous Pericarditis Anatomical features are obscured by the shaggy deposits of fibrin on the surface of the epicardium.

132. Organizing Pericarditis A fibrinous pericarditis is undergoing organization. Much of the fibrin (thin arrow) is replaced by granulation tissue (thick arrow) containing new blood vessels and fibroblasts laying down immature connective tissue.  

133. Myocardial rupture Longitudinal section of the heart. Left atrium  Mitral valve   Left ventricle The thick arrow points to the site of rupture of the apex of the left ventricle. The rupture occurred secondary to an acute transmural infarction. The thin arrows outline the pericardial sac which is filled with blood.

134. Ventricular aneurysm Longitudinal section of the heart through the. left atrium  left ventricle The section shows a large apical aneurysm. represents the inlet to the aneurysm which contains a laminated thrombus (*). Notice the thin fibrotic wall (arrow) of the aneurysm.

135. Ventricular aneurysm Longitudinal section of the heart through the. Aortic valve Left ventricle (half of the left ventritricle is folded back (*) Arrows delineate the thin, fibrotic wall of the aneurysm, which contains red thrombus.

136. Acute coronary artery thrombosis The artery is "bread loaved" (cut in serial section)

137. Mural Thrombus The section shows a red mural thrombus attached to the left ventricular wall at the apex. The wall is thin and white because of a healed myocardial infarction (arrow). The endocardium above the thrombus (*) is white because of fibrosis.

138. Hypertensive heart disease Cross section of the heart through the right ventricle and left ventricle The wall of the left ventricle shows concentric hypertrophy. The thickness of the wall exceeds the upper limits of normal (1.2cm)

139. Mitral valve prolapse The photograph demonstrates a mitral valve prolapse ("floppy valve.”) The heart is opened revealing the inside of : the left atrium and left ventricle Anterior mitral leaflet Posterior mitral leaflet

140. Mitral valve prolapse The photograph demonstrates a mitral valve prolapse ("floppy valve.”) The view is from the open left atrium looking down on the redundant leaflets (arrows) of the mitral valve.

141. Degenerative Calcified Aortic stenosis Cross section of the root of the aorta demonstrating a bicuspid valve. The calcified masses (*) occupy the sinuses of valsalva. Notice the edges of the leaflets are free of calcium, a finding which is typical of degenerative calcified aortic stenosis.

142. Chronic Valvular Heart Disease Cross section of the root of the aorta demonstrating a tricuspid valve. Large calcified masses (*) involve the edges of the leaflets and cause fusion of the commissures, a finding typical of aortic stenosis associated with calcification of chronic rheumatic valvular disease.