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Pathology Of The Heart

By:Khalid Elsiddig Khalid

 Heart is considered as the site of emotions , strength , and Compassion. Aristotle Believed that heart is the seat of Soul! Mohammed Ibn Abd Allah ,peace and bless upon him , said in a prophetic Hadith what it means that (In the body there is a single organ if it becomes good , all the body is Better ,If it becomes bad , all the body will worsen)

 Heart is a muscular organ inside your chest ,its Main Physiological function is to Pump blood throughout the body. The heart Pumps about 6000 liters perday. Thus it maintains perfusion of tissues and their supply with oxygen and Nutrients , and Washing out the waste products to their site of excretion.

 Thus Diseases affecting the Heart affects all of the body. And Impaired Cardiac dysfunction can result in a devastating physiological consequences. Heart diseases are the most common Causes of mortality in the Industrial countries 40% of all Deaths. Twice as more as all mortality caused by all types of Cancer combined.

Heart Failure!!!
Is a state by which the heart is Unable to meet the body metabolic demands

Most commonly occur due to failure of myocardial contractility Systolic dysfunction. Can also occur due to filling defects Diastolic failure,.esp in Diabetic and Hypertensive women. Valvular disease i.e(infective endocarditis). Circulatory Over Load. High output cardiac failure

CONGENITAL HEART DISEASES 2

By: Khalid Elsiddig Khalid

Right to left shunts

Cardiac malformations associated with right to left shunting ,are characterized By Cyanosis at birth or near time of Birth. This is because unoxygenated blood from the right side of the heart is introduced directly into the arterial circulation. Two of the most common Congenital Cyanotic diseases are : 1)Tetralogy of fallot 2)Transposition of the great vessels

Tetralogy of Fallot
5% of Congenital heart disease The most common cause of cyanotic heart disease Four features are VSD Aorta that over-rides VSD Obstruction of the out dflow tract of the right ventricle(sub pulmonioc obstructi9on) Hypertrophy of the right Ventricle

morphology
Due to anterioposterior dis-placement of the infundibular septum. Thus leads to abnormal division of the aortic and pulmonary roots

 The heart is large and boot shaped due to right ventricular hypertrophy. Proximal aortic arch enlargement with diminished Pulmonary trunk. The left side of the heart is NORMAL. Enlarged and thickened left ventricle may exceed that of the left part. VSD lies in the vicinity of the membranous part. Aorta just above the VSD.

 Rare extra findings in the tetralogy: 1. Pulmonary valve stenosis 2. ASD 3. PDA,.which may be helpful in the maintenance of the pulmonary circulation

Clinical features
The clinical severity depends on the degree of obstruction of the right venticular outflow tract The main pathology s increased aortic volume,.and decreased pulmonary blood flow If there is mild obstruction it can be as mild as Isolated VSD ,. If there is severe stenosis right to left shunting occurs NO PULMONARY HYPERTENSION. Because the lung is protected by pulmonary stenosis Hyperviscosity,Polycythemia , Hypertrophic osteoarthropathy,paradoxical embolism,infective endocarditis and brain abcessare common clinical findings.

Transposition of the great vessels

Due to discordant vascular association of the right and left heart,. Due to truncal and aortopulmonary septal defects,The aorta arises from the right ventricle. The pulmonary artery from the left.While the atria are normal Thus No pulmonary systemic anastomosis,

 A condition In compatible with post-natal life,Unless a shunt exists for adequate mixing of blood. Patients with TGA and VSD (35%) and tend to have a relatively stable shunt. While patients Patent foramen Ovale (ASD) , or PDA (65%) tend to have unstable shunts,..and tend to close within the first weeks, and require surgical Intervention.

Morphology
The main Pathology is the abnormal origin of the Aorta and the Pulmonary trunk. Varying degrees of VSD , ASD , PDA are seen in patients surviving beyond the Neonatal period. There is hypertrophy of the Right ventricle since it is the Systemic ventricle. The left Ventricle is somewhat atrophy ,because it only needs the force to eject blood in the low resistance Pulmonary circulation.

Clinical:
The main Clinical finding in pts of TGA is Cyanosis. The out look of Neonates with TGA depends on 1. The Degree of Shunting 2. The severity of the Hypoxia 3. The ability of the right Ventricle to maintain the Systemic circulation

Treatment
Correctional Surgery (Switching the great vessels ) within the first week Preservation of the ductal patency by Infusion of PGE . Atrial septostomy.

