A Basic PowerPoint conversion : For study, sharing and download as a tool in preparation to sit for the USMLE Step

1 Source of Images Webpath- University of Utah Hypermedia Image Source Tables included
Conversion prepared and presented by Marc Imhotep Cray, M.D. Basic Medical Sciences Teacher

Webpath Hypermedia Source Tables

http://library.med.utah.edu/WebPath/CVHTML/CVIDX.html

Purpose
The purpose of this PowerPoint conversion is
1. To enable the learner to bring Webpath Cardiovascular Pathology image plates to their desktop for offline study 2. To contribute to mobile device viewing diversity 3. It serves as a part of the IVMS ANS and Cardiovascular
Pharmacology Sequenced Course Demonstration Open Demo

Normal Heart

Normal Heart
Normal heart, gross Normal aortic valve, gross Normal tricuspid valve, gross Normal coronary artery, microscopic Normal myocardium, medium power microscopic

Normal heart, gross

This is the external appearance of a normal heart.The epicardial surface is smooth and glistening. The amount of epicardial fat is usual.The left anterior descending coronary artery extends down from the aortic root to the apex

Normal tricuspid valve, gross

This is the tricuspid valve. The leaflets and thin and delicate. Just like the mitral valve, the leaflets have thin chordae tendineae that attach the leaflet margins to the papillary muscles of the ventricular wall below
6

Normal coronary artery, microscopic

This is a normal coronary artery. The lumen is large, without any narrowing by atheromatous plaque. The muscular arterial wall is of normal proportion

Normal myocardium, medium power microscopic

This is the normal appearance of myocardial fibers in longitudinal section. Note the central nuclei and the syncytial arrangement of the fibers, some of which have pale pink intercalated disks
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Atherosclerotic Cardiovascular Disease

Atherosclerotic Cardiovascular Disease (1)

Coronary artery with atherosclerotic narrowing, microscopic Coronary artery with recanalized thrombosis, microscopic Coronary artery with calcific atherosclerosis, microscopic Coronary artery atherosclerosis, occlusive, microscopic Coronary artery thrombosis, recent, microscopic Atheromatous plaque, high power, microscopic Aorta with rare lipid streaks, gross Aorta with lipid streaks, gross Aortas demonstrating various degrees of atherosclerosis, gross

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Coronary artery with atherosclerotic narrowing, microscopic

The coronary artery shown here has narrowing of the lumen due to build up of atherosclerotic plaque. Severe narrowing can lead to angina, ischemia, and infarction
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Coronary artery with recanalized thrombosis, microscopic

This section of coronary artery demonstrates remote thrombosis with recanalization to leave only two small, narrow channels

12

Coronary artery with calcific atherosclerosis, microscopic

There is a severe degree of narrowing in this coronary artery. It is "complex" in that there is a large area of calcification on the lower right, which appears bluish on this H&E stain. Complex atheroma have calcification, thrombosis, or hemorrhage. Such calcification would make coronary angioplasty difficult
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Aortas demonstrating various degrees of atherosclerosis, gross

These three aortas demonstrate mild, moderate, and severe atherosclerosis from bottom to top. At the bottom, the mild atherosclerosis shows only scattered lipid plaques. The aorta in the middle shows many more larger plaques. The severe atherosclerosis in the aorta at the top shows extensive ulceration in the plaques
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Aorta, atherosclerotic aneurysm, gross

Here is an example of an atherosclerotic aneurysm of the aorta in which a large "bulge" appears just above the aortic bifurcation. Such aneurysms are prone to rupture when they reach about 6 to 7 cm in size. They may be felt on physical examination as a pulsatile mass in the abdomen.Most such aneurysms are conveniently located below the renal arteries so that surgical resection can be performed with placement of a dacron graft
15

Atherosclerotic Cardiovascular Disease (2)

Aorta, atherosclerotic aneurysm, gross [CT] Aorta, atheroma, low power, microscopic Aorta, atheroma, high power, microscopic Aorta, ulcerative atherosclerosis with mural thrombosis, gross Cholesterol emboli in kidney, medium power microscopic Coronary artery, mild atherosclerosis, gross Coronary artery, severe atherosclerosis, gross Coronary artery, hemorrhage into plaque, gross Coronary artery, occlusive atherosclerosis, gross Heart and LAD coronary artery with recent thrombus, gross Coronary artery with recent thrombus, longitudinal section, gross Coronary artery with recent thrombus, cross section, gross

