Atherosclerotic Aneurysms

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Atherosclerotic Aneurysms

• Site - abdominal aorta, common iliac, aortic arch
  and thoracic aorta
• Significance - rupture, impingement of adjacent
  structures, occlusion, embolism, or abdominal mass

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Atherosclerotic aneurism with thrombus
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Atherosclerotic aneurism with thrombus
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Atherosclerotic aneurism with thrombus
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Syphilitic Aneurysms

• Site - thoracic aorta or arch
• Morphology - saccular, fusiform or cylindroid
  with destruction of media
• Microscopic - obliterative endarteritis of vasa
  vasorum by plasma cells and lymphocytes with
  intimal and subintimal fibrosis
• Significance - LV hypertrophy

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Syphilitic aortitis with "tree bark"
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Syphilitic aortitis with "tree bark"
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Syphilitic aortitis with "tree bark"
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Dissecting Aneurysms

• Site - ascending aorta or arch
• Morphology - intimal tear with hematoma in media
• Microscopic - cystic medial necrosis with
  separation of media by ground substance
• Significance - external hemorrhage or occlusion
  of aortic branches

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Dissecting aortic aneurism
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Dissecting aortic aneurism (type A, which means
it involves the aortic root)
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Aortic dissection into esophagus. This
unfortunate patient had massive hematemesis just
before death.
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Intimal tear in aortic arch
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Cystic medionecrosis with irregular loss of
elastic (elastin stain).
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Increased Alcian blue staining in cystic
medionecrosis.
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Mycotic Aneurysms

• Infection of major artery with wall weakness and
  dilatation

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Aneurysm Classification

• Saccular
• Fusiform
• Cylindroid

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Vasculitis Based on Vessel Size

• Large - Giant cell arteritis, Takayasus
• Medium - Polyarteritis nodosa, Kawasaki disease
• Small - Wegeners granulomatosis, Churg-Strauss,
  microscopic PAN, Henoch-Schonlein purpura,
  essential cryoglobulinemic arteritis,
  leukocytoclastic vasculitis

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Vasculitis Based on Pathogenesis

• Infectious - Bacterial, Fungal, Viral
• Immunologic - Immune complex mediated (SLE),
  direct antibody mediated (Kawasaki), ANCA
  (Wegeners, microscopic PAN), cell-mediated
  (allograft rejection)
• Unknown - Giant cell, Takayasus, polyarteritis
  nodosa

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Polyarteritis Nodosa

• Site - kidneys 85, heart 75, liver 65, GI 50
• Morphology - acute (fibrinoid necrosis with
  infiltrate), healed (fibrosis, calcification and
  infiltrate)
• Significance - fever, malaise, weakness,
  leukocytosis and specific organ involvement

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Polyarteritis nodosa
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Giant Cell Arteritis

• Site - focal granulomatous inflammation of
  cranial medium to small arteries
• Morphology - giant cells, lymphocytes,
  neutrophils, eosinophils and fibrosis
• Significance - most common vasculitis, headache,
  blindness

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Giant cell arteritis in smaller arteries
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Giant cell arteritis in temporal artery
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Giant cell arteritis with giant cells
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Giant cell arteritis. The giant cells are near
the internal elastic lamella.
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Giant cell arteritis.
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Raynauds Disease and Phenomenon

• Disease - paroxysmal pallor or cyanosis of digits
  due to intense vasospasm without organic changes
• Phenomenon - arterial insufficiency of
  extremities due to arterial narrowing induced by
  various diseases

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Varicose Veins

• Site - superficial veins of lower extremities
• Significance - stasis dermatitis and ulcers

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Thrombophlebitis

• Site - pelvic or deep leg veins
• Significance - pulmonary embolism
• Variants - Phlegmasia alba dolens (painful white
  leg) and migratory thrombophlebitis (migrating
  venous thrombi)

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Lymphatic Abnormalities

• Acute lymphangitis
• Obstructive lymphedema - tumors, surgery,
  radiation or fibrosis

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Pericardial Effusion

• Serous - straw-colored fluid due to CHF or
  hypoproteinemia
• Serosanguineous - blood-tinged due to blunt chest
  trauma or CPR
• Chylous - watery with lipid droplets due to
  lymphatic obstruction
• Hemopericardium - pure blood due to traumatic
  perforation of heart or aorta

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Pericardial sac (yellow)
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Cardiac Tamponade

• Rapid accumulation of 200-300 ml of blood
  reducing ventricular diastolic filling
• Often fatal, especially when the increased volume
  in the pericardial space is rapid

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Cardiac tamponade
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Serous Pericarditis

• Etiology - viral, RF, SLE, tumors or uremia
• Morphology - 50-200 ml exudate with scant
  inflammatory cells without fibrous adhesions or
  organization

