Conversion prepared and presented by

Marc Imhotep Cray, M.D.

Basic Medical Sciences Teacher

A Basic PowerPoint conversion :

For study, sharing and download as a tool in preparation to

sit for the USMLE Step 1

Source of Images

Webpath- University of Utah

Hypermedia Image Source Tables included

Webpath Hypermedia Source Tables

2

http://library.med.utah.edu/WebPath/CVHTML/CVIDX.html

Purpose The purpose of this PowerPoint conversion is

1. To enable the learner to bring Webpath Cardiovascular

Pathology image plates to their desktop for offline study

2. To contribute to mobile device viewing diversity

3. It serves as a part of the IVMS ANS and Cardiovascular

Pharmacology Sequenced Course Demonstration

Open Demo

Normal Heart

3

Normal Heart

4

•Normal heart, gross

•Normal aortic valve, gross

•Normal tricuspid valve, gross

•Normal coronary artery, microscopic

•Normal myocardium, medium power microscopic

Normal heart, gross

• This is the external

appearance of a normal

heart.The epicardial surface

is smooth and glistening.

• The amount of epicardial fat

is usual.The left anterior

descending coronary artery

extends down from the aortic

root to the apex

5

Normal tricuspid valve, gross

• This is the tricuspid

valve. The leaflets and

thin and delicate.

• Just like the mitral valve,

the leaflets have thin

chordae tendineae that

attach the leaflet margins

to the papillary muscles

of the ventricular wall

below

6

Normal coronary artery,

microscopic

• This is a normal

coronary artery.

• The lumen is large,

without any narrowing

by atheromatous

plaque. The muscular

arterial wall is of

normal proportion

7

Normal myocardium, medium

power microscopic

• This is the normal

appearance of

myocardial fibers in

longitudinal section.

• Note the central

nuclei and the

syncytial arrangement

of the fibers, some of

which have pale pink

intercalated disks 8

Atherosclerotic

Cardiovascular

Disease

9

Atherosclerotic

Cardiovascular Disease (1)

10

•Coronary artery with atherosclerotic narrowing, microscopic

•Coronary artery with recanalized thrombosis, microscopic

•Coronary artery with calcific atherosclerosis, microscopic

•Coronary artery atherosclerosis, occlusive, microscopic

•Coronary artery thrombosis, recent, microscopic

•Atheromatous plaque, high power, microscopic

•Aorta with rare lipid streaks, gross

•Aorta with lipid streaks, gross

•Aortas demonstrating various degrees of atherosclerosis, gross

Coronary artery with

atherosclerotic narrowing,

microscopic • The coronary artery

shown here has

narrowing of the lumen

due to build up of

atherosclerotic plaque.

• Severe narrowing can

lead to angina,

ischemia, and infarction

11

Coronary artery with recanalized

thrombosis, microscopic

• This section of

coronary artery

demonstrates remote

thrombosis with

recanalization to leave

only two small, narrow

channels

12

Coronary artery with calcific

atherosclerosis, microscopic • There is a severe degree of

narrowing in this coronary artery.

• It is "complex" in that there is a large area of calcification on the lower right, which appears bluish on this H&E stain.

• Complex atheroma have calcification, thrombosis, or hemorrhage. Such calcification would make coronary angioplasty difficult

13

Aortas demonstrating various

degrees of atherosclerosis, gross

• These three aortas demonstrate mild, moderate, and severe atherosclerosis from bottom to top.

• At the bottom, the mild atherosclerosis shows only scattered lipid plaques.

• The aorta in the middle shows many more larger plaques. The severe atherosclerosis in the aorta at the top shows extensive ulceration in the plaques

14

Aorta, atherosclerotic

aneurysm, gross

• Here is an example of an atherosclerotic aneurysm of the aorta in which a large "bulge" appears just above the aortic bifurcation.

• Such aneurysms are prone to rupture when they reach about 6 to 7 cm in size.

