chap 19

Question 1

Acute Pericarditis

Answer 1

Acute pericarditis is most often of viral origin
It may occur in several forms:
less thn 2 weeks duration
increased capillary peremeability
Serous pericarditis :
slowly accumulating exudates - 50 to 200 ml of
produced by nonbacterial involvement RHD, LES, tumours, uremia and primary viral infection (Coxsackie).
inflammatory reaction in the epicardial and pericardial surfaces - scant numbers of PMN, lymphocytes, and macrophages

Question 2

Fibrinous and serofibrinous pericarditis

Answer 2

the most frequent type of pericarditis
causes: acute MI, the postinfarction (Dressler) sdr. and cardiac surgery
the surface is dry, with a fine granular roughening
an increased inflammatory process  thicker fluid, yellow and cloudy owing to leukocytes and erythrocytes
exudate may be completely resolved or be organized causing adhesive pericarditis

Question 3

Purulent or Suppurative Pericarditis

Answer 3

due to bacteria (Staphylococci, Streptococci, and Pneumococci), fungus or parasitic infection.
by direct extension, by hematogenous or lymphatic route from the neighbouring areas of infection (pneumonia, subphrenic abscess)
thin to creamy pus - 400 to 500 ml
erythematous, granular serous surfaces
may produce mediastinopericarditis
it usually organizes  constrictive pericarditis

Question 4

Hemorrhagic pericarditis:

Answer 4

exudates of blood admixed with fibrinous to suppurative effusion
follows cardiac surgery or is associated with tuberculosis or malignancy.
It usually organizes with or without calcification.

Question 5

Caseous pericarditis:

Answer 5

This form is due to tuberculosis (by direct extension from neighbouring lymphnodes) or less commonly, mycotic infection.
causes fibrocalcific constrictive

Question 6

Chronic pericarditis

Answer 6

Organization produces plaque-like fibrous thickenings of the serosal membranes (“soldier’s plaque”) or thin, delicate adhesions

Types:
Adhesive pericarditis (in rheumatic disease) 
Adhesive mediastinopericarditis (the pericardial sac is obliterated )
Constrictive pericarditis (pericardial space is obliterated by a dense fibrous tissue, often calcified)

Question 7

cardiac tamponade

Answer 7

compression of the heart due to accumulation of fluid or blood in the peridacial sac. limitaion of ventricular diastolic filling, red of SV amd CO

Question 8

METABOLITES

Answer 8

MEDIATORS FOR THE VASODLATIONthat accompies increased cardiac work. other shit like adenosine has the greatest vasodilator effect

Question 9

Congenital Heart Disease

Answer 9

Abnormalities of the heart or great vessels that are present from birth.

The most common type of heart disease among children.

The incidence is higher in premature infants and in stillborns.

Some forms of produce manifestations soon after birth, others not become evident until adulthood

Question 10

Atrial septal defect

Answer 10

A heart condition called Atrial Septal Defect is characterized by an opening between the atria. This allows extra blood flow and leads to an enlargement of the right heart and pulmonary arteries.

Question 11

Tetralogy of Fallot

Answer 11

Heart condition called Tetralogy of Fallot can lead to insufficient blood flow to the lungs and a weakening of the right ventricle.

Question 12

Ventricular septal defect

Answer 12

also called a hole in the heart, is a common heart defect that’s present at birth (congenital). The defect involves an opening (hole) in the heart forming between the heart’s lower chambers, allowing oxygen-rich and oxygen-poor blood to mix.

Question 13

Most CommonCongenital Heart Diseases arise from

Answer 13

Most arise from faulty embryogenesis during gestational weeks 3 through 8, when major cardiovascular structures develop.

Defects compatible with embryologic maturation and birth are morphogenetic defects of individual chambers or regions of the heart, with the remainder of the heart developing relatively normally

Question 14

ventricular septal defect

Answer 14

Are classified according to size and location

Most are about the size of the aortic valve orifice

Question 15

Ischemic Heart Disease

Answer 15

Common Health problem.
High Mortality  & Morbidity. 
Etiology – common Atherosclerosis (next 4 slides) 
Patterns:
-Angina Pectoris
-Acute Myocardial Infarction
Sudden cardiac death
Risk  factors:
-Hypertension (2d)
-Hypercholesterolemia
-Diabetes
-Smoking, Life style, Diet, Genetic

Question 16

Congestive heart failure:

Answer 16

an inability of theheartto provide sufficient pump action to distributeblood flowto meet the needs of the body.

