Gross Description

The patient weighed 60 kg and measured 172 cm. On external exam, both hands and feet showed necrotic changes at the tip of all fingers and toes. The heart weighed 450 g. The pericardial surface was rough with fibrous adhesions. Both atria were hypertrophic and dilated with multiple intramural thrombi present. Both ventricles were also hypertrophic and dilated, with right and left ventricular wall thickness measurements of 0.8 cm and 1.8 cm, respectively. The valves measured as follows tricuspid...

Case Analysis

The clinical history and the autopsy findings illustrate the potential life-threatening complications of long-term high dose steroid use, but also the cardiac manifestations of this patient's underlying disease, SLE. Systemic Lupus Erythematosus (SLE) is a chronic, systemic disease associated with abnormalities of the immune system. The cause of this disorder is unknown, but its basis is the production of autoantibodies, particularly antibodies against nuclear proteins, DNA, and RNA. The...

Suggested Readings

The clinical and diagnostic features of mitral valve disease. HospMed. 2001 62 72-8. 2. Carabello BA. The pathophysiology of mitral regurgitation. J Heart Valve Dis. 2000 9 600-8. 3. Kronick-Mest C. Postpericardiotomy syndrome etiology, manifestations, and interventions. Heart Lung. 1989 18 192-8 4. Engle MA. Humoral immunity and heart disease postpericardiotomy syndrome. Adv Exp Med Biol. 1983 161 471-8 Figure 35. Mitral valve prolapse. The mitral valve has redundant leaflets and...

Annulus

The fibrous ring that supports each of the 4 cardiac valves. The annulus for the tricuspid, mitral, and aortic valves is virtually a continuous structure arranged like a pretzel. The pulmonic valve annulus is somewhat separate from the other 3 (it arises from distinctly independent embryologic tissue, e.g. bulbus cordis). The valve base inserts into the annulus with inter-digitating connective tissue fibers. Infection of the valve tissue (endocarditis) can affect these connections thereby...

Laboratory data and other tests

Laboratory WBC 10.3 (S 53 , L 39 , M 7 , E 1 ), Hb Hct 16 51, Plt 293 SGOT 384 U L, LDH 751 U L, CK 1875 U L (CK-MB 11 ). ECG sinus tachycardia at 107 and ST elevation V1-V5. The diagnosis of acute myocardial infarction was made. The patient was given thrombolytic therapy (tissue plasminogen activator, TPA) in the ER with resolution of the chest pain and clearance of the cardiac enzymes over the following 3 days. On the 5th hospital day, the WBC was noted to be increasing to 14 (S 77 and Bands...

Ductus Arteriosus

It represents one of the physiologic shunts of the fetal circulation (see also foramen ovale). It is the arterial connection between the left pulmonary artery and the aorta just distal to the origin of the left subclavian artery. The ductus allows for a bypass of the high-resistance pulmonary circulation, and the passage of oxygenated blood in the pulmonary artery into the aorta. It begins to close shortly after birth, and completes the closure within the first weeks of life. Persistence of a...

Clinical Summary

The patient was a 52 year old woman with past medical history significant for morbid obesity (205 kg), cigarette smoking with chronic obstructive pulmonary disease (COPD), and cor pulmonale. She was on oxygen therapy at home for the past 7 months. She presented to the hospital with complaints of increasing weight gain, abdominal and lower extremity edema with pruritus and skin ulcers. She had no fever, chills, cough, dysuria, chest pain or palpitations. She denied any trauma to her legs. Her...

Gross and Microscopic Description

The patient measured 154 cm and weighed 64 kg. The heart weighed 450 g. The pericardium was thickened. The left ventricle revealed concentric hypertrophy consistent with long-standing hypertension (wall thickness 1.9 cm). The lateral wall of the left ventricle had an area of discoloration, which on histologic examination consisted of multiple foci of fibrosis and granulation tissue consistent with subacute and remote myocardial infarcts. The right ventricle was of normal thickness (0.5 cm)....

Microscopic Description

Sections of the heart, stained with H& E, showed active infective endocarditis of the mitral valve with septic vasculitis and acute epicarditis with microabscess formation. The lungs and liver had changes of chronic passive congestion. The lungs were also affected by centrilobular emphysema. Sections from the spleen revealed multiple infarcts with cavitation, as well as hemorrhage in the area of rupture and acute inflammation. The kidneys showed interstitial chronic nephritis, but no recent...

Mitral Valve

The mitral valve has an unusual configuration, with marked asymmetry of the leaflets. The anterior leaflet is a broad, shield-shaped structure that fills approximately two-thirds of the valve orifice, but only one-third of the annular circumference. It extends much deeper into the ventricular chamber than the posterior leaflet. The latter is a shallow, usually scalloped leaflet that has a broad annular attachment, but comprises only one-third of the orifice area....

Pre Autopsy Evaluation and Analysis

Crucial clinical information can be derived from the first sentence of the history 1) a 45 year old woman, 2) a smoker, 3) seropositive for hepatitis B, 4) affected by migraine headaches, and 5) someone who had experienced multiple episodes of syncope (although the time frame is not indicated). Her presentation was suggestive for acute ischemic heart disease. The quality and characteristics described are very specific for coronary pain ( 95 specificity, and a high positive predictive value)....

