Difference between revisions of "Heart"

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Heart (view source)

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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.


Image: [http://en.wikipedia.org/wiki/File:CT_pericardial_effusion.jpg Pericardial effusion - CT scan (wikipedia.org)].
Image: [http://en.wikipedia.org/wiki/File:CT_pericardial_effusion.jpg Pericardial effusion - CT scan (wikipedia.org)].


==Myocardial infarction==
==Fibrinous pericarditis==
*Abbreviated ''MI''.
*[[AKA]] ''bread and butter pericarditis''.
*[[AKA]] ''myocardial infarct''.
*Post-[[myocardial infarction]] this is known as ''Dressler's syndrome''.<ref name=Ref_PCPBoD8_293>{{Ref PCPBoD8|293}}</ref>
===Clinical===
===General===
*Usually diagnosed clinically - with blood work (troponin, CK-MB) or EKG.
Etiology:
*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>
*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.
*[[Myocardial infarction]] (MI).
**Classically occurs at 2-3 days following a MI.<ref name=Ref_PCPBoD8_293>{{Ref PCPBoD8|293}}</ref>


Classic symptoms:
Note:
*Chest pain (with radiation down the arms).
*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>
*Nausea & vomiting.
*Diaphoresis.


Post-MI:
===Gross===
*''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).
*Pericardium with a shaggy rough appearance.
**Described as "buttered bread dropped-on-the-floor look".<ref name=pmid14991530>{{Cite journal | last1 = Cohen | first1 = MB. | last2 = Laennec | first2 = RT. | title = Cross your heart: Some historical comments about fibrinous pericarditis. | journal = Hum Pathol | volume = 35 | issue = 2 | pages = 147-9 | month = Feb | year = 2004 | doi = | PMID = 14991530 }}</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>
Image:
*CK: peaks at day 1, resolves after 2-3 days.
*[http://library.med.utah.edu/WebPath/CVHTML/CV047.html Bread and butter pericarditis (utah.edu)].
*AST: peaks close to day 2, resolves after 4-5 days.
===Microscopic===
*LDH: peaks day 2, resolves after ~6 days.
Features:
*Fibrin - pink amorphous material.


===Pathologic===
Note:
====Microscopic====
*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>
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
Images:
*4-12 hours - Coagulative [[necrosis]] & loss of cross striations, contraction bands, edema, hemorrhage, PMN infiltrate.
*[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>
*18-24 hours - Coagulative necrosis, pyknosis of nuclei, and marginal contraction bands.
<gallery>
*1-3 days - Loss of nuclei (karyolysis), loss of striations, abundant PMNs.
Image:Pericarditis_fibrinosa.jpg | Fibrinous pericarditis. (WC)
*3-7 days - Macrophage and mononuclear infiltration, fibrovascular response.
</gallery>
*10-21 days - Fibrovascular response, prominent granulation tissue.
*6 weeks - Fibrosis.


=====Contraction band necrosis=====
===Sign out===
General:
<pre>
*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>
Pericardium, Excision:
*Thought to arise in reperfusion from hypercontraction.
- Fibrinous pericardial heart disease.
</pre>


Microscopic:
==Myocardial infarction==
*Thick intensely eosinophilic staining bands (on H&E) ~ typically 4-5 micrometres wide
*Abbreviated ''MI''.
**Span the short axis of myocyte.  
*[[AKA]] ''myocardial infarct''.
**Can be thought of bunched-up striae.
{{Main|Myocardial infarction}}
 
==Coronary artery atherosclerosis==
{{Main|Atherosclerosis}}
*[[AKA]] ''coronary artery disease'', abbreviated ''CAD''.
*[[AKA]] ''atherosclerotic heart disease'', abbreviated ''ASHD''.
*[[AKA]] ''atherosclerotic coronary artery disease''.


Notes:
===General===
*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>
*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>


Images:
Clinical presentations:
*[http://commons.wikimedia.org/wiki/File:MI_with_contraction_bands_high_mag.jpg CBN - high mag. (WC)].
*Stable angina.
*[http://commons.wikimedia.org/wiki/File:MI_with_contraction_bands_very_high_mag.jpg CBN - very high mag. (WC)].
*Unstable angina.
*[[Myocardial infarction]].
*[[Sudden cardiac death]].


====Gross====
Note:
Sequence:<ref>[http://library.med.utah.edu/WebPath/TUTORIAL/MYOCARD/MYOCARD.html http://library.med.utah.edu/WebPath/TUTORIAL/MYOCARD/MYOCARD.html]</ref>
*''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''.
*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==
Treatment:
{{Main|Vascular disease#Atherosclerosis}}
*Medical management (blood pressure control (antihypertensives), cholesterol control (e.g. statins, exercise), [[diabetes mellitus|diabetes]] control, smoking cessation).
*Greater than 75% (diameter) stenosis - considered significant.<ref>Chamberlain. March 7, 2008.</ref>
*[[Coronary artery bypass surgery]] (CABG).
*Percutaneous coronary intervention (PCI).


