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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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| *Posterior (non-coronary cusp). | | *Posterior (non-coronary cusp). |
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| | Note: |
| | *The [[cut-up]] is described in ''[[grossing aortic valves]]''. |
| ===Microscopic=== | | ===Microscopic=== |
| Three layers (from proximal (ventricular side) to distal (valsalva side)):<ref name=Ref_PBoD558>{{Ref PBoD|558}}</ref> | | Three layers (from proximal (ventricular side) to distal (valsalva side)):<ref name=Ref_PBoD558>{{Ref PBoD|558}}</ref> |
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| **No fusion. | | **No fusion. |
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| | 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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| ==Calcific aortic stenosis== | | ==Calcific aortic stenosis== |
| *Abbreviated ''CAS''. | | *Abbreviated ''CAS''. |
| ===General===
| | {{Main|Calcific aortic stenosis}} |
| *Somewhat similar to [[atherosclerosis]]; however, considered a separate entity.<ref>{{cite journal |author=Otto CM |title=Calcific aortic stenosis--time to look more closely at the valve |journal=N. Engl. J. Med. |volume=359 |issue=13 |pages=1395-8 |year=2008 |month=September |pmid=18815402 |doi=10.1056/NEJMe0807001 |url=}}</ref>
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| *Mitral valve is usually normal.
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| *Most common cause of aortic stenosis.
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| DDx of aortic stenosis:
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| #Calcific aortic stenosis.
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| #[[Bicuspid aortic valve]] with calcific aortic stenosis.
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| #[[Rheumatic heart disease]].
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| Clinical (mnemonic ''SAD''):
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| *Syncope.
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| *Angina.
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| *Dyspnea (shortness of breath) - first symptom.
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| ===Microscopic===
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| Features:<ref name=Ref_PBoD590>{{Ref PBoD|590}}</ref>
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| *[[Dystrophic calcification]]<ref name=pmid12779138>{{Cite journal | last1 = Novaro | first1 = GM. | last2 = Griffin | first2 = BP. | title = Calcific aortic stenosis: another face of atherosclerosis? | journal = Cleve Clin J Med | volume = 70 | issue = 5 | pages = 471-7 | month = May | year = 2003 | doi = | PMID = 12779138 | URL = http://www.ccjm.org/cgi/pmidlookup?view=long&pmid=12779138 }}</ref> - affects the valsalva side of the valve.
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| **It affects the fibrosa.
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| *Primarily at the base of the valve, i.e. there is relative sparing the free edge.
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| Note:
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| *There should be no [[neutrophil]]s and no microorganisms.
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| *An expanded spongiosa layer may be seen in the context of calcification.{{fact}}
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| DDx:
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| *[[Infective endocarditis]] - inflammatory cells (esp. neutrophils), microorganisms (e.g. cocci).
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| *[[Bicuspid aortic valve]].
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| *[[Rheumatic heart disease]].
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| ===Sign out===
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| <pre>
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| AORTIC VALVE, VALVE REPLACEMENT:
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| - CALCIFIC AORTIC STENOSIS.
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| </pre>
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| ====Micro====
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| The sections show valve tissue with marked calcification of the fibrosa layer. No neutrophils are identified. No microorganisms are identified with routine stains.
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| ==Localized dystrophic heart valve amyloidosis== | | ==Localized dystrophic heart valve amyloidosis== |
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| ==Myxomatous degeneration== | | ==Myxomatous degeneration== |
| ===General===
| | {{Main|Myxomatous degeneration}} |
| *Usually affects the mitral valve.
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| *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>
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| *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>
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| ===Gross===
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| Features:<ref name=Ref_PBoD591>{{Ref PBoD|591}}</ref>
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| *No commissural fusion.
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| **Commissural fusion typical of rheumatic heart disease.
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| *Thickened.
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| *Rubbery consistency.
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| *Reactive/secondary changes.
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| **Fibrosis due to prolapse/abnormal contact of valve with other structures.
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| **Clots/organized thrombus - due to stasis.
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| ===Microscopic===
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| *Thinning of ''fibrosa layer''.
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| *Thickening of ''spongiosa layer'' with mucoid (myxomatous) material. (key feature).
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| *+/-Secondary changes (due to valvular dysfunction): thrombi, fibrosis.
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| ====Staining====
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| *Movat stain.
