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Cardiovascular Module

Faculty of Medicine and Surgery


Department of Pathology
Cardiovascular Pathology

Case Analysis

Rodelio D. Lim, MD
Alejandro E. Arevalo, MD
Objectives
2. To analyze cardiovascular clinical
situations utilizing the principles of
science
3. To recognize and describe the
common cardiovascular lesions
4. To explain the pathogenesis of these
lesions utilizing the basic principles
of pathology
5. To make a clinico-pathologic
correlation
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.
1. State the problem/s from the
patient’s and your points of view
2. State the facts
3. Make hypotheses to explain the
problems (both points of view)
utilizing basic principles of
pathology
Physical examination showed the following:
2. Prominent neck veins
3. Enlarged heart with systolic and diastolic
murmurs over the mitral valve area
4. Crackles over both lung fields
5. Palpable liver
6. Bipedal edema

Utilizing the principles of fluid and


hemodynamic changes, explain the
pathogenesis of these physical signs.
While in the hospital, the dyspnea became
severe and the patient died shortly
thereafter.
2. Explain the possible direct or immediate
cause of death
3. Explain the possible contributory causes
of death
Which of these two pictures of the mitral valve explains
the heart findings of the patient? Indicate and describe
the lesion.
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?
1. Utilizing the basic principles of
inflammation and repair, explain the
pathogenesis of the mitral valve
lesions.
2. Based on the structural changes of the
heart you have identified and
described, explain the pathophysiology
of the murmurs.
Section of the lung. Identify and describe the
lesion. Discuss the pathogenesis of this lesion.
The gross and histology of the liver. Identify and describe
the lesion. Correlate the gross and microscopic features.
Discuss the pathogenesis.
Make a clinico-pathologic correlation (final
hypothesis), which includes the following:
2. Pathophysiologic explanation of the
signs and symptoms of the patient based
on the lesions identified
3. Direct or immediate cause of death.
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.
Gross and
microscopic
appearance of the
mitral valve. Identify
and describe the
lesion..
Section of the
myocardium (LP &
HP).
Identify and
describe the lesion.
Gross and
microscopic of the
pericardium.
Identify and
describe the lesion.
1. Using the basic principles of pathology,
discuss the pathogenesis of the lesions
identified in the:
- Mitral valve
- Myocardium
- Pericardium.
2. Based on the pathologic lesions identified,
discuss the possible physiologic alterations
of the heart and their corresponding clinical
signs and symptoms.
As a consequence of the mitral valve lesion, a complication
can occur in the left atrium as indicated by the arrow.
Classify the lesion and discuss the pathogenesis. Give the
most common consequence of this lesion.
Chronic rheumatic heart
disease may also
involve the aortic valve
and may be further
complicated by
infectious endocarditis.
Identify and describe the
lesion. In the lower
picture, the probe goes
through a perforation of
one of the aortic cusps
and the arrow shows a
perforation through one
of the leaflets of the
mitral valve.
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.
Mitral valve prolapse is
another common lesions
that involves the mitral valve
and may present clinically
as a murmur. Identify and
describe the lesion.
Discuss the pathogenesis of
the lesion. What kind of
degenerative change occurs
in the leaflets?
Discuss possible short and
long term complications of
the lesion.
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 work. 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.
1. State the problem/s from the
patient’s and your points of view
2. State the facts
3. Make hypotheses to explain the
problems (both points of view)
utilizing basic principles of
pathology
Which of these 2 pictures of the coronary arteries best explains
the episodes of chest pains of the patient? Identify and describe
the lesions in both pictures.
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.
Which of these 2 pictures is expected to be seen
in the heart of this patient? Explain. Identify and
describe the lesion.
1. Using basic principles of pathology,
discuss briefly the etiopathogenesis of
the lesions in both pictures taking into
consideration the risk factors present in
the patient.
2. Discuss briefly the mechanism of chest
pain.
This is the heart of a patient with similar signs and
symptoms and coronary lesions but was revived and
died after 3 days. Identify and describe the lesion.
Discuss briefly the possible mechanisms of death.
Which of these 3 pictures corresponds to the gross heart in
the previous slide? Explain. Identify and describe the lesions
in all the pictures. Can these lesions also be seen in the
patient’s heart? Explain.
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. An autopsy was performed.
1. State the problem/s from the
patient’s and your points of view
2. State the facts
3. Make hypotheses to explain the
problems (both points of view)
utilizing basic principles of
pathology
Which of these 2 hearts best correlates with the
sudden death of the patient taking into consideration
the age and history of the patient ? Identify and
describe the lesions in both heart.
Match these 2 microscopic sections with the gross
hearts in the previous slide. Identify and describe
the lesions.
1. Using the basic principles of pathology,
discuss the possible etiopathogenesis
of the lesions in both hearts.
2. Can both lesions cause sudden death?
3. Discuss briefly the possible
pathophysiologic mechanisms for the
sudden death in each lesion.
4. Make a clinico-pathologic correlation
The arrow indicates a complication seen in
this kind of cardiac pathology. Identify and
describe. Discuss briefly the pathogenesis.
The next series of slides show the more
common congenital anomalies. These
are:
2. Atrial septal defect
3. Ventricular septal defect
4. Tetralogy of Fallot
5. Coarctation of the Aorta
6. Patent ductus arteriosus
In the region of the foramen ovale on the
This diagram depicts an atrial interatrial septum is a small atrial septal defect,
septal defect (ASD) of the as seen in this heart opened on the right side.
secundum type. There is a left-to- Here the defect is not closed by the septum
right shunt, but the lower atrial secundum, so a shunt exists across from left to
pressures make this type of defect right.
not as severe as most other types
of congenital heart disease.
Atrial Septal Defect

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

Views from the


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

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.

Opened
This diagram depicts an aortic
coarctation of the post-ductal (adult This fetal heart demonstrates an aortic
type) variety. There is aortic outflow coarctation of the pre-ductal (infantile)
obstruction, leading to increased pulse variety. There is aortic outflow
pressures in upper body and obstruction, leading to aortic root dilation.
extremities, while pulse pressures in The pulmonic trunk is also visible. This
the lower extremities are reduced. female fetus was found to have a 45, X
Increased collateral circulation through karyotype, consistent with Turner's
intercostal arteries can result in "rib syndrome. Congenital anomalies often
notching". include the heart.
The aorta is opened longitudinally revealing a coarctation.
In the region of the narrowing, there was increased
turbulence that led to increased atherosclerosis.
1. Which of these congenital heart diseases in
the course of time will lead to 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.
Grade 1 Grade 2

Grade 3 Grade 4
Using basic principles of pathology,
discuss briefly the pathogenesis of
the 4 grades of the lesion.
Life begins with a heart beat . . . . . .
……… and ends in a heart beat.