1. Cardiovascular Pathology Case Analysis Prepared by Rodelio D. Lim, M.D. with Pathology Course Committee SY 2009-2010

2. Objectives 1.To analyze common cardiovascular clinical situations utilizing the basic principles of pathology 2.To recognize and describe the common cardiovascular lesions 3.To explain the pathogenesis of these lesions 4.To make a clinico-pathologic correlation

3. Case No. 1 A 20 year old female was admitted to a hospital because of progressive dyspnea which was first noticed one month prior to admission. This was accompanied by easy fatigability. Past history showed that she had recurrent sore throat for the past 6 years accompanied by episodes of low grade fever and joint pains.

4. 1.Explain the possible physiologic basis for the signs and symptoms of the patient 2.Make hypotheses to explain the signs and symptoms utilizing basic principles of pathology as: - A daptive change - Cell injury/death - Inflammation/Immune response - Hemodynamic changes - Neoplastic

5. Physical examination showed the following: 1.Prominent neck veins 2.Enlarged heart with systolic and diastolic murmurs over the mitral valve area 3.Crackles over both lung fields 4.Palpable liver 5.Bipedal edema Utilizing the principles of basic pathology particularly fluid and hemodynamic changes, explain the pathogenesis of these physical signs.

6. Which of these two pictures of the mitral valve explains the heart findings of the patient? Indicate and describe the lesions.

7. View of a mitral valve from the opened left atrium. Which of the hearts in the previous slide would correspond with this view of the mitral valve?

8. 1.Utilizing the basic principles of pathology esp. inflammation and repair, explain the pathogenesis of the mitral valve lesions. 2.Based on the structural changes of the mitral valve you have identified and described, explain the pathophysiology of the murmurs.

9. Section of the lung. The asterisk and arrows indicate the significant lesions. Identify and describe the lesions. *

10. The gross and histology of the liver. Identify and describe the lesion. Correlate the gross and microscopic features.

11. 1.Discuss briefly the etiopathogenesis of the previous lung and liver lesions in the context of left- and right-sided heart failure. 2.Discuss briefly the physiologic basis for heart failure in this case using the basic principles of cell adaptation and injury/death.

12. Make a clinico-pathologic correlation (final hypothesis), which includes the following: 1.Pathophysiologic explanation of the signs and symptoms of the patient based on the lesions identified 2.If the patient died, explain the probable cause of death.

13. Further investigation revealed that at age 12, she was diagnosed by a physician as having acute rheumatic fever. Medications were prescribed but compliance was poor. The next set of slides illustrates the pathology of the heart at that time.

14. Gross and microscopic appearance of the mitral valve. Identify and describe the lesions. Discuss the pathogenesis using the basic principles of pathology.

15. Section of the myocardium. Identify and describe the lesion. Discuss its pathogenesis using basic principles of pathology, esp. the concept of immune response.

16. Gross and microscopic of the pericardium. Identify and describe the lesion. Discuss the pathogenesis using the basic principles of pathology esp. concept of inflammation.

17. 1.Discuss possible complications of infectious endocarditis complicating chronic rheumatic valvular disease. 2.Discuss the physiologic consequences of the perforations of the aortic and mitral valves.

18. Mitral valve prolapse is another common lesion that involves the mitral valve and may present clinically as a murmur. Identify and describe the lesion. Discuss the pathogenesis of the lesion. Discuss possible short and long term complications of the lesion.

19. Case No. 2 A 60 year old man had episodes of chest pains for the past 5 years experienced especially while engaged in stressful mental and physical activities. The chest pains were relieved after taking vasodilators prescribed by a physician. He is a known hypertensive for the past 12 years and a chronic smoker (40 pack years). The night of his death, while eating and drinking heavily with some friends, he complained of heaviness of the chest and collapsed. He was rushed to a nearby hospital, where despite resuscitation (with defibrillation), the patient was pronounced dead after 15 minutes.

20. Which of these 2 pictures of the coronary arteries best explains the episodes of chest pains of the patient? Identify and describe the lesions using the basics principles of pathology.

21. Which of these 2 pictures of the coronary arteries with their corresponding X-sections (insets) best explain the sudden demise of the patient despite resuscitative efforts? Can the other picture also be a cause of sudden death? Explain.

22. Discuss the pathogenesis of both arterial lesions using the basic principles of pathology. What are the risk factors and why?

23. A section of the left ventricle. Identify and describe the lesions. Discuss the pathogenesis using the basic principles of pathology.

