Download ventricular septal defect (VSD)

Cardiovascular Pathology
Case Analysis
Prepared by
Rodelio D. Lim, M.D.
with
Pathology Course Committee
SY 2009-2010
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
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. 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:
- Adaptive change
- Cell injury/death
- Inflammation/Immune response
- Hemodynamic changes
- Neoplastic
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.
Which of these two pictures of the mitral valve explains the
heart findings of the patient? Indicate and describe the
lesions.
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 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.
Section of the lung. The asterisk and arrows indicate
the significant lesions. Identify and describe the lesions.
*
The gross and histology of the liver. Identify and describe
the lesion. Correlate the gross and microscopic features.
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.
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.
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 lesions. Discuss the pathogenesis
using the basic principles of pathology.
Section of the myocardium. Identify and describe the
lesion. Discuss its pathogenesis using basic principles
of pathology, esp. the concept of immune response.
Gross and microscopic
of the pericardium.
Identify and describe
the lesion. Discuss the
pathogenesis using the
basic principles of
pathology esp. concept
of inflammation.
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 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.
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.
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.
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.
Discuss the pathogenesis of both arterial lesions
using the basic principles of pathology. What
are the risk factors and why?
A section of the left ventricle. Identify and describe the
lesions. Discuss the pathogenesis using the basic
principles of pathology.
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.
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.
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.
A
B
C
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.
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.
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
This diagram depicts an atrial
septal defect (ASD) of the
secundum type. There is a left-toright 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.
Atrial Septal Defect
View from the Right atrium
View from the Left atrium
This diagram depicts a ventricular
septal defect (VSD) in the
membranous septum. There is a leftto-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.
Ventricular Septal Defect
Views from the
Left Ventricle
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.
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
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.
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.
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.
Grade 1
Grade 2
Grade 3
Grade 4
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.
THE END