Difference between revisions of "Heart valves"

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Heart valves (view source)

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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).


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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Notes:
Notes:
*The loading of the ventricular aspect is tensile and the valsalva side compressive. Thus, it makes sense that the tissue on the ventricular aspect is good in tensile loading and the tissue on the valsalva side good in compression.  The elastic tissue can be thought of as [http://en.wikipedia.org/wiki/Rebar rebar]... the collagen as concrete.
*The loading of the ventricular aspect is tensile and the valsalva side compressive. Thus, it makes sense that the tissue on the ventricular aspect is good in tensile loading and the tissue on the valsalva side good in compression.  The elastic tissue can be thought of as [http://en.wikipedia.org/wiki/Rebar rebar]... the collagen as concrete.
Image:
*[http://www.e-heart.org/Photos/01_Cardiac_Structure_Photos/%C2%A9Mitral%20Valve%20Normal%20Chordae%20Tendinea%20640%20x%20419.jpg Normal mitral valve (e-heart.org)].<ref>URL: [http://www.e-heart.org/pages/01_cardiac_structure/01_Cardiac_Structure_MV_003.htm http://www.e-heart.org/pages/01_cardiac_structure/01_Cardiac_Structure_MV_003.htm]. Accessed on: 20 December 2012.</ref>


==Mitral valve==
==Mitral valve==
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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:
#Atrialis.
#Atrialis.<ref name=pmid6821906 >{{Cite journal  | last1 = Chesler | first1 = E. | last2 = King | first2 = RA. | last3 = Edwards | first3 = JE. | title = The myxomatous mitral valve and sudden death. | journal = Circulation | volume = 67 | issue = 3 | pages = 632-9 | month = Mar | year = 1983 | doi =  | PMID = 6821906 | URL = http://circ.ahajournals.org/content/67/3/632.full.pdf }}</ref>
#Spongiosa.
#Spongiosa.
#Fibrosa.
#Fibrosa.
Line 80: Line 88:
==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>
*Mitral valve is usually normal.
*Most common cause of aortic stenosis.
 
DDx of aortic stenosis:
#Calcific aortic stenosis.
#[[Bicuspid aortic valve]] with calcific aortic stenosis.
#[[Rheumatic heart disease]].
 
Clinical (mnemonic ''SAD''):
*Syncope.
*Angina.
*Dyspnea (shortness of breath) - first symptom.
 
===Microscopic===
Features:<ref name=Ref_PBoD590>{{Ref PBoD|590}}</ref>
*[[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.
**It affects the fibrosa.
*Primarily at the base of the valve, i.e. there is relative sparing the free edge.
 
Note:
*There should be no [[neutrophil]]s and no microorganisms.
 
DDx:
*[[Infective endocarditis]] - inflammatory cells (esp. neutrophils), microorganisms (e.g. cocci).
*[[Bicuspid aortic valve]].
*[[Rheumatic heart disease]].
 
===Sign out===
<pre>
AORTIC VALVE, VALVE REPLACEMENT:
- CALCIFIC AORTIC STENOSIS.
</pre>
 
====Micro====
The sections show valve tissue with marked calcification of the fibrosa layer. No neutrophils are identified. No microorganisms are identified with routine stains.


==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.
*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:
*[http://commons.wikimedia.org/wiki/File:Myxomatous_aortic_valve.jpg Myxomatous valve (WC)].


=Infective conditions=
=Infective conditions=
==Rheumatic heart disease==
==Rheumatic heart disease==
*Abbreviated ''RHD''.
{{Main|Rheumatic heart disease}}
===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:
** [http://en.wikipedia.org/wiki/File:Rheumatic_heart_disease,_gross_pathology_20G0013_lores.jpg Rheumatic heart disease at autopsy - showing valvular thickening and thickening of the cordae tendinae (WP)].
**[http://commons.wikimedia.org/wiki/File:Aortic_stenosis_rheumatic,_gross_pathology_20G0014_lores.jpg Rheumatic heart disease - showing valvular thickening - aortic valve (WP)].
 
===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:
*[[WC]]:
**[http://commons.wikimedia.org/wiki/File:Rheumatic_heart_disease_-_intermed_mag.jpg RHD - intermed. mag. (WC)].
**[http://commons.wikimedia.org/wiki/File:Rheumatic_heart_disease_-_3_-_high_mag.jpg RHD - high mag. (WC)].
**[http://commons.wikimedia.org/wiki/File:Rheumatic_heart_disease_-_3b_-_very_high_mag.jpg RHD - very high mag. (WC)].
*[[WC]] - other:
**[http://commons.wikimedia.org/wiki/File:Aschoff_Body_in_Rheumatic_Myocarditis.jpg Aschoff body (WC)].
**[http://en.wikipedia.org/wiki/File:Anitschkow_Myocytes_in_an_Aschoff_Body,_Rheumatic_Myocarditis.jpg Anitschkow myocytes (WC)].
 
