Difference between revisions of "Heart valves"

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Heart valves (view source)

Revision as of 01:14, 26 July 2016

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→‎Rheumatic heart disease: split out
 
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[[Image:Gray497.png|thumb|right|Aortic valve - drawing. (WC/Gray's Anatomy)]]
'''[[Heart]] valves''' are the domain of the cardiac surgeon and their bread & butter.
'''[[Heart]] valves''' are the domain of the cardiac surgeon and their bread & butter.


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**No fusion.  
**No fusion.  


Note:
*The [[cut-up]] is described in ''[[grossing mitral valves]]''.
===Microscopic===
===Microscopic===
Similar to the aortic valve - layers:
Similar to the aortic valve - layers:
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==Myxomatous degeneration==
==Myxomatous degeneration==
===General===
{{Main|Myxomatous degeneration}}
*Usually affects the mitral valve.
*Female > male,<ref>URL: [http://emedicine.medscape.com/article/759004-overview http://emedicine.medscape.com/article/759004-overview]. Accessed on: 8 June 2010.</ref> disputed by Toronto data.<ref name=leong>{{cite journal |author=Leong SW, Soor GS, Butany J, Henry J, Thangaroopan M, Leask RL |title=Morphological findings in 192 surgically excised native mitral valves |journal=Can J Cardiol |volume=22 |issue=12 |pages=1055-61 |year=2006 |month=October |pmid=17036100 |doi= |url=}}</ref>
*Associated with [[Marfan's syndrome]] and [[Turner syndrome]] (Monosomy X).<ref>{{cite journal |author=Wigle ED, Rakowski H, Ranganathan N, Silver MC |title=Mitral valve prolapse |journal=Annu. Rev. Med. |volume=27 |issue= |pages=165–80 |year=1976 |pmid=779595 |doi=10.1146/annurev.me.27.020176.001121 |url=}}</ref>
 
===Gross===
Features:<ref name=Ref_PBoD591>{{Ref PBoD|591}}</ref>
*No commissural fusion.
**Commissural fusion typical of rheumatic heart disease.
*Thickened.
*Rubbery consistency.
*Reactive/secondary changes.
**Fibrosis due to prolapse/abnormal contact of valve with other structures.
**Clots/organized thrombus - due to stasis.
 
===Microscopic===
*Thinning of ''fibrosa layer''.
*Thickening of ''spongiosa layer'' with mucoid (myxomatous) material. (key feature).
*+/-Secondary changes (due to valvular dysfunction): thrombi, fibrosis.
 
====Staining====
*Movat stain.
**Acid fuchsin, alcian blue, crocein scarlet, elastic hematoxylin, pathology consultation, and saffron.<ref>URL: [http://www.mayomedicallaboratories.com/test-catalog/Overview/9832 http://www.mayomedicallaboratories.com/test-catalog/Overview/9832]. Accessed on: 8 June 2010.</ref><ref name=penn_med>Modified Movat's Pentachrome Stain. University Penn Medicine. URL: [http://www.med.upenn.edu/mcrc/histology_core/movat.shtml http://www.med.upenn.edu/mcrc/histology_core/movat.shtml]. Accessed on: January 29, 2009.</ref>
 
Interpretation of Movat stain:<ref name=penn_med/>
*Black = nuclei and elastic fibers.
*Yellow = collagen and reticular fibers.
*Blue = mucin, ground substance.
*Red (intense) = fibrin.
*Red = muscle.
 
Image:
<gallery>
Image:Myxomatous_aortic_valve.jpg | Myxomatous valve. [[Movat stain]]. (WC/Nephron)
</gallery>


=Infective conditions=
=Infective conditions=
==Rheumatic heart disease==
==Rheumatic heart disease==
:''Rheumatic fever'' redirects here.
{{Main|Rheumatic heart disease}}
*Abbreviated ''RHD''.
===General===
*Classically leads to mitral valve stenosis.
**Rheumatic fever accounts for 99% of mitral stenosis.<ref name=Ref_PBoD594>{{Ref PBoD|594}}</ref>
***Caused by ''Streptococcus pyogenes''.<ref name=pmid18306530>{{Cite journal  | last1 = Chopra | first1 = P. | last2 = Gulwani | first2 = H. | title = Pathology and pathogenesis of rheumatic heart disease. | journal = Indian J Pathol Microbiol | volume = 50 | issue = 4 | pages = 685-97 | month = Oct | year = 2007 | doi =  | PMID = 18306530 }}</ref>
*Disease less frequent today - as streptococcal pharynigits is treated.
 
===Gross===
*"Fish-mouth appearance".
**Slit-like morphology; elliptical cross-sectional flow area (mitral valve) has an abnormally small semi-minor axis<ref>URL: [http://en.wikipedia.org/wiki/Ellipse http://en.wikipedia.org/wiki/Ellipse]. Accessed on: 13 November 2010.</ref> axis due to valve thickening.
**Image: [http://www.principia-eng.com/services/construction/IMG_3098.jpg Fish-mouth appearance - pipe (principia-eng.com)].
*Significant valvular thickening.
*Thickening and shortening of the cordae tendinae.
 
