Atlas of Cardiovascular Pathology PDF
Preview Atlas of Cardiovascular Pathology
Atlas of Cardiovascular Pathology To A.S.G. Current Histopathology Consultant Editor Professor G. Austin Gresham, TO, ScO, MO, FRC Path. Professor of Morbid Anatomy and Histology, University of Cambridge Volume Twelve &u[1&~ @~ CARDIOVASCULAR PATHOLOGY BY E. G. J. OLSEN, MO, FRC Path., FACC Consultant Pathologist National Heart Hospital. London assisted by R. A. FLORIO, FIMLS National Heart Hospital. London .M.TP PRESS LI.M.ITED ~ ~ a member of the KLUWER ACADEMIC PUBLISHERS GROUP . LANCASTER / BOSTON / THE HAGUE / DORDRECHT Published in the UK and Europe by MTP Press Limited Falcon House Queen Square Lancaster. England © Copyright 1987 E. G. J. Olsen Softcover reprint of the hardcover 1s t edition 1987 All rights reserved. No part of this publication may be reproduced. stored in a retrieval system. or transmitted in any form or by any means. electronic. mechanical. photocopying. recording or otherwise. without prior permission from the publishers. British Library Cataloguing in Publication Data Olsen. E. G. J. Atlas of cardiovascular pathology. - (Current histo pathology; v.12) 1. Cardiovascular system - Diseases - Atlases I. Title II. Florio. R. A. III. Series 616.1'0022'2 RC669 ISBN-13: 978-94-010-7940-2 e-ISBN-13: 978-94-009-3209-8 001: 10.1007/978-94-009-3209-8 Published in the USA by MTP Press A division of Kluwer Academic Publishers 101 Philip Drive Norwell. MA 02061. USA Library of Congress Cataloging in Publication Data Olsen. E. G. J. (Eckhardt G. J.) Atlas of cardiovascular pathology (Current histopathology; v. 12) Includes bibliographies and index. 1. Heart-Diseases-Atlases. 2. Histology. Pathological-Atlases. I. Florio. R. A. II. Title. III. Series. [DNLM: 1. Heart-pathology-atlases. WI CU788JBA v.12 /WG 17 052al RC682.9.047 1987 616.1'207 86-27533 Phototypesetting by Titus Wilson. Kendal. Colour origination by Laserscan. Stretford. Manchester. Bound by Butler and Tanner Ltd .. Frome and London. Contents Consultant Editor's Note 7 Acknowledgements 8 Preface 9 1 The normal heart 11 2 Hypertropy and dilatation 31 3 Changes in the endocardium 37 4 Degeneration, deposition and diseases of connective tissue 42 5 Ischaemic heart disease and myocardial infarction 53 6 Rheumatic heart disease 64 7 Infective endocarditis 69 8 Myocarditis and pericarditis 74 9 Cardiomyopathies 86 10 Neoplasms of the heart and pericardium 100 11 Arterial diseases 107 12 Pulmonary hypertension 117 Index 128 Current Histopathology Series Already published in this series: Volume 1 Atlas of Lymph Node Pathology Volume 2 Atlas of Renal Pathology Volume 3 Atlas of Pulmonary· Pathology Volume 4 Atlas of Liver Pathology Volume 5 Atlas of Gynaecological Pathology Volume 6 Atlas of Gastrointestinal Pathology Volume 7 Atlas of Breast Pathology Volume 8 Atlas of Oral Pathology Volume 9 Atlas of Skeletal Muscle Pathology Volume 10 Atlas of Male Reproductive Pathology Volume 11 Atlas of Skin Pathology Other volumes currently scheduled in this series include the following titles: Atlas of Articular Pathology Atlas of General Cytology Atlas of Connective Tissue Pathology Atlas of Neuropathology Atlas of Ophthalmic Pathology Atlas of Experimental Toxicological Pathology Consultant Editor's Note At the present time books on morbid anatomy and histo niques which should be within the compass of the logy can be divided into two broad groups: extensive worker in a unit with reasonable facilities. textbooks often written primarily for students and mono (3) New types of material. e.g. those derived from graphs on research topics. endoscopic biopsy should be covered fully. This takes no account of the fact that the vast majority (4) There should be an adequate number of illustra of pathologists are involved in an essentially practical tions on each subject to demonstrate the variation field of general Diagnostic Pathology providing an in appearance that is encountered. important service to their clinical colleagues. Many of (5) Colour illustrations should be used wherever they these pathologists are expected to cover a broad range aid recognition. of disciplines and even those who remain solely within The present concept stemmed from this definition but the field of histopathology usually have single and sole it was immediately realized that these aims could only responsibility within the hospital for all this work. They be achieved within the compass of a series, of which may often have no chance for direct discussion on prob this volume is one. Since histopathology is, by its very lem cases with colleagues in the same department. In nature, systemized, the individual volumes deal with the field of histopathology, no less than in other medical one system or where this appears more appropriate with fields, there have been extensive and recent advances, a single organ. not only in new histochemical techniques but also in the This atlas of cardiovascular pathology is a valuable type of specimen provided by new surgical procedures. addition to the Current Histopath%gyseries. It reflects There is a great need for the provision of appropriate the increasing use of new methods in diagnostic work information for this group. This need has been defined and illustrates the importance of proper