• They may be felt on physical examination as a pulsatile mass in the abdomen.Most such aneurysms are conveniently located below the renal arteries so that surgical resection can be performed with placement of a dacron graft

15

16

•Aorta, atherosclerotic aneurysm, gross [CT]

•Aorta, atheroma, low power, microscopic

•Aorta, atheroma, high power, microscopic

•Aorta, ulcerative atherosclerosis with mural thrombosis, gross

•Cholesterol emboli in kidney, medium power microscopic

•Coronary artery, mild atherosclerosis, gross

•Coronary artery, severe atherosclerosis, gross

•Coronary artery, hemorrhage into plaque, gross

•Coronary artery, occlusive atherosclerosis, gross

•Heart and LAD coronary artery with recent thrombus, gross

•Coronary artery with recent thrombus, longitudinal section, gross

•Coronary artery with recent thrombus, cross section, gross

Atherosclerotic

Cardiovascular Disease (2)

CT scan with contrast

• This abdominal high speed CT scan with contrast demonstrates an abdominal aortic aneurysm approximately 6 cm in diameter.

• At this size, there is increased risk for rupture

17

Coronary artery, mild

atherosclerosis, gross

• A coronary artery has been opened longitudinally.

• The coronary extends from left to right across the middle of the picture and is surrounded by epicardial fat. Increased epicardial fat correlates with increasing total body fat.

• There is a lot of fat here, suggesting one risk factor for atherosclerosis.

• This coronary shows only mild atherosclerosis, with only an occasional yellow-tan lipid plaque and no narrowing

18

Coronary artery, severe

atherosclerosis, gross

• This is the left coronary artery from the aortic root on the left.

• Extending across the middle of the picture to

the right is the anterior descending branch.

• This coronary shows severe atherosclerosis with extensive calcification. At the far right, there is an area of significant narrowing

19

Coronary artery, hemorrhage

into plaque, gross

• This is coronary

atherosclerosis with the

complication of

hemorrhage into

atheromatous plaque,

seen here in the center

of the photograph.

• Such hemorrhage

acutely may narrow the

arterial lumen 20

Heart and LAD coronary artery

with recent thrombus, gross

• The anterior surface of the heart demonstrates an opened left anterior descending coronary artery.

• Within the lumen of the coronary can be seen a dark red recent coronary thrombosis.

• The dull red color to the myocardium as seen below the glistening epicardium to the lower right of the thrombus is consistent with underlying myocardial infarction

21

Myocardial Infarction

22

Myocardial Infarction

23

•Heart, left ventricle, acute myocardial infarction, gross

•Heart, left ventricle and septum, myocardial infarction, gross

•Myocardium, contraction band necrosis, microscopic

•Myocardium, acute myocardial infarction, 1 to 2 days, microscopic

•Myocardium, acute myocardial infarction, 1 to 2 days, microscopic

•Myocardium, acute myocardial infarction, 3 to 4 days, microscopic

•Myocardium, intermediate myocardial infarction, 1 to 2 weeks, microscopic

•Heart, transmural myocardial infarction with rupture and hemopericardium,

gross

•Heart, transmural myocardial infarction with rupture, gross

•Heart, remote myocardial infarction, medium power microscopic

•Heart, remote myocardial infarction, low power microscopic

•Heart, remote myocardial infarction, gross

•Heart, left ventricular aneurysm, gross

•Heart, left ventricular aneurysm, gross

•Heart, coronary artery bypass graft, gross

Heart, left ventricle, acute

myocardial infarction, gross

• This is the left ventricular wall which has been sectioned lengthwise to reveal a large recent myocardial infarction.

• The center of the infarct contains necrotic muscle that appears yellow-tan.

• Surrounding this is a zone of red hyperemia. Remaining viable myocardium is reddish- brown

24

Heart, left ventricle and septum,

myocardial infarction, gross

• This cross section through the heart demonstrates the left ventricle on the left.

• Extending from the anterior portion and into the septum is a large recent myocardial infarction.

• The center is tan with surrounding hyperemia.

• The infarction is "transmural" in that it extends through the full thickness of the wall

25

Heart, transmural myocardial infarction

with rupture and hemopericardium,

gross

• One complication of a transmural myocardial infarction is rupture of the myocardium.

• This is most likely to occur in the first week between 3 to 5 days following the initial event, when the myocardium is the softest.

• The white arrow marks the point of rupture in this anterior-inferior myocardial infarction of the left ventricular free wall and septum.

