Cardiac Pathology 2 Flashcards
2 main types of valvular disease (what are they?)
Both cause what?
- Stenosis (doesn’t open)
- Insufficiency (doesn’t close)
Both –> Hypertrophy
Chronic stenosis –> ____ overload hypertrophy
Pressure
Chronic insufficiency –> ____ overload hypertrophy
Volume
Most common valve abnormality
Describe
Calcific aortic stenosis
Valves have osteoblast-like cells –> osteoid substance –> mounded calcifications prevent complete opening
Causes of calcific stenosis
AGE, chronic HTN, hyperlipidemia, inflammation
Female > 60, benign deposits on mitral valve
Mitral annular calcification
Potential dangers of mitral annular calcification (3)
- Thrombus formation
- Infective endocarditis
- Mitral valve prolapse
Female, incidental mid-systolic click in L-side of heart
Mitral valve prlopase (back into L atrium in systole)
Mitral valve prolapse will show what on the valve?
Myxomatous degeneration (thick, rubbery, proteoglycan)
While often incidental, what can secondarily cause mitral valve prolapse?
Dilated hypertrophy (valve insufficiency, volume overload, contractility deficit) –> stretches valve, can’t close
Rare dangers of mitral valve prolapse
- Thrombi accumulation –> emboli
- I.E.
- Mitral insufficiency
- Arrhythmias
Typical presentation of mitral valve prolapse
Asymptomatic, maybe some angina/dyspnea
Rheumatic fever - description
Inflammatory disorder AFTER group A strep pharyngeal infection
Rheumatic heart disease - pathogenesis
Immune response to strep M proteins –> cross-react with cardiac (and other) self-antigens
Blood tests to confirm rheumatic fever
ASO, anti-DNase B
Symptoms of rheumatic fever
- PANCARDITIS (focus here)
- Migratory polyarthritis
- SubQ nodules
- Rash
- SYDENHAM chorea
Heart inflammation, random moving joint pains, skin rash and nodules, random unplanned movements
Rheumatic fever
Cardiac features of acute rheumatic fever
- Pancarditis w/ Aschoff bodies (T cells and macrophages)
- Fibrinoid necrosis w/ verrucae (vegetations) of valves
Cardiac features of chronic rheumatic heart disease
- Mitral leaflet thickening
- Fusion/thickening of tendinous cords
- MITRAL STENOSIS (only cause of this)
See mitral valve STENOSIS…
Think ______
Rheumatic heart disease
Potential dangers of rheumatic heart disease
- L atrial enlargement –> A. fib, thrombosis
- Pulmonary congestion –> RIGHT heart failure
Acute infective endocarditis - description
Organism?
Treatment?
Rapidly progressing, destruction of normal valve
- Staph. aureus - Surgery + antibiotics
Subacute infective endocarditis - description
Example of pre-existing condition?
Treatment?
Slow-progressing infection of PREVIOUSLY DEFORMED valve
- Ex. via chronic rheumatic heart disease - Treat w/ antibiotics alone
Predisposing factors for infective endocarditis
- Valvular abnormalities
- RHD, prosthetic valve, MV prolapse, calcific stenosis, bicuspid aortic valve
- Bacteremia
- Infection, dental work, needles/drugs, skin scrape
A valve with infective endocarditis will look how?
- Friable (crumply), bulky, vegetations
Vegetations in endocarditis are made of what?
Fibrin, inflammatory cells, and organisms
What might a SUBACUTE endocarditis vegetation have as well as fibrin, inflammatory cells, organisms?
Granulation tissue
Presentation of infective endocarditis
- NONSPECIFIC symptoms (fever, weight loss, fatigue)
- Murmur
A valve has small, sterile thrombi on cardiac valves along the line of closure. Name of this?
Potential causes?
Nonbacterial thrombotic endocarditis
- Malignancy (mucinous adenocarcinoma)
- Sepsis
- Catheter-induced endocardial trauma
2 cardiovascular things associated w/ mucinous adenocarcinomas
- Migratory thrombophlebitis
- Nonbacterial thrombotic endocarditis
Describe pathway following dilated L atrium
A fib –> mural thrombosis –> thromboembolism
L atrial dilation is always present in what class of diseases?
Cardiomyopathy
3 types of cardiomyopathy
- Dilated
- Hypertrophic
- Restrictive
Most common type of cardiomyopathy
Dilated cardiomyopathy (90%)
Dilated cardiomyopathy…
Genetics?
Causes?
- Titin (TTN) mutation
- Autosomal dominant
- Alcohol, myocarditis, doxorubicin, iron overload (hemoch.)