OBSTRUCTIVE CARDIAC CONGENITAL MALFORMATION LESIONS

BY:Khalid El siddig Khalid

 Obstruction of blood flow is a common pathological finding It can occur in the blood vessels , Valves and even Heart chambers(sub_Pulmonic stenosis in the Tetralogy of Fallot). Most Common forms are Aortic coarcitation , Pulmonary Valve stenosis , Aortic stenosis , and Aortic atresia.

CO-ARCITATION OF THE AORTA

Is defined as : Narrowing or constriction of the Lumen of the aorta. The most Important form of the Obstructive lesions. Accounts for 5% of all congenital heart anomalies Males have Twice risk compared to Females.

 However Turner Syndrome in Females is commonly associated with coarcitation of the Aorta. 2 forms of coarcitation have been pronounced 1. Infantile form: Aortic Hypoplasia proximal to the ductus arteriosis 2. Adult form : characterized By ridge like infolding of the aorta distal to the Ligamentoum arteriosum

Calcific Aortic Valve

Most common cause of aortic stenosis in the US. Occurs usually due to the aging process (wear and tear) Can be primary. Can be due to congenital Bi cuspid aortic valve Usuall patients of Bicuspid aortic valve are asymptomatic , 2 leaflets ,one is bigger with a central RAPHE

 More Prone to Calcification than Normal Valve. Can result in LHF , and CHF ,..and can complicate as Infective Endo carditis

Morphology
The hall mark of calcific aortic stenosis is Heaped up masses of Calcification. They protrude in the sinus of Valsalva and thus Impede valve opening. Commisural fusion isnt a common feature though calcific Valve may lead to fibrosis and thickening CONCENTERISC LEFT VENTRICULAR HYPERTROPHYIS A VERY PROMINENT FEATURE

CLINICAL FEATURES
Ischemia and Angina Syncope Systolic and diastolic dysfunction leads to CHF.

Mitral calcification
Is usually rare ,..the calcification mainly occurs in the Annunlus. Mainly Asymptomatic.,Unless the surrounding conductive system is involved

MYXOMATOUS MITRAL VALVE

Also called floppy or prolapsed mitral valve. The mitral valve hoods (balloons) inside the left atrium during Systole. Primary: Is due to primary Myxomatous degeneration of the Mitral valve 3-5% of the population. Women are more prone 7 times more than males.

 Secondary: Due to other underlying disease that causes mitral regurgitation (IHD).

MORPHOLOGY
Is characterized by Balloning or hooding of the mitral leaflets in the left atrium. The leaflets become ,Redundant , thickened snd rubbery.the cords also become thin and may rupture. The Fibrosa layer which gives the valve its Integrity is thinned , while thickening of the spongiosa layer in the Valve due to myxomatous degeneration. This occurs in both Primary or Secondary Mitral prolapse.

Pathogenesis
The basis of pathogenesis is unknown. -But is almost always associated with intrinsic connective tissue abnormalities Like fibrillin_1 in Marfan syndrome. Some additional hint to CT disease like scoliosis , and high arched palates are found.

 It is believed that this abnormal structural protein as a consequence of haemdynamic stree may lead to defective synthesis or catabolism , of the extracellular matrix. In secondary Mitral prolapse , the disease results from degenerative changes in the valve myofibroblast , responding to chronically aberrant haemodynamic forces.

CLINICAL FEATURES
Mostly Asymptomatic , discovered incidently in examination. Some may complain of Dyspnea , palpitation and Atypical chest pain. Mid systolic click due to tension of the valve leaflets. Most Cases are benign but 3% have complications

Complications
Significant Mitral regurgitation CHF Stroke Infective endocarditis Arrhythmia

Rheumatic Heart Disease

Rheumatic fever is an Acute Immunologically mediated multisystem inflammatory condition. It occurs after 2-3 weeks from Streptococcal Pharyngitis. Rarely after an skin infection. Mainly in children age 5-15 years.

 In the rescent years there is a decline in ARF , due to Rapid diagnosis and treatment of Pharyngitis , Decrease in the virulence of the organism, and Improved socioeconomic conditions. But in developing countries it is still a significant problem.

 Rheumatic heart disease has two forms 1.ARF:changes in A_Myocardium: degenarative area of eosinophi,ic matrix , Aschoff bodies (antischkow cells{macrophages with redundant cytoplasm ,and slender Central Chromatin ,Caterpillar cells} , T lymphocytes , some plasma cells). B_Valves :Fibrinoid necrosis and Aschoff bodies, and vegetations (Verrucae) due to fibrin deposition in erosed areas resulting in warts that have little effect in the heart.

 C_Pericardium: Fibrinous pericarditis. D-Endocardium: Vegetations , Mac Callum plaques (endocardial thickening in the left atrium ) ,