Cardiovascular Pathology Annotated PictorialsSources: WebPath : Cardiovascular Pathology Annotated PictorialsSources: WebPath Companion:
IVMS Comprehensive Cardiovascular Basic Medical Science PPS
IVMS Cardiovascular
Pharmacology Lecture Prepared and Presented by:
Marc Imhotep Cray, M.D. Learning Objectives:
http://www.usmle.org/Examinations/step1/content/cardiovascular.html
Slide 2 : Imhotep Virtual Medical School 2004-Updated 2008 2 Normal Heart
Normal heart, gross : Imhotep Virtual Medical School 2004-Updated 2008 3 Normal heart, gross This is the external appearance of a normal heart.The epicardial surface is smooth and glistening.The amount of epicardial fat is usual.The left anterior descending coronary artery extends down from the aortic root to the apex
Normal tricuspid valve, gross : Imhotep Virtual Medical School 2004-Updated 2008 4 Normal tricuspid valve, gross This is the tricuspid valve. The leaflets and thin and delicate. Just like the mitral valve, the leaflets have thin chordae tendineae that attach the leaflet margins to the papillary muscles of the ventricular wall below
Normal coronary artery, microscopic : Imhotep Virtual Medical School 2004-Updated 2008 5 Normal coronary artery, microscopic This is a normal coronary artery. The lumen is large, without any narrowing by atheromatous plaque. The muscular arterial wall is of normal proportion
Normal myocardium, medium power microscopic : Imhotep Virtual Medical School 2004-Updated 2008 6 Normal myocardium, medium power microscopic This is the normal appearance of myocardial fibers in longitudinal section. Note the central nuclei and the syncytial arrangement of the fibers, some of which have pale pink intercalated disks
Slide 7 : Imhotep Virtual Medical School 2004-Updated 2008 7 Atherosclerotic Cardiovascular Disease
Coronary artery with atherosclerotic narrowing, microscopic : Imhotep Virtual Medical School 2004-Updated 2008 8 Coronary artery with atherosclerotic narrowing, microscopic The coronary artery shown here has narrowing of the lumen due to build up of atherosclerotic plaque. Severe narrowing can lead to angina, ischemia, and infarction
Coronary artery with recanalized thrombosis, microscopic : Imhotep Virtual Medical School 2004-Updated 2008 9 Coronary artery with recanalized thrombosis, microscopic This section of coronary artery demonstrates remote thrombosis with recanalization to leave only two small, narrow channels
Coronary artery with calcific atherosclerosis, microscopic : Imhotep Virtual Medical School 2004-Updated 2008 10 Coronary artery with calcific atherosclerosis, microscopic There is a severe degree of narrowing in this coronary artery. It is "complex" in that there is a large area of calcification on the lower right, which appears bluish on this H&E stain. Complex atheroma have calcification, thrombosis, or hemorrhage. Such calcification would make coronary angioplasty difficult
Aortas demonstrating various degrees of atherosclerosis, gross : Imhotep Virtual Medical School 2004-Updated 2008 11 Aortas demonstrating various degrees of atherosclerosis, gross These three aortas demonstrate mild, moderate, and severe atherosclerosis from bottom to top. At the bottom, the mild atherosclerosis shows only scattered lipid plaques. The aorta in the middle shows many more larger plaques. The severe atherosclerosis in the aorta at the top shows extensive ulceration in the plaques
Aorta, atherosclerotic aneurysm, gross : Imhotep Virtual Medical School 2004-Updated 2008 12 Aorta, atherosclerotic aneurysm, gross Here is an example of an atherosclerotic aneurysm of the aorta in which a large "bulge" appears just above the aortic bifurcation.Such aneurysms are prone to rupture when they reach about 6 to 7 cm in size.
They may be felt on physical examination as a pulsatile mass in the abdomen.