Question 17

Pathogenesis of Ischemic Heart Disease

Answer 17

Obstruction to blood flow.
-Atheroma, Thrombosis
Diminished  coronary perfusion
Ischemia Angina
Infarction Necrosis
-Inflammation
-Granulation tissue
-Fibrous scarring.

Question 18

Atheroma

Answer 18

is an accumulation and swelling in artery walls made up of (mostly) macrophage cells, or debris, and containing lipids (cholesterol)

Question 19

Angina

Answer 19

is a chest pain or discomfort that occurs if an area of your heart muscle doesn’t get enough oxygen-rich blood

Question 20

Thrombosis

Answer 20

is the formation of a blood clot inside a blood vessel, obstructing the flow of blood through the circulatory system

Question 21

Myocardial Infarction-MI

Answer 21

“Death of heart tissue due to lack of blood supply”
Atherosclerosis is the common cause
Coagulative necrosis – intact cell shape
Severe chest pain, breathlessness & sweating
Complications – cardiogenic shock, Death or Cardiac failure.

Question 22

Cardiogenic shock:

Answer 22

a condition in which a suddenly weakened heart isn’t able to pump enough blood to meet the body’s needs

Question 23

Cellular changes in MI

Answer 23

Reversible
• Glycogen depletion
• Mitochondrial swelling

Irreversible
• Myofibril disruption
• Sarcolemmal disruption
• Mitochondrial deposits

Question 24

Progression of myocardial necrosis after coronary artery occlusion

Answer 24

Necrosis begins in a small zone of the myocardium.
This entire region of myocardium (shaded) depends on the occluded vessel for perfusion and is the area at risk.

The end result of the obstruction to blood flow is necrosis of the muscle that was dependent on perfusion from the coronary artery obstructed.

Nearly the entire area at risk loses viability. The process is called myocardial infarction, and the region of necrotic muscle is a myocardial infarct.

Question 25

Complications of MI

Answer 25

``` Cardiogenic shock, death Arrhythmias and conduction defects Congestive heart failure (pulmonary edema) Mural thrombosis Myocardial wall rupture Ventricular aneurysm ```

Question 26

OUTCOME OF MYOCARDIAL INFATRACT

Answer 26

1ST DAY= sudden death and arrhythmia first week= arrhythmia, chf, shock, heart rupture first year= chf, arrhythmia, aneurysm chronic left heart weakness= chf, infarcts, arrhythmia

Question 27

Congestive Heart Failure

Answer 27

Cardiac output insufficient for metabolic requirements of the body Systolic dysfunction – decreased myocardial contractility Diastolic dysfunction – insufficient expansion for ventricular volume Problems are accentuated by increased demand – high output heart failure

Question 28

Rheumatic fever (RF)

Answer 28

acute, immunologically mediated, multisystem inflammatory occurs a few weeks following an episode of group A streptococcal pharyngitis (not skin infection) Acute rheumatic carditis may progress to chronic rheumatic heart disease (RHD) chronic valvular deformities (mitral stenosis )

Question 29

Chronic Rheumatic Heart Disease

Answer 29

organization of the acute inflammation and subsequent fibrosis mitral valve is virtually always abnormal irregular thickening and calcification of its leaflets, often with fusion of its commissures  aortic valve, the 2nd most commonly involved valve  stenosis or insufficiency --RHD is overwhelmingly the most frequent cause of mitral stenosis (99% of cases).

Question 30

Stenosis 

Answer 30

"narrowing" is an abnormal narrowing in a blood vessel or other tubular organ or structure

Question 31

Infectious Diseases of the Heart

Answer 31

Endocarditis Myocarditis Pericarditis

Question 32

Endocarditis

Answer 32

Microbial infection of the endocardial surface The characteristic lesion, a vegetation*, is composed of a collection of platelets, fibrin, microorganisms, and inflammatory cells Involves most commonly heart valves Endocarditis may develop on: - Previously normal valves - Deformed valves - Artificial (prosthetic) valves Predisposing influences - host factors - neutropenia, immunodeficiency, malignancy, therapeutic -immunosuppression, - diabetes mellitus - alcohol - intravenous drug abuse

Question 33

Bacterial Endocarditis

Answer 33

vegetation is composed of a collection of platelets, fibrin, microorganisms, and inflammatory cells

Question 34

Causes of Infectious Myocarditis

Answer 34

Viruses (most common) Bacteria (immunosuppressed persons or in sepsis) Parasites & protozoa (e.g., Trypanosoma cruzi)

Question 35

Causes of Pericarditis

Answer 35