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CT scan with contrast

This abdominal high speed CT scan with contrast demonstrates an abdominal aortic aneurysm approximately 6 cm in diameter. At this size, there is increased risk for rupture

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Coronary artery, mild atherosclerosis, gross

A coronary artery has been opened longitudinally. The coronary extends from left to right across the middle of the picture and is surrounded by epicardial fat. Increased epicardial fat correlates with increasing total body fat. There is a lot of fat here, suggesting one risk factor for atherosclerosis. This coronary shows only mild atherosclerosis, with only an occasional yellow-tan lipid plaque and no narrowing
18

Coronary artery, severe atherosclerosis, gross

This is the left coronary artery from the aortic root on the left. Extending across the middle of the picture to the right is the anterior descending branch. This coronary shows severe atherosclerosis with extensive calcification. At the far right, there is an area of significant narrowing
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Coronary artery, hemorrhage into plaque, gross

This is coronary atherosclerosis with the complication of hemorrhage into atheromatous plaque, seen here in the center of the photograph. Such hemorrhage acutely may narrow the arterial lumen
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Heart and LAD coronary artery with recent thrombus, gross

The anterior surface of the heart demonstrates an opened left anterior descending coronary artery. Within the lumen of the coronary can be seen a dark red recent coronary thrombosis. The dull red color to the myocardium as seen below the glistening epicardium to the lower right of the thrombus is consistent with underlying myocardial infarction
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Myocardial Infarction

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Myocardial Infarction
Heart, left ventricle, acute myocardial infarction, gross Heart, left ventricle and septum, myocardial infarction, gross Myocardium, contraction band necrosis, microscopic Myocardium, acute myocardial infarction, 1 to 2 days, microscopic Myocardium, acute myocardial infarction, 1 to 2 days, microscopic Myocardium, acute myocardial infarction, 3 to 4 days, microscopic Myocardium, intermediate myocardial infarction, 1 to 2 weeks, microscopic Heart, transmural myocardial infarction with rupture and hemopericardium, gross Heart, transmural myocardial infarction with rupture, gross Heart, remote myocardial infarction, medium power microscopic Heart, remote myocardial infarction, low power microscopic Heart, remote myocardial infarction, gross Heart, left ventricular aneurysm, gross Heart, left ventricular aneurysm, gross Heart, coronary artery bypass graft, gross 23

Heart, left ventricle, acute myocardial infarction, gross

This is the left ventricular wall which has been sectioned lengthwise to reveal a large recent myocardial infarction. The center of the infarct contains necrotic muscle that appears yellow-tan. Surrounding this is a zone of red hyperemia. Remaining viable myocardium is reddishbrown
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Heart, left ventricle and septum, myocardial infarction, gross

This cross section through the heart demonstrates the left ventricle on the left. Extending from the anterior portion and into the septum is a large recent myocardial infarction. The center is tan with surrounding hyperemia. The infarction is "transmural" in that it extends through the full thickness of the wall
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Heart, transmural myocardial infarction with rupture and hemopericardium, gross

One complication of a transmural myocardial infarction is rupture of the myocardium. This is most likely to occur in the first week between 3 to 5 days following the initial event, when the myocardium is the softest. The white arrow marks the point of rupture in this anterior-inferior myocardial infarction of the left ventricular free wall and septum. Note the dark red blood clot forming the hemopericardium. The hemopericardium can lead to tamponade
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Heart, left ventricular aneurysm, gross

A cross section through the heart reveals a ventricular aneurysm with a very thin wall at the arrow. Note how the aneurysm bulges out. The stasis in this aneurysm allows mural thrombus, which is present here, to form within the aneurysm
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Arterial Dissection

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Arterial Dissection
Aorta, dissection with tear in arch, gross Heart, dissection with tear through media, low power microscopic Hemopericardium with cardiac tamponade, gross Aorta, dissection, gross Aorta, dissection, microscopic Carotid artery, dissection with compression, gross Aorta, dissection, microscopic Aorta, dissection, Marfan's syndrome, gross Floppy mitral valve with prolapse, Marfan's syndrome, gross Floppy mitral valve with prolapse, Marfan's syndrome, gross Aorta, cystic medial necrosis, Marfan's syndrome, Mucin stain, microscopic Arachnodactyly, Marfan's syndrome, gross

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Aorta, dissection with tear in arch, gross

There is a tear (arrow) located 7 cm above the aortic valve and proximal to the great vessels in this aorta with marked atherosclerosis. This is an aortic dissection

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Hemopericardium with cardiac tamponade, gross