DDx:
*Thickening of the cordae tendinae due to micronodular [[cirrhosis]].<ref name=Ref_AoGP25>{{Ref AoGP|25}}</ref>
 
====Images====
<gallery>
Image:Rheumatic_heart_disease,_gross_pathology_20G0013_lores.jpg | RHD - showing valvular thickening and thickening of the cordae tendinae. (WC)
Image:Aortic_stenosis_rheumatic,_gross_pathology_20G0014_lores.jpg | RHD - showing valvular thickening - aortic valve. (WC)
</gallery>
===Microscopic===
Features:<ref name=Ref_PBoD593>{{Ref PBoD|593}}</ref>
*Caterpillar cells ([[AKA]] Anitschkow cells)
**Abundant eosinophilic cytoplasm.
**Moderately-poorly defined cell border.
**Well-defined central ovoid nucleus with a prominent wavy ribbon-like chromatin -- looks vaguely like a caterpillar with some imagination.
**Pathognomonic for rheumatic fever.
 
*Aschoff bodies - usually in the heart itself:
**Jumbled collagen, eosinophilic.
**Surrounded by lymphocytes (T cells) +/- plasma cells.
 
Notes:
*Anitschkow cells are thought to be histocytes and Aschoff bodies are thought to be [[granuloma]]s.<ref name=pmid3070554>{{Cite journal  | last1 = Love | first1 = GL. | last2 = Restrepo | first2 = C. | title = Aschoff bodies of rheumatic carditis are granulomatous lesions of histiocytic origin. | journal = Mod Pathol | volume = 1 | issue = 4 | pages = 256-61 | month = Jul | year = 1988 | doi =  | PMID = 3070554 }}</ref>
**This is disputed.<ref name=pmid10399163>{{Cite journal  | last1 = Stehbens | first1 = WE. | last2 = Zuccollo | first2 = JM. | title = Anitschkow myocytes or cardiac histiocytes in human hearts. | journal = Pathology | volume = 31 | issue = 2 | pages = 98-101 | month = May | year = 1999 | doi =  | PMID = 10399163 }}</ref>
 
====Images====
<gallery>
Image:Rheumatic_heart_disease_-_intermed_mag.jpg | RHD - intermed. mag. (WC/Nephron)
Image:Rheumatic_heart_disease_-_3_-_high_mag.jpg | RHD - high mag. (WC/Nephron)
Image:Rheumatic_heart_disease_-_3b_-_very_high_mag.jpg | RHD - very high mag. (WC/Nephron)
Image:Aschoff_Body_in_Rheumatic_Myocarditis.jpg | Aschoff body (WC/Uthman)
Image:Anitschkow_Myocytes_in_an_Aschoff_Body,_Rheumatic_Myocarditis.jpg | Anitschkow myocytes (WC/Uthman)
</gallery>
===IHC===
Features (Aschoff bodies & Anitschkow cells):<ref name=pmid3070554>{{Cite journal  | last1 = Love | first1 = GL. | last2 = Restrepo | first2 = C. | title = Aschoff bodies of rheumatic carditis are granulomatous lesions of histiocytic origin. | journal = Mod Pathol | volume = 1 | issue = 4 | pages = 256-61 | month = Jul | year = 1988 | doi =  | PMID = 3070554 }}</ref>
*S100 -ve.
*Muscle specific actin -ve.
*Desmin -ve.
*NF -ve.
*Vimentin +ve.
*CD45 +ve (weak).


==Infective endocarditis==
==Infective endocarditis==
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===Microscopic===
===Microscopic===
Features:<ref name=pmid3049284/><ref name=Ref_PCPBoD8_296>{{Ref PCPBoD8|296}}</ref>
Features:<ref name=pmid3049284/><ref name=Ref_PCPBoD8_296>{{Ref PCPBoD8|296}}</ref>
*Increased thickness of spongiosa layer.
*Increased thickness of spongiosa layer. ‡
*Thinning of the fibrosa layer.
*Thinning of the fibrosa layer.
*+/-Fibrin deposition - atrial aspect.
*+/-Fibrin deposition - atrial aspect.
Notes:
*‡ The Tthicking may be due to superimposed fibrosis, instead of spongiosa layer thickening.<ref name=pmid24316086>{{Cite journal  | last1 = Roberts | first1 = WC. | last2 = Vowels | first2 = TJ. | last3 = Ko | first3 = JM. | last4 = Hebeler | first4 = RF. | title = Gross and histological features of excised portions of posterior mitral leaflet in patients having operative repair of mitral valve prolapse and comments on the concept of missing (= ruptured) chordae tendineae. | journal = J Am Coll Cardiol | volume = 63 | issue = 16 | pages = 1667-74 | month = Apr | year = 2014 | doi = 10.1016/j.jacc.2013.11.017 | PMID = 24316086 }}</ref>


DDx:
DDx:
Michael
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