``` Viruses (most common) Bacteria Fungi (rare) Rheumatic heart disease Open heart surgery ```

Question 36

Cardiac Tumors

Answer 36

Rare Most common primary tumor: atrial myxoma, which is benign; can be removed surgically Metastases: most often from lung cancer; involve pericardium

Question 37

Diseases of Veins

Answer 37

Varicose veins Thrombi Thrombophlebitis

Question 38

Myocardial diseases

Answer 38

``` Infectious / Inflammatory (myocarditis) Metabolic Developmental / Degenerative Toxic-metabolic Neoplastic ```

Question 39

Clinical, functional, and pathologic patterns

Answer 39

Types: Dilated cardiomyopathy Hypertrophic cardiomyopathy Restrictive cardiomyopathy The dilated form is most common (90% of cases) Each of these patterns can be either idiopathic or due to a specific identifiable cause

Question 40

Dilated cardiomyopathy

Answer 40

LEFT VENT EJECTION FRACTION=

Question 41

Hypertrophic cardiomyopathy | Restrictive

Answer 41

LEFT VENT EJECTION FRACTION=50-80%, diastolic dysfunction, genetic,

Question 42

Restrictive cardiomyopathy

Answer 42

LEFT VENT EJECTION FRACTION= 45-90%, DIASTOLIC DYSFUNCTION, idiopathic , pericardial constriction

Question 43

Myocarditis morphology

Answer 43

Dilated cardiomyopathy pattern- Gross –dilated, flabby heart, pale patches with hemorrhage Microscopic – interstitial inflammatory infiltrate with myocyte necrosis, fibrosis Mononuclear cells – idiopathic or viral Neutrophils – bacterial Eosinophils –hypersensitivity or protozoa Granulomatous – TB or sarcoid

Question 44

Diphtheria myocarditis –

Answer 44

due to a toxin rather than bacterial invasion. There is | some inflammation, myocyte changes

Question 45

Giant Cell Myocarditis

Answer 45

Myocyte necrosis Multinucleated giant cells Lymphocytes, plasma cells, macrophages, eosinophils, and neutrophils Often fulminant, rapid progression to death Differential diagnosis – cardiac sarcoidosis

Question 46

Dilated Cardiomyopathy

Answer 46

Gross – increased weight, dilatation, endocardial fibrosis, normal valves and coronary arteries Microscopic – myocyte hypertrophy, myofibrillar loss and interstitial fibrosis Etiology – viral, genetic, toxins Clinical significance – heart failure & death

Question 47

Cardiomyopathy –

Answer 47

trichrome stain showing extensive fibrosis (blue) between the myocytes. The myocytes also vary in size, and some have partial loss of myofibrils.

Question 48

Hypertrophic Cardiomyopathy

Answer 48

Etiology – hereditary, mostly autosomal dominant, can appear sporadically Clinical significance – syncope, arrhythmias and sudden death with a risk of 2-6% per year Cannot equate with hypertrophy alone!

Question 49

Hypertrophic Cardiomyopathy

Answer 49

``` Hypertrophy of ventricular septum (95%) Disarray of myofibers (100%) Volume reduction of ventricles (90%) Endocardial thickening of LV (75%) Mitral valve leaflet thickening (75%) Dilated atria (100%) Abnormal intramural coronaries (50%) ```

Question 50

myofiber dysarray

Answer 50

– not all fibers are pulling the same direction >contraction is ineffective. However, the cardiac conduction system can have these same problems, which might cause the arrhythmias and sudden death these patients tend to die of.

Question 51

Restrictive Cardiomyopathy

Answer 51

Amyloidosis Endomyocardial fibrosis – subendocardial fibrosis Loeffler’s endocarditis – eosinophilic infiltrate Endocardial fibroelastosis

Question 52

Amyloidosis –

Answer 52

this heart is thickened, pale, and has a rubbery consistency that interferes with cardiac expansion during diastole.

Question 53

Specific Heart Muscle Diseases

Answer 53

Toxic – alcohol, catecholamines, cocaine, Adriamycin Metabolic – hemochromatosis, hyperthyroidism, hyper/hypoK-emie Neuromuscular – muscular dystrophy Storage disease – glycogen, Fabry’s disease Infiltrative - sarcoidosis

Question 54

- Becker’s muscular dystrophy

Answer 54

fibrosis and loss of myofibrils in some cells.