An aortic dissection may lead to hemopericardium when blood dissects through the media proximally. Such a massive amount of hemorrhage can lead to cardiac tamponade

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Aorta, dissection, gross

This aorta has been opened longitudinally to reveal an area of fairly limited dissection that is organizing. The red-brown thrombus can be seen in on both sides of the section as it extends around the aorta. The intimal tear would have been at the left. This creates a "double lumen" to the aorta. This aorta shows severe atherosclerosis which, along with cystic medial necrosis and hypertension, is a risk factor for dissection
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Aorta, dissection, microscopic

Here, the dissection went into the muscular wall. In any case, an aortic dissection is an extreme emergency and can lead to death in a matter of minutes. The blood can dissect up or down the aorta. Blood dissecting up around the great vessels can close off the carotids. Blood can dissect down to the coronaries and shut them off
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Carotid artery, dissection with compression, gross

The right carotid artery is compressed by blood dissecting upward from a tear with aortic dissection. Blood may also dissect to coronary arteries. Thus patients with aortic dissection may have symptoms of severe chest pain (for distal dissection) or may present with findings that suggest a stroke (with carotid dissection) or myocardial ischemia (with coronary dissection).
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Infective Endocarditis

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Non-infective Endocarditis Non-bacterial thrombotic endocarditis, gross Non-bacterial thrombotic endocarditis, gross Non-bacterial thrombotic endocarditis, microscopic Libman-Sacks endocarditis (and mitral rheumatic valvulitis), gross Mitral valve, acute rheumatic vegetations, gross Mitral valve, rheumatic mitral stenosis, gross

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Aortic valve, infective endocarditis, gross

This is infective endocarditis. The aortic valve demonstrates a large, irregular, reddish tan vegetation. Virulent organisms, such as Staphylococcus aureus, produce an "acute" bacterial endocarditis, while some organisms such as Streptococcus viridans produce a "subacute" bacterial endocarditis
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Infective endocarditis spreading to myocardium, gross

In this case, the infective endocarditis demonstrates how the infection tends to spread from the valve surface. Here, vegetations can be seen on the endocardial surfaces, and the infection is extending into to underlying myocardium
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Infective endocarditis, microscopic

Microscopically, the valve in infective endocarditis demonstrates friable vegetations of fibrin and platelets (pink) mixed with inflammatory cells and bacterial colonies (blue). The friability explains how portions of the vegetation can break off and embolize
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Pericarditis

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Pericarditis Serous pericarditis, diagram Fibrinous pericarditis, diagram Fibrinous pericarditis, gross Fibrinous pericarditis, gross Fibrinous pericarditis, gross Fibrinous pericarditis, microscopic Hemorrhagic pericarditis, gross Hemorrhagic pericarditis, gross Purulent pericarditis, gross

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Fibrinous pericarditis, gross

A window of adherent pericardium has been opened to reveal the surface of the heart. There are thin strands of fibrinous exudate that extend from the epicardial surface to the pericarial sac. This is typical for a fibrinous pericarditis

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Hemorrhagic pericarditis, gross

The pericarditis here not only has fibrin, but also hemorrhage. Thus, this is called a "hemorrhagic pericarditis". It is really just fibrinous pericarditis with hemorrhage. Without inflammation, blood in the pericardial sac would be called "hemopericardium
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Myocarditis

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Myocarditis
Heart, microabscesses, gross Heart, microabscess, gross Heart, microabscess, microscopic Acute rheumatic carditis, microscopic Acute rheumatic carditis, microscopic Acute rheumatic carditis, microscopic Chronic rheumatic valvulitis, gross Interstitial viral myocarditis, microscopic

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Heart, microabscesses, gross

The epicardial surface of the heart is smooth and glistening, but there are small scattered pinpoint yellowish microabscesses. (Higher magnification in next photo).

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Heart, microabscess, gross

This magnification of the preceding photograph shows the small yellowish pinpoint microabscesses on the epicardial surface. Microabscesses may appear in persons who are septic. They may also represent emboli from an infective endocarditis in which small portions of a vegetation have embolized out the coronary arteries.

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Heart, microabscess, microscopic

The microscopic appearance of a microabscess is shown here. The center consists of blue bacterial colonies and is surrounded by acute inflammatory cells.
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Acute rheumatic carditis, microscopic (1)

Microscopically, acute rheumatic carditis is marked by a peculiar form of granulomatous inflammation with so-called "Aschoff nodules" seen best in myocardium. These are centered in interstitium around vessels as shown here. The myocarditis may be severe enough to cause congestive heart failure.
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Acute rheumatic carditis, microscopic (2)

Here is an Aschoff nodule at high magnification. The most characteristic component is the Aschoff giant cell. Several appear here as large cells with two or more nuclei that have prominent nucleoli. Scattered inflammatory cells accompany them and can be mononuclears or occasionally neutrophils.

