Cardiovascular Pathology (part 1)

Cardiovascular Pathology (part 1) The heart and arterial system.

Normal Heart

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 aortic valve, gross
The aortic valve shows three thin and delicate cusps. The coronary artery orifices can be seen just above.The endocardium is smooth, beneath which can be seen a red-brown myocardium. The aorta above the valve displays a smooth intima with no atherosclerosis.

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
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
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.

Atherosclerotic Cardiovascular Disease

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
This section of coronary artery demonstrates remote thrombosis with recanalization to leave only two small, narrow channels.

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.

Coronary artery atherosclerosis, occlusive, microscopic
This distal portion of coronary artery shows significant narrowing. Such distal involvement is typical of severe coronary atherosclerosis, such as can appear with diabetes mellitus or familial hypercholesterolemia. This would make a coronary bypass operation difficult.

Coronary artery thrombosis, recent, microscopic
There is a pink to red recent thrombosis in this narrowed coronary artery. The open, needle-like spaces in the atheromatous plaque are cholesterol clefts.

Aorta with lipid streaks, gross
Put down that jelly doughnut and look carefully at this aorta. The white arrow denotes the most prominent fatty streak in the photo, but there are other fatty streaks scattered over the aortic surface. Fatty streaks are the earliest lesions seen with atherosclerosis in arteries.

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 [CT]
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.

Aorta, atheroma , low power, microscopic
This microscopic cross section of the aorta shows a large overlying atheroma on the left. Cholesterol clefts are numerous in this atheroma. The surface on the far left shows ulceration and hemorrhage. Despite this ulceration, atheromatous emboli are rare (or at least, complications of them are rare).

Aorta, atheroma , high power, microscopic
This is a high magnification of the aortic atheroma with foam cells and cholesterol clefts.

Aorta, ulcerative atherosclerosis with mural thrombosis, gross
This is severe atherosclerosis of the aorta in which the atheromatous plaques have undergone ulceration along with formation of overlying mural thrombus.

Atheromatous plaque, high power, microscopic
This high magnification of the atheroma shows numerous foam cells and an occasional cholesterol cleft. A few dark blue inflammatory cells are scattered within the atheroma.

Aorta with rare lipid streaks, gross
This is about as normal as an adult aorta in America gets. The faint reddish staining is from hemoglobin that leaked from RBC's following death. The surface is quite smooth, with only occasional faint small yellow lipid streaks visible.

Cholesterol emboli in kidney, medium power microscopic
Despite the frequency of aortic atherosclerosis, cholesterol emboli are rare, or at least insignficant most of the time. Seen here in a renal artery branch are cholesterol clefts of such an embolus. This patient had severe ulcerative, friable atheromatous plaques and had undergone angiography, which increases the risk for such emboli.

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
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
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.

Coronary artery, occlusive atherosclerosis, gross
Cross sections of this anterior descending coronary artery demonstrate marked atherosclerosis with narrowing. This is most pronounced at the left in the more proximal portion of this artery. In general, the worst atherosclerosis is proximal, where arterial blood flow is more turbulent. More focal lesions mean that angioplasty or bypass can be more useful procedures.

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.

Coronary artery with recent thrombus, longitudinal section, gross
At high magnification, the dark red thrombus is apparent in the lumen of the coronary. The yellow tan plaques of atheroma narrow this coronary significantly, and the thrombus occludes it completely.

Coronary artery with recent thrombus, cross section, gross
A thrombosis of a coronary artery is shown here in cross section. This acute thrombosis diminishes blood flow and leads to ischemia and/or infarction, marked clinically by the sudden onset of chest pain.

Myocardial Infarction

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
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.

Myocardium, contraction band necrosis, microscopic
The earliest change histologically seen with acute myocardial infarction in the first day is contraction band necrosis. The myocardial fibers are beginning to lose cross striations and the nuclei are not clearly visible in most of the cells seen here. Note the many irregular darker pink wavy contraction bands extending across the fibers.

Myocardium, acute myocardial infarction, 1 to 2 days, microscopic
This high power microscopic view of the myocardium demonstrates an infarction of about 1 to 2 days in duration. The myocardial fibers have dark red contraction bands extending across them. The myocardial cell nuclei have almost all disappeared. There is beginning acute inflammation. Clinically, such an acute myocardial infarction is marked by changes in the electrocardiogram and by a rise in the MB fraction of creatine kinase.

In this microscopic view of a recent myocardial infarction, there is extensive hemorrhage along with myocardial fiber necrosis with contraction bands and loss of nuclei.

This myocardial infarction is about 3 to 4 days old. There is an extensive acute inflammatory cell infiltrate and the myocardial fibers are so necrotic that the outlines of them are only barely visible.

Myocardium, intermediate myocardial infarction, 1 to 2 weeks, microscopic
This is an intermediate myocardial infarction of 1 to 2 weeks in age. Note that there are remaining normal myocardial fibers at the top. Below these fibers are many macrophages along with numerous capillaries and little collagenization.

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, transmural myocardial infarction with rupture, gross
In cross section, the point of rupture of the myocardium is shown with the arrow. In this case, there was a previous myocardial infarction 3 weeks before, and another myocardial infarction occurred, rupturing through the already thin ventricular wall 3 days later.

Heart, remote myocardial infarction, medium power microscopic
There is pale white collagen within the interstitium between myocardial fibers. This represents an area of remote infarction.

Heart, remote myocardial infarction, low power microscopic
The myocardium beneath the endocardial surface at the top demonstrates pale fibrosis with collagenization following healing of a subendocardial myocardial infarction.

Heart, remote myocardial infarction, gross
The heart is opened to reveal the left ventricular free wall on the right and the septum in the center. There has been a remote myocardial infarction that extensively involved the anterior left ventricular free wall and septum. The white appearance of the endocardial surface indicates the extensive scarring.

Heart, left ventricular aneurysm, gross
There has been a previous extensive transmural myocardial infarction involving the free wall of the left ventricle. Note that the thickness of the myocardial wall is normal superiorly, but inferiorly is only a thin fibrous wall. The infarction was so extensive that, after healing, the ventricular wall was replaced by a thin band of collagen, forming an aneurysm. Such an aneurysm represents non-contractile tissue that reduces stroke volume and strains the remaining myocardium. The stasis of blood in the aneurysm predisposes to mural thrombosis.

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.

Heart, coronary artery bypass graft, gross
This patient underwent coronary artery bypass grafting with autogenous vein (saphenous vein) grafts. The largest of these runs down the center of the heart to anastomose with the left anterior descending artery distally. Another graft extends in a "Y" fashion just to the right of this to branches of the circumflex artery. A white temporary pacing wire extends from the mid left surface.

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UP NEXT!!!
Part 2
Arterial Dissection
Infective Endocarditis
Non-infective Endocarditis
Pericarditis
Myocarditis
Neoplasia
Congenital Heart Disease
Cardiomyopathies
Miscellaneous Cardiac Diseases

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Cardiovascular Pathology (part 1)

by Louie Ray on May 08, 2008

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Cardiovascular Pathology (part 1) — Presentation Transcript