Titin protein
Limits sarcomere stretch
- Deficient in dilated cardiomyopathy (familial)
Dilated cardiomyopathy - presentation
20-50, dyspnea, exertional fatigue, decreased EF, arrhythmias, mural thromboembolism, functional regurg. murmur
Arrhythmogenic RV cardiomyopathy - description and potential result
Genetic?
- Myocardium of RV wall REPLACED by ADIPOSE and FIBROSIS –> V tach. and V fib. –> SUDDEN DEATH
Autosomal dominant
Hypertrophic cardiomyopathy - description
Genetic?
Genetic disorder –> Myocardial hypertrophy and DIASTOLIC dysfunction –> lower SV, outflow obstruction
Beta-myosin heavy chain
MASSIVE left ventricular hypertrophy (including septum), with microscopic MYOCYTE DISARRAY
Hypertrophic cardiomyopathy
Consequences of long term hypertrophic cardiomyopathy (morphologic, pathologic, presentation)
- Foci of ischemia
- L atrial dilation –> mural thrombus
- Pulmonary congestion –> exertional dyspnea
- Arrrhythmias
- SUDDEN DEATH
A patient has increased stiffness of the ventricle, leading to diastolic dysfunction. BOTH atria are enlarged. What is this? Why are the ventricular walls stiff?
Restrictive cardiomyopathy
- Amyloid or post-radiation fibrosis w/in the wall
Amyloidosis
Restrictive cardiomyopathy
Radiation –> diastolic heart dysfunction, atria enlarged
Restrictive cardiomyopathy
Insoluble beta-pleated sheet deposits
Amyloid
Causes of amyloid deposits
- Multiple myeloma (systemic deposition)
- Transthyretin mutation (heart-localized deposition)
Deposition of transthyretin in the ____ results in a restrictive cardiomyopathy
Interstitium of the myocardium (between myocardial cells)
See myocarditis (inflammation w/in muscle wall)…
Think _____
Coxsackie A/B viruses
See myocarditis plus travel history to S. America…
Think _____
Trypanosomes (Chagas disease)
NON-infectious causes of myocarditis
IMMUNE-Mediated Reactions
- Rheumatic fever, SLE, drug hypersensitivity
See eosinophilic myocarditis…
Think _____
Hypersensitivity reaction
See lymphocytic (B/T cells) myocarditis…
Think _____
Viral (Coxsackie)
Most common cause of congenital heart disease
Trisomy 21 (Down syndrome)
Atrial septal defect - describe resulting path.
L to R shunt –> R side volume overload –> pulmonary hypertension, R heart failure
Unique potentially lethal complication w/ atrial septal defect
Paradoxical embolization (ex. DVT –> L side –> stroke, etc.)
Most common form of congenital heart disease
Ventricular septal defect
Small vs. large VSD
Small - close spontaneously
Large - L to R shunt
Morphologic and symptomatic findings w/ large VSD
- R ventricular hypertrophy (via L to R shunt)
- Pulmonary hypertension
A patient has a VSD and starts turning blue. Cause?
Pulmonary HTN from L to R shunt –> increased R-side pressure –> REVERSED R to L shunt –> CYANOSIS
Child w/ harsh, machinery-like murmur
Patent ductus arteriosus
Cause of patent ductus arteriosus
Hypoxic infant and/or increased pulmonary vascular pressure (LIKE W/ A VSD)
Effect of a PDA is determined by the _____
Explain.
DIAMETER - large shunt = increased pulmonary pressure = shunt reversal = CYANOSIS
How is a VSD similar to a PDA?
Both are initially L to R shunts, but can reverse to R to L with significant pulmonary HTN and cause CYANOSIS
2 types of initial R to L shunts
- Tetralogy of Fallot
- Transposition of great arteries
Tetralogy of Fallot
- VSD
- Obstructed pulmonary valve/outflow
- Aorta overrides via pumping deox. blood from RV
- RV hypertrophy
Classic description of Tetralogy of Fallot - imaging
Boot-shaped (via RVH)
Clinical severity of Tetralogy of Fallot depends on ____
Degree of pulmonary stenosis
What is required for any life w/ transposition of great arteries?
A shunt (VSD, PDA, patent FO) - to mix blood btwn circuits
Treatment for transposition of great arteries?
Corrective surgery - needed for survival
Morphology of transposition of great arteries
- RVH
- LV atrophy
Coarctation of aorta: infant vs. adult
Which is worse?
Infant = w/ PDA Adult = w/o PDA
Infant (PDA) –> cyanosis
Adult w/ coarctation of aorta - presentation and morphology
- HTN in UEs, hypotension LEs
- Concentric LV hypertrophy, narrowing at lig. arteriosum
Why are lower extremities cold and hypotensive w/ coarctation of aorta?
Blood flow compromised beyond site of narrowing