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Acute rheumatic carditis, microscopic (3)

Another peculiar cell seen with acute rheumatic carditis is the Anitschkow myocyte. This is a long, thin cell with an elongated nucleus.

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Chronic rheumatic valvulitis, gross

In time, chronic rheumatic valvulitis may develop by organization of the acute endocardial inflammation along with fibrosis, as shown here affecting the mitral valve. Note the shortened and thickened chordae tendineae.

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Interstitial viral myocarditis, microscopic

The interstitial lymphocytic infiltrates shown here are characteristic for a viral myocarditis, which is probably the most common type of myocarditis. Many of these cases are probably subclinical. Some may be a cause for sudden death in young persons. There is usually little necrosis. The most common viral agent is Coxsackie B.

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Neoplasia

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Neoplasia
Heart, rhabdomyoma, gross Heart, atrial myxoma, gross Heart, atrial myxoma, microscopic Heart, epicardium, metastases, gross Heart, myocardium, metastatic melanoma, microscopic

55

Heart, rhabdomyoma, gross

This two year old child died suddenly. At autopsy, a large firm, white tumor mass was found filling much of the left ventricle. This is a cardiac rhabdomyoma. Such primary tumors of the heart are rare
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Heart, atrial myxoma, gross

The left atrium has been opened to reveal the most common primary cardiac neoplasm--an atrial myxoma. These benign masses are most often attached to the atrial wall, but can arise on a valve or in a ventricle. They can produce a "ball valve" effect by intermittently occluding the atrioventricular valve orifice. Embolization of fragments of tumor may also occur. Myxomas are easily diagnosed by echocardiography

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Heart, epicardium, metastases, gross

Primary tumors of the heart are uncommon. Metastases to the heart are more common, but rare overall (only about 5 to 10% of all malignancies have cardiac metastases). Seen over the surface of the epicardium are pale white-tan nodules of metastatic tumor. Metastases may lead to a hemorrhagic pericarditis.
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Congenital Heart Disease

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Congenital Heart Disease

Congenital heart disease, table Heart, probe patent foramen ovale, and paradoxical embolus, gross Heart, atrial septal defect, gross Heart, atrial septal defect, Eisenmenger's complex, gross Heart, ventricular septal defect, gross Heart, atrial septal defect and ventricular septal defect, gross Aorta, coarctation, gross Aorta, coarctation, gross Pulmonic valve, quadricuspid, gross Aortic valve, bicuspid, gross Aortic valve, senile calcific aortic stenosis, gross Heart, tetralogy of Fallot, diagram Heart, persistent truncus arteriosus, diagram Heart, transposition of great vessels, diagram
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Congenital Heart Disease

Type of Defect Mechanism

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Type of Defect Mechanism

Ventricular Septal Defect (VSD) There is a hole within the membranous or muscular portions of the intraventricular septum that produces a left-to-right shunt, more severe with larger defects Atrial Septal Defect (ASD) A hole from a septum secundum or septum primum defect in the interatrial septum produces a modest left-to-right shunt

Patent Ductus Arteriosus (PDA) The ductus arteriosus, which normally closes soon after birth, remains open, and a left-to-right shunt develops

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Type of Defect Mechanism

Tetralogy of Fallot Pulmonic stenosis results in right ventricular hypertrophy and a right-to-left shunt across a VSD, which also has an overriding aorta Transposition of Great Vessels The aorta arises from the right ventricle and the pulmonic trunk from the left ventricle. A VSD, or ASD with PDA, is needed for extrauterine survival. There is right-toleft shunting . Truncus ArteriosusThere is incomplete separation of the aortic and pulmonary outflows, along with VSD, which allows mixing of oxygenated and deoxygenated blood and right-to-left shunting

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Type of Defect Mechanism

Hypoplastic Left Heart Syndrome There are varying degrees of hypoplasia or atresia of the aortic and mitral valves, along with a small to absent left ventricular chamber Coarctation of Aorta Either just proximal (infantile form) or just distal (adult form) to the ductus is a narrowing of the aortic lumen, leading to outflow obstruction Total Anomalous Pulmonary Venous Return (TAPVR) The pulmonary veins do not directly connect to the left atrium, but drain into left innominate vein, coronary sinus, or some other site, leading to possible mixing of blood and right-sided overload
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Heart, atrial septal defect, gross

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

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Heart, ventricular septal defect, gross

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.