===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==
:''Bacterial endocarditis'' and ''subacute bacterial endocarditis'' redirect here.
{{Main|Infective endocarditis}}
*Abbreviated ''IE''.
===General===
*Infection of the endocardium - often involves the valves (which are covered by endocardium).
*Before the time of antibiotics -- 100% fatal.
 
====Organisms====
Most common organism overall:
*''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>
 
Organisms associated with particular clinical scenarios:
*IV drug users / normal valves = ''Staphylococcus aureus''.<ref name=Ref_PCPBoD8_298>{{Ref PCPBoD8|298}}</ref>
*Previously damaged valve = ''Streptococcus viridans''.
*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>
 
Organisms that less commonly cause ''IE'' are known as the ''HASEK group'':<ref name=Ref_PCPBoD8_298>{{Ref PCPBoD8|298}}</ref>
*'''''H'''aemophilus'' (''Haemophilus parainfluenzae'', ''Haemophilus aphrophilus'', ''Haemophilus paraphrophilus'').
*'''''A'''ctinobacillus'' (''Actinobacillus actinomycetemcomitans'', ''Aggregatibacter aphrophilus'').
*'''''C'''ardiobacterium hominis.
*'''''E'''ikenella corrodens''. †
*'''''K'''ingella'' (''Kingella kingae'').
 
Notes:
* † ''Enterococci'' are not included in this list but are lumped with the ''HACEK organisms''.<ref name=Ref_PCPBoD8_298>{{Ref PCPBoD8|298}}</ref>
 
====Clinical====
*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>
**Positive blood cultures.
**Cardiac involvement - vegetation.
**+/-Febrile.
 
Subdivided into:
#Acute IE.
#*Classically due to ''Staphylococcus aureus''.
#Subacute IE.
#*Classically due to ''Streptococcus viridans''.
 
===Gross===
*Location - left-sided involvement (mitral, aortic) more common than right-sided involvement (pulmonic, tricuspid).
**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>
*+/-Valvular destruction.
**More common in acute IE.
*+/-Distant emboli, e.g. [[splenic infarct]].
**More common in acute IE.
*+/-Valvular vegetations.
**Irregular ball of loosely adherent tissue - dull, irregular surface.
**On the ventricular aspect in aortic valve IE.
**Larger in acute IE.
 
Image:
*[http://www.flickr.com/photos/11462589@N05/1126726482/ Infective endocarditis - aortic valve (flickr.com)].
 
===Microscopic===
*Inflammatory infiltrate (key feature @ low power):
**+/-Plasma cells.
**+/-Neutrophils.
*Microorganisms - '''key feature''' (diagnostic).
**Hard to see (even at high power).
 
===Stains===
*[[GMS stain]] (Gomori Methenamine-silver stain).
**Look for [[fungi]].
*[[Gram stain]].
**Look for bacteria.


=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.
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:
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===Gross===
===Gross===
*Vegetations anywhere on the valve surface<ref name=pmid19946116>{{Cite journal  | last1 = Plastiras | first1 = SC. | last2 = Pamboucas | first2 = CA. | last3 = Tektonidou | first3 = M. | last4 = Toumanidis | first4 = ST. | title = Real-time three-dimensional echocardiography in evaluating Libman-Sacks vegetations. | journal = Eur J Echocardiogr | volume = 11 | issue = 2 | pages = 184-5 | month = Mar | year = 2010 | doi = 10.1093/ejechocard/jep172 | PMID = 19946116 }}</ref> - often seen on both sides (flow surface & non-flow surface).<ref>{{Ref PBoD8|567}}</ref>  
*Vegetations anywhere on the valve surface<ref name=pmid19946116>{{Cite journal  | last1 = Plastiras | first1 = SC. | last2 = Pamboucas | first2 = CA. | last3 = Tektonidou | first3 = M. | last4 = Toumanidis | first4 = ST. | title = Real-time three-dimensional echocardiography in evaluating Libman-Sacks vegetations. | journal = Eur J Echocardiogr | volume = 11 | issue = 2 | pages = 184-5 | month = Mar | year = 2010 | doi = 10.1093/ejechocard/jep172 | PMID = 19946116 }}</ref> - often seen on both sides (flow surface & non-flow surface).<ref>{{Ref PBoD8|567}}</ref>  
*Flat, pale brown/tan, usually small.<ref>URL: [http://library.med.utah.edu/WebPath/CVHTML/CV122.html http://library.med.utah.edu/WebPath/CVHTML/CV122.html]. Accessed on: 6 March 2013.</ref>


