Morphological changes in porcine bioprosthetic valves of a HeartMate left ventricular assist device.

A 27-year-old man who received a HeartMate (Thoratec Corporation, USA) left ventricular assist device for progressive heart failure as a bridge to orthotopic heart transplantation is described in the present report. The device failed (mechanical failure) after almost 19 months. The porcine bioprosthetic valves in the inflow and outflow cannulae showed hemorrhage, cusp tears and inflammatory cells, located largely on the inflow valve cusps. The role of the inflammatory cell reaction in the bioprosthetic valve is discussed.

Pulmonary site bioprostheses: morphologic findings in 40 cases.

CONTEXT: From January 1995 to June 2003, there were 514 patients who underwent pulmonary valve replacements at either the Hospital for Sick Children or Toronto General Hospital. Fifty-four (10.5%) of these adults returned for replacement of their prostheses because of failure. Forty (74.1%) of the 54 explants were bioprostheses, and 14 (25.9%) were homografts. OBJECTIVE: To present the morphologic findings from this consecutive series of 40 pulmonary-site bioprostheses. DESIGN: Data were obtained by review of pathologic, clinical, and surgical records for all 40 patients with bioprosthetic pulmonary valves explanted from 1995 to June of 2003. RESULTS: The mean duration of valve implantation was 14.3 +/- 5.2 years (2-26 years). Median age at implantation was 16.7 +/- 10.3 years (range, 3 months to 53 years). Structural valve deterioration was found in 39 (97.5%) of the valves. Morphologic evidence of stenosis was found in all valves, whereas incompetence was found in 28 (70.0%). Calcification was present in 32 (80.0%) of the valves and was severe and diffuse in 22 (55.0%). Host tissue overgrowth, or pannus, was present on 39 (97.5%) of the valves and was severe in 35 (87.5%). Tears were present in 19 (47.5%) of the valves. CONCLUSIONS: Explanted bioprostheses showed a high degree of calcification and pannus, which together led to stenosis. Cusp immobilization, involving all 3 cusps, was frequent and was more common in patients younger than 30 years of age at explantation (P < .001). Host-tissue overgrowth is a significant problem with bioprostheses, and pulmonary-site bioprostheses are no exception.

Cocaine cardiotoxicity: a review of the pathophysiology, pathology, and treatment options.

Cocaine is a powerful stimulant that gives users a temporary sense of euphoria, mental alertness, talkativeness, and a decreased need for food and sleep. Cocaine intoxication is the most frequent cause of drug-related death reported by medical examiners in the US, and these events are most often related to the cardiovascular manifestations of the drug. Once playing a vital role in medicine as a local anesthetic, decades of research have established that cocaine has the ability to cause irreversible structural damage to the heart, greatly accelerate cardiovascular disease, and initiate sudden cardiac death. Although pathologic findings are often reported in the literature, few images are available to support these findings, and reviews of cocaine cardiopathology are rare. We describe the major pathologic findings linked to cocaine abuse in earlier research, their underlying mechanisms, and the treatment approaches currently being used in this patient population. A MEDLINE search was conducted to identify all English language articles from January 2000 to June 2008 with the subject headings and key words 'cocaine', 'heart', 'toxicity', and 'cardiotoxicity'. Epidemiologic, laboratory, and clinical studies on the pathology, pathophysiology, and pharmacology of the effects of cocaine on the heart were reviewed, along with relevant treatment options. Reference lists were used to identify earlier studies on these topics, and related articles from Google Scholar were also included. There is an established connection between cocaine use and myocardial infarction (MI), arrhythmia, heart failure, and sudden cardiac death. Numerous mechanisms have been postulated to explain how cocaine contributes to these conditions. Among these, cocaine may lead to MI by causing coronary artery vasoconstriction and accelerated atherosclerosis, and by initiating thrombus formation. Cocaine has also been shown to block K+ channels, increase L-type Ca2+ channel current, and inhibit Na+ influx during depolarization, all possible causes for arrhythmia. Additionally, cocaine use has been associated with left ventricular hypertrophy, myocarditis, and dilated cardiomyopathy, which can lead to heart failure if drug use is continued. Certain diagnostic tools, including ECG and serial cardiac markers, are not as accurate in identifying MI in cocaine users experiencing chest pain. As a result, clinicians should be suspicious of cocaine use in their differential diagnosis of chest pain, especially in the younger male population, and proceed more cautiously when use is suspected. Treatment for cocaine-related cardiovascular disease is in many ways similar to treatment for traditional cardiovascular disease. However use of beta-receptor antagonists and class Ia and III anti-arrhythmics is strongly discouraged if the patient is likely to continue cocaine use, because of documented adverse effects. The medical community is in urgent need of a pharmacologic adjunct to cocaine-dependence treatment that can deter relapse and reduce the risks associated with cardiovascular disease in these patients.

