Pathology of Pericardial Disease, Cardiac Tumors, and Congestive Heart Failure

Question 1

What are the two major types of pericardial sac accumulations?

Answer 1

1. Pericardial effusion - due to transudate or exudate

2. Hemopericardium - due to trauma or rupture

Question 2

What is the most likely clinical complication of pericardial fluid accumulation and why?

Answer 2

Cardiac tamponade - due to compression of cardiac chambers and impaired diastolic filling of the heart

Question 3

What are the five types of acute pericarditis (fluid accumulation in pericardial sac with associated inflammation)? Include fluid characteristics

Answer 3

1. Serous - least extra cells in fluid
2. Fibrinous - Extra fibrin + inflammatory cells
3. Purulent / suppurative - worst, with acute inflammatory infiltrate
4. Hemorrhagic - fibrinous + RBCs
5. Caseous - caseous necrosis within pericardium

Question 4

What are the usual etiologies of serous pericarditis?

Answer 4

Uremia (as in chronic kidney disease), autoimmune disorders like SLE, viral infection

Question 5

What are the microscopic features of serous pericarditis?

Answer 5

Spare number of WBCs in a relateively clear fluid

Question 6

What is the most common type of pericarditis and what are some common causes?

Answer 6

Fibrinous pericarditis

Causes:
Same as serous - 
Uremia, autoimmune disorders
Things which will cause clotting -
s/p myocardial infarction
s/p cardiac surgery
s/p radiation exposure
early bacterial infection

Question 7

How does fibrinous pericarditis appear grossly?

Answer 7

Rough, opaqua visceral / parietal pericardial surfaces with interconnecting stringy fibrous adhesions and varying amounts of cloudly fluid

Stringy adhesions are akin to butter holding two pieces of toast together

“bread and butter” pericarditis = fibrinous

Question 8

How does fibrinous pericarditis appear microscopically, and what characteristic clinical physical exam finding is associated?

Answer 8

Microscopically - moderate number of acute inflammatory cells, with an eosinophilic, fibrous exudate

Clinical finding - pericardial friction rub

Question 9

What causes purulent / suppurative pericarditis and how does it appear grossly / microscopically?

Answer 9

Cause - bacteria infection, maybe from adjacent site or hematogenous / lymphatic spread

Grossly - Creamy / white/ pus fluid in pericardial sac associated w/HYPEREMIA

Microscopically - neutrophils / macrophages of acute inflammatory exudate

Question 10

What is hemorrhagic pericarditis and how does it look?

Answer 10

Fibrinous pericarditis + RBCs -> blood-like fluid in pericardium

Will like a collection of pericardial blood fluid, differing microscopically depending on etiology

Question 11

What are the causes of hemorrhagic pericarditis?

Answer 11

1. Metastatic malignancy (due to angiogenesis)
2. Infections i.e. TB, early on which are destructive
3. Coagulopathies
4. s/p cardiac surgery

Question 12

What causes caseous pericarditis?

Answer 12

Usually TB

Spreads via local spread from lungs next door, or via mediastinal lymph nodes to pericardial sac

Question 13

What is the gross and microscopic appearance of caseous pericarditis?

Answer 13

Gross: crumbly-white material within pericardial surfaces

Microscopically: Granulomatous inflammation -> with necrotic centers

Question 14

What is the most common type of chronic pericarditis, and what does it result from? What is it?

Answer 14

Adhesive pericarditis -> follows serous or fibrinous pericarditis

It is residual strands of fibrous connective tissue extending between the pericardial surfaces (like the bread and butter)

Question 15

What are soldier’s plaques?

Answer 15

A type of chronic pericarditis characterized by focal, firm, collagenous pericardial thickening which may become calcified

-> when soldiers are marching, they stop abruptly and their RV slams against their chest wall

Question 16

What is the most frequent chronic pericarditis which results from purulent or caseous pericarditis? Describe.

Answer 16

Constrictive pericarditis

-> replacement of pericardial space with a dense collagen or calcified collagen (dense shell)

Question 17

What are the clinical results of constrictive pericarditis?

Answer 17

Dense shell causes impaired cardiac diastolic filling and a reduction in cardiac output

Question 18

What is adhesive mediastinopericarditis and what does it follow?

Answer 18

Fibrous attachment of parietal pericardium to surrounding mediastinal structures, forcing an incresaed cardiac workload, causing cardiac hypertrophy / dilatation

Most often follows mediastinal radiation / surgery, but can follow purulent / caseous pericarditis

Question 19

What is the most frequent cardiac neoplasm of adults, and and is it benign or malignant?