Question 55

Pericarditis

Answer 55

Usually secondary to disorders involving the heart, or adjacent mediastinal structures

Question 56

Classification on the basis of etiological factors:

Answer 56

Acute nonspecific (idiopathic) Infective : a) Bacterial  b) Viral  c) Other infections Immunologic : a) Rheumatic fever b) Other connective tissue disorder Neoplastic Metabolic : a) Uremic b) Myxedema c) Gout. Traumatic (including after cardiac surgery) Associated with myocardial infarction

Question 57

Tumors of the Heart

Answer 57

80% to 90% of primary tumors of the heart are benign

Question 58

Myxoma

Answer 58

the most common primary tumor of the heart in adults 90% are located in the atria- predilection to fossa ovalis majority are attached to the endocardium by broad based or pedunculated stalk, ¼ sesile can be: -Firm surface and lobular -Myxoid and gelatinous -Friable and irregular

Question 59

Histologically (myoixa)

Answer 59

covered on the surface by endothelium stellate or globular myxoma ("lepidic") cells, endothelial cells, smooth muscle cells, and undifferentiated cells embedded within an abundant acid MPZ ground substance and peculiar structures ~ glands or vessels are characteristic. hemorrhage and mononuclear inflammation are usually present.

Question 60

Papillary fibroelastoma

Answer 60

incidental, lesions, most often identified at autopsy occurs on endocardial surfaces – sites of greatest hemodynamic stress cluster of hair-like projections up to 1 cm in diameter avascular myxoid connective tissue containing abundant MPZ matrix and elastic fibers covered by endothelium,

Question 61

Lipoma

Answer 61

- Rare (~3% of primary cardiac tumors) - Predominantly adults - Occur in the subendocardium, myocardium and subepicardium - Symptoms related to local tissue encroachment (arrhythmia, heart block, and sudden death) - Circumscribed, spherical or elliptical mass - Composed of mature adipocytes - Differ from lipomatous hypertrophy of IAS=interatrial septum: - -Usually encapsulated - -No brown fat cells - -No myocytes found

Question 62

Lipomatous septal hypertrophy

Answer 62

``` Not a true tumor Exaggerated growth of normal fat in IAS Up to 2cm in thickness Seen in elderly and obese people Only consider surger if symptomatic: Atrial arrhythmias and Heart block ```

Question 63

Rhabdomyomas

Answer 63

Primarily pediatric | Usually age

Question 64

Fibromas

Answer 64

Second most common tumor in children Firm, white, bulging well circumscribed mass Usually involves ventricle Calcification is common May markedly cellular in young patients – DDx fibrosarcoma Cardiac arrhythmias, heart failure

Question 65

Teratoma

Answer 65

Obviously a pediatric issue Arise within pericardium Benign in nature but cause drastic complications via tamponade High risk of death in-utero or after birth

Question 66

Hemangiomas

Answer 66

Found at any age but tend to occur in adults Two basic pathologic type circumscribed type - cavernous vascular spaces with a myxoid background Infiltrating type - more symptoms Symptoms: arrhythmias, pericardial effusions, congestive heart failure Associated with GI tract or skin hemangioma (Kasabach-Merritt syndrome)

Question 67

Paraganglioma

Answer 67

Extremely rare Arise from chromaffin cells, mainly in atria Majority produce catecholamines Positive biomarkers similar to pheocromocytoma 20% of patients also have extracardiac tumor Surgical excision is definitive treatment chief cells arranged in clusters, "zellballen" surrounded by capillary network

Question 68

most common malignant tumors

Answer 68

in adults=angiosarcoma= 28% | rhabdomyosarcoma, children 41%, infants, 50%

Question 69

Sarcomas

Answer 69

Constitute most of all malignant tumors Overall, 2nd most common cardiac tumor Virtually all cell types have been reported Clinical presentation depends on location, rather than its histopathology.

Question 70

Angiosarcoma

Answer 70

Composed of malignant cells that form vascular channels Predominantly in the right atrium

Question 71

Leiomyosarcomas

Answer 71

Spindle-celled, high-grade tumors Arise in the left atrium High rate of local recurrence and systemic spread

Question 72

Lymphoma

Answer 72

``` Very rare Typically non-Hodgkin type Mostly occur in the immunocompromised Presentation: progressive heart failure, chest pain, tamponade,SVC syndrome Can be multiple, firm white nodules Can be fish-flesh homogenous appearance More than one cardiac chamber Pericardiac effusion is common ```