Difference between revisions of "Heart"

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Heart (view source)

Revision as of 05:33, 21 July 2016

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→‎Myocarditis: split out
(→‎Myocarditis: split out)
 
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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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====Younger adults (20-60 years)====
====Younger adults (20-60 years)====
Based on ''Ludwig'':<ref name=Ref_Ludwig569>Ludwig P.569.</ref>
Based on ''Ludwig'':<ref name=Ref_Ludwig569>{{Ref Ludwig|569}}</ref>
{| class="wikitable sortable"  
{| class="wikitable sortable"  
! Measure
! Measure
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| 10.6 (10.2-10.9)
| 10.6 (10.2-10.9)
|}
|}
Based on ''Ludwig'':<ref name=Ref_Ludwig569>Ludwig P.569.</ref>
Based on ''Ludwig'':<ref name=Ref_Ludwig569>{{Ref Ludwig|569}}</ref>
{| class="wikitable sortable"  
{| class="wikitable sortable"  
! Feature
! Feature
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|}
|}
====Older adults (>60 years)====
====Older adults (>60 years)====
Based on ''Ludwig'':<ref name=Ref_Ludwig569>Ludwig P.569.</ref>
Based on ''Ludwig'':<ref name=Ref_Ludwig569>{{Ref Ludwig|569}}</ref>
{| class="wikitable sortable"  
{| class="wikitable sortable"  
! Measure
! Measure
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| 10.5 (10.0-11.1)
| 10.5 (10.0-11.1)
|}
|}
Based on ''Ludwig'':<ref name=Ref_Ludwig569>Ludwig P.569.</ref>
Based on ''Ludwig'':<ref name=Ref_Ludwig569>{{Ref Ludwig|569}}</ref>
{| class="wikitable sortable"  
{| class="wikitable sortable"  
! Feature
! Feature
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==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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*[[Myocardial infarction]] (MI).
*[[Myocardial infarction]] (MI).
**Classically occurs at 2-3 days following a MI.<ref name=Ref_PCPBoD8_293>{{Ref PCPBoD8|293}}</ref>
**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:
*Retrosternal chest pain +/- with radiation down the arms.
*Nausea & vomiting.
*Diaphoresis.
 
Enzymatic tests:<ref>URL: [http://pro2services.com/Lectures/Fall/CardEnz/a6mienz.gif http://pro2services.com/Lectures/Fall/CardEnz/a6mienz.gif]. Accessed on: 27 April 2012.</ref>
*CK: peaks at day 1, resolves after 2-3 days.
*AST: peaks close to day 2, resolves after 4-5 days.
*LDH: peaks day 2, resolves after ~6 days.
 
Complications of MI:<ref name=Ref_PCPBoD8_293>{{Ref PCPBoD8|293}}</ref>
*Contractile dysfunction.
*Cardiac arrhythmia.
*Aneurysm formation, e.g. left ventricular aneurysm.
*Ventricular rupture:
**Ventricular free wall rupture.
**Ventricular septal rupture.
*[[Fibrinous pericarditis]].
**''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).
*Mural thrombosis.
*Extension of MI.
 
===Pathologic===
====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).
 
====Microscopic====
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:
*[http://path.upmc.edu/cases/case158/micro.html MI (upmc.edu)].
 
=====Contraction band necrosis=====
General:
*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>
*Thought to arise in reperfusion from hypercontraction.
 
Microscopic:
*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)].


==Coronary artery atherosclerosis==
==Coronary artery atherosclerosis==
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<math>percent\ stenosis = ( 1 - ( minimal\ diameter ) / ( poststenotic\ diameter ) ) x 100%.</math>
<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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*Hypertrophic [[cardiomyopathy]] (usually eccentric).
*Hypertrophic [[cardiomyopathy]] (usually eccentric).


<gallery>
Image: Heart_left_ventricular_hypertrophy_sa.jpg | Concentric LVH. (WC)
</gallery>
====Eccentric left ventricular hypertrophy====
====Eccentric left ventricular hypertrophy====
*[[Hypertrophic cardiomyopathy]], includes [[hypertrophic obstructive cardiomyopathy]] (HOCM).
*[[Hypertrophic cardiomyopathy]], includes [[hypertrophic obstructive cardiomyopathy]] (HOCM).
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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.
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{{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==
===Gross===
{{Main|Myocarditis}}
*Not apparent on gross.
 
Grossing:
*Requires 10 sections to exclude;<ref>KC. 1 October 2010.</ref> sections should include right ventricle and left ventricle.
**It is often missed with five.<ref name=pmid9559966>{{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==
Michael
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