Answer 19

Myxoma - benign

Question 20

Where are myxomas found, and what do they look like grossly and microscopically?

Answer 20

Location - atrium, most commonly left atrium, grossly hanging off the wall as a single, polyploid, gelatinous mass

Microscopically - Scattered, spindle-shaped / stellate cells like fibroblasts which are living in a prominent myxoid matrix (secreting extracellular proteoglycans)

Question 21

What are the possible complications of myxoma?

Answer 21

1. Valvular obstruction / injury - seems like mitral stenosis, can injure like a wrecking ball
2. Tumor embolization -
3. Cytokine-mediated symptoms - inflammation caused by immune response

Question 22

What is the most common cardiac tumor in children? Describe it. What disease is associated?

Answer 22

Rhabdomyoma - bulging, intramyocardial hamartoma (derived from cardiac myocytes)

-Tuberous sclerosis is the common association

Question 23

What are the potential complications of rhabdomyoma and when are they most severe?

Answer 23

Valvular or cardiac outflow obstruction because they can be very large relative to the heart, can also cause arrhythmias since they are in the walls

Most severe early on as they are congenital, but as heart grows they do not -> become less problematic overtime

Question 24

Name the cardiac tumor which is an aggregate of myxoid, fibrillary processes located on the upstream valvular surface (i.e. atrium in an AV valve). What is its main complication?

Answer 24

Papillary fibroelastoma

Complication - embolization

Question 25

What types of tumors can metastasize to the heart? and where do they typically spread?

Answer 25

Carcinomas nearby (i.e. lung / breast)
Melanoma (can go anywhere)
WBC malignancies like leukemias / lymphomas

Question 26

When tumors metastasize to the heart, where do they most commonly spread to and what are the complications of this?

Answer 26

Typically the pericardial surfaces

Complications -> cardiac constriction, or hemorrhagic pericardial effusion due to formation of new blood vessels

Question 27

How can mediastinal malignancies interfere with heart function even without metastasis?

Answer 27

Block the emptying of SVC -> congestion / edema of head, neck, and arms

Question 28

How do hepatocellular and renal cell carcinoma interfere with heart function?

Answer 28

Venous extension can crawl like a snake up the vessels and obstruct the IV

Question 29

How can pulmonary tumor emboli cause heart problems?

Answer 29

Metastasis to lungs increased pulmonary pressures -> RV failure

Question 30

What types of cancers commonly cause nonbacterial thrombotic endocarditis (NBTE)?

Answer 30

Mucinous adenocarcinomas, especially pancreatic

Question 31

How can lymphomas / leukemias cause heart problems via tumor mediators?

Answer 31

Amyloidosis -> overproduction of lambda light chain -> deposition in heart

Question 32

What are the three primary etiologies of congestive heart failure (in a broad sense)?

Answer 32

1. Decreased myocardial contractility - i.e. ischemic heart disease, drug toxicities like doxorubicin
2. Increased resistance to ventricular filling / ejection - cardiac tamponade, severe HTN, aortic stenosis, coarctation
3. Systemic diseases - hyperthyroidism, severe anemia

Question 33

What is the end result of how the heart looks in all forms of congestive heart failure?

Answer 33

May be initial hypertrophy depending on etiology, but ultimately -> chamber dilatation

Question 34

What physical exam finding is auscultated in the lungs with severe left-sided heart failure?

Answer 34

Rales -> due to intra-alveolar transudative edema due to pulmonary congestion and backup of fluid

Question 35

What are heart failure cells?

Answer 35

Hemosiderin-laden macrophages caused by phagocytosis of micro-hemorrhages in chronic lung congestion

Question 36

How do the kidneys worsen left-sided heart failure?

Answer 36

Decreased renal perfusion leads to activation of RAA system, leading to further fluid retention and worsening pulmonary edema

Question 37

What happens to the brain in left-sided heart failure?

Answer 37

Hypoxic encephalopathy -> often manifests as confusion

Question 38

Right-sided heart failure is most common caused by left-sided failure first. What is it called when right-sided failure is caused by significant pulmonary disease?

Answer 38

Cor pulmonale

Question 39

Identify the manifestions of heart right-sided heart failure in each of the following locations:

1. Liver
2. Spleen
3. Subcutaneous soft tissue
4. Pleura, pericardium, &/or peritoneum

Answer 39

1. Liver - nutmeg liver -> centrilobular passive congestion
2. Spleen - increased portal pressure -> splenic congestion -> splenomegaly
3. Subcutaneous soft tissue - dependent edema
4. Pleura, pericardium, &/or peritoneum - transudative effusions (fluid buildup)