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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**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:
Line 83: 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.
*An expanded spongiosa layer may be seen in the context of calcification.{{fact}}
 
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==
Line 149: Line 117:


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


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


==Infective endocarditis==
==Infective endocarditis==
:''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 ''HACEK 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>
 
Others:
*''Stenotrophomonas maltophilia'' (previously ''Pseudomonas maltophilia'') - Gram-negative bacillus,<ref>{{Cite journal  | last1 = Gautam | first1 = V. | last2 = Ray | first2 = P. | last3 = Vandamme | first3 = P. | last4 = Chatterjee | first4 = SS. | last5 = Das | first5 = A. | last6 = Sharma | first6 = K. | last7 = Rana | first7 = S. | last8 = Garg | first8 = RK. | last9 = Madhup | first9 = SK. | title = Identification of lysine positive non-fermenting gram negative bacilli (Stenotrophomonas maltophilia and Burkholderia cepacia complex). | journal = Indian J Med Microbiol | volume = 27 | issue = 2 | pages = 128-33 | month =  | year =  | doi = 10.4103/0255-0857.49425 | PMID = 19384035 }}</ref> rarely causes endocarditis,<ref name=pmid23021356>{{Cite journal  | last1 = Carrillo-Córdova | first1 = JR. | last2 = Amezcua-Guerra | first2 = LM. | title = Autoimmunity as a possible predisposing factor for Stenotrophomonas maltophilia endocarditis. | journal = Arch Cardiol Mex | volume = 82 | issue = 3 | pages = 204-7 | month =  | year =  | doi = 10.1016/j.acmx.2012.03.001 | PMID = 23021356 }}</ref> high mortality.<ref>{{Cite journal  | last1 = Fontenier | first1 = G. | last2 = Freschard | first2 = R. | last3 = Mourot | first3 = M. | title = Study of the corrosion in vitro and in vivo of magnesium amodes involved in an implantable bioelectric battery. | journal = Med Biol Eng | volume = 13 | issue = 5 | pages = 683-9 | month = Sep | year = 1975 | doi =  | PMID = 1186330 }}</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''.
 
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>
*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>
*Valve replacement.
*Valve repair.
*Valvectomy - for tricuspid valve.
 
===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 - subacute.
**+/-Neutrophils - typically abundant, may be rare in subacute.<ref>URL: [http://emedicine.medscape.com/article/216650-overview#a0104 http://emedicine.medscape.com/article/216650-overview#a0104]. Accessed on: 26 November 2013.</ref>
*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.
 
===Sign out===
<pre>
TRICUSPID VALVE, VALVECTOMY:
- FRAGMENTS OF VALVE WITH INFECTIVE ENDOCARDITIS -- ABUNDANT COCCI
  ORGANISMS IDENTIFIED.
- THIN RIM OF CARDIAC MUSCLE WITHOUT APPARENT PATHOLOGY.
</pre>
 
<pre>
MITRAL VALVE, VALVE REPLACEMENT:
- FRAGMENTS OF VALVE WITH INFECTIVE ENDOCARDITIS -- ABUNDANT COCCI
  ORGANISMS IDENTIFIED.
</pre>
 
====No microorganisms====
<pre>
AORTIC VALVE (BICUSPID), VALVE REPLACEMENT:
- BICUSPID VALVE WITH CALCIFIC AORTIC STENOSIS AND MILD ENDOCARDITIS.
- NO MICROORGANISMS APPARENT.
</pre>
 
====Micro====
The sections show valve tissue with an attached vegetation with abundant cocci organisms
and neutrophils. No calcification is apparent.
 
=====No microorganisms=====
The sections show valve tissue with marked calcification, scattered neutrophils and plasma cells. No microorganisms are identified with routine stains.


=Non-infective conditions=
=Non-infective conditions=
Line 382: Line 162:
===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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*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>
*[[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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===Sign out===
===Sign out===
<pre>
AORTIC VALVE, VALVE REPLACEMENT:
- BICUSPID VALVE WITH CALCIFIC AORTIC STENOSIS.
</pre>
====Cannot determine at gross====
<pre>
<pre>
AORTIC VALVE, REPLACEMENT:
AORTIC VALVE, REPLACEMENT:
- AORTIC VALVE WITH CALCIFIC STENOSIS, REPORTED BICUSPID AT SURGERY.
- BICUSPID AORTIC VALVE WITH CALCIFIC STENOSIS.
</pre>
</pre>


Michael
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