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| **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>
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| Interpretation of Movat stain:<ref name=penn_med/>
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| *Black = nuclei and elastic fibers.
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| *Yellow = collagen and reticular fibers.
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| *Blue = mucin, ground substance.
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| *Red (intense) = fibrin.
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| *Red = muscle.
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| Image:
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| <gallery>
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| Image:Myxomatous_aortic_valve.jpg | Myxomatous valve. [[Movat stain]]. (WC/Nephron)
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| </gallery>
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| =Infective conditions= | | =Infective conditions= |
| ==Rheumatic heart disease== | | ==Rheumatic heart disease== |
| :''Rheumatic fever'' redirects here.
| | {{Main|Rheumatic heart disease}} |
| *Abbreviated ''RHD''.
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| ===General===
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| *Classically leads to mitral valve stenosis.
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| **Rheumatic fever accounts for 99% of mitral stenosis.<ref name=Ref_PBoD594>{{Ref PBoD|594}}</ref>
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| ***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>
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| *Disease less frequent today - as streptococcal pharynigits is treated.
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| ===Gross===
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| *"Fish-mouth appearance".
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| **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.
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| **Image: [http://www.principia-eng.com/services/construction/IMG_3098.jpg Fish-mouth appearance - pipe (principia-eng.com)].
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| *Significant valvular thickening.
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| *Thickening and shortening of the cordae tendinae.
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| DDx:
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| *Thickening of the cordae tendinae due to micronodular [[cirrhosis]].<ref name=Ref_AoGP25>{{Ref AoGP|25}}</ref>
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| ====Images====
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| <gallery>
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| Image:Rheumatic_heart_disease,_gross_pathology_20G0013_lores.jpg | RHD - showing valvular thickening and thickening of the cordae tendinae. (WC)
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| Image:Aortic_stenosis_rheumatic,_gross_pathology_20G0014_lores.jpg | RHD - showing valvular thickening - aortic valve. (WC)
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| </gallery>
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| ===Microscopic===
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| Features:<ref name=Ref_PBoD593>{{Ref PBoD|593}}</ref>
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| *Caterpillar cells ([[AKA]] Anitschkow cells)
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| **Abundant eosinophilic cytoplasm.
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| **Moderately-poorly defined cell border.
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| **Well-defined central ovoid nucleus with a prominent wavy ribbon-like chromatin -- looks vaguely like a caterpillar with some imagination.
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| **Pathognomonic for rheumatic fever.
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| *Aschoff bodies - usually in the heart itself:
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| **Jumbled collagen, eosinophilic.
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| **Surrounded by lymphocytes (T cells) +/- plasma cells.
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| Notes:
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| *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>
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| **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>
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| ====Images====
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| <gallery>
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| Image:Rheumatic_heart_disease_-_intermed_mag.jpg | RHD - intermed. mag. (WC/Nephron)
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| Image:Rheumatic_heart_disease_-_3_-_high_mag.jpg | RHD - high mag. (WC/Nephron)
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| Image:Rheumatic_heart_disease_-_3b_-_very_high_mag.jpg | RHD - very high mag. (WC/Nephron)
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| Image:Aschoff_Body_in_Rheumatic_Myocarditis.jpg | Aschoff body (WC/Uthman)
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| Image:Anitschkow_Myocytes_in_an_Aschoff_Body,_Rheumatic_Myocarditis.jpg | Anitschkow myocytes (WC/Uthman)
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| </gallery>
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| ===IHC===
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| 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>
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| *S100 -ve.
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| *Muscle specific actin -ve.
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| *Desmin -ve.
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| *NF -ve.
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| *Vimentin +ve.
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| *CD45 +ve (weak).
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| ==Infective endocarditis== | | ==Infective endocarditis== |
| :''Bacterial endocarditis'' and ''subacute bacterial endocarditis'' redirect here.
| | {{Main|Infective endocarditis}} |
| *Abbreviated ''IE''.
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| ===General===
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| *Infection of the endocardium - often involves the valves (which are covered by endocardium).
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| *Before the time of antibiotics -- 100% fatal.
