Difference between revisions of "Heart"

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===Right ventricle===
===Right ventricle===
*Make cut throught the apex (transverse/biventicular section).
*Make cut through the apex (transverse/biventicular section).
*Open along lateral edge (from RA cut).
*Open along lateral edge (from RA cut).


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*After the heart is opened it should be sliced at 5-10 mm intervals to the semilunar valves.
*After the heart is opened it should be sliced at 5-10 mm intervals to the semilunar valves.


==Standard measures==
==Standard measures of the heart==
*Mass (weight).
*Mass (weight).
*Left ventricle (LV) - 2 cm below the MV.
*Left ventricle (LV) - 2 cm below the MV.
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*Pulmonic valve (PV) circumference.
*Pulmonic valve (PV) circumference.
*Tricuspid valve (TV) circumference.
*Tricuspid valve (TV) circumference.
===Normal measures===
====Younger adults (20-60 years)====
Based on ''Ludwig'':<ref name=Ref_Ludwig569>{{Ref Ludwig|569}}</ref>
{| class="wikitable sortable"
! Measure
! Men
! Women
|-
|Aortic valve
| 6.7 (6.0-7.4)
| 6.3 (5.7-6.9)
|-
|Pulmonary valve
| 6.6 (6.1-7.1)
| 6.2 (5.7-6.7)
|-
|Mitral valve
| 9.6 (9.4-9.9)
| 8.6 (8.2-9.1)
|-
|Tricuspid valve
| 11.4 (11.2-11.7)
| 10.6 (10.2-10.9)
|}
Based on ''Ludwig'':<ref name=Ref_Ludwig569>{{Ref Ludwig|569}}</ref>
{| class="wikitable sortable"
! Feature
! Measure
|-
|Left ventricle
| 1.25 (1.00-1.50)
|-
|Right ventricle
| 0.4 (0.25-0.50)
|-
|}
====Older adults (>60 years)====
Based on ''Ludwig'':<ref name=Ref_Ludwig569>{{Ref Ludwig|569}}</ref>
{| class="wikitable sortable"
! Measure
! Men
! Women
|-
|Aortic valve
| 8.3 (8.1-8.5)
| 7.6 (7.3-7.9)
|-
|Pulmonary valve
| 7.3 (7.2-7.5)
| 7.1 (6.8-7.4)
|-
|Mitral valve
| 9.5 (9.2-9.8)
| 8.6 (8.2-9.0)
|-
|Tricuspid valve
| 11.6 (11.4-11.8)
| 10.5 (10.0-11.1)
|}
Based on ''Ludwig'':<ref name=Ref_Ludwig569>{{Ref Ludwig|569}}</ref>
{| class="wikitable sortable"
! Feature
! Measure
|-
|Left ventricle
| 1.15 (1.05-1.25)
|-
|Right ventricle
| 0.38 (0.35-0.40)
|-
|}


==Standard sections==
==Standard sections==
Minimalist approach (Cybulsky):
Minimalist approach (Dr. C.):
#LV and PPM (left ventricle and posterior papillary muscle).
#LV and PPM (left ventricle and posterior papillary muscle).
#LV and APM (left ventricle and anterior papillary muscle).
#LV and APM (left ventricle and anterior papillary muscle).
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#RV.
#RV.


Make the lab work hard approach (Butany):
Make the lab work hard approach (Dr. B.):
#PRV (post. RV) with tricuspid valve.
#PRV (post. RV) with tricuspid valve.
#ARV (ant. RV) with pulm. valve.
#ARV (ant. RV) with pulm. valve.
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===Indications for examining the conducting system<ref>KC. 1 October 2010.</ref>===
===Indications for examining the conducting system<ref>KC. 1 October 2010.</ref>===
#History of syncope.
#History of syncope.
#History of arrhythmia.
#History of [[cardiac arrhythmia|arrhythmia]].
#[[Autopsy#Negative autopsy|Negative autopsy]].
#[[Autopsy#Negative autopsy|Negative autopsy]].


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*+/-Vacuoles.
*+/-Vacuoles.


Images:
=====Images=====
*[http://commons.wikimedia.org/wiki/File:Sinoatrial_node_low_mag.jpg SA node - low mag. - vignetting (WC)].
<gallery>
*[http://commons.wikimedia.org/wiki/File:Sinoatrial_node_2_low_mag.jpg SA node - low mag. (WC)].
Image:Sinoatrial_node_low_mag.jpg | SA node - low mag. - vignetting (WC)
*[http://commons.wikimedia.org/wiki/File:Sinoatrial_node_high_mag.jpg SA node - high mag.(WC)].
Image:Sinoatrial_node_2_low_mag.jpg | SA node - low mag. (WC)
Image:Sinoatrial_node_high_mag.jpg | SA node - high mag.(WC)
</gallery>


===Atrioventricular node===
===Atrioventricular node===
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The pathologist (like radiologists) can say...
The pathologist (like radiologists) can say...
*Pericardial [[effusion]].
*[[Pericardial]] [[effusion]].
**Hemopericardium.
**Hemopericardium.


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==Fibrinous pericarditis==
==Fibrinous pericarditis==
*[[AKA]] ''bread and butter pericarditis''.
*[[AKA]] ''bread and butter pericarditis''.
*Post-[[myocardial infarction]] this is known as ''Dressler's syndrome''.<ref name=Ref_PCPBoD8_293>{{Ref PCPBoD8|293}}</ref>
===General===
===General===
Etiology:
Etiology:
*Radiation.<ref name=pmid436483 >{{Cite journal  | last1 = Schneider | first1 = JS. | last2 = Edwards | first2 = JE. | title = Irradiation-induced pericarditis. | journal = Chest | volume = 75 | issue = 5 | pages = 560-4 | month = May | year = 1979 | doi =  | PMID = 436483 }}</ref>
*Radiation.<ref name=pmid436483 >{{Cite journal  | last1 = Schneider | first1 = JS. | last2 = Edwards | first2 = JE. | title = Irradiation-induced pericarditis. | journal = Chest | volume = 75 | issue = 5 | pages = 560-4 | month = May | year = 1979 | doi =  | PMID = 436483 }}</ref>
*Uremia.
*Uremia.
*[[Myocardial infarction]] (MI).
**Classically occurs at 2-3 days following a MI.<ref name=Ref_PCPBoD8_293>{{Ref PCPBoD8|293}}</ref>
Note:
*Roberts suggests that ''pericardial heart disease'' may be a better term for this, as this isn't really an inflammatory process.<ref name=pmid16200146>{{Cite journal  | last1 = Roberts | first1 = WC. | title = Pericardial heart disease: its morphologic features and its causes. | journal = Proc (Bayl Univ Med Cent) | volume = 18 | issue = 1 | pages = 38-55 | month = Jan | year = 2005 | doi =  | PMID = 16200146 }}</ref>


===Gross===
===Gross===
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*Fibrin - pink amorphous material.
*Fibrin - pink amorphous material.