Nuclei Myocyte

Myocytic nuclei are relatively large, round to oval-shaped structures at birth. During embryogenesis, mitotic division of nuclei and cells can be easily appreciated. Shortly after birth, mitoses become exceedingly rare. For years it has been assumed that myocytes are terminally differentiated cells, with no new cell proliferation after birth. Recent evidence suggests that limited numbers of cells may proliferate in adulthood around areas of injury (e.g. healing myocardial infarction). It is...

Preface

Autopsy derives from the greek word autopsia, which means act of seeing with one's own eyes. It remains the most objective and accurate method to understand human.disease. Unfortunately, the volume of autopsies in teaching hospitals has decreased dramatically over the past years. The crucial factors that account for this are the recent progress and development of new technologies, especially in diagnostic imaging, immunology, cell biology and genetics. Additionally, the perpetual fear of legal...

Right Ventricle

As described in the organization of the myocardium, the right ventricle is a thin-walled structure with several poorly defined layers of myocardium. The free-wall and septum are heavily trabeculated. The freewall is often infiltrated by fibroadipose tissue that extends between the muscle fibers from the epicardial fat towards the endocardium. This tends to increase with obesity, and is often associated with diabetes mellitus. There is generally no functional consequence of this increase of...

Case 18 Clinical Summary

This patient was a 60 year old man with a history of cigarette smoking and alcohol use, who visited his internist with complaints of shortness of breath, intermittent fever, fatigue and weight loss. The physical exam revealed splenomegaly (4 cm below the left costal margin), a holosystolic murmur, and bilateral pulmonary rales. His laboratory tests were significant only for mild pancytopenia and hematuria. His liver chemistry was within normal limits. A bone marrow exam was done and reported as...

Case 22 Clinical Summary

The patient was a 34 year old African American woman, HIV negative, smoker (one pack per day for 20 years), asthmatic, with a history of positive PPD and tuberculous infection, treated with 4 antituberculous medications. As part of the work-up a CT scan of the chest was done, which revealed a large mass involving the middle and lower lobes of the right lung. In addition, a bronchial washing was reported positive for adenocarcinoma, and subsequently she underwent right pneumonectomy. The right...

Bundle of His and conduction bundles

The bundle of His and conduction fibers are composed of modified cardiac muscle tissue. The bundle of His crosses through the annulus at the base of the cardiac septum. Upon reaching the ventricle, it divides into left and right divisions. The left division skirts around the membranous septum, where it then divides further into an anterior and posterior branch. The right bundle branch extends over the base of the septum into the right ventricle, where it runs superficially in a muscle known as...

Coronary Ostia

The two openings for the left and right coronary arteries, usually located centrally at the upper portion of the sinus of Valsalva, approximately parallel to the free edge of the aortic valve. The location is variable. High insertion in the aortic wall has been associated with sudden cardiac death, presumably secondary to transient decrease of coronary flow (with high insertion, the ostium is affected by systolic pressure that can compress the opening, rather than diastolic pressure with which...

Chordae tendineae

The fine fibrous bands that extend from the tips of the papillary muscles to the atrio-ventricular heart valves. The chordae branch at least 3 times and become smaller between the papillary muscle tip, known as the myotendon junction, and the valve. In total, there are approximately 120 chordae at the valve level. They insert on the undersurface of the valve, at the commissural junction, and at the free edge. With contraction of the ventricle, pressure within the cavity increases thereby...

Organization Myocardium

As discussed in connective tissue matrix, the myocardium is composed of obliquely oriented layers that 'wrap' around the ventricular cavity. This is particular obvious in the left ventricle, with 3 layers whereas, the thinner, low-pressure right ventricle generally has 2 less well-defined layers. Since the layers in the left ventricle are oriented obliquely to each other, sectioning through the ventricular wall reveals groups of myocardial cells parallel to each other, but oriented at...

Typical vs Atypical Ischemia

Once we consider it more likely than not that this patient had ischemic disease, the question of whether it was typical or atypical is somewhat more difficult to ascertain. First, it is necessary to define these two terms. Typical ischemic heart disease is generally considered secondary to coronary atherosclerosis, with atherosclerotic plaque (s) narrowing the lumen and causing damage to the coronary artery wall. The presence of atherosclerosis may increase the possibility of superimposed...

Case

The death of this middle-aged man several weeks after an interventional catheterization and coronary artery procedure resulted in a suit against the treating cardiologist. The claim against the physicians is based on the performance of an unjustified procedure in lieu of recognized interventions with high clinical success and low morbidity or mortality, such as undertaking a coronary artery bypass or a balloon angioplasty with stenting. It is also suggested that the failure to adequately follow...

Lambls Excrescence

A small papillary frond-like vegetation that is found on the closing edge of valve cusps and leaflets. It is typically seen in the central closing edge of the aortic valve cusps. The excrescence resembles a fine thread-like structure. Microscopically, they have a fibrous core, and a surface of endothelial cells. They are thought to arise from localized trauma to the valve from repetitive closure, with organization of the resulting fibrin and platelet vegetation. They are related to the much...