Anomalous left coronary artery from the pulmonary artery: case report and review of the literature.

Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is an uncommon occurrence, usually diagnosed at a young age. We report a 71-year-old patient who died suddenly of acute bilateral bronchopneumonia, and was found to have ALCAPA at autopsy. The patient had reported no cardiac symptoms during his lifetime. Autopsy revealed collateral connections between the left coronary artery (LCA) and right coronary artery (RCA), which were diffusely dilated, calcified and atherosclerotic.

Peripheral vascular disease: who gets it and why? A histomorphological analysis of 261 arterial segments from 58 cases.

AIMS: This retrospective study aimed to document and illustrate the histomorphological changes underlying peripheral vascular disease (PVD). More specifically, it aimed to analyse and quantify those changes that lead to lower limb amputations. Histological changes were assessed in relation to various clinical pathologies, and significant correlations were sought thereafter. METHODS: A total of 1305 arterial segments were examined from 58 consecutive patients undergoing a lower limb amputation from January 2002 to December 2003. Serial arterial segments were taken from the femoral, popliteal, anterior tibial, posterior tibial, peroneal, and dorsalis pedis arteries, and the degrees of atherosclerotic stenosis and medial calcification were histologically quantified. RESULTS: Atherosclerosis was associated with severe arterial stenosis. An increased occurrence of severe atherosclerotic narrowing coincided with increasing patient age (p = 0.0166), hypertension (p = 0.0019), and diabetes mellitus (p = 0.0036). The presence of medial calcification was an important pathological feature in patients under 70 years of age (p = 0.0308) and significantly more severe in those with diabetes mellitus (p<0.001). CONCLUSION: Atherosclerosis and medial calcification are significant underlying lesions in diabetic patients undergoing lower limb amputation. Medial calcification can cause significant stiffening of the arterial wall and a reduction in its ability to respond to vasodilator stimuli.

Histological analysis of aortic dissections following previous cardiovascular surgery.

BACKGROUND: Aortic dissections have been reported as a rare complication post-cardiovascular surgery due to areas of cross clamping, suture lines and cannulation sites as locations for peri-operative injury. This study aimed to review the histological features of aortic tissues of 11 patients with aortic dissections who underwent previous cardiovascular surgery and to identify evidence of trauma within the area of surgery. METHODS: A review of our records from January 2000 to July 2005 showed that 11 patients had developed a postoperative aortic dissection. Surgically excised aortic tissues were obtained either at surgery or at autopsy for further gross and histological analysis. Clinical records were also reviewed for relevant history. RESULTS: The mean age of the 11 patients in this study was 60.1+/-12.5 years. The year of index surgery for all patients was between 1960 and 2005, and the interval between index surgery and admission for re-operation was 13.8+/-12.9 years (range, 1 day to 45 years). Five patients (45%) demonstrated aortic intimal thickening, two of which showed evidence of atherosclerotic plaques. Three (27%) exhibited cystic medial change. All cases showed mild to moderate medial changes near or at the site of traumatic injury, as demonstrated by a sharp discontinuity in the media of the aorta. Other than the four aortic tissues obtained at autopsy, long-term follow-up for the remaining patients was not obtained. CONCLUSION: Evidence of previous trauma in close proximity to cannulation, cross-clamping and/or aortotomy sites was found in all patients in this series. All deaths in this series were found in the acute group rather than in the chronic group. It is important that the occurrence of dissections in patients undergoing previous cardiac surgery be not only reported, but analyzed by both the clinician and the pathologist. Hopefully, these efforts may identify particular patient risk factors and clarify preventative measures peri-operatively which may decrease the incidence of these potentially lethal complication.