Note:
*Inflammation is not a strict requirement for the diagnosis.<ref name=pmid16200146>{{Cite journal  | last1 = Roberts | first1 = WC. | title = Pericardial heart disease: its morphologic features and its causes. | journal = Proc (Bayl Univ Med Cent) | volume = 18 | issue = 1 | pages = 38-55 | month = Jan | year = 2005 | doi =  | PMID = 16200146 }}</ref>
Images:
Images:
*[http://autopsy.stanford.edu/images/FibrinousPericarditis.jpg Fibrinous pericarditis (stanford.edu)].<ref>URL: [http://autopsy.stanford.edu/fellowships.html http://autopsy.stanford.edu/fellowships.html]. Accessed on: 21 January 2012.</ref>
*[http://autopsy.stanford.edu/images/FibrinousPericarditis.jpg Fibrinous pericarditis (stanford.edu)].<ref>URL: [http://autopsy.stanford.edu/fellowships.html http://autopsy.stanford.edu/fellowships.html]. Accessed on: 21 January 2012.</ref>
*[http://commons.wikimedia.org/wiki/File:Pericarditis_fibrinosa.jpg Fibrinous pericarditis (WC)].
<gallery>
Image:Pericarditis_fibrinosa.jpg | Fibrinous pericarditis. (WC)
</gallery>
 
===Sign out===
<pre>
Pericardium, Excision:
- Fibrinous pericardial heart disease.
</pre>


==Myocardial infarction==
==Myocardial infarction==
*Abbreviated ''MI''.
*Abbreviated ''MI''.
*[[AKA]] ''myocardial infarct''.
*[[AKA]] ''myocardial infarct''.
===Clinical===
{{Main|Myocardial infarction}}
*Usually diagnosed clinically - with blood work (troponin, CK-MB) or EKG.
*MI may be precipitated by cocaine use... and further exacerbated by treatment with a beta-blocker.<ref name=pmid19127137>{{cite journal |author=Mohamad T, Kondur A, Vaitkevicius P, Bachour K, Thatai D, Afonso L |title=Cocaine-induced chest pain and beta-blockade: an inner city experience |journal=Am J Ther |volume=15 |issue=6 |pages=531-5 |year=2008 |pmid=19127137 |doi=10.1097/MJT.0b013e3181758cfc |url=}}</ref>
*Acute myocardial infarction (abbreviated AMI) = MI < 6 hours old.<ref name=pmid19258462>{{Cite journal  | last1 = Senter | first1 = S. | last2 = Francis | first2 = GS. | title = A new, precise definition of acute myocardial infarction. | journal = Cleve Clin J Med | volume = 76 | issue = 3 | pages = 159-66 | month = Mar | year = 2009 | doi = 10.3949/ccjm.75a.08092 | PMID = 19258462 | URL = http://www.ccjm.org/content/76/3/159.full }}</ref>
**Usually no [[PMN]] infiltrate.


Classic symptoms:
==Coronary artery atherosclerosis==
*Retrosternal chest pain +/- with radiation down the arms.
{{Main|Atherosclerosis}}
*Nausea & vomiting.
*[[AKA]] ''coronary artery disease'', abbreviated ''CAD''.
*Diaphoresis.
*[[AKA]] ''atherosclerotic heart disease'', abbreviated ''ASHD''.
*[[AKA]] ''atherosclerotic coronary artery disease''.


Post-MI:
===General===
*''Dressler's syndrome'' [[AKA]] ''postmyocardial infarction syndrome'';<ref name=pmid5039567>{{cite journal |author=Hutchcroft BJ |title=Dressler's syndrome |journal=Br Med J |volume=3 |issue=5817 |pages=49 |year=1972 |month=July |pmid=5039567 |pmc=1788531 |doi= |url=}}</ref> pericarditis post-myocardial infarction +/- pericardial effusion (clinically tamponade).
*Greater than 75% (diameter) stenosis - considered significant.<ref>Chamberlain, D. March 7, 2008.</ref>
*Leading cause of morbidity and mortality, esp. in the elderly.
*''Left main coronary artery (LMCA) disease'' is particularly fatal.<ref name=pmid10580359>{{Cite journal | last1 = Kanjwal | first1 = MY. | last2 = Carlson | first2 = DE. | last3 = Schwartz | first3 = JS. | title = Chronic/subacute total occlusion of the left main coronary artery--a case report and review of literature. | journal = Angiology | volume = 50 | issue = 11 | pages = 937-45 | month = Nov | year = 1999 | doi = | PMID = 10580359 }}</ref>


Enzymatic tests:<ref>[http://pro2services.com/Lectures/Fall/CardEnz/a6mienz.gif http://pro2services.com/Lectures/Fall/CardEnz/a6mienz.gif]</ref><ref>[http://www.hope-academic.org.uk/biochem/pbl/IMG00030.GIF http://www.hope-academic.org.uk/biochem/pbl/IMG00030.GIF]</ref>
Clinical presentations:
*CK: peaks at day 1, resolves after 2-3 days.
*Stable angina.
*AST: peaks close to day 2, resolves after 4-5 days.
*Unstable angina.
*LDH: peaks day 2, resolves after ~6 days.
*[[Myocardial infarction]].
*[[Sudden cardiac death]].


===Pathologic===
Note:
====Microscopic====
*''Coronary artery atherosclerosis'' is '''not''' the only type of ''coronary artery disease''... but it is by far the most common; thus, CAD is generally considered synonymous with ''coronary artery atherosclerosis''.
Sequence:<ref>[http://library.med.utah.edu/WebPath/TUTORIAL/MYOCARD/MYOCARD.html http://library.med.utah.edu/WebPath/TUTORIAL/MYOCARD/MYOCARD.html]</ref>
*1-3 hours - Wavy (myocardial) fibers
*4-12 hours - Coagulative [[necrosis]] & loss of cross striations, contraction bands, edema, hemorrhage, PMN infiltrate.
*18-24 hours - Coagulative necrosis, pyknosis of nuclei, and marginal contraction bands.
*1-3 days - Loss of nuclei (karyolysis), loss of striations, abundant PMNs.
*3-7 days - Macrophage and mononuclear infiltration, fibrovascular response.
*10-21 days - Fibrovascular response, prominent granulation tissue.
*6 weeks - Fibrosis.  


