Title: Cardiovascular Pathology (modification of Dr. Veinot’s presentation)
1Cardiovascular Pathology (modification of Dr.
Veinots presentation)
- Michel Dionne MD FRCPC
- for
- John P. Veinot MD FRCPC
- Professor of Pathology
- University of Ottawa
- Pathology and Laboratory Medicine
- Ottawa Hospital
2You may only access and use this PowerPoint
presentation for educational purposes. You may
not post this presentation online or distribute
it without the permission of the author.
3Overview
- Atherosclerosis
- Aneurysms
- Ischemic heart disease
- Cardiomyopathies
- Valvular heart disease
- Hypertension
4(No Transcript)
5CVS Anatomy 101
6Endothelium
7muscular artery
intima
media
adventitia
8Aorta
9Media of aorta an elastic artery
10Atherosclerosis
- Disease of large and medium sized arteries
(elastic and muscular), particularly - aorta, iliac, coronary, popliteal, carotid,
circle of Willis - Develop intimal lesions called atheromas or
atheromatous plaques which - protrude into the lumen resulting in stenosis
(narrowing of lumen) and possibly occlusion
(lumen blocked) - can weaken the underlying media, possibly leading
to aneurysm formation
11Atherosclerosis - risk factors
- Hyperlipidemia
- high LDL
- low HDL
- Hypertension
- Smoking
- Diabetes
- Age
- Male gender
- Family history/ genetics
Other physical inactivity, diet, obesity etc.
12Atherosclerosis - pathogenesis
- Chronic endothelial injury resulting in
endothelial dysfunction - increased permeability
- increased adhesion of leukocytes (monocytes and
lymphocytes) and platelets - accumulation of lipids in intima
- Migration of monocytes into intima leading to
formation of foam cells (lipid-laden macrophages) - Release of cytokines and growth factors result in
smooth muscle cell migration into intima,
proliferation of smooth muscle cells, deposition
of extracellular matrix (e.g. collagen) - From hemodynamic forces, hyperlipidemia, HTN,
smoking etc.
13From Robbins and Cotran Pathologic Basis of
Disease, 8th Edition
14Aorta fatty streaks
15(No Transcript)
16Aorta fibrofatty/atheromatous plaques
17Aorta complicated plaques
18Aortic arch vessels advanced plaques causing
severe stenosis
19Coronary artery
20Atheromatous material foam cells (lipid laden
macrophages) and cholesterol clefts
21From Robbins and Cotran Pathologic Basis of
Disease, 8th Edition
22Atherosclerosis - complications
- Calcification
- Plaque hemorrhage and rupture
- Plaque erosion/ulceration
- Thrombosis
- Embolization of atheromatous material
(atheroemboli) - Aneurysm formation and rupture
23Renal infarct from embolization
24Atherosclerosis - major consequences
- Symptomatic disease most often affects the
heart, brain, kidneys and lower extremities - Heart angina and myocardial infarction
- Brain cerebral infarction (stroke)
- Aorta (particularly abdominal)
- Aneurysms
- Stenosis of ostia of major branches leading to
visceral ischemia - Lower extremities peripheral vascular (arterial)
disease claudication, gangrene
25Aneurysm - definition
- a localized abnormal dilatation of a vessel
26Aneurysm types
Atherosclerotic aneurysms are the most common,
but there are other types!
27Aneurysms - complications
- Stasis of blood
- Thrombosis
- obstruction
- embolism
- Mass effect
- Rupture
28Abdominal Aortic Aneurysm (AAA)
thrombus
29Aneurysm rupture
blood
lumen
tear
thrombus
vessel wall
30AAA rupture
Hemorrhage into surrounding tissue
31Dissecting aneurysm
32Coronary artery aneurysms secondary to vasculitis
(inflammation of blood vessels)
33Left lung
SVC
Aorta
Left atrium
Pericardium
Right atrium
Right lung
Left ventricle
Right ventricle
34Left atrium
Right atrium
Left ventricle
Right ventricle
Interventricular septum
35Coronary artery anatomy
http//www.drchander.com/diagnoseCAD.html
36Coronary artery atherosclerosis
- affects the epicardial arteries tends to be more
pronounced in the proximal portion of these
vessels - can involve 1, 2 or all 3 of the main vessels /-
their large branches - if degree of obstruction is significant, can
result in angina (pain from myocardial ischemia) - an atherosclerotic plaque can become unstable
(acute plaque lesion) - intraplaque hemorrhage
- plaque rupture or erosion resulting in thrombosis
- acute plaque lesions can result in an acute
coronary syndrome (unstable angina, myocardial
infarct)
37(No Transcript)
38(No Transcript)
39Myocardial infarct terminology
40(No Transcript)
41(No Transcript)
42(No Transcript)
43(No Transcript)
44Recent MI - about 24 hours old
45Contraction band necrosis
46Recent MI - about 3 days old
47Recent MI - interstitial infiltrate of neutrophils
48Recent MI - 5-7 days old
49Recent MI - 7-10 days old
Residual necrotic myocytes
Phagocytosis of dead cells at margin of infarct
Sick myocytes bordering the infarct
50Remote myocardial infarcts
51(No Transcript)
52Transmural rupture
53Infarct rupture and tamponade
54Papillary muscle rupture
55Left ventricle aneurysm
56Ischemic heart disease - interventions
- Non-surgical
- thrombolysis
- PTCA / stenting
- atherectomy
- rotablation
- Surgical
- Coronary Artery Bypass Grafting (CABG)
typically using saphenous vein grafts and/or
internal thoracic arteries - endarterectomy
57Atherectomy device
58PTCA balloon
59(No Transcript)
60Angiogram pre/post PTCA
61(No Transcript)
62(No Transcript)
63(No Transcript)
64Aortic valve - normal
65Mitral valve - normal
66Aortic stenosis - causes
67Aortic stenosis causing LVH
68Mitral stenosis - rheumatic
69Floppy mitral valve - mitral valve prolapse (MVP)
70Hypertension
- PRIMARY (ESSENTIAL)
- Genetic and environmental factors
- Defects in sodium homeostasis, vascular smooth
muscle structure, regulation of vascular tone - SECONDARY
- renal disease
- vascular disease
- endocrinopathies
- drugs
- neurogenic etc
71Reno-vascular hypertension
72Hypertension - complications
- enhance other diseases (risk factor)
- small vessel changes
- scarring/sclerosis
- microaneurysms
- large vessel changes
- ectasia / aneurysms / aortic regurgitation
- dissection
- vessel rupture
- cardiac hypertrophy
- etc
73Arteriolo-nephrosclerosis
74Brain hypertensive bleed
75Hypertensive brain stem bleed
76LVH (look familiar?)