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| ====Organisms====
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| Most common organism overall:
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| *''Staphylococcus aureus''.<ref name=pmid12092480>{{Cite journal | last1 = Petti | first1 = CA. | last2 = Fowler | first2 = VG. | title = Staphylococcus aureus bacteremia and endocarditis. | journal = Infect Dis Clin North Am | volume = 16 | issue = 2 | pages = 413-35, x-xi | month = Jun | year = 2002 | doi = | PMID = 12092480 }}</ref>
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| Organisms associated with particular clinical scenarios:
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| *IV drug users / normal valves = ''Staphylococcus aureus''.<ref name=Ref_PCPBoD8_298>{{Ref PCPBoD8|298}}</ref>
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| *Previously damaged valve = ''Streptococcus viridans''.
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| *Prosthetic valves = ''Staphylococcus epidermidis''.<ref name=pmid19660339>{{Cite journal | last1 = Alonso-Valle | first1 = H. | last2 = Fariñas-Alvarez | first2 = C. | last3 = García-Palomo | first3 = JD. | last4 = Bernal | first4 = JM. | last5 = Martín-Durán | first5 = R. | last6 = Gutiérrez Díez | first6 = JF. | last7 = Revuelta | first7 = JM. | last8 = Fariñas | first8 = MC. | title = Clinical course and predictors of death in prosthetic valve endocarditis over a 20-year period. | journal = J Thorac Cardiovasc Surg | volume = 139 | issue = 4 | pages = 887-93 | month = Apr | year = 2010 | doi = 10.1016/j.jtcvs.2009.05.042 | PMID = 19660339 }}</ref>
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| Organisms that less commonly cause ''IE'' are known as the ''HASEK group'':<ref name=Ref_PCPBoD8_298>{{Ref PCPBoD8|298}}</ref>
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| *'''''H'''aemophilus'' (''Haemophilus parainfluenzae'', ''Haemophilus aphrophilus'', ''Haemophilus paraphrophilus'').
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| *'''''A'''ctinobacillus'' (''Actinobacillus actinomycetemcomitans'', ''Aggregatibacter aphrophilus'').
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| *'''''C'''ardiobacterium hominis.
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| *'''''E'''ikenella corrodens''. †
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| *'''''K'''ingella'' (''Kingella kingae'').
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| Notes:
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| * † ''Enterococci'' are not included in this list but are lumped with the ''HACEK organisms''.<ref name=Ref_PCPBoD8_298>{{Ref PCPBoD8|298}}</ref>
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| ====Clinical====
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| *Diagnosed (clinically) using the ''Duke criteria''.<ref>[http://www.medcalc.com/endocarditis.html http://www.medcalc.com/endocarditis.html]</ref><ref>{{cite journal |author=Durack DT, Lukes AS, Bright DK |title=New criteria for diagnosis of infective endocarditis: utilization of specific echocardiographic findings. Duke Endocarditis Service |journal=Am. J. Med. |volume=96 |issue=3 |pages=200-9 |year=1994 |month=March |pmid=8154507 |doi= |url=}}</ref>
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| **Positive blood cultures.
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| **Cardiac involvement - vegetation.
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| **+/-Febrile.
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| Subdivided into:
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| #Acute IE.
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| #*Classically due to ''Staphylococcus aureus''.
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| #Subacute IE.
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| #*Classically due to ''Streptococcus viridans''.
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| Treatment:<ref name=pmid23968767>{{Cite journal | last1 = Gaca | first1 = JG. | last2 = Sheng | first2 = S. | last3 = Daneshmand | first3 = M. | last4 = Rankin | first4 = JS. | last5 = Williams | first5 = ML. | last6 = O'Brien | first6 = SM. | last7 = Gammie | first7 = JS. | title = Current Outcomes for Tricuspid Valve Infective Endocarditis Surgery in North America. | journal = Ann Thorac Surg | volume = | issue = | pages = | month = Aug | year = 2013 | doi = 10.1016/j.athoracsur.2013.05.046 | PMID = 23968767 }}</ref>
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| *Usually medical management.<ref name=pmid16506645>{{Cite journal | last1 = Chait | first1 = RD. | last2 = Midwall | first2 = J. | title = Tricuspid valvectomy: long-term survival and surgical options. | journal = Clin Cardiol | volume = 29 | issue = 2 | pages = 83-4 | month = Feb | year = 2006 | doi = | PMID = 16506645 | URL = http://onlinelibrary.wiley.com/doi/10.1002/clc.4960290210/pdf }}</ref>
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| *Valve replacement.
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| *Valve repair.
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| *Valvectomy - for tricuspid valve.