Images:
Treatment:
*[http://path.upmc.edu/cases/case158/micro.html MI (upmc.edu)].
*Medical management (blood pressure control (antihypertensives), cholesterol control (e.g. statins, exercise), [[diabetes mellitus|diabetes]] control, smoking cessation).
*[[Coronary artery bypass surgery]] (CABG).
*Percutaneous coronary intervention (PCI).


=====Contraction band necrosis=====
====Stenosis definition====
General:
Definition (as per NASCET):<ref name="pmid9811916">{{cite journal |author=Barnett HJ, Taylor DW, Eliasziw M, ''et al.'' |title=Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators |journal=The New England Journal of Medicine |volume=339 |issue=20 |pages=1415–25 |year=1998 |month=November |pmid=9811916 |doi= |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=9811916&promo=ONFLNS19}}</ref><br>
*Mediated by catecholamines.<ref>{{cite journal |author=Hopster DJ, Milroy CM, Burns J, Roberts NB |title=Necropsy study of the association between sudden cardiac death, cardiac isoenzymes and contraction band necrosis |journal=J. Clin. Pathol. |volume=49 |issue=5 |pages=403–6 |year=1996 |month=May |pmid=8707956 |pmc=500481 |doi= |url=}}</ref>
<math>percent\ stenosis = ( 1 - ( minimal\ diameter ) / ( poststenotic\ diameter ) ) x 100%.</math>
*Thought to arise in reperfusion from hypercontraction.


Microscopic:
With a bit of algebra one can show:<br>
*Thick intensely eosinophilic staining bands (on H&E) ~ typically 4-5 micrometres wide
**Span the short axis of myocyte.
**Can be thought of bunched-up striae.
 
Notes:
*Better seen with special stains (Masson or Gomori trichrome).<ref>{{cite journal |author=Hopster DJ, Milroy CM, Burns J, Roberts NB |title=Necropsy study of the association between sudden cardiac death, cardiac isoenzymes and contraction band necrosis |journal=J. Clin. Pathol. |volume=49 |issue=5 |pages=403–6 |year=1996 |month=May |pmid=8707956 |pmc=500481 |doi= |url=}}</ref>
 
Images:
*[http://commons.wikimedia.org/wiki/File:MI_with_contraction_bands_high_mag.jpg CBN - high mag. (WC)].
*[http://commons.wikimedia.org/wiki/File:MI_with_contraction_bands_very_high_mag.jpg CBN - very high mag. (WC)].
 
====Gross====
Sequence:<ref>[http://library.med.utah.edu/WebPath/TUTORIAL/MYOCARD/MYOCARD.html http://library.med.utah.edu/WebPath/TUTORIAL/MYOCARD/MYOCARD.html]</ref>
*18-24 hours - myocardial pallor.
*1-3 days - pallor, moderate hyperemia (redness due to congestion with blood).
*3-7 days - yellow lesion with hyperemic border.
*10-21 days - maximally yellow.
*6 weeks - white (fibrosis).
 
==Coronary artery atherosclerosis==
{{Main|Vascular disease#Atherosclerosis}}
*Greater than 75% (diameter) stenosis - considered significant.<ref>Chamberlain. March 7, 2008.</ref>
 
Stenosis definition (as per NASCET):<ref name="pmid9811916">{{cite journal |author=Barnett HJ, Taylor DW, Eliasziw M, ''et al.'' |title=Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators |journal=The New England Journal of Medicine |volume=339 |issue=20 |pages=1415–25 |year=1998 |month=November |pmid=9811916 |doi= |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=9811916&promo=ONFLNS19}}</ref><br>
<math>percent stenosis = ( 1 - ( minimal\ diameter ) / ( poststenotic\ diameter ) ) x 100%.</math>
 
With a bit of allegbra one can show:<br>
<math>A_x=x^2 A_o</math><br>
<math>A_x=x^2 A_o</math><br>
Where:
Where:
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*A 75% diameter reduction results in a 93.75% area reduction.
*A 75% diameter reduction results in a 93.75% area reduction.
*A 90% diameter reduction results in a 99% area reduction.
*A 90% diameter reduction results in a 99% area reduction.
===Microscopic===
:See ''[[Atherosclerosis]]''.


==Abnormal hearts==
==Abnormal hearts==
===Hypertrophy===
===Cardiac hypertrophy===
Can be by:
Can be by:
*Mass criteria described in a couple of articles from the ''Mayo Clinic Proceedings''.<ref name=pmid3276973>{{cite journal |author=Scholz DG, Kitzman DW, Hagen PT, Ilstrup DM, Edwards WD |title=Age-related changes in normal human hearts during the first 10 decades of life. Part I (Growth): A quantitative anatomic study of 200 specimens from subjects from birth to 19 years old |journal=Mayo Clin. Proc. |volume=63 |issue=2 |pages=126–36 |year=1988 |month=February |pmid=3276973 |doi= |url=}}</ref><ref name=pmid3276974>{{cite journal |author=Kitzman DW, Scholz DG, Hagen PT, Ilstrup DM, Edwards WD |title=Age-related changes in normal human hearts during the first 10 decades of life. Part II (Maturity): A quantitative anatomic study of 765 specimens from subjects 20 to 99 years old |journal=Mayo Clin. Proc. |volume=63 |issue=2 |pages=137–46 |year=1988 |month=February |pmid=3276974 |doi= |url=}}</ref>
*Mass criteria described in a couple of articles from the ''Mayo Clinic Proceedings''.<ref name=pmid3276973>{{cite journal |author=Scholz DG, Kitzman DW, Hagen PT, Ilstrup DM, Edwards WD |title=Age-related changes in normal human hearts during the first 10 decades of life. Part I (Growth): A quantitative anatomic study of 200 specimens from subjects from birth to 19 years old |journal=Mayo Clin. Proc. |volume=63 |issue=2 |pages=126–36 |year=1988 |month=February |pmid=3276973 |doi= |url=}}</ref><ref name=pmid3276974>{{cite journal |author=Kitzman DW, Scholz DG, Hagen PT, Ilstrup DM, Edwards WD |title=Age-related changes in normal human hearts during the first 10 decades of life. Part II (Maturity): A quantitative anatomic study of 765 specimens from subjects 20 to 99 years old |journal=Mayo Clin. Proc. |volume=63 |issue=2 |pages=137–46 |year=1988 |month=February |pmid=3276974 |doi= |url=}}</ref>
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*[[Amyloidosis]].
*[[Amyloidosis]].