Inflammatory myofibroblastic tumor with valvular involvement: a case report and review of the literature.

BACKGROUND: Inflammatory myofibroblastic tumor (IMT) of the heart is extremely rare with unpredictable clinical expression. IMTs, characterized by spindle cells, plasma cells, and a polymorphic inflammatory infiltrate, have a predilection for children and young adults. Clinically, IMT mimics malignancy, making a definitive diagnosis difficult, prior to histopathological examination. METHODS AND RESULTS: We describe a case of an intracardiac IMT in a 69-year-old woman. Histopathological examination of excised specimens revealed a marked, polymorphic, infiltrate of lymphocytes and plasma cells. CONCLUSIONS: Cardiac IMTs are benign lesions with favorable prognosis. Herein, we present this case, along with a review of all cardiac IMTs published after the last review in 2002, with emphasis on clinical, pathologic, and immunohistochemical features.

Inflammation and infection in nine surgically explanted Medtronic Freestyle stentless aortic valves.

BACKGROUND: The Medtronic Freestyle valve is fixed in glutaraldehyde at zero pressure on the cusps and treated with alpha-amino oleic acid. This valve reportedly has excellent clinical and hemodynamic results, but little has been reported about its long-term pathology. METHODS AND RESULTS: Nine Freestyle valves explanted between 2003 and 2005 were reviewed to assess the reasons for bioprosthesis failure (six implanted at our institution). All valves were examined in detail, using histochemistry and immunohistochemistry to identify the cellular response. One Freestyle valve, explanted for mitral valve endocarditis on the fifth postoperative day, was excluded from analysis. Average implant duration was 52.8+/-35.5 months. Four valves were explanted for infective endocarditis, three for aortic insufficiency, two for aortic stenosis with cusp calcification seen in five valves, pannus and thrombus in all valves and a chronic inflammatory reaction involving the xenograft arterial wall seen in eight of nine valves. This was associated with significant damage to the porcine aortic wall in seven cases, and cusp myocardial shelf damage in six cases. CONCLUSIONS: In this series of valves, we found (1) infective endocarditis; (2) pannus, thrombus, and calcification; and (3) unusual and significant inflammatory reaction and aortic tissue damage, which could by itself lead to aortic incompetence.

A 10-year comparison of explanted Hancock-II and Carpentier-Edwards supraannular bioprostheses.

BACKGROUND: Bioprosthetic heart valves are more frequently being used in valve replacement procedures today. Although second-generation bioprosthetic valves have improved functionality over their first-generation counterparts, they still often fail due to primary tissue degeneration. METHODS: This study examines two second-generation porcine valves after surgical explantation, the Hancock-II (HAN; Medtronic Heart Valve Division, Irvine, CA, USA) and the Carpentier-Edwards supraannular (CE-SAV; Baxter Healthcare Corporation, now Edwards LifeSciences, Irvine, CA, USA), with special attention to morphological/histological changes and reasons for valve failure. A total of 98 HAN and 65 CE-SAV valves were explanted and seen over a 10-year period. RESULTS: CE-SAV valves had a longer average implant duration than HAN valves (13.9+/-3.9 years vs. 10.0+/-5.1 years). Compared with HAN valves, CE-SAV valves also had a higher incidence of stent deformation (41.5% vs. 14.3%), calcification (75.4% vs. 54.1%), and pannus (100% vs. 91.8%). CONCLUSIONS: The greater degenerative changes seen with CE-SAV valves over HAN valves may be due to the longer implant duration of CE-SAV valves in this series. To our knowledge, the present study is the first direct morphological comparison of these two valve models.