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| ===Gross===
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| *Location - left-sided involvement (mitral, aortic) more common than right-sided involvement (pulmonic, tricuspid).
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| **This is reversed in IV drug users.<ref name=Ref_PCPBoD8_298>{{Ref PCPBoD8|298}}</ref><ref name=pmid16401952>{{Cite journal | last1 = Mathura | first1 = KC. | last2 = Thapa | first2 = N. | last3 = Rauniyar | first3 = A. | last4 = Magar | first4 = A. | last5 = Gurubacharya | first5 = DL. | last6 = Karki | first6 = DB. | title = Injection drug use and tricuspid valve endocarditis. | journal = Kathmandu Univ Med J (KUMJ) | volume = 3 | issue = 1 | pages = 84-6 | month = | year = | doi = | PMID = 16401952 }}</ref>
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| *+/-Valvular destruction.
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| **More common in acute IE.
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| *+/-Distant emboli, e.g. [[splenic infarct]].
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| **More common in acute IE.
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| *+/-Valvular vegetations.
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| **Irregular ball of loosely adherent tissue - dull, irregular surface.
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| **On the ventricular aspect in aortic valve IE.
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| **Larger in acute IE.
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| Image:
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| *[http://www.flickr.com/photos/11462589@N05/1126726482/ Infective endocarditis - aortic valve (flickr.com)].
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| ===Microscopic===
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| *Inflammatory infiltrate (key feature @ low power):
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| **+/-Plasma cells.
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| **+/-Neutrophils.
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| *Microorganisms - '''key feature''' (diagnostic).
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| **Hard to see (even at high power).
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| ===Stains===
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| *[[GMS stain]] (Gomori Methenamine-silver stain).
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| **Look for [[fungi]].
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| *[[Gram stain]].
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| **Look for bacteria.
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| ===Sign out===
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| <pre>
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| TRICUSPID VALVE, VALVECTOMY:
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| - FRAGMENTS OF VALVE WITH INFECTIVE ENDOCARDITIS -- ABUNDANT COCCI
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| ORGANISMS IDENTIFIED.
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| - THIN RIM OF CARDIAC MUSCLE WITHOUT APPARENT PATHOLOGY.
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| </pre>
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| =Non-infective conditions= | | =Non-infective conditions= |
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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. |
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| | 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> |
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| DDx: | | DDx: |
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| *Associated with ascending [[aortic aneurysm]]s - x10 risk of [[aortic dissection]] vs. normal population.<ref name=pmid18514024/> | | *Associated with ascending [[aortic aneurysm]]s - x10 risk of [[aortic dissection]] vs. normal population.<ref name=pmid18514024/> |
| *30% develop serious morbidity.<ref name=pmid18514024/> | | *30% develop serious morbidity.<ref name=pmid18514024/> |
| *Associated with early development of [[calcific aortic stenosis]]. | | *Associated with early development of [[calcific aortic stenosis]] - often in 50s. |
| | **Calcific disease in normal (tricuspid) aortic valves is typically seen in the 70s. |
| | *[[Coarctation of the aorta]].<ref name=pmid16129122>{{Cite journal | last1 = Braverman | first1 = AC. | last2 = Güven | first2 = H. | last3 = Beardslee | first3 = MA. | last4 = Makan | first4 = M. | last5 = Kates | first5 = AM. | last6 = Moon | first6 = MR. | title = The bicuspid aortic valve. | journal = Curr Probl Cardiol | volume = 30 | issue = 9 | pages = 470-522 | month = Sep | year = 2005 | doi = 10.1016/j.cpcardiol.2005.06.002 | PMID = 16129122 }}</ref> |
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| ===Gross=== | | ===Gross=== |
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| ===Sign out=== | | ===Sign out=== |
| <pre> | | <pre> |
| AORTIC VALVE, VALVE REPLACEMENT: | | AORTIC VALVE, REPLACEMENT: |
| - BICUSPID VALVE WITH CALCIFIC AORTIC STENOSIS. | | - BICUSPID AORTIC VALVE WITH CALCIFIC STENOSIS. |
| </pre> | | </pre> |
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| | ====Micro==== |
| | The sections show valve tissue with marked calcification of the fibrosa layer. No neutrophils are identified. No microorganisms are identified with routine stains. |
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| =Heart valve tumours= | | =Heart valve tumours= |