====Concentric LV hypertrophy====
====Concentric left ventricular hypertrophy====
Concentric left ventricular hypertrophy is a common gross pathologic finding.
Concentric left ventricular hypertrophy is a common gross pathologic finding.


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Other considerations:
Other considerations:
*Hypertrophic [[cardiomyopathy]] (usually eccentric).
*Hypertrophic [[cardiomyopathy]] (usually eccentric).
<gallery>
Image: Heart_left_ventricular_hypertrophy_sa.jpg | Concentric LVH. (WC)
</gallery>
====Eccentric left ventricular hypertrophy====
*[[Hypertrophic cardiomyopathy]], includes [[hypertrophic obstructive cardiomyopathy]] (HOCM).


==Detail articles==
==Detail articles==
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===Congenital heart disease===
===Congenital heart disease===
{{main|Congenital heart disease}}
{{main|Congenital heart disease}}
Congential heart disease... a domain of paediatric cardiac surgery and occasionally adult cardiac surgery.
Congenital heart disease... a domain of pediatric cardiac surgery and occasionally adult cardiac surgery.


The article covers shunts, both left-to-right and right-to-left.
The article covers shunts, both left-to-right and right-to-left.
Line 329: Line 396:


===Endocarditis===
===Endocarditis===
:See: ''[[infective endocarditis]]''.
{{Main|Infective endocarditis}}


==Cardiac sarcoidosis==
==Cardiac sarcoidosis==
{{main|Sarcoidosis}}
{{main|Sarcoidosis}}
===General===
===General===
*Can be in insolation or part of systemic sarcoidosis.<ref name=pmid9608713>{{cite journal |author=Veinot JP, Johnston B |title=Cardiac sarcoidosis--an occult cause of sudden death: a case report and literature review |journal=J. Forensic Sci. |volume=43 |issue=3 |pages=715–7 |year=1998 |month=May |pmid=9608713 |doi= |url=}}</ref>
*Can be in isolation or part of systemic sarcoidosis.<ref name=pmid9608713>{{cite journal |author=Veinot JP, Johnston B |title=Cardiac sarcoidosis--an occult cause of sudden death: a case report and literature review |journal=J. Forensic Sci. |volume=43 |issue=3 |pages=715–7 |year=1998 |month=May |pmid=9608713 |doi= |url=}}</ref>
*May mimic hypertrophic [[cardiomyopathy]] clinically.<ref name=pmid10981852>{{cite journal |author=Matsumori A, Hara M, Nagai S, ''et al.'' |title=Hypertrophic cardiomyopathy as a manifestation of cardiac sarcoidosis |journal=Jpn. Circ. J. |volume=64 |issue=9 |pages=679–83 |year=2000 |month=September |pmid=10981852 |doi= |url=}}</ref>
*May mimic hypertrophic [[cardiomyopathy]] clinically.<ref name=pmid10981852>{{cite journal |author=Matsumori A, Hara M, Nagai S, ''et al.'' |title=Hypertrophic cardiomyopathy as a manifestation of cardiac sarcoidosis |journal=Jpn. Circ. J. |volume=64 |issue=9 |pages=679–83 |year=2000 |month=September |pmid=10981852 |doi= |url=}}</ref>
*Clinical: associated with heart block.<ref name=pmid9608713/>
*Clinical: associated with heart block.<ref name=pmid9608713/>
Line 363: Line 430:


Notes:
Notes:
*Myocyte necrosis and eosinophils are features of ''granulomatous myocarditis''.<ref name=pmid19660614/>
*Myocyte necrosis and [[eosinophil]]s are features of ''granulomatous myocarditis''.<ref name=pmid19660614/>


==Myocarditis==
==Myocarditis==
===Work-up===
{{Main|Myocarditis}}
*Requires 10 sections to exclude;<ref>KC. 1 October 2010.</ref> sections should include RV and LV.
**It is often missed with five.<ref>{{Cite journal  | last1 = Kubo | first1 = N. | last2 = Morimoto | first2 = S. | last3 = Hiramitsu | first3 = S. | last4 = Uemura | first4 = A. | last5 = Kimura | first5 = K. | last6 = Shimizu | first6 = K. | last7 = Hishida | first7 = H. | title = Feasibility of diagnosing chronic myocarditis by endomyocardial biopsy. | journal = Heart Vessels | volume = 12 | issue = 4 | pages = 167-70 | month =  | year = 1997 | doi =  | PMID = 9559966 }}</ref>
 
===Classification<ref name=emedicine1612533>[http://emedicine.medscape.com/article/1612533-overview http://emedicine.medscape.com/article/1612533-overview]</ref>===
*Eosinophilic - ''hypersensitivity myocarditis'' - most common.
**May be assoc. with peripheral blood eosinophilia.<ref name=pmid20181108>{{cite journal |author=Amini R, Nielsen C |title=Eosinophilic myocarditis mimicking acute coronary syndrome secondary to idiopathic hypereosinophilic syndrome: a case report |journal=J Med Case Reports |volume=4 |issue= |pages=40 |year=2010 |pmid=20181108 |pmc=2830978 |doi=10.1186/1752-1947-4-40 |url=}}</ref>
*Lymphocytic - viral, autoimmune.
*Granulomatous - infectious, [[idiopathic granulomatous myocarditis|idiopathic]].
*Neutrophilic.
*Reperfusion (associated with myocardial infarction).
 