Most such aneurysms are conveniently located below the renal arteries so that surgical resection can be performed with placement of a dacron graft
CT scan with contrast : Imhotep Virtual Medical School 2004-Updated 2008 13 CT scan with contrast This abdominal high speed CT scan with contrast demonstrates an abdominal aortic aneurysm approximately 6 cm in diameter. At this size, there is increased risk for rupture
Coronary artery, mild atherosclerosis, gross : Imhotep Virtual Medical School 2004-Updated 2008 14 Coronary artery, mild atherosclerosis, gross A coronary artery has been opened longitudinally. The coronary extends from left to right across the middle of the picture and is surrounded by epicardial fat. Increased epicardial fat correlates with increasing total body fat. There is a lot of fat here, suggesting one risk factor for atherosclerosis. This coronary shows only mild atherosclerosis, with only an occasional yellow-tan lipid plaque and no narrowing
Coronary artery, severe atherosclerosis, gross : Imhotep Virtual Medical School 2004-Updated 2008 15 Coronary artery, severe atherosclerosis, gross This is the left coronary artery from the aortic root on the left. Extending across the middle of the picture to the right is the anterior descending branch. This coronary shows severe atherosclerosis with extensive calcification. At the far right, there is an area of significant narrowing
Coronary artery, hemorrhage into plaque, gross : Imhotep Virtual Medical School 2004-Updated 2008 16 Coronary artery, hemorrhage into plaque, gross This is coronary atherosclerosis with the complication of hemorrhage into atheromatous plaque, seen here in the center of the photograph. Such hemorrhage acutely may narrow the arterial lumen
Heart and LAD coronary artery with recent thrombus, gross : Imhotep Virtual Medical School 2004-Updated 2008 17 Heart and LAD coronary artery with recent thrombus, gross The anterior surface of the heart demonstrates an opened left anterior descending coronary artery.Within the lumen of the coronary can be seen a dark red recent coronary thrombosis. The dull red color to the myocardium as seen below the glistening epicardium to the lower right of the thrombus is consistent with underlying myocardial infarction
Slide 18 : Imhotep Virtual Medical School 2004-Updated 2008 18 Myocardial Infarction
Heart, left ventricle, acute myocardial infarction, gross : Imhotep Virtual Medical School 2004-Updated 2008 19 Heart, left ventricle, acute myocardial infarction, gross This is the left ventricular wall which has been sectioned lengthwise to reveal a large recent myocardial infarction. The center of the infarct contains necrotic muscle that appears yellow-tan. Surrounding this is a zone of red hyperemia. Remaining viable myocardium is reddish- brown
Heart, left ventricle and septum, myocardial infarction, gross : Imhotep Virtual Medical School 2004-Updated 2008 20 Heart, left ventricle and septum, myocardial infarction, gross This cross section through the heart demonstrates the left ventricle on the left. Extending from the anterior portion and into the septum is a large recent myocardial infarction. The center is tan with surrounding hyperemia. The infarction is "transmural" in that it extends through the full thickness of the wall
Heart, transmural myocardial infarction with rupture and hemopericardium, gross : Imhotep Virtual Medical School 2004-Updated 2008 21 Heart, transmural myocardial infarction with rupture and hemopericardium, gross One complication of a transmural myocardial infarction is rupture of the myocardium. This is most likely to occur in the first week between 3 to 5 days following the initial event, when the myocardium is the softest. The white arrow marks the point of rupture in this anterior-inferior myocardial infarction of the left ventricular free wall and septum. Note the dark red blood clot forming the hemopericardium. The hemopericardium can lead to tamponade
Heart, left ventricular aneurysm, gross : Imhotep Virtual Medical School 2004-Updated 2008 22 Heart, left ventricular aneurysm, gross A cross section through the heart reveals a ventricular aneurysm with a very thin wall at the arrow. Note how the aneurysm bulges out. The stasis in this aneurysm allows mural thrombus, which is present here, to form within the aneurysm
Slide 23 : Imhotep Virtual Medical School 2004-Updated 2008 23 Arterial Dissection
Aorta, dissection with tear in arch, gross : Imhotep Virtual Medical School 2004-Updated 2008 24 Aorta, dissection with tear in arch, gross There is a tear (arrow) located 7 cm above the aortic valve and proximal to the great vessels in this aorta with marked atherosclerosis. This is an aortic dissection
Hemopericardium with cardiac tamponade, gross : Imhotep Virtual Medical School 2004-Updated 2008 25 Hemopericardium with cardiac tamponade, gross An aortic dissection may lead to hemopericardium when blood dissects through the media proximally. Such a massive amount of hemorrhage can lead to cardiac tamponade