• Note the dark red blood clot forming the hemopericardium. The hemopericardium can lead to tamponade

26

Heart, left ventricular aneurysm,

gross

• A cross section through the heart reveals a ventricular aneurysm with a very thin wall at the arrow.

• Note how the aneurysm bulges out. The stasis in this aneurysm allows mural thrombus, which is present here, to form within the aneurysm

27

Arterial Dissection

28

Arterial Dissection

29

•Aorta, dissection with tear in arch, gross

•Heart, dissection with tear through media, low power microscopic

•Hemopericardium with cardiac tamponade, gross

•Aorta, dissection, gross

•Aorta, dissection, microscopic

•Carotid artery, dissection with compression, gross

•Aorta, dissection, microscopic

•Aorta, dissection, Marfan's syndrome, gross

•Floppy mitral valve with prolapse, Marfan's syndrome, gross

•Floppy mitral valve with prolapse, Marfan's syndrome, gross

•Aorta, cystic medial necrosis, Marfan's syndrome, Mucin stain, microscopic

•Arachnodactyly, Marfan's syndrome, gross

Aorta, dissection with tear in

arch, gross

• There is a tear (arrow) located 7 cm above the aortic valve and proximal to the great vessels in this aorta with marked atherosclerosis.

• This is an aortic dissection

30

Hemopericardium with cardiac

tamponade, gross

• An aortic dissection may

lead to hemopericardium

when blood dissects

through the media

proximally.

• Such a massive amount of

hemorrhage can lead to

cardiac tamponade

31

Aorta, dissection, gross

• This aorta has been opened longitudinally to reveal an area of fairly limited dissection that is organizing.

• The red-brown thrombus can be seen in on both sides of the section as it extends around the aorta. The intimal tear would have been at the left.

• This creates a "double lumen" to the aorta.

• This aorta shows severe atherosclerosis which, along with cystic medial necrosis and hypertension, is a risk factor for dissection

32

Aorta, dissection, microscopic

• Here, the dissection went into the muscular wall. In any case, an aortic dissection is an extreme emergency and can lead to death in a matter of minutes.

• The blood can dissect up or down the aorta.

• Blood dissecting up around the great vessels can close off the carotids.

• Blood can dissect down to the coronaries and shut them off

33

Carotid artery, dissection with

compression, gross

• The right carotid artery is compressed by blood dissecting upward from a tear with aortic dissection.

• Blood may also dissect to coronary arteries.

• Thus patients with aortic dissection may have symptoms of severe chest pain (for distal dissection) or may present with findings that suggest a stroke (with carotid dissection) or myocardial ischemia (with coronary dissection).

34

Infective Endocarditis

35

36

Non-infective Endocarditis

•Non-bacterial thrombotic endocarditis, gross

•Non-bacterial thrombotic endocarditis, gross

•Non-bacterial thrombotic endocarditis, microscopic

•Libman-Sacks endocarditis (and mitral rheumatic

valvulitis), gross

•Mitral valve, acute rheumatic vegetations, gross

•Mitral valve, rheumatic mitral stenosis, gross

Aortic valve, infective

endocarditis, gross

• This is infective endocarditis. The aortic valve demonstrates a large, irregular, reddish tan vegetation.

• Virulent organisms, such as Staphylococcus aureus, produce an "acute" bacterial endocarditis, while some organisms such as Streptococcus viridans produce a "subacute" bacterial endocarditis

37

Infective endocarditis spreading to

myocardium, gross

• In this case, the infective endocarditis demonstrates how the infection tends to spread from the valve surface.

• Here, vegetations can be seen on the endocardial surfaces, and the infection is extending into to underlying myocardium

38

Infective endocarditis,

microscopic

• Microscopically, the valve in infective endocarditis demonstrates friable vegetations of fibrin and platelets (pink) mixed with inflammatory cells and bacterial colonies (blue).