Images:
*[http://commons.wikimedia.org/wiki/File:Viral_myocarditis_%281%29.JPG Myocarditis (viral) - 1 (WC)].
*[http://commons.wikimedia.org/wiki/File:Viral_myocarditis_%282%29.JPG Myocarditis (viral) - 2 (WC)].
*[http://jmedicalcasereports.com/content/4/1/40/figure/F5 Eosinophilic myocarditis (jmedicalcasereports.com)].<ref name=pmid20181108>{{cite journal |author=Amini R, Nielsen C |title=Eosinophilic myocarditis mimicking acute coronary syndrome secondary to idiopathic hypereosinophilic syndrome: a case report |journal=J Med Case Reports |volume=4 |issue= |pages=40 |year=2010 |pmid=20181108 |pmc=2830978 |doi=10.1186/1752-1947-4-40 |url=}}</ref>


==Idiopathic granulomatous myocarditis==
==Idiopathic granulomatous myocarditis==
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==Chagas disease==
==Chagas disease==
*[[AKA]] ''American trypanosomiasis''.
*[[AKA]] ''American trypanosomiasis''.
 
{{Main|Chagas disease}}
===General===
*Essentially a South American disease.
*Etiology: protozoa ''Trypanosoma cruzi'' - transmitted by ''reduvid bugs'',<ref name=PMH0002348>URL: [http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002348/ http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002348/]. Accessed on: 4 December 2011.</ref> also known as ''kissing bug''.<ref>URL: [http://www.who.int/topics/chagas_disease/en/ http://www.who.int/topics/chagas_disease/en/]. Accessed on: 1 December 2011.</ref>
 
Clinical:<ref name=pmid17072450>{{Cite journal  | last1 = Teixeira | first1 = AR. | last2 = Nascimento | first2 = RJ. | last3 = Sturm | first3 = NR. | title = Evolution and pathology in chagas disease--a review. | journal = Mem Inst Oswaldo Cruz | volume = 101 | issue = 5 | pages = 463-91 | month = Aug | year = 2006 | doi =  | PMID = 17072450 |URL = http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0074-02762006000500001&lng=en&nrm=iso&tlng=en }}</ref>
*Depends on phase of infection.
*Arrhythmias (late).
 
Dx:<ref>URL: [http://www.cdc.gov/parasites/chagas/diagnosis.html http://www.cdc.gov/parasites/chagas/diagnosis.html]. Accessed on: 4 December 2011.</ref>
*Usually serology.
*Thin blood smear.
 
Tx:
*Antimicrobials: benznidazole, nifurtimox.<ref name=PMH0002348/>
 
===Microscopic===
Features:
*Inflammation - main finding.<ref name=pmid17072450/>
*Intramuscular organisms (without an inflammatory response).
*Neuronal loss in atrial ganglia.<ref name=pmid17339569/>
 
DDx:
*[[Toxoplasmosis]].<ref>URL: [http://path.upmc.edu/cases/case160/micro.html http://path.upmc.edu/cases/case160/micro.html]. Accessed on: 8 January 2012.</ref> (???)
 
Images:
*[http://www.uaz.edu.mx/histo/pathology/ed/ch_9c/c9c_chagas.htm Chagas disease (uaz.edu.mx)].
*[http://cardiovascres.oxfordjournals.org/content/60/1/96/F1.expansion.html Chagas disease (oxfordjournals.org)].<ref>{{Cite journal  | last1 = Higuchi | first1 = Mde L. | last2 = Benvenuti | first2 = LA. | last3 = Martins Reis | first3 = M. | last4 = Metzger | first4 = M. | title = Pathophysiology of the heart in Chagas' disease: current status and new developments. | journal = Cardiovasc Res | volume = 60 | issue = 1 | pages = 96-107 | month = Oct | year = 2003 | doi =  | PMID = 14522411 }}</ref>
 
===IHC===
*Anti–T cruzi immunoperoxidase.<ref name=pmid17339569>{{Cite journal  | last1 = Marin-Neto | first1 = JA. | last2 = Cunha-Neto | first2 = E. | last3 = Maciel | first3 = BC. | last4 = Simões | first4 = MV. | title = Pathogenesis of chronic Chagas heart disease. | journal = Circulation | volume = 115 | issue = 9 | pages = 1109-23 | month = Mar | year = 2007 | doi = 10.1161/CIRCULATIONAHA.106.624296 | PMID = 17339569 |URL = http://circ.ahajournals.org/content/115/9/1109.long }}</ref>


==Cardiac amyloidosis==
==Cardiac amyloidosis==
Line 467: Line 489:
Notes:
Notes:
*ABCs of pink on H&E = '''a'''myloid, '''b'''lood (fibrin), '''c'''ollagen, '''s'''mooth muscle.
*ABCs of pink on H&E = '''a'''myloid, '''b'''lood (fibrin), '''c'''ollagen, '''s'''mooth muscle.
==Mesothelial/monocytic incidental cardiac excrescence==
*[[AKA]] ''Cardiac MICE''.
===General===
*Very rare.
*Benign.
*May be confused with a tumour.<ref name=pmid12879644>{{Cite journal  | last1 = de Gouveia | first1 = RH. | last2 = Ramos | first2 = S. | last3 = Ribeiro | first3 = MA. | last4 = Ferreira | first4 = M. | last5 = Martins | first5 = AP. | title = Cardiac MICE--tumor or thrombus? | journal = Rev Port Cardiol | volume = 22 | issue = 4 | pages = 523-9 | month = Apr | year = 2003 | doi =  | PMID = 12879644 }}</ref>
===Microscopic===
Features:<ref name=pmid12879644/>
*Mesothelial cells.


==Cocaine toxicity==
==Cocaine toxicity==

Latest revision as of 05:33, 21 July 2016

The heart is an important organ. It moves the blood around. For orthopods, it gets the Ancef (cefazolin) to the bones. When it stops for an extended time... people end-up in the morgue or being seen by a pathologist for an autopsy.

An introduction to cardiovascular pathology is found in the cardiovascular pathology article.

Obscure anatomy

Main article: Heart anatomy

Heart dissection

Pericardium

If adhesions are present decide whether they are:

  1. Fibrinous (recent) or,
  2. Fibrous (old).

Identifying hardware

  • Defibrillator - thick wires.
  • Pacer - thin wires.

General rule

  • Open along the lines of flow.

Note:

  • Do not open right atrium (RA) SVC to IVC.
    • Why? A.: You cut through the territory of the SA node.

Coronary arteries

  • These are often done first, i.e. before the heart is opened.
  • They should be sectioned (axially) at ~2 mm intervals.
    • Longitudinally opening the coronaries does not allow accurate assessment of luminal stenosis.[1]
  • A significant stenosis (defined by diameter narrowing) is 70-75%.[2]

Notes:

  • If calcified:
    • Dissect off the coronary tree + decal.