Image:
Images:
*[http://media.photobucket.com/image/nonbacterial%20thrombotic%20endocarditis/cat_at_uw/Osler%20-%20Cardiac/libman-sacks.jpg?t=1269402236 Libman-Sacks endocarditis (photobucket.com)].
*[http://media.photobucket.com/image/nonbacterial%20thrombotic%20endocarditis/cat_at_uw/Osler%20-%20Cardiac/libman-sacks.jpg?t=1269402236 Libman-Sacks endocarditis (photobucket.com)].
*[http://library.med.utah.edu/WebPath/CVHTML/CV122.html Libman-Sacks endocarditis (utah.edu)].


===Microscopic===
===Microscopic===
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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>


===Gross===
===Gross===
Line 417: Line 248:
*"No evidence of fusion."<ref name=Ref_AoGP>{{Ref AoGP|2}}</ref>
*"No evidence of fusion."<ref name=Ref_AoGP>{{Ref AoGP|2}}</ref>
*Elastic fibres through-out (not interrupted by fibrous tissue). (???)
*Elastic fibres through-out (not interrupted by fibrous tissue). (???)
Note:
*The clinical impression and gross pathologic impression of bicuspid valve should concur.


DDx:
DDx:
*Senile [[calcific aortic stenosis]].
*Senile [[calcific aortic stenosis]] with fusion of leaflets.
 
===Sign out===
<pre>
AORTIC VALVE, REPLACEMENT:
- BICUSPID AORTIC VALVE WITH CALCIFIC STENOSIS.
</pre>
 
====Micro====
The sections show valve tissue with marked calcification of the fibrosa layer. No neutrophils are identified. No microorganisms are identified with routine stains.


=Heart valve tumours=
=Heart valve tumours=
{{main|Cardiac tumours}}
{{main|Cardiac tumours}}
[[Papillary fibroelastoma]]s are the most common tumour of the valve.
[[Papillary fibroelastoma]]s are the most common tumour of the valve.
=Other=
==Subvalvular membrane==
:''Subvalvular aortic membrane'' redirects here.
===General===
*Rare.
*May lead to [[sudden natural death]].<ref name=pmid16501359>{{Cite journal  | last1 = Turan | first1 = AA. | last2 = Guven | first2 = T. | last3 = Karayel | first3 = F. | last4 = Pakis | first4 = I. | last5 = Gurpinar | first5 = K. | last6 = Ozaslan | first6 = A. | title = Subvalvular aortic stenosis as a cause of sudden death: two case reports. | journal = Am J Forensic Med Pathol | volume = 27 | issue = 1 | pages = 90-2 | month = Mar | year = 2006 | doi = 10.1097/01.paf.0000203301.96511.f7 | PMID = 16501359 }}</ref>
Clinical:
*Symptoms of aortic stenosis.
*No ejection sound (as in aortic valvular stenosis).<ref name=pmid5817839>{{Cite journal  | last1 = van der Schaar | first1 = PJ. | last2 = Roos | first2 = JP. | last3 = Rohmer | first3 = J. | title = Subvalvular membranous aortic stenosis. Results of surgical therapy. | journal = Thorax | volume = 24 | issue = 3 | pages = 276-82 | month = May | year = 1969 | doi =  | PMID = 5817839 }}</ref>
===Microscopic===
Features:
*Fibrous tissue.<ref name=pmid16501359/><ref name=pmid21881724>{{Cite journal  | last1 = Dearani | first1 = JA. | last2 = Croti | first2 = UA. | last3 = Price | first3 = TN. | last4 = Braile | first4 = DM. | title = Subvalvular aortic membrane resection. | journal = Rev Bras Cir Cardiovasc | volume = 26 | issue = 1 | pages = 135-6 | month =  | year =  | doi =  | PMID = 21881724 }}</ref>
Note:
*Similar to valvular tissue.
===Stains===
*[[Movat stain]].
===Sign out===
<pre>
SUBVALVULAR MEMBRANE, AORTA, EXCISION:
- BENIGN PAUCICELLULAR FIBROUS TISSUE CONSISTENT WITH SUBVALVULAR MEMBRANE.
</pre>


=See also=
=See also=
Michael
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