preparation of in the following terms. specimens together with a detailed clinicopathological (1) It should be aimed at the general clinical patholo correlation in order to enhance diagnostic success. gist or histopathologist with existing practical train Cardiovascular disease confronts every pathologist. ing, but should also have value for the trainee This well illustrated comprehensive volume will be a pathologist. useful bench manual in pathology laboratories. (2) It should concentrate on the practical aspects of G. Austin Gresham histopathology taking account of the new tech- Cambridge Acknowledgements I gratefully acknowledge the co-operation of The Mac millan Press Limited who have permitted me to repro duce previously published illustrations and tables. My thanks are also due to those colleagues who have supplied me with material for illustration. I am gratefully indebted to Miss P. J. Higham for typing the entire manuscript and to Mr B. Richards for his help with the photographs. Preface Pathology in general is closely linked with clinical medi cardiographic changes may be desired and therefore a cine and in cardiovascular pathology this interdepend short section has been included on cutting the heart ence is, perhaps, greater than in most other specialities. according to conventionally used echocardiographic In recent years great advances in investigatory proce planes. dures have taken place, including the examination of The heart can only react to physiological changes or fresh endomyocardial tissue obtained by bioptome, per damage in a limited way and therefore a separate chapter mitting not only clinico-pathological correlation but also on hypertrophy and dilatation and another chapter deal examination at histochemical and ultrastructural levels. ing with changes in the endocardium, which reflect hae Angiography has gained wider usage and two-dimen modynamic alteration and may additionally show sional echocardiography is no longer the preserve of diagnostic features, are also included. Degeneration to specialized units. Percutaneous coronary transluminal gether with changes in connective tissue and ischaemic angioplasty is a relatively new approach to relieving heart disease are separately presented. Atherogenesis, obstructive coronary artery disease. Cardiac pathology recognition of myocardial infarction and the earliest mor has therefore moved apace, providing not only a back phological changes discernible at histochemical and ground to clinical manifestations but also visual proof for ultrastructural levels of investigation, which are within other investigations such as immunology and virology. the scope of modern routine laboratories, are empha Such investigations have played an essential role in sized. establishing pathogenetic mechanisms for diseases Recently, great advances have been made in our un such as cardiomyopathies. derstanding of myocarditis, facilitated by the evaluation Changes in the pattern of disease have also taken of sequential biopsies. This has permitted diagnostic place with, for example, a decrease in rheumatic heart criteria to be established, a new definition to be formu disease in industrialized countries. Portals of entry and lated and a classification to be proposed. The intimate infective agents in infective endocarditis have also relationship of myocarditis with dilated cardiomyopathy changed. However, despite sophisticated techniques of has been detailed and additional reference to investiga recognition and up-to-date therapeutic approaches, tory studies using molecular virological techniques has endocarditis has remained a world problem. Separate been made. Similar advances in endomyocardial disease chapters have been dedicated to these topics. related to eosinophilia have been highlighted. The aim of an atlas is to link the written word with Chapter 10 deals with neoplasms of the heart and pictorial representation of disease but, in this volume, pericardium and Chapter 11 with common and rare the text also includes a summary of the background and diseases of the arteries. A chapter on pulmonary hyper advances made and, where appropriate, a classification. tension combining angiographic and morpholgical Key references are cited so that this short volume is a changes, and also incorporating a large section on the complete overview of the topics under discussion. normal pulmonary vasculature, completes this book. A large section has been devoted to the normal heart. The topics of this Atlas have been carefully chosen Detailed knowledge of the anatomy, microscopy and and, in order to avoid repetition of other publications, ultrastructure is essential to understand and interpret congenital heart disease and the changes following the changes which occur in diseases and which, more surgery have been omitted. often than not, can be subtle. There is no routine proce This Atlas is principally directed to pathologists in dure for opening the heart as this is dependent on the practice or in training but it is also hoped that it will be possible future procedures that are planned, such as of value to physicians and surgeons and other workers morphometric analysis. The conventional procedure, engaged in the study of the heart. It is also hoped it that of 'following the blood stream', is however detailed. will be of help to teachers, at both postgraduate and Pathological correlation and the interpretation of echo- undergraduate levels. 