Right atrium

  • Open anteriorly ~ 1 cm above the tricuspid valve annulus.
    • Open right auricle at the same time.

Examination of apex

  • Slice apex (perpendicular to the long axis of the heart), such that both ventricles can be seen.

Right ventricle

  • Make cut through the apex (transverse/biventicular section).
  • Open along lateral edge (from RA cut).

Right ventricular outflow tract

  • Cut along pulmonary artery.

Left atrium

  • Isolate the four pulmonary veins - cut 'em so they are long on the heart.
  • Join the pulmonary veins on the right with a cut.
  • Join the pulmonary veins on the left with a cut.
  • Open the posterior aspect of the LA by joining the two previous cuts.
  • Open the left auricle (to look for thrombus).

Left ventricle

  • Open on the lateral aspect with a long knife.

Left ventricular outflow tract

  • Open LVOT with cut(s) from LV; stay close to intraventricular septum.[3]
    • Avoid cutting the pulmonary artery.
    • With luck you end-up between the left coronary cusp and right coronary cusp.
      • Check whether the aortic valve and coronary ostia are normal.

Slicing

  • After the heart is opened it should be sliced at 5-10 mm intervals to the semilunar valves.

Standard measures of the heart

  • Mass (weight).
  • Left ventricle (LV) - 2 cm below the MV.
  • Right ventricle (RV) - 2 cm below the TV.
  • Aortic valve (AV) circumference.
  • Mitral valve (MV) circumference.
  • Pulmonic valve (PV) circumference.
  • Tricuspid valve (TV) circumference.

Normal measures

Younger adults (20-60 years)

Based on Ludwig:[4]

Measure Men Women
Aortic valve 6.7 (6.0-7.4) 6.3 (5.7-6.9)
Pulmonary valve 6.6 (6.1-7.1) 6.2 (5.7-6.7)
Mitral valve 9.6 (9.4-9.9) 8.6 (8.2-9.1)
Tricuspid valve 11.4 (11.2-11.7) 10.6 (10.2-10.9)

Based on Ludwig:[4]

Feature Measure
Left ventricle 1.25 (1.00-1.50)
Right ventricle 0.4 (0.25-0.50)

Older adults (>60 years)

Based on Ludwig:[4]

Measure Men Women
Aortic valve 8.3 (8.1-8.5) 7.6 (7.3-7.9)
Pulmonary valve 7.3 (7.2-7.5) 7.1 (6.8-7.4)
Mitral valve 9.5 (9.2-9.8) 8.6 (8.2-9.0)
Tricuspid valve 11.6 (11.4-11.8) 10.5 (10.0-11.1)

Based on Ludwig:[4]

Feature Measure
Left ventricle 1.15 (1.05-1.25)
Right ventricle 0.38 (0.35-0.40)

Standard sections

Minimalist approach (Dr. C.):

  1. LV and PPM (left ventricle and posterior papillary muscle).
  2. LV and APM (left ventricle and anterior papillary muscle).

Compromise approach:

  1. LV and PPM.
  2. LV and APM.
  3. LV lateral wall.
  4. Intraventricular septum.
  5. RV.

Make the lab work hard approach (Dr. B.):

  1. PRV (post. RV) with tricuspid valve.
  2. ARV (ant. RV) with pulm. valve.
  3. PLV (post. LV) with mitral valve.
  4. ALV (ant. LV) with aortic valve.
  5. Lat. LV.
  6. LV and PPM.
  7. Post. septum.
  8. Mid. septum.
  9. Ant. septum.
  10. Ant. LV wall.
  11. LV and APM.
  12. RCA.
  13. LAD.
  14. LCx.

Stock

  • One slice (close to apex).
  • +/-Region of SA node.
  • +/-Region of AV node.

Conducting system

Indications for examining the conducting system[5]

  1. History of syncope.
  2. History of arrhythmia.
  3. Negative autopsy.

Sinoatrial node

  • Sinoatrial (SA) node is at the lateral aspect of sulcus terminalis; lateral aspect of the superior vena cava and right atrium junction.[6]
    • Cannot be identified grossly.
    • Artery of the SA (branch of RCA) may be a clue to where it lies.

Submitting the SA Node:[6]

  • Submit all of lateral sulcus terminalis -- serially section perpendicular to the sulcus terminalis, i.e. cuts are in the axis of the SVC (superior to inferior).

Notes: Gulino[7] has a good description and good pictures.

SA node histology

The SA node is best identified by it location:

  • The SA Node is superficial to cardiac muscle, i.e. distant to the RA relative to the cardiac muscle.
    • The SA nodal tissue abuts cardiac muscle.
  • It sits around the sinoatrial node artery - which should be seen on its lumen if the sections were taken properly.
  • The SA node is deep to adipose tissue that covers that epicardial aspect of the heart.
  • Nerve fibres (from the vagus nerve) are typically found between that adipose tissue and SA nodal tissue.

Histologic characteristics:

  • Spindle cell morphology + wavy nucleus.
  • Cytoplasm stains lighter with eosin than cardiac muscle.
  • +/-Vacuoles.
Images

  • SA node - low mag. - vignetting (WC)

  • SA node - low mag. (WC)

  • SA node - high mag.(WC)

Atrioventricular node

Approach 1 (Peter method):

  • Open the LVOT - if it hasn't been opened yet.
  • Cut a section of that includes the right coronary cusp (of the aortic valve) and about 1.5 cm below it (this has the membranous septum and the superior muscular septum).[8]
    • This section should then be serially sectioned in the axis of the VLOT.

Approach 2 (Virmani method):

  1. View from right atrium: AV node is between the coronary sinus and membranous septum.
  2. View from LVOT: Inferior to the posterior (non-coronary) cusp of the aortic valve.
    • One should cut a (coronal) section of that includes the posterior (non-coronary) cusp and about 1.5 cm below it (this has the membranous septum and the superior muscular septum) -- see: Figure 1-15 in Virmani et al.[9]
      • This section should then be serially sectioned in the axis of the VLOT.

Approach 3 (Location by triangle of Koch):

  • Atrioventicular (AV) node is in the triangle of Koch.

Triangle of Koch according to Virmani[10] is the floor of the RA and:

  • Tendon of Todaro = "superior".
  • Tricuspid valve annulus = "inferior".
  • Coronary sinus = "posterior".