Aorta, dissection, gross : Imhotep Virtual Medical School 2004-Updated 2008 26 Aorta, dissection, gross This aorta has been opened longitudinally to reveal an area of fairly limited dissection that is organizing. The red-brown thrombus can be seen in on both sides of the section as it extends around the aorta. The intimal tear would have been at the left. This creates a "double lumen" to the aorta. This aorta shows severe atherosclerosis which, along with cystic medial necrosis and hypertension, is a risk factor for dissection
Aorta, dissection, microscopic : Imhotep Virtual Medical School 2004-Updated 2008 27 Aorta, dissection, microscopic Here, the dissection went into the muscular wall. In any case, an aortic dissection is an extreme emergency and can lead to death in a matter of minutes. The blood can dissect up or down the aorta. Blood dissecting up around the great vessels can close off the carotids. Blood can dissect down to the coronaries and shut them off
Carotid artery, dissection with compression, gross : Imhotep Virtual Medical School 2004-Updated 2008 28 Carotid artery, dissection with compression, gross The right carotid artery is compressed by blood dissecting upward from a tear with aortic dissection. Blood may also dissect to coronary arteries. Thus patients with aortic dissection may have symptoms of severe chest pain (for distal dissection) or may present with findings that suggest a stroke (with carotid dissection) or myocardial ischemia (with coronary dissection).
Slide 29 : Imhotep Virtual Medical School 2004-Updated 2008 29 Infective Endocarditis
Aortic valve, infective endocarditis, gross : Imhotep Virtual Medical School 2004-Updated 2008 30 Aortic valve, infective endocarditis, gross This is infective endocarditis. The aortic valve demonstrates a large, irregular, reddish tan vegetation.Virulent organisms, such as Staphylococcus aureus, produce an "acute" bacterial endocarditis, while some organisms such as Streptococcus viridans produce a "subacute" bacterial endocarditis
Infective endocarditis spreading to myocardium, gross : Imhotep Virtual Medical School 2004-Updated 2008 31 Infective endocarditis spreading to myocardium, gross In this case, the infective endocarditis demonstrates how the infection tends to spread from the valve surface. Here, vegetations can be seen on the endocardial surfaces, and the infection is extending into to underlying myocardium
Infective endocarditis, microscopic : Imhotep Virtual Medical School 2004-Updated 2008 32 Infective endocarditis, microscopic Microscopically, the valve in infective endocarditis demonstrates friable vegetations of fibrin and platelets (pink) mixed with inflammatory cells and bacterial colonies (blue). The friability explains how portions of the vegetation can break off and embolize
Slide 33 : Imhotep Virtual Medical School 2004-Updated 2008 33 Pericarditis
Fibrinous pericarditis, gross : Imhotep Virtual Medical School 2004-Updated 2008 34 Fibrinous pericarditis, gross A window of adherent pericardium has been opened to reveal the surface of the heart. There are thin strands of fibrinous exudate that extend from the epicardial surface to the pericarial sac. This is typical for a fibrinous pericarditis
Hemorrhagic pericarditis, gross : Imhotep Virtual Medical School 2004-Updated 2008 35 Hemorrhagic pericarditis, gross The pericarditis here not only has fibrin, but also hemorrhage. Thus, this is called a "hemorrhagic pericarditis". It is really just fibrinous pericarditis with hemorrhage. Without inflammation, blood in the pericardial sac would be called "hemopericardium
Slide 36 : Imhotep Virtual Medical School 2004-Updated 2008 36 Neoplasia
Heart, rhabdomyoma, gross : Imhotep Virtual Medical School 2004-Updated 2008 37 Heart, rhabdomyoma, gross This two year old child died suddenly. At autopsy, a large firm, white tumor mass was found filling much of the left ventricle. This is a cardiac rhabdomyoma. Such primary tumors of the heart are rare
Heart, atrial myxoma, gross : Imhotep Virtual Medical School 2004-Updated 2008 38 Heart, atrial myxoma, gross The left atrium has been opened to reveal the most common primary cardiac neoplasm--an atrial myxoma. These benign masses are most often attached to the atrial wall, but can arise on a valve or in a ventricle. They can produce a "ball valve" effect by intermittently occluding the atrioventricular valve orifice. Embolization of fragments of tumor may also occur. Myxomas are easily diagnosed by echocardiography
Heart, epicardium, metastases, gross : Imhotep Virtual Medical School 2004-Updated 2008 39 Heart, epicardium, metastases, gross Primary tumors of the heart are uncommon. Metastases to the heart are more common, but rare overall (only about 5 to 10% of all malignancies have cardiac metastases). Seen over the surface of the epicardium are pale white-tan nodules of metastatic tumor. Metastases may lead to a hemorrhagic pericarditis.