• The friability explains how portions of the vegetation can break off and embolize

39

Pericarditis

40

41

Pericarditis

•Serous pericarditis, diagram

•Fibrinous pericarditis, diagram

•Fibrinous pericarditis, gross

•Fibrinous pericarditis, gross

•Fibrinous pericarditis, gross

•Fibrinous pericarditis, microscopic

•Hemorrhagic pericarditis, gross

•Hemorrhagic pericarditis, gross

•Purulent pericarditis, gross

Fibrinous pericarditis, gross

• A window of adherent

pericardium has been

opened to reveal the

surface of the heart.

• There are thin strands of

fibrinous exudate that

extend from the epicardial

surface to the pericarial

sac.

• This is typical for a

fibrinous pericarditis 42

Hemorrhagic pericarditis, gross

• The pericarditis here not only has fibrin, but also hemorrhage. Thus, this is called a "hemorrhagic pericarditis".

• It is really just fibrinous pericarditis with hemorrhage. Without inflammation, blood in the pericardial sac would be called "hemopericardium

43

44

Myocarditis

Myocarditis

45

•Heart, microabscesses, gross

•Heart, microabscess, gross

•Heart, microabscess, microscopic

•Acute rheumatic carditis, microscopic

•Acute rheumatic carditis, microscopic

•Acute rheumatic carditis, microscopic

•Chronic rheumatic valvulitis, gross

•Interstitial viral myocarditis, microscopic

Heart, microabscesses, gross

46

The epicardial surface of the

heart is smooth and

glistening, but there are

small scattered pinpoint

yellowish microabscesses.

(Higher magnification in next

photo).

Heart, microabscess, gross

47

This magnification of the preceding

photograph shows the small yellowish

pinpoint microabscesses on the

epicardial surface. Microabscesses

may appear in persons who are septic.

They may also represent emboli from

an infective endocarditis in which small

portions of a vegetation have

embolized out the coronary arteries.

Heart, microabscess,

microscopic

48

The microscopic

appearance of a

microabscess is shown

here.

The center consists of

blue bacterial colonies

and is surrounded by

acute inflammatory

cells.

Acute rheumatic carditis,

microscopic (1)

49

Microscopically, acute

rheumatic carditis is marked

by a peculiar form of

granulomatous inflammation

with so-called "Aschoff

nodules" seen best in

myocardium.

These are centered in

interstitium around vessels as

shown here. The myocarditis

may be severe enough to

cause congestive heart failure.

Acute rheumatic carditis,

microscopic (2)

50

Here is an Aschoff nodule at

high magnification.

The most characteristic

component is the Aschoff giant

cell.

Several appear here as large

cells with two or more nuclei

that have prominent nucleoli.

Scattered inflammatory cells

accompany them and can be

mononuclears or occasionally

neutrophils.

Acute rheumatic carditis,

microscopic (3)

51

Another peculiar cell seen

with acute rheumatic

carditis is the Anitschkow

myocyte.

This is a long, thin cell with

an elongated nucleus.

Chronic rheumatic valvulitis,

gross

52

In time, chronic rheumatic

valvulitis may develop by

organization of the acute

endocardial inflammation along

with fibrosis, as shown here

affecting the mitral valve.

Note the shortened and

thickened chordae tendineae.

Interstitial viral myocarditis,

microscopic

53

The interstitial lymphocytic

infiltrates shown here are

characteristic for a viral

myocarditis, which is probably

the most common type of

myocarditis.

Many of these cases are

probably subclinical.

Some may be a cause for

sudden death in young

persons. There is usually little

necrosis.

The most common viral

agent is Coxsackie B.

Neoplasia

54

Neoplasia

55

•Heart, rhabdomyoma, gross

•Heart, atrial myxoma, gross

•Heart, atrial myxoma, microscopic

•Heart, epicardium, metastases, gross

•Heart, myocardium, metastatic melanoma, microscopic

Heart, rhabdomyoma,

gross • This two year old child

died suddenly. At

autopsy, a large firm,

white tumor mass was

found filling much of the

left ventricle.

• This is a cardiac

rhabdomyoma. Such

primary tumors of the

heart are rare

56

Heart, atrial myxoma, gross

• The left atrium has been opened to reveal the most common primary cardiac neoplasm--an atrial myxoma.

• These benign masses are most often attached to the atrial wall, but can arise on a valve or in a ventricle.