24. The next picture is the heart of a hypertensive patient who survived an acute episode of acute myocardial infarction of the left ventricle. After one year despite medications, he again experienced severe chest pain and collapsed, and died shortly thereafter.

25. Identify and describe the lesions. Discuss the possible mechanisms of sudden death in the context of the lesions seen using the basic principles of pathology esp. cell injury/death.

26. All the features seen in the next set of pictures were seen in different areas of the left ventricle. Do the following: 1.Identify and describe the lesions 2.Discuss the pathogenesis of the lesions using basic principles of pathology 3.Again, using basic principles of pathology, explain how each of these lesions could have contributed to the sudden cardiac death of the patient.

27. ABC

28. Case No. 3 A 24 year old male developed fever of 38.5 º C accompanied by cough and malaise. He just stayed home and took symptomatic treatment at the advise of a doctor friend. After four days when his temperature was 37º C and other signs and symptoms had subsided, and at the prodding of his friends, he decided to play basketball with them. After 10 minutes of playing, he developed weakness and dizziness and, subsequently, collapsed. He was rushed to a hospital where he was pronounced dead on arrival.

29. The gross and microscopic appearance of the heart. Identify and describe the lesions. Explain the signs and symptoms and the pathophysiologic mechanism for the sudden death of the patient utilizing the basic principles of pathology esp. loss of function of a cell in inflammation.

30. The next series of slides show the more common congenital anomalies. These are: 1.Atrial septal defect 2.Ventricular septal defect 3.Tetralogy of Fallot 4.Coarctation of the Aorta 5.Patent ductus arteriosus

31. This diagram depicts an atrial septal defect (ASD) of the secundum type. There is a left-to- right shunt, but the lower atrial pressures make this type of defect not as severe as most other types of congenital heart disease. In the region of the foramen ovale on the interatrial septum is a small atrial septal defect, as seen in this heart opened on the right side. Here the defect is not closed by the septum secundum, so a shunt exists across from left to right.

32. View from the Right atrium Atrial Septal Defect View from the Left atrium

33. This diagram depicts a ventricular septal defect (VSD) in the membranous septum. There is a left- to-right shunt, the severity of which depends upon the size of the defect. Over time, about half will close spontaneously. Persons with VSD's (as with most cardiac defects) are at greater risk for infective endocarditis. This is the heart of a premature stillborn with Trisomy 13 in which a ventricular septal defect is visible in the membranous septum. About 90% of VSD's are in the membranous septum and 10% in the muscular septum.

34. Views from the Left Ventricle Ventricular Septal Defect

35. This diagram depicts the features of Tetralogy of Fallot: 1. Ventricular septal defect; 2. Overriding aorta; 3. Pulmonic stenosis; 4. Right ventricular hypertrophy. The obstruction to right ventricular outflow creates a right-to-left shunt that leads to cyanosis. Tetralogy of Fallot viewed from the right ventricle showing overriding of the aorta, ventricular septal defect and right ventricular hypertrophy. Pulmonic stenosis is not seen from this view.

36. The diagram and pictures depict a patent ductus arteriosus. The ductus ordinarily closes soon after birth. If it remains open, a left-to-right shunt results. Unopened Opened

37. This diagram depicts an aortic coarctation of the post-ductal (adult type) variety. There is aortic outflow obstruction, leading to increased pulse pressures in upper body and extremities, while pulse pressures in the lower extremities are reduced. Increased collateral circulation through intercostal arteries can result in "rib notching". This fetal heart demonstrates an aortic coarctation of the pre-ductal (infantile) variety. There is aortic outflow obstruction, leading to aortic root dilation. The pulmonic trunk is also visible. This female fetus was found to have a 45, X karyotype, consistent with Turner's syndrome. Congenital anomalies often include the heart.

38. Coarctation of the Aorta. The aorta is opened longitudinally revealing a coarctation. In the region of the narrowing, there is increased turbulence of blood flow leading to atherosclerosis.

39. 1.Which of these congenital heart disease in the course of time will develop pulmonary hypertension? 2.Discuss briefly the pathogenesis of pulmonary hypertension. The next slide depicts the 4 grades of pulmonary arteriolar change leading to pulmonary hypertension. Identify and describe the lesions. Pictures depicting grades 1-3 were stained with Van Gieson’s stain.

40. Grade 1Grade 2 Grade 3 Grade 4

41. Using basic principles of pathology, discuss briefly the pathogenesis of the 4 grades of the lesion esp., the adaptive response of cells to stress or injury.

42. THE END