Slide 40 : Imhotep Virtual Medical School 2004-Updated 2008 40 Congenital Heart Disease
Congenital Heart Disease : Congenital Heart Disease Type of Defect Mechanism
Type of Defect Mechanism : Imhotep Virtual Medical School 2004-Updated 2008 42 Type of Defect Mechanism Ventricular Septal Defect (VSD) There is a hole within the membranous or muscular portions of the intraventricular septum that produces a left-to-right shunt, more severe with larger defects
Atrial Septal Defect (ASD) A hole from a septum secundum or septum primum defect in the interatrial septum produces a modest left-to-right shunt
Patent Ductus Arteriosus (PDA) The ductus arteriosus, which normally closes soon after birth, remains open, and a left-to-right shunt develops
Type of Defect Mechanism : Imhotep Virtual Medical School 2004-Updated 2008 43 Type of Defect Mechanism Tetralogy of Fallot Pulmonic stenosis results in right ventricular hypertrophy and a right-to-left shunt across a VSD, which also has an overriding aorta
Transposition of Great Vessels The aorta arises from the right ventricle and the pulmonic trunk from the left ventricle. A VSD, or ASD with PDA, is needed for extrauterine survival. There is right-to-left shunting
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Truncus ArteriosusThere is incomplete separation of the aortic and pulmonary outflows, along with VSD, which allows mixing of oxygenated and deoxygenated blood and right-to-left shunting
Type of Defect Mechanism : Imhotep Virtual Medical School 2004-Updated 2008 44 Type of Defect Mechanism Hypoplastic Left Heart Syndrome There are varying degrees of hypoplasia or atresia of the aortic and mitral valves, along with a small to absent left ventricular chamber
Coarctation of Aorta Either just proximal (infantile form) or just distal (adult form) to the ductus is a narrowing of the aortic lumen, leading to outflow obstruction
Total Anomalous Pulmonary Venous Return (TAPVR) The pulmonary veins do not directly connect to the left atrium, but drain into left innominate vein, coronary sinus, or some other site, leading to possible mixing of blood and right-sided overload
Heart, atrial septal defect, gross : Imhotep Virtual Medical School 2004-Updated 2008 45 Heart, atrial septal defect, gross In the region of the foramen ovale on the interatrial septum is a small atrial septal defect, as seen in this heart opened on the right side. Here the defect is not closed by the septum secundum, so a shunt exists across from left to right
Heart, ventricular septal defect, gross : Imhotep Virtual Medical School 2004-Updated 2008 46 Heart, ventricular septal defect, gross This is the heart of a premature stillborn with Trisomy 13 in which a ventricular septal defect is visible in the membranous septum. About 90% of VSD's are in the membranous septum and 10% in the muscular septum.