• They can produce a "ball valve" effect by intermittently occluding the atrioventricular valve orifice. Embolization of fragments of tumor may also occur. Myxomas are easily diagnosed by echocardiography 57

Heart, epicardium, metastases,

gross

• Primary tumors of the heart are uncommon.

• Metastases to the heart are more common, but rare overall (only about 5 to 10% of all malignancies have cardiac metastases).

• Seen over the surface of the epicardium are pale white-tan nodules of metastatic tumor. Metastases may lead to a hemorrhagic pericarditis.

58

Congenital Heart

Disease

59

Congenital Heart Disease

60

•Congenital heart disease, table

•Heart, probe patent foramen ovale, and paradoxical embolus, gross

•Heart, atrial septal defect, gross

•Heart, atrial septal defect, Eisenmenger's complex, gross

•Heart, ventricular septal defect, gross

•Heart, atrial septal defect and ventricular septal defect, gross

•Aorta, coarctation, gross

•Aorta, coarctation, gross

•Pulmonic valve, quadricuspid, gross

•Aortic valve, bicuspid, gross

•Aortic valve, senile calcific aortic stenosis, gross

•Heart, tetralogy of Fallot, diagram

•Heart, persistent truncus arteriosus, diagram

•Heart, transposition of great vessels, diagram

Congenital Heart Disease

Type of Defect Mechanism

61

Type of Defect Mechanism

• Ventricular Septal Defect (VSD) There is a hole within the membranous or muscular portions of the intraventricular septum that produces a left-to-right shunt, more severe with larger defects

• Atrial Septal Defect (ASD) A hole from a septum secundum or septum primum defect in the interatrial septum produces a modest left-to-right shunt

•

• Patent Ductus Arteriosus (PDA) The ductus arteriosus, which normally closes soon after birth, remains open, and a left-to-right shunt develops

62

Type of Defect

Mechanism • Tetralogy of Fallot Pulmonic stenosis results in right ventricular

hypertrophy and a right-to-left shunt across a VSD, which also has an overriding aorta

• Transposition of Great Vessels The aorta arises from the right ventricle and the pulmonic trunk from the left ventricle. A VSD, or ASD with PDA, is needed for extrauterine survival. There is right-to-left shunting

• .

• Truncus ArteriosusThere is incomplete separation of the aortic and pulmonary outflows, along with VSD, which allows mixing of oxygenated and deoxygenated blood and right-to-left shunting

63

Type of Defect

Mechanism • Hypoplastic Left Heart Syndrome There are varying

degrees of hypoplasia or atresia of the aortic and mitral valves, along with a small to absent left ventricular chamber

• Coarctation of Aorta Either just proximal (infantile form) or just distal (adult form) to the ductus is a narrowing of the aortic lumen, leading to outflow obstruction

• Total Anomalous Pulmonary Venous Return (TAPVR) The pulmonary veins do not directly connect to the left atrium, but drain into left innominate vein, coronary sinus, or some other site, leading to possible mixing of blood and right-sided overload

64

Heart, atrial septal defect,

gross

• In the region of the foramen

ovale on the interatrial

septum is a small atrial

septal defect, as seen in this

heart opened on the right

side.

• Here the defect is not

closed by the septum

secundum, so a shunt exists

across from left to right

65

Heart, ventricular septal defect,

gross

• This is the heart of a

premature stillborn with

Trisomy 13 in which a

ventricular septal defect is

visible in the membranous

septum.

• About 90% of VSD's are in

the membranous septum and

10% in the muscular septum.

66

Aorta, coarctation, gross

• This portion of aorta was

resected from a patient

with a coarctation.

• The aorta narrows

postductally here to about

a 3 mm opening

67

Aorta, coarctation, gross

• The aorta is opened

longitudinally here to

reveal a coarctation.

• In the region of the

narrowing, there was

increased turbulence

that led to increased

atherosclerosis.

68

Heart, tetralogy of Fallot,

diagram

This diagram depicts the features of Tetralogy of Fallot:

1. Ventricular septal defect;

2. Overriding aorta;

3. Pulmonic stenosis;

4. Right ventricular hypertrophy. The obstruction to right ventricular outflow creates a right-to-left shunt that leads to cyanosis.