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>
====Stenosis definition====
<math>percent stenosis = ( 1 - ( minimal\ diameter ) / ( poststenotic\ diameter ) ) x 100%.</math>
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>
With a bit of algebra 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 303: 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/>
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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>===
==Idiopathic granulomatous myocarditis==
*Eosinophilic - ''hypersensitivity myocarditis'' - most common.
*[[AKA]] ''giant cell myocarditis''<ref name=emedicine1612533>[http://emedicine.medscape.com/article/1612533-overview http://emedicine.medscape.com/article/1612533-overview]</ref> and less ambiguously ''idiopathic giant cell myocarditis''.
**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.
*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>
==Granulomatous myocarditis==
===General===
===General===
*AKA ''giant cell myocarditis''.<ref name=emedicine1612533>[http://emedicine.medscape.com/article/1612533-overview http://emedicine.medscape.com/article/1612533-overview]</ref>
*Unknown etiology.<ref name=upmc175>URL: [http://path.upmc.edu/cases/case175/dx.html http://path.upmc.edu/cases/case175/dx.html]. Accessed on: 8 January 2012.</ref>


===Histology===
===Microscopic===
Features:<ref name=pmid19660614/>
Features:<ref name=pmid19660614/>
*Granulomas.  
*[[Granuloma]]s.  
*Myocyte necrosis.
*Myocyte [[necrosis]].
*Eosinophils.
*Eosinophils.


Note:
Note:
*Eosinophils and myocyte necrosis differentiate this entity from ''cardiac sarcoidosis''.
*Eosinophils and myocyte necrosis differentiate this entity from ''[[cardiac sarcoidosis]]''.
 
**Granulomas in sarcoidosis are well formed and also involve the fat.<ref name=upmc175>URL: [http://path.upmc.edu/cases/case175/dx.html http://path.upmc.edu/cases/case175/dx.html]. Accessed on: 8 January 2012.</ref>
==Chagas disease==
*[[AKA]] ''American trypanosomiasis''.


===General===
DDx:
*Essentially a South American disease.
*Infectious granulomatous myocarditis, e.g. [[tuberculosis]].
*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>
*[[Rheumatic myocarditis]].
*Lymphocytic myocarditis.


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>
Images:
*Depends on phase of infection.
*[http://path.upmc.edu/cases/case175.html Giant cell myocarditis (upmc.edu)].
*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>
===Stains===
*Usually serology.
*[[Ziehl-Neelsen stain]] -ve.
*Thin blood smear.
*[[GMS stain]] -ve.


Tx:
==Chagas disease==
*Antimicrobials: benznidazole, nifurtimox.<ref name=PMH0002348/>
*[[AKA]] ''American trypanosomiasis''.
 
{{Main|Chagas disease}}
===Microscopic===
Features:
*Inflammation - main finding.<ref name=pmid17072450/>
*Intramuscular organisms (without an inflammatory response).
*Neuronal loss in atrial ganglia.<ref name=pmid17339569/>
 
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 405: Line 471:
===General===
===General===
*Amyloid in the heart.
*Amyloid in the heart.
*Rare.
*Common in the elderly - see ''[[senile systemic amyloidosis]]''.


===Histology===
===Microscopic===
Features (H&E stain):
Features ([[H&E stain]]):
*Acellular fluffy pink material.
*Acellular fluffy pink material.


Line 424: Line 490:
*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.


==Cocaine toxicity==
==Mesothelial/monocytic incidental cardiac excrescence==
*[[AKA]] ''Cardiac MICE''.
===General===
===General===
*Anatomical pathology findings at autopsy are uncommon (most common situation) or non-specific (atherosclerosis +/- acute thrombosis).<ref name=pmid1749414>{{cite journal |author=Virmani R |title=Cocaine-associated cardiovascular disease: clinical and pathological aspects |journal=NIDA Res. Monogr. |volume=108 |issue= |pages=220–9 |year=1991 |pmid=1749414 |doi= |url=}}</ref>
*Very rare.
*Toxicity mechanisms:  
*Benign.
**Direct effects of norepinephrine on myocytes
*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>
**Vasospasm leading to myocardial ischemia.
 
===Microscopic===
Features:<ref name=pmid12879644/>
*Mesothelial cells.


===Gross===
==Cocaine toxicity==
Features:<ref name=pmid1346509>{{cite journal |author=Kloner RA, Hale S, Alker K, Rezkalla S |title=The effects of acute and chronic cocaine use on the heart |journal=Circulation |volume=85 |issue=2 |pages=407–19 |year=1992 |month=February |pmid=1346509 |doi= |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=1346509}}</ref>
{{Main|Cocaine toxicity}}
*+/-Atherosclerosis out of keeping with age.
*+/-Large areas of confluent necrosis.
*+/-Fibrosis.


===Microscopic===
No distinctive pathologic findings. May appear older than one would expect, e.g. advanced [[atherosclerosis]] in a young man.
Features:<ref name=pmid1346509/>
*+/-Large areas of confluent necrosis.
*+/-Contraction band necrosis.
*+/-Fibrosis.
*+/-Myocarditis (usu. eosinophilic).


==Heart transplant pathology==
==Heart transplant pathology==
Michael
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