Aorta, coarctation, gross : Imhotep Virtual Medical School 2004-Updated 2008 47 Aorta, coarctation, gross This portion of aorta was resected from a patient with a coarctation. The aorta narrows postductally here to about a 3 mm opening
Aorta, coarctation, gross : Imhotep Virtual Medical School 2004-Updated 2008 48 Aorta, coarctation, gross The aorta is opened longitudinally here to reveal a coarctation. In the region of the narrowing, there was increased turbulence that led to increased atherosclerosis.
Heart, tetralogy of Fallot, diagram : Imhotep Virtual Medical School 2004-Updated 2008 49 Heart, tetralogy of Fallot, diagram This diagram depicts the features of Tetralogy of Fallot:1. Ventricular septal defect; 2. Overriding aorta; 3. Pulmonic stenosis; 4. Right ventricular hypertrophy. The obstruction to right ventricular outflow creates a right-to-left shunt that leads to cyanosis.
Heart, transposition of great vessels, diagram : Imhotep Virtual Medical School 2004-Updated 2008 50 Heart, transposition of great vessels, diagram In the diagram above, transposition of the great vessels is shown. This occurs when the trunco-conal septum does not spiral down. Instead, it descends straight down. As a result, the outflow of right ventricle is into the aorta and the outflow from the left ventricle is into the pulmonic trunk.In order for this system to work, there must be a connection between the system and pulmonic circulations. Sometimes this is through a ventricular septal defect or an atrial septal defect. In the diagram at the left, this is through a patent ductus arteriosus
Slide 51 : Imhotep Virtual Medical School 2004-Updated 2008 51 Cardiomyopathies
Type of CMP Findings : Imhotep Virtual Medical School 2004-Updated 2008 52 Type of CMP Findings Dilated (Congestive) All four chambers are dilated, and there is also hypertrophy. The most common cause is chronic alcoholism, though some may be the end-stage of remote viral myocarditis.
Hypertrophic The most common form, idiopathic hypertrophic subaortic stenosis (IHSS) results from asymmetric interventricular septal hypertrophy, resulting in left ventricular outflow obstruction.
Restrictive The myocardium is infiltrated with a material that results in impaired ventricular filling. The most common causes are amyloidosis and hemochromatosis.
Heart, dilated cardiomyopathy, gross : Imhotep Virtual Medical School 2004-Updated 2008 53 Heart, dilated cardiomyopathy, gross This very large heart has a globoid shape because all of the chambers are dilated. It felt very flabby, and the myocardium was poorly contractile. This is an example of a cardiomyopathy. This term is used to denote conditions in which the myocardium functions poorly and the heart is large and dilated, but there is no specific histologic finding
Heart, dilated cardiomyopathy, [XRAY] : Imhotep Virtual Medical School 2004-Updated 2008 54 Heart, dilated cardiomyopathy, [XRAY] This chest radiograph demontrates marked cardiomegaly, with the left heart edge appearing far to the left
Heart, cardiomyopathy, microscopic : Imhotep Virtual Medical School 2004-Updated 2008 55 Heart, cardiomyopathy, microscopic Microscopically, the heart in cardiomyopathy demonstrates hypertrophy of myocardial fibers (which also have prominent dark nuclei) along with interstitial fibrosis
Heart, hypertrophic cardiomyopathy, explanted heart, gross : Imhotep Virtual Medical School 2004-Updated 2008 56 Heart, hypertrophic cardiomyopathy, explanted heart, gross There is marked left ventricular hypertrophy, with asymmetric bulging of a very large interventricular septum into the left ventricular chamber. This is hypertrophic cardiomyopathy. About half of these cases are familial, though a variety of different genes may be responsible for this disease. Both children and adults can be affected, and sudden death can occur. Seen here is the explanted heart. Pacemaker wires enter the right ventricle. The atria with venous connections, along with great vessels, remained behind to connect to the transplanted heart (provided by someone who cared enough to make transplantation possible).