77Cardiomyopathy - definition
- Heterogenous group of diseases of the myocardium
associated with mechanical or electrical
dysfunction that usually (but not invariably)
exhibit inappropriate ventricular hypertrophy or
dilation and are due to a variety of causes that
frequently are genetic. - Cardiomyopathies are either confined to the heart
or are part of generalized systemic disorders
often leading to cardiovascular death or
progressive heart failure related disability. - Circulation 2006 1131807-1816
78Cardiomyopathy types(clinical/functional/morphol
ogic patterns)
- Dilated (DCM) 90
- Hypertrophic (HCM)
- Restrictive
79Primary cardiomyopathy (confined to the heart) -
etiology
- Genetic
- e.g. HCM, ARVC, mitochondrial defects,
channelopathies (e.g. LQTS) - Acquired
- e.g. due to myocarditis (inflammation of the
myocardium) - Mixed
- Idiopathic
80Secondary cardiomyopathy (part of generalized
systemic disorder) examples of etiologies
- Amyloidosis
- Hemochromatosis
- Sarcoidosis
- Medication/Toxin induced - e.g. cancer
chemotherapy, alcoholism - Autoimmune diseases - e.g. SLE, rheumatoid
arthritis - Infections
- Endocrine disorders - e.g. hypothyroidism
- Neuromuscular diseases - e.g. muscular
dystrophies - Storage diseases - e.g. glycogen storage disease
- Nutritional deficiencies - e.g. thiamine
81Primary dilated cardiomyopathy
- Primary myocardial abnormality
- NO SIGNIFICANT
- coronary artery disease
- valve disease
- systemic arterial hypertension
- systemic disorder, history of toxin exposure etc.
82(No Transcript)
83(No Transcript)
84(No Transcript)
85(No Transcript)
86Non-specific myocardial degenerative changes
87DCM - clinical presentation
- Progressive heart failure
- systolic dysfunction
- 4 chamber dilatation
- hypokinesis
- Arrhythmias
- Thromboembolism
- Sudden death
88Familial (genetic) DCM
- About 30 of DCM
- Often asymptomatic LV dilatation at detection -
minority progress - Examples
- muscular dystrophy
- mitochondrial defects - maternal inheritance
- inherited metabolic disorders
89Cardiomyopathy genetic abnormalities
- Dilated - cytoskeletal elements largely affected
- dystrophin - X-linked, some muscular dystrophies
- lamin
- desmin
- actin
- etc
- mitochondrial genes
- Hypertrophic - contractile elements affected
(sarcomeric genes) - myosin
- troponin
- tropomyosin
- myosin binding protein C
- etc
90(No Transcript)
91Viral myocarditis and DCM
- Enteroviral protease cleaves dystrophin
- Disrupted dystrophin / sarcoglycan complex
- Similar to primary genetic defects found in DCM
92(No Transcript)
93Hypertrophic cardiomyopathy
- a genetic disease autosomal dominant, variable
penetrance - phenotype variations even with same mutation - ?
environmental influences - myocardial hypertrophy (thickened myocardium)
- diastolic dysfunction
- sub-aortic obstruction
- sudden death (60 of deaths are sudden)
94Hypertrophic cardiomyopathy
Disproportionate thickening of the
interventricular septum
95Myocyte disarray and hypertrophy and interstitial
fibrosis
96HCM - diastolic dysfunction
- ventricular hypertrophy
- myocyte disarray
- interstitial fibrosis
- myocardial microinfarcts
97(No Transcript)
98(No Transcript)
99Cardiomyopathy - summary
- Gross and histopathologic findings are non-
specific but may be diagnostic - Most require clinicopathological correlation
- Many mimics and secondary diseases
- Molecular diagnosis / genetics developing