Images:

Tamponade

  • Tamponade is a clinical diagnosis (classically: elevated JVP, low BP). It cannot be made at autopsy.

The pathologist (like radiologists) can say...

Image: Pericardial effusion - CT scan (wikipedia.org).

Fibrinous pericarditis

General

Etiology:

Note:

  • Roberts suggests that pericardial heart disease may be a better term for this, as this isn't really an inflammatory process.[14]

Gross

  • Pericardium with a shaggy rough appearance.
    • Described as "buttered bread dropped-on-the-floor look".[15]

Image:

Microscopic

Features:

  • Fibrin - pink amorphous material.

Note:

  • Inflammation is not a strict requirement for the diagnosis.[14]

Images:

  • Fibrinous pericarditis. (WC)

Sign out

Pericardium, Excision:
- Fibrinous pericardial heart disease.

Myocardial infarction

  • Abbreviated MI.
  • AKA myocardial infarct.
Main article: Myocardial infarction

Coronary artery atherosclerosis

Main article: Atherosclerosis
  • AKA coronary artery disease, abbreviated CAD.
  • AKA atherosclerotic heart disease, abbreviated ASHD.
  • AKA atherosclerotic coronary artery disease.

General

  • Greater than 75% (diameter) stenosis - considered significant.[17]
  • Leading cause of morbidity and mortality, esp. in the elderly.
  • Left main coronary artery (LMCA) disease is particularly fatal.[18]

Clinical presentations:

Note:

  • Coronary artery atherosclerosis is not the only type of coronary artery disease... but it is by far the most common; thus, CAD is generally considered synonymous with coronary artery atherosclerosis.

Treatment:

  • Medical management (blood pressure control (antihypertensives), cholesterol control (e.g. statins, exercise), diabetes control, smoking cessation).
  • Coronary artery bypass surgery (CABG).
  • Percutaneous coronary intervention (PCI).

Stenosis definition

Definition (as per NASCET):[19]

With a bit of algebra one can show:

Where:

  • x = 1 - (percent diameter reduction/100).
  • Ao = the initial area.
  • Ax = the area with diameter x.

If one applies the above equation:

  • A 50% diameter reduction results in a 75% area reduction.
  • A 75% diameter reduction results in a 93.75% area reduction.
  • A 90% diameter reduction results in a 99% area reduction.

Microscopic

See Atherosclerosis.

Abnormal hearts

Cardiac hypertrophy

Can be by:

  • Mass criteria described in a couple of articles from the Mayo Clinic Proceedings.[20][21]
  • Thickness criteria.

Rules of thumb:[22]

  • >400 g is often abnormal.
  • >500 g is abnormal.
  • >1.5 cm left ventricle thickness.
  • >0.5 cm right ventricle thickness.

Common patterns

Dilated hearts

Dilated pattern DDx:[23]

  • Hypertensive heart disease.
  • Hypertrophic cardiomyopathy.
  • Amyloidosis.

Concentric left ventricular hypertrophy

Concentric left ventricular hypertrophy is a common gross pathologic finding.

The main DDx is:

Other considerations:

  • Concentric LVH. (WC)

Eccentric left ventricular hypertrophy

Detail articles

Cardiomyopathy

Main article: Cardiomyopathy

In the land of cardiology... there is a thing called cardiomyopathy. This article deals with it.

It includes discussion of dilated cardiomyopathy, hypertrophic cardiomyopathy and arrhythmogenic right ventricular cardiomyopathy.

Congenital heart disease

Main article: Congenital heart disease

Congenital heart disease... a domain of pediatric cardiac surgery and occasionally adult cardiac surgery.

The article covers shunts, both left-to-right and right-to-left.

Tumours

Main article: Tumours of the heart

These are rare buggers.

Valvular disease

Main article: Valvular heart disease

This is the domain of cardiac surgery... only seen in hospitals with cardiac surgery.

Endocarditis

Main article: Infective endocarditis

Cardiac sarcoidosis

Main article: Sarcoidosis

General

  • Can be in isolation or part of systemic sarcoidosis.[24]
  • May mimic hypertrophic cardiomyopathy clinically.[25]
  • Clinical: associated with heart block.[24]

Gross

  • Ventricular septum base - most common site of involvement.[24]

Distribution by autopsy findings:[26]

Notes:

  • Advanced lesions are fibrotic and may mimic old infarcts (grossly) due to coronary artery atherosclerosis.

Microscopic

Features:[26]

  • Non-caseating granulomas.
  • Subepicardial predominance.
  • +/-Fibrosis - old lesions are fibrotic.

Negatives:

  • Significant number of eosinophils.
  • Myocyte necrosis.

Notes:

  • Myocyte necrosis and eosinophils are features of granulomatous myocarditis.[26]

Myocarditis

Main article: Myocarditis

Idiopathic granulomatous myocarditis

  • AKA giant cell myocarditis[27] and less ambiguously idiopathic giant cell myocarditis.

General

  • Unknown etiology.[28]

Microscopic

Features:[26]

Note:

  • Eosinophils and myocyte necrosis differentiate this entity from cardiac sarcoidosis.
    • Granulomas in sarcoidosis are well formed and also involve the fat.[28]

DDx:

Images:

Stains

Chagas disease

  • AKA American trypanosomiasis.
Main article: Chagas disease

Cardiac amyloidosis

Main article: Amyloidosis

General

Microscopic

Features (H&E stain):

  • Acellular fluffy pink material.

Special stains:

  • Congo red stain - red (normal light), apple-green in polarized light.[29]
  • Thioflavin-T stain[30]

Images (amyloidosis cardiac):

Images (amyloidosis - non-cardiac):

Notes:

  • ABCs of pink on H&E = amyloid, blood (fibrin), collagen, smooth muscle.

Mesothelial/monocytic incidental cardiac excrescence

  • AKA Cardiac MICE.

General

  • Very rare.
  • Benign.
  • May be confused with a tumour.[31]

Microscopic

Features:[31]

  • Mesothelial cells.

Cocaine toxicity

Main article: Cocaine toxicity

No distinctive pathologic findings. May appear older than one would expect, e.g. advanced atherosclerosis in a young man.

Heart transplant pathology

Main article: Heart transplant pathology

Comes in different flavours... cellular, acute vascular chronic.