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Aorta, coarctation, gross

This portion of aorta was resected from a patient with a coarctation. The aorta narrows postductally here to about a 3 mm opening

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Aorta, coarctation, gross

The aorta is opened longitudinally here to reveal a coarctation. In the region of the narrowing, there was increased turbulence that led to increased atherosclerosis.

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Heart, tetralogy of Fallot, diagram

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.
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Heart, transposition of great vessels, diagram

In the diagram, transposition of the great vessels is shown occurs when the trunco-conal septum does not spiral down. Instead, it descends straight down. As a result, outflow of right ventricle is into aorta and outflow from left ventricle is into the pulmonic trunk. In order for this system to work, there must be a connection between the system and pulmonic circulations. Sometimes this is through a ventricular septal defect or an atrial septal defect. In the diagram at the left, this is through a patent ductus arteriosus
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Cardiomyopathies

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Cardiomyopathies
Cardiomyopathies, table Heart, dilated cardiomyopathy, gross [XRAY] Heart, dilated cardiomyopathy, gross Heart, cardiomyopathy, microscopic Heart, hypertrophic cardiomyopathy, explanted heart, gross Heart, restrictive cardiomyopathy from hemochromatosis, microscopic Heart, restrictive cardiomyopathy from amyloidosis, microscopic Myocardium, amyloidosis, apple-green birefringence with polarized light, Congo red stain, microscopic Heart, hypertension with left ventricular hypertrophy, gross Heart, hypertrophy with hypertension, gross

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Type of CMP Findings

Dilated (Congestive) All four chambers are dilated, and there is also hypertrophy. The most common cause is chronic alcoholism, though some may be the end-stage of remote viral myocarditis.

Hypertrophic The most common form, idiopathic hypertrophic subaortic stenosis (IHSS) results from asymmetric interventricular septal hypertrophy, resulting in left ventricular outflow obstruction.

Restrictive The myocardium is infiltrated with a material that results in impaired ventricular filling. The most common causes are amyloidosis and hemochromatosis.

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Heart, dilated cardiomyopathy, gross

This very large heart has a globoid shape because all of the chambers are dilated. It felt very flabby, and the myocardium was poorly contractile. This is an example of a cardiomyopathy. This term is used to denote conditions in which the myocardium functions poorly and the heart is large and dilated, but there is no specific histologic finding

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Heart, dilated cardiomyopathy, [XRAY]

This chest radiograph demontrates marked cardiomegaly, with the left heart edge appearing far to the left

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Heart, cardiomyopathy, microscopic

Microscopically, the heart in cardiomyopathy demonstrates hypertrophy of myocardial fibers (which also have prominent dark nuclei) along with interstitial fibrosis
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Heart, hypertrophic cardiomyopathy, explanted heart, gross

There is marked left ventricular hypertrophy, with asymmetric bulging of a very large interventricular septum into the left ventricular chamber. This is hypertrophic cardiomyopathy. About half of these cases are familial, though a variety of different genes may be responsible for this disease. Both children and adults can be affected, and sudden death can occur. Seen here is the explanted heart. Pacemaker wires enter the right ventricle. The atria with venous connections, along with great vessels, remained behind to connect to the transplanted heart (provided by someone who cared enough to make transplantation possible).

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Heart, hypertension with left ventricular hypertrophy, gross

This left ventricle is very thickened (slightly over 2 cm in thickness), but the rest of the heart is not greatly enlarged. This is typical for hypertensive heart disease. The hypertension creates a greater pressure load on the heart to induce the hypertrophy

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Heart, hypertrophy with hypertension, gross

The left ventricle is markedly thickened in this patient with severe hypertension that was untreated for many years. The myocardial fibers have undergone hypertrophy
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Arterial and Venous Diseases

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Renal arteriole, fibrinoid necrosis with malignant hypertension, microscopic

One complication of hyperplastic arteriolosclerosis with malignant hypertension is fibrinoid necrosis, as seen here in a renal arteriole

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Varicose veins, gross

The prominent veins shown here on the lower leg are varicosities. Varicose veins are a common problem with aging. The venous valves become incompetent. There may be muscular atrophy with less tone to provide a massage effect on the large superficial veins, and skin becomes less elastic with time. Hydrostatic pressure from standing for long periods exacerbates the problem
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