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Serous pericarditis. Note the dull, irregular
epicardial surface.
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Serofibrinous Pericarditis

• Etiology - MI, uremia, trauma, SLE, viral,
  cardiac surgery
• Morphology - serous fluid with fibrin,
  inflammatory cells and fibrous organization
  without restricting cardiac motion
• Significance - pain, fever, pericardial friction
  rub

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Serofibrinous pericarditis. There is a layer of
fibrin on the epicardial surface.
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Serofibrinous pericarditis. Fibrin and
inflammatory cells at left - at the pericardial
surface.
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Serofibrinous pericarditis. Fibrin and
inflammatory cells at left - at the pericardial
surface.
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Serofibrinous pericarditis. Fibrin and
inflammatory cells at left - at the pericardial
surface. There is also a layer of hyperplastic
mesothelial cells (arrow).
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CMV Pericarditis.
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CMV Pericarditis. See the CMV inclusion (arrow).
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Purulent Pericarditis

• Etiology - bacterial, mycotic or parasitic
• Morphology - 400-500 ml of thin to creamy pus
  with reddened, granular coated serosal surface
• Significance - organization with constrictive
  pericarditis

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Pus in purulent pericarditis (arrows).
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Hemorrhagic Pericarditis

• Etiology - TB, neoplasms or bacterial
• Morphology - organization with or without
  calcification

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Hemorrhagic pericarditis - clot at epicardial
surface
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Caseous Pericarditis

• Etiology - TB
• Significance - most frequent cause of
  fibrocalcific chronic constrictive pericarditis

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TB pericarditis. Area of caseous necrosis at
arrow.
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Inflammatory cells and fibrin in TB pericarditis
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Pericarditis Etiology

• Infectious - viral (Coxsackie, influenza),
  bacterial, TB, fungal or parasites
• Immunologic - Rheumatic fever, SLE, drugs
• Miscellaneous - MI, uremia,neoplasia, trauma or
  radiation

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Adhesive Mediastinopericarditis

• Etiology - healed caseous or suppurative
  pericarditis
• Morphology - obliteration of pericardial sac and
  adherence to surrounding structures
• Significance increased cardiac work with
  systolic retraction of rib cage and pulsus
  paradoxicum

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Adhesive mediastinopericarditis. There were
adhesions between the heart and the pericardium.
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Constrictive Pericarditis

• Etiology - caseous pericarditis
• Morphology - dense fibrous or fibrocalcific scar
  with limited diastolic filling and restricted
  cardiac output
• Significance - small quiet heart with reduced
  pressure and cardiac output

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Cardiac Tumors

• Primary tumors incidence 0.0017-0.33
• Secondary tumors more commonly involve
  pericardium than myocardium

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Benign Primary Cardiac Tumors
Adult Children Infants
Myxoma Rhabdomyoma Rhabdomyoma
Lipoma Fibroma Teratoma
Papillary fibroelastoma Myxoma fibroma
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Papillary fibroelastoma in left atrium
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Myxoma. There is a gelatinous appearance
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Myxoma
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Myxoma. Histologically, the tumor cells are
embedded in abundant fibrin. It almost looks
like an organizing thrombus.
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Myxoma, with perivascular tumor cells.
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Myxoma, with a myxoid area.
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Myxoma, with a myxoid area.
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Malignant Primary Cardiac Tumors
Adult Children Infants
Angiosarcoma Malignant teratoma Fibrosarcoma
Rhabdo-myosarcoma Rhabdo-myosarcoma Rhabdo-myosarcoma
Mesothelioma
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Malignant fibrous histiocytoma of the heart. This
was cured by heart transplant.
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Lymphoma involving heart
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Lymphoma involving heart
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Tumors of Blood Vessels

• Benign - Hemangioma, Glomus tumor, vascular
  ectasias
• Intermediate - Hemangioendothelioma
• Malignant - Hemangiopericytoma, Kaposis sarcoma,
  Angiosarcoma

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Tumors of Blood Vessels

• Hemangioma - most common vascular tumor usually
  seen in childhood or infancy
• Kaposis sarcoma - associated with AIDS or
  transplantation
• Angiosarcoma - highly malignant tumor

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Hemangioma
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Hemangioma
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Kaposi's sarcoma. Most common in HIV infection
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Indications for Endomyocardial Biopsy

• Grading of rejection in cardiac transplant
  recipients
• Diagnosis of myocarditis
• Diagnosis of primary cardiomyopathy
• Diagnosis of specific heart muscle disease
• Restrictive vs constrictive heart disease

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Endomyocardial biopsy forceps
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Biopsies are done of the right ventricular septum
near the apex.