1 The Normal Heart It is not the purpose of this atlas to detail the various External Landmarks techniques of postmortem examination for which the Ventral View reader is referred to specialized texts, but to concentrate Place the heart in the normal anatomical position. Ident on the removal of the heart from the lungs after the ify the following structures: the aorta, the pulmonary rib cage has been opened. The heart can be removed trunk, right and left atrial appendages, right and left following removal of the thoracic viscera (Figure 1.1 a). pulmonary veins. anterior longitudinal sulcus. right cor It is appropriate to follow the time-honoured dictum onary sinus. acute margin. obtuse margin. apex and 'never touch or cut before inspection'. incisura apicis cordis and the superior vena cava. See Inspect the outer surfaces of the pericardium. Identify Figure 1.2. the pulmonary veins. In cases of suspected pericarditis, it is advisable to secure a swab for bacterial (or viral) investigation. Any Dorsal View fluid accumulation should be carefully measured; 5- Identify the orifice of the inferior vena cava, right and 10 ml of clear, pale, yellow fluid is normal but pericardial left atria. pulmonary veins. coronary sinus and posterior effusion is usually deemed to be present if the fluid longitudinal sinus. right and left ventricles (Figure 1.3). accumulation in the pericardial cavity exceeds 50 ml of It will be noted that anteriorly the heart is mainly fluid. The pericardium should then be opened fully by composed of the right atrium and right ventricle with only fashioning an inverted T-incision (Figure 1.1 b). Separation a small portion of the left ventricle showing, whereas. of any adhesions may require sharp dissection. Once the posteriorly equal portions of right and left atria and pericardium has been deflected, further inspection can ventricles can be identified. now be undertaken. The coronary arteries should then be gently palpated. Examination of Coronary Arteries If extensive calcification is present it is often wiser not to proceed further but, after separation of the heart Reference has already been made to dealing with the from the lungs, large segments of the affected coronary coronary arteries in which calcification can be felt. If no arterial tree can be removed and decalcified and further abnormalities are observed sectioning at half centimetre examination can then be undertaken. The pulmonary intervals along the course of the arteries at right angles trunk should be incised with care to avoid dislodgement to the lumen can now be undertaken at this stage or of any possible pulmonary embolus. The heart can now deferred after opening the cardiac chambers. be removed. If ischaemic heart disease or cardiac infarction is sus The pericardium should then be fully opened and the pected the coronary arteries should be injected with aorta and pulmonary trunk are now displayed (Figure radio-opaque material before opening the heart. This can 1.1 c). The pericardium is then trimmed around the in be achieved by manual injection or by an adaptation of ferior vena cava. Place the index finger and middle finger the apparatus designed for injecting pulmonary vascula in close apposition into the transverse sinus of the per ture (Figure 1.4). The bottles containing water and formal icardial cavity and divide the aorta and pulmonary trunk saline can be raised or lowered to the diastolic pressure between these two fingers. If this simple technique during life. A normal coronary arteriogram is illustrated is followed a uniform length of great vessels for the in Figure 1.5. particular examiner is assured. To identify the pulmonary It may be necessary to study individual coronary arter veins the apex of the heart should be firmly gripped and ies in detail. The heart is then opened as follows: the pulled up so that the pulmonary veins are under slight origins of the right and left coronary arteries are identified tension (Figure 1.1 d). By retaining the grip on the cardiac and for the apex a cut is made as close as possible apex the atria should be gently freed from adhesions to the interventricular septum anteriorly through the and the pericardial reflection should be divided. Working ventricles and as close as possible to the origin of the towards the right side of the heart taking care not to coronary arteries. The right ventricle is then unfolded damage the bronchus or right pulmonary artery, the and the right coronary artery can then be X-rayed (Figure superior vena cava and right pulmonary veins should be 1.6). The left ventricle and vessels of the interventricular identified, freed from surrounding tissue and should then septum can be separately evaluated. be divided. The last cut through the inferior cava is then made if the heart is removed in situ, or after organs Opening of the Heart have been removed en bloc according to the Rokitansky method. The heart is now free 1. There is no 'routine' procedure for opening the heart. Abnormalities such as stenosed valves should be left intact and adaptations are necessary. depending on the 11
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