69

Heart, transposition of great

vessels, diagram • In the diagram, transposition of the

great vessels is shown

• occurs when the trunco-conal septum does not spiral down. Instead, it descends straight down. As a result, outflow of right ventricle is into aorta and outflow from left ventricle is into the pulmonic trunk.

• In order for this system to work, there must be a connection between the system and pulmonic circulations.

• Sometimes this is through a ventricular septal defect or an atrial septal defect.

• In the diagram at the left, this is through a patent ductus arteriosus

70

Cardiomyopathies

71

Cardiomyopathies

72

•Cardiomyopathies, table

•Heart, dilated cardiomyopathy, gross [XRAY]

•Heart, dilated cardiomyopathy, gross

•Heart, cardiomyopathy, microscopic

•Heart, hypertrophic cardiomyopathy, explanted heart, gross

•Heart, restrictive cardiomyopathy from hemochromatosis, microscopic

•Heart, restrictive cardiomyopathy from amyloidosis, microscopic

•Myocardium, amyloidosis, apple-green birefringence with polarized

light, Congo red stain, microscopic

•Heart, hypertension with left ventricular hypertrophy, gross

•Heart, hypertrophy with hypertension, gross

Type of CMP Findings

• Dilated (Congestive) All four chambers are dilated, and there is also hypertrophy. The most common cause is chronic alcoholism, though some may be the end-stage of remote viral myocarditis.

• Hypertrophic The most common form, idiopathic hypertrophic subaortic stenosis (IHSS) results from asymmetric interventricular septal hypertrophy, resulting in left ventricular outflow obstruction.

• Restrictive The myocardium is infiltrated with a material that results in impaired ventricular filling. The most common causes are amyloidosis and hemochromatosis.

73

Heart, dilated cardiomyopathy,

gross

• This very large heart has a globoid shape because all of the chambers are dilated.

• It felt very flabby, and the myocardium was poorly contractile.

• This is an example of a cardiomyopathy.

• This term is used to denote conditions in which the myocardium functions poorly and the heart is large and dilated, but there is no specific histologic finding 74

Heart, dilated cardiomyopathy,

[XRAY]

• This chest radiograph

demontrates marked

cardiomegaly, with

the left heart edge

appearing far to the

left

75

Heart, cardiomyopathy,

microscopic

• Microscopically, the

heart in cardiomyopathy

• demonstrates

hypertrophy of

myocardial fibers

(which also have

prominent dark nuclei)

along with interstitial

fibrosis 76

Heart, hypertrophic cardiomyopathy,

explanted heart, gross

• There is marked left ventricular hypertrophy, with asymmetric bulging of a very large interventricular septum into the left ventricular chamber.

• This is hypertrophic cardiomyopathy. About half of these cases are familial, though a variety of different genes may be responsible for this disease.

• Both children and adults can be affected, and sudden death can occur. Seen here is the explanted heart. Pacemaker wires enter the right ventricle.

• The atria with venous connections, along with great vessels, remained behind to connect to the transplanted heart (provided by someone who cared enough to make transplantation possible).

77

Heart, hypertension with left

ventricular hypertrophy, gross

• This left ventricle is very thickened (slightly over 2 cm in thickness), but the rest of the heart is not greatly enlarged.

• This is typical for hypertensive heart disease.

• The hypertension creates a greater pressure load on the heart to induce the hypertrophy

78

Heart, hypertrophy with

hypertension, gross

• The left ventricle is

markedly thickened in

this patient with severe

hypertension that was

untreated for many

years.

• The myocardial fibers

have undergone

hypertrophy

79

Arterial and Venous

Diseases

80

Renal arteriole, fibrinoid necrosis with

malignant hypertension, microscopic

• One complication of

hyperplastic

arteriolosclerosis with

malignant hypertension is

fibrinoid necrosis, as seen

here in a renal arteriole

81

Varicose veins, gross

• The prominent veins shown here on the lower leg are varicosities. Varicose veins are a common problem with aging. The venous valves become incompetent.

• There may be muscular atrophy with less tone to provide a massage effect on the large superficial veins, and skin becomes less elastic with time.

• Hydrostatic pressure from standing for long periods exacerbates the problem

82