Morphologic Compensatory Mechanisms in the Heart

Peter B. Baker, M.D.

Cardiopulmonary Block Objectives

Describe the pathologic changes in the cardiac chambers when subjected to a chronic pressure and/or volume load by various causes of heart disease Define compensated and decompensated heart disease by pathologic characteristics with particular attention to the ventricles

Specific Lecture Objectives

1. Describe the morphologic features of hypertrophy and dilation at the gross, histologic and ultrastructural levels 2. Define the term remodel as it relates to compensatory changes 3. Understand the concept of compensated heart disease 4. Describe the features of compensated and decompensated hypertensive heart disease.

Compensatory Changes in Congestive Heart Failure Hypertrophy

Handout I.B

Remodeling General term that refers to changes in gross and/or microscopic morphology of the heart Hypertrophy Increased heart weight and size of myocardial cells in response to pressure or volume overload Myofibrils added in parallel Patterns of hypertrophy Concentric increased muscle mass with either no change, or small decrease in chamber volume Eccentric increased muscle mass which develops along with chamber dilation, so there are 2 things going on hypertrophy and dilation

Changes Associated with Myocardial Hypertrophy

Handout I.B.6

Altered protein synthesis Synthesis of abnormal proteins Fibrosis Inadequate blood supply due to decreased capillary density Altered handling of intracellular calcium
These alterations may eventually lead to reduced myocyte contractility and CHF

Normal Myocytes

Hypertrophic Myocytes

Mi

My

Compensatory Changes in Congestive Heart Failure Dilation

Handout I.C

Dilation Increase chamber size in response to increase volume or pressure/volume load Sarcomeres added in series Hypertrophy is always present with longstanding dilation Excessive dilation results in decreased wall thickness and increased wall tension

Compensated versus Decompensated Heart Disease

Handout I.D

Compensated hypertrophy, dilation and physiologic mechanisms are sufficient to maintain cardiac output Decompensated compensatory mechanisms no longer provide adequate cardiac output, CHF develops

Patterns of Compensatory Remodeling

Left Ventricle 1. Pure pressure overload concentric hypertrophy Examples - hypertensive heart disease - aortic stenosis 2. Pressure and volume overload eccentric hypertrophy Examples - mitral / aortic valve insufficiency - ventricular septal defect 3. Regional loss of myocardium eccentric hypertrophy Example - healed myocardial infarction

Hypertensive Heart Disease

Handout II.A

Compensated left ventricular concentric hypertrophy maintains adequate cardiac output

Decompensated hypertrophy no longer provides adequate cardiac output due to decreased myocardial contractility, resulting in LV dilation and gradual onset of CHF

LV

LV

Hypertensive Heart Disease

Handout II.A.2 Compensated Congestive Heart Failure LV Hypertrophy LV Dilation Increased Heart Weight Increased Heart Dimensions Increase LV Wall Thickness RV Hypertrophy & Dilation No Yes No Yes No Yes No Decompensated Yes Yes Yes* Yes Yes Yes or No Yes

*In some patients, marked LV wall stiffness leads to CHF with little ventricular dilation

Key Points
Morphologic compensatory changes hypertrophy and dilation and the term remodeling Compensated heart disease Pathologic features of compensated / decompensated hypertensive heart disease