48,706
edits
(→Non-infective conditions: +gross) |
(→Rheumatic heart disease: split out) |
||
(62 intermediate revisions by the same user not shown) | |||
Line 1: | Line 1: | ||
[[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. | ||
Line 53: | Line 54: | ||
*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> | ||
Line 64: | Line 67: | ||
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== | ||
Line 71: | Line 77: | ||
**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 79: | Line 87: | ||
=Degenerative conditions= | =Degenerative conditions= | ||
==Calcific aortic stenosis== | ==Calcific aortic stenosis== | ||
*Abbreviated ''CAS''. | |||
{{Main|Calcific aortic stenosis}} | |||
* | |||
==Localized dystrophic heart valve amyloidosis== | ==Localized dystrophic heart valve amyloidosis== | ||
Line 127: | Line 117: | ||
==Myxomatous degeneration== | ==Myxomatous degeneration== | ||
{{Main|Myxomatous degeneration}} | |||
=Infective conditions= | =Infective conditions= | ||
==Rheumatic heart disease== | ==Rheumatic heart disease== | ||
{{Main|Rheumatic heart disease}} | |||
=== | ==Infective endocarditis== | ||
{{Main|Infective endocarditis}} | |||
=Non-infective conditions= | |||
==Mitral valve prolapse== | |||
*Abbreviated ''MVP''. | |||
*[[AKA]] ''floppy mitral valve''.<ref name=pmid11433820>{{Cite journal | last1 = Boudoulas | first1 = H. | last2 = Wooley | first2 = CF. | title = Floppy mitral valve/mitral valve prolapse/mitral valvular regurgitation: effects on the circulation. | journal = J Cardiol | volume = 37 Suppl 1 | issue = | pages = 15-20 | month = | year = 2001 | doi = | PMID = 11433820 }}</ref> | |||
=== | |||
* | |||
* | |||
===General=== | ===General=== | ||
* | *Classically young women. | ||
* | *Afflicts ~ 3% of population in the USA.<ref name=Ref_PCPBoD8_296>{{Ref PCPBoD8|296}}</ref> | ||
Clinical: | |||
*Pansystolic murmur. | |||
* | *+/-Left ventricular hypertrophy - secondary to MVP. | ||
Complications:<ref name=Ref_PCPBoD8_296>{{Ref PCPBoD8|296}}</ref> | |||
*[[Infective endocarditis]]. | |||
* | *Congestive heart failure. | ||
* | *[[Sudden cardiac death]].<ref name=pmid21133272>{{Cite journal | last1 = Franchitto | first1 = N. | last2 = Bounes | first2 = V. | last3 = Telmon | first3 = N. | last4 = Rougé | first4 = D. | title = Mitral valve prolapse and out-of-hospital sudden death: a case report and literature review. | journal = Med Sci Law | volume = 50 | issue = 3 | pages = 164-7 | month = Jul | year = 2010 | doi = | PMID = 21133272 }}</ref> | ||
*Thromboembolism. | |||
===Gross=== | |||
* | Features - any of the following:<ref name=pmid3049284>{{Cite journal | last1 = Virmani | first1 = R. | last2 = Atkinson | first2 = JB. | last3 = Forman | first3 = MB. | title = The pathology of mitral valve prolapse. | journal = Herz | volume = 13 | issue = 4 | pages = 215-26 | month = Aug | year = 1988 | doi = | PMID = 3049284 }}</ref> | ||
# "Intrachordal hooding" = ballooning/bulging of leaflet between chordal attachments. | |||
# Hooding or doming of the body of the leftlet into the left atrium. | |||
* | #* Extreme concavity of the valve when seen from the left ventricle. | ||
* | # Elongated leaflets/large valve area. | ||
# Dilated valve annulus. | |||
*Thickening of the valve. | |||
*+/-Left ventricular hypertrophy. | |||
Note - location: | |||
*Posterior leaflet pathology more common than anterior leaflet pathology.<ref name=pmid3049284/> | |||
Image: | Image: | ||
*[http://www. | *[http://www.e-heart.org/Pages/06_Valvular_Disease/06_Valvular_Disease_MV_Acquired_MVP_001.htm MVP - intrachordal hooding (e-heart.org)]. | ||
===Microscopic=== | ===Microscopic=== | ||
Features:<ref name=pmid3049284/><ref name=Ref_PCPBoD8_296>{{Ref PCPBoD8|296}}</ref> | |||
** | *Increased thickness of spongiosa layer. ‡ | ||
*Thinning of the fibrosa layer. | |||
*+/-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: | |||
*[[ | *[[Myxomatous degeneration]].{{fact}} | ||
==Nonbacterial thrombotic endocarditis== | ==Nonbacterial thrombotic endocarditis== | ||
*Abbreviated ''NBTE''. | *Abbreviated ''NBTE''. | ||
Line 296: | Line 193: | ||
==Libman-Sacks endocarditis== | ==Libman-Sacks endocarditis== | ||
===General=== | ===General=== | ||
*Associated with [[systemic lupus erythematosus]] | *Associated with [[systemic lupus erythematosus]]. | ||
**Seen in approximately in 1/10 SLE cases by echocardiography.<ref name=pmid19946116/> | |||
*Affects the mitral and aortic valves.<ref name=pmid19089657>{{Cite journal | last1 = Lee | first1 = JL. | last2 = Naguwa | first2 = SM. | last3 = Cheema | first3 = GS. | last4 = Gershwin | first4 = ME. | title = Revisiting Libman-Sacks endocarditis: a historical review and update. | journal = Clin Rev Allergy Immunol | volume = 36 | issue = 2-3 | pages = 126-30 | month = Jun | year = 2009 | doi = 10.1007/s12016-008-8113-y | PMID = 19089657 }}</ref> | |||
**Mitral valve most commonly affected.<ref name=pmid8608627>{{Cite journal | last1 = Hojnik | first1 = M. | last2 = George | first2 = J. | last3 = Ziporen | first3 = L. | last4 = Shoenfeld | first4 = Y. | title = Heart valve involvement (Libman-Sacks endocarditis) in the antiphospholipid syndrome. | journal = Circulation | volume = 93 | issue = 8 | pages = 1579-87 | month = Apr | year = 1996 | doi = | PMID = 8608627 }}</ref> | |||
*It has been suggested that it may be a manifestation of APLA syndrome.<ref name=pmid19089657/><ref name=pmid8608627/> | |||
Clinical: | |||
*Usually regurgitation. | |||
===Gross=== | ===Gross=== | ||
*Vegetations anywhere on the valve surface | *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> | |||
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=== | ||
Features: | Features:{{fact}} | ||
* | *Fibrin. | ||
*No microorganisms. | |||
*No inflammation. | |||
==Biscupid aortic valve== | ==Biscupid aortic valve== | ||
Line 321: | Line 229: | ||
*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 338: | 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: | |||
*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= |
edits