See also

References

  1. ↑ URL: http://www.histopathology-india.net/CAEx.htm. Accessed on: 7 July 2011.
  2. ↑ Burton, Julian L.; Rutty, Guy N. (2010). The Hospital Autopsy A Manual of Fundamental Autopsy Practice (3rd ed.). Oxford University Press. pp. 147. ISBN 978-0340965146.
  3. ↑ {{Ref HospAuto|
  4. ↑ 4.0 4.1 4.2 4.3 Ludwig, Jurgen (2002). Handbook of Autopsy Practice (3rd ed.). Humana Press. pp. 569. ISBN 978-1588291691.
  5. ↑ KC. 1 October 2010.
  6. ↑ 6.0 6.1 Virmani et al. Cardiovascular Pathology. 2nd Ed. 2001. P.16.
  7. ↑ Gulino SP (September 2003). "Examination of the cardiac conduction system: forensic application in cases of sudden cardiac death". Am J Forensic Med Pathol 24 (3): 227–38. doi:10.1097/01.paf.0000083453.43318.74. PMID 12960658.
  8. ↑ PF. August 21, 2009.
  9. ↑ Virmani et al. Cardiovascular Pathology. 2nd Ed. 2001. P.18.
  10. ↑ Virmani et al. Cardiovascular Pathology. 2nd Ed. 2001. P.17.
  11. ↑ Macedo, PG.; Patel, SM.; Bisco, SE.; Asirvatham, SJ. (2010). "Septal accessory pathway: anatomy, causes for difficulty, and an approach to ablation.". Indian Pacing Electrophysiol J 10 (7): 292-309. PMID 20680108.
  12. ↑ 12.0 12.1 Mitchell, Richard; Kumar, Vinay; Fausto, Nelson; Abbas, Abul K.; Aster, Jon (2011). Pocket Companion to Robbins & Cotran Pathologic Basis of Disease (8th ed.). Elsevier Saunders. pp. 293. ISBN 978-1416054542.
  13. ↑ Schneider, JS.; Edwards, JE. (May 1979). "Irradiation-induced pericarditis.". Chest 75 (5): 560-4. PMID 436483.
  14. ↑ 14.0 14.1 Roberts, WC. (Jan 2005). "Pericardial heart disease: its morphologic features and its causes.". Proc (Bayl Univ Med Cent) 18 (1): 38-55. PMID 16200146.
  15. ↑ Cohen, MB.; Laennec, RT. (Feb 2004). "Cross your heart: Some historical comments about fibrinous pericarditis.". Hum Pathol 35 (2): 147-9. PMID 14991530.
  16. ↑ URL: http://autopsy.stanford.edu/fellowships.html. Accessed on: 21 January 2012.
  17. ↑ Chamberlain, D. March 7, 2008.
  18. ↑ Kanjwal, MY.; Carlson, DE.; Schwartz, JS. (Nov 1999). "Chronic/subacute total occlusion of the left main coronary artery--a case report and review of literature.". Angiology 50 (11): 937-45. PMID 10580359.
  19. ↑ Barnett HJ, Taylor DW, Eliasziw M, et al. (November 1998). "Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators". The New England Journal of Medicine 339 (20): 1415–25. PMID 9811916. http://content.nejm.org/cgi/pmidlookup?view=short&pmid=9811916&promo=ONFLNS19.
  20. ↑ Scholz DG, Kitzman DW, Hagen PT, Ilstrup DM, Edwards WD (February 1988). "Age-related changes in normal human hearts during the first 10 decades of life. Part I (Growth): A quantitative anatomic study of 200 specimens from subjects from birth to 19 years old". Mayo Clin. Proc. 63 (2): 126–36. PMID 3276973.
  21. ↑ Kitzman DW, Scholz DG, Hagen PT, Ilstrup DM, Edwards WD (February 1988). "Age-related changes in normal human hearts during the first 10 decades of life. Part II (Maturity): A quantitative anatomic study of 765 specimens from subjects 20 to 99 years old". Mayo Clin. Proc. 63 (2): 137–46. PMID 3276974.
  22. ↑ KC. 14 October 2010.
  23. ↑ Cotran, Ramzi S.; Kumar, Vinay; Fausto, Nelson; Nelso Fausto; Robbins, Stanley L.; Abbas, Abul K. (2005). Robbins and Cotran pathologic basis of disease (7th ed.). St. Louis, Mo: Elsevier Saunders. pp. 602. ISBN 0-7216-0187-1.
  24. ↑ 24.0 24.1 24.2 Veinot JP, Johnston B (May 1998). "Cardiac sarcoidosis--an occult cause of sudden death: a case report and literature review". J. Forensic Sci. 43 (3): 715–7. PMID 9608713.
  25. ↑ Matsumori A, Hara M, Nagai S, et al. (September 2000). "Hypertrophic cardiomyopathy as a manifestation of cardiac sarcoidosis". Jpn. Circ. J. 64 (9): 679–83. PMID 10981852.
  26. ↑ 26.0 26.1 26.2 26.3 Tavora F, Cresswell N, Li L, Ripple M, Solomon C, Burke A (August 2009). "Comparison of necropsy findings in patients with sarcoidosis dying suddenly from cardiac sarcoidosis versus dying suddenly from other causes". Am. J. Cardiol. 104 (4): 571–7. doi:10.1016/j.amjcard.2009.03.068. PMID 19660614.
  27. ↑ http://emedicine.medscape.com/article/1612533-overview
  28. ↑ 28.0 28.1 URL: http://path.upmc.edu/cases/case175/dx.html. Accessed on: 8 January 2012.
  29. ↑ Ebert EC, Nagar M (March 2008). "Gastrointestinal manifestations of amyloidosis". Am. J. Gastroenterol. 103 (3): 776-87. doi:10.1111/j.1572-0241.2007.01669.x. PMID 18076735.
  30. ↑ Nishi S, Alchi B, Imai N, Gejyo F (April 2008). "New advances in renal amyloidosis". Clin. Exp. Nephrol. 12 (2): 93-101. doi:10.1007/s10157-007-0008-3. PMID 18175051.
  31. ↑ 31.0 31.1 de Gouveia, RH.; Ramos, S.; Ribeiro, MA.; Ferreira, M.; Martins, AP. (Apr 2003). "Cardiac MICE--tumor or thrombus?". Rev Port Cardiol 22 (4): 523-9. PMID 12879644.
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