Heart, hypertension with left ventricular hypertrophy, gross : Imhotep Virtual Medical School 2004-Updated 2008 57 Heart, hypertension with left ventricular hypertrophy, gross This left ventricle is very thickened (slightly over 2 cm in thickness), but the rest of the heart is not greatly enlarged. This is typical for hypertensive heart disease. The hypertension creates a greater pressure load on the heart to induce the hypertrophy
Heart, hypertrophy with hypertension, gross : Imhotep Virtual Medical School 2004-Updated 2008 58 Heart, hypertrophy with hypertension, gross The left ventricle is markedly thickened in this patient with severe hypertension that was untreated for many years. The myocardial fibers have undergone hypertrophy
Slide 59 : Imhotep Virtual Medical School 2004-Updated 2008 59 Arterial and Venous Diseases
Renal arteriole, fibrinoid necrosis with malignant hypertension, microscopic : Imhotep Virtual Medical School 2004-Updated 2008 60 Renal arteriole, fibrinoid necrosis with malignant hypertension, microscopic One complication of hyperplastic arteriolosclerosis with malignant hypertension is fibrinoid necrosis, as seen here in a renal arteriole
Varicose veins, gross : Imhotep Virtual Medical School 2004-Updated 2008 61 Varicose veins, gross The prominent veins shown here on the lower leg are varicosities. Varicose veins are a common problem with aging. The venous valves become incompetent. There may be muscular atrophy with less tone to provide a massage effect on the large superficial veins, and skin becomes less elastic with time. Hydrostatic pressure from standing for long periods exacerbates the problem
Cardiovascular Animations and Interactive Tutorials : Imhotep Virtual Medical School 2004-Updated 2008 62 Cardiovascular Animations and Interactive Tutorials Cardiovascular System Topics by ADAM
Basic Heart Circulation Bristol-Myers Squibb
Heart Structure by Nucleus Communications
Heart functions and Problems Cardiology Associates
Electrocardiogram -ECG Technician Nobel eMuseum
Hyper heart by Knowlege Weavers
The Arrhythma Center HeartCenterOnline
Cardiac Cell Death San Diego State University
Prenatal Heart HeartCenterOnline
Congenital Heart Disease HeartCenterOnline
Cardiovascular Animations and Interactive Tutorials(2) : Imhotep Virtual Medical School 2004-Updated 2008 63 Cardiovascular Animations and Interactive Tutorials(2) Valvular Functions and Diseases HeartCenterOnline
Electro Cardio Gram by Knowlege Weavers
Mammal Fetal Circulation by HHMI
Cardiology - Visible Heart by HHMI
The Electrocardiogram Basics McGill University
Heart Animations Science Museum of Minnesota
Operation Heart Transplant from PBS
Interpeting an EKG
EKG Tutorial RnCeus Interactive
Blaufuss Medical Multimedia
Heart Valves Movie by Marcy Thomas at Wellesley
Aninations of Common Heart Defects and RepairMiami Children's Hospital
Cadaver Dissection of the Human Heart
Virtual Autopsy HBO
Free Useful Plugins : Imhotep Virtual Medical School 2004-Updated 2008 64 Free Useful Plugins Adobe Acrobat Reader - Document Distribution
Adobe Flash Player - Web Animation -The leading rich client for Internet content and applications across the broadest range of platforms.
Adobe Shockwave Player - With Adobe Shockwave Player, you can enjoy multimedia games and learning applications, using exciting new 3D technology. Adobe Authorware Player - With Adobe Authorware Web Player, you can experience online learning applications on the Web
. QuickTime Player- Streaming/Multimedia
Free Useful Plugins : Imhotep Virtual Medical School 2004-Updated 2008 65 Free Useful Plugins RealOne Player - Streaming/Multimedia
Microsoft Windows Media Player - Streaming/Multimedia
Microsoft Word Viewer - Viewing Word documents online (required if Word is not installed on resident computer; PC only)
Microsoft PowerPoint Viewer - Viewing PowerPoint presentations online (required if PowerPoint is not installed on computer) Animated PowerPoint Add-in -needed if you do not have Office XP
Microsoft Excel Viewer - Viewing Excel documents online (required if Excel is not installed on resident computer; PC only) MDL Chime interactively displays 2D and 3D molecules directly in Web pages.