A Carpentier-Edwards porcine-valved dacron conduit: at twenty-five years.

We report the longest duration of implantation of a porcine bioprosthesis in the English language literature--a Carpentier-Edwards valved conduit excised after twenty-five years. This 50-year-old man had undergone a modified Fontan operation for tricuspid atresia. He presented with progressive dyspnea, fatigue and edema. The bioprosthesis' dysfunction was due to the pathologic findings of pannus, significant thrombus (on the sinus surface of a cusp), mild structural valve deterioration and pseudo-intimal formation within the conduit. The bioprosthesis' longevity is likely related to low-pressure circulation in the right heart and to host tissue (pannus) overgrowth that covered the cusps and thereby reduced tissue degeneration.

Early changes in bioprosthetic heart valves following ventricular assist device implantation.

Heart valve bioprostheses can undergo early post-implantation changes, including pannus and thrombus, which may be hastened by the presence of a left ventricular assist device (LVAD). We report the case of a 21 year-old male who was diagnosed with dilated cardiomyopathy and severe aortic insufficiency, and had his aortic valve replaced with a #25 BioPhysio valve (currently in clinical trials--Edwards Life Sciences, Irvine, CA, USA). His symptoms of congestive heart failure continued to worsen, and he received a Novacor LVAD (WorldHeart, Oakland, CA, USA), and subsequently, an orthotopic heart transplantation. The relevant pathologies of the heart, BioPhysio valve (in place for 4.5 months), and Novacor device are presented.

Infective endocarditis of the tricuspid valve.

Infective endocarditis (IE) usually involves the left-sided valves, and IE involving the tricuspid valve (TV) is rare, often developing in intravenous drug users (IDU). We present a case of a 32-year-old male, an intravenous drug abuser (IDA), who presented with nonspecific septic symptoms, and was treated with TV conserving surgery. Pathological examination confirmed tissue destruction, friable thrombotic vegetations, and microorganisms in the leaflet tissue.

Morphological findings in 192 surgically excised native mitral valves.

INTRODUCTION: Mitral valve disease (MVD) is a significant clinical problem that is becoming more common in the 21st century. The pathogenesis of MVD seems to be changing and is not well understood. PATIENTS AND METHODS: The present study details the morphological findings in 192 native mitral valves excised over a one-year period at the Toronto General Hospital, Toronto, Ontario. The mean patient age was 59.7+/-12.3 years at operation. RESULTS: There were 106 men (55.2%) and 86 women (44.8%) in the present study. The most frequent changes in the surgically excised valvular leaflets were fibrosis (78.6%) and thickening (66.2%). Fusion (32.3%) and calcification (25.2%) were common changes at the commissures. Chordae tendineae most often showed evidence of thickening (47.9%) and fibrosis (37.0%). In total, 110 valves showed mitral incompetence (57.3%), 72 showed mitral stenosis (37.5%), and 10 showed a combination of stenosis and incompetence (5.2%). CONCLUSIONS: In the present series, MVD was most frequently caused by postinflammatory (rheumatic) valve disease (RVD) (35.9%), followed by myxomatous degeneration (33.3%). Patients with RVD were usually female (66.7%), while those with myxomatous degeneration were more likely to be male (76.6%). RVD remains a significant problem even though the incidence of acute rheumatic fever with cardiac involvement has declined in Canada. This most likely reflects the current sociodemographic composition of the referral population.

The role of pannus in the longevity of an Ionescu-Shiley pericardial bioprosthesis.

As the population ages, bioprosthetic heart valves are increasingly being used to replace diseased native valves. Bioprosthetic valve durability depends on patient age and other factors, but rarely exceeds 15 years. Explanted bioprosthetic valves commonly show tissue degeneration, tears, and calcification. Host tissue overgrowth (pannus), to the extent of interfering with their function, is another finding in bioprostheses that have been in place for long periods. We present a case in which a bovine pericardial valve was explanted after more than 20 years of implantation. The longevity of this pericardial valve may have been related to excessive pannus growth, which most likely protected the valve from earlier failure.

The intricacies of cardiac sarcoidosis: a case report involving the coronary arteries and a review of the literature.

BACKGROUND: Primary cardiac sarcoidosis (CS) is rare, and concomitant involvement of the coronary arteries is rarer still. Successful diagnosis of this disease is difficult due to its nonspecific symptoms which mimic those of idiopathic dilated cardiomyopathy (IDCM). METHODS AND RESULTS: We describe a 47-year-old Caucasian male who underwent orthotopic heart transplant for presumed IDCM. Examination of the explanted heart revealed numerous nonnecrotizing granulomata throughout, similar granulomata in the walls of the large coronary arteries, and large areas of fibrosis. CONCLUSIONS: In cases of IDCM with symptoms of angina or acute coronary syndrome, the possibility of CS should be considered. Herein, we present this case and a review of the relevant literature.

A giant coronary artery aneurysm in the right coronary artery.

Aneurysms of the coronary arteries are uncommon occurrences that usually develop secondary to atherosclerosis and are often asymptomatic. They are usually diagnosed incidentally during investigation for ischemic heart disease or at autopsy for sudden death. We present a case of a "giant" right coronary artery aneurysm (CAA) discovered incidentally at surgery. Pathological examination confirmed that this was a true aneurysm showing marked thinning of the media and fibrocalcific plaques with small, multifocal areas of lymphocytic infiltrates.

Morphological and clinical findings in 247 surgically excised native aortic valves.

Aortic valve disease is an increasingly common medical problem in the 20th century; however, its pathogenesis is poorly understood. The present paper reviews 247 cases of aortic valves surgically excised over a one-year period, with special attention to the morphological and histological changes observed in surgically excised aortic valves, and to how those changes relate to the mechanisms of valve failure. Patient age ranged from 17 to 86 years, with a mean of 64.1 +/-13.4 years, and there were 156 men (63.2%) and 91 women (36.8%). A total of 172 valves (69.6%) were tricuspid and 75 valves (30.4%) were congenitally abnormal, of which 67 valves (27.1%) were congenitally bicuspid, six valves (2.4%) were congenitally unicommissural and one valve (0.4%) was quadricuspid; the status of one valve could not be determined. Almost 70% of patients had features of aortic stenosis. Calcification was seen in the large majority of cases, with almost 70% of the valves showing either grade 3 or grade 4 calcification. Ulceration of calcific nodules was present in 42.0% of cases and in the majority of the valves with grade 4 calcification. A total of 15% of the valves showed evidence of postinflammatory changes consistent with rheumatic disease. Neovascularization was present in two-thirds of all valves, while one-half showed inflammatory cell infiltrates. Inflammatory cells were composed mainly of lymphocytes and macrophages, and were located primarily near areas of neovascularization. There was no significant difference in the pathological findings between men and women.

A 30-year analysis of cardiac neoplasms at autopsy.

INTRODUCTION: Cardiac neoplasms are rare and the vast majority are metastatic in origin. Symptoms of cardiac neoplasms (primary or metastatic) usually appear late in the course of the disease and are often ignored because of the more severe effects of the primary malignant disorder or its therapy. Consequently, cardiac neoplasms, especially metastatic ones, are often not discovered until autopsy. OBJECTIVES: To assess the incidence of cardiac neoplasms at autopsy and to determine the sites of origins of metastatic cardiac neoplasms. METHODS: The pathology records from consecutive autopsies performed at the University Health Network, Toronto, Ontario, from January 1973 to May 2004 were reviewed. They showed 266 cases of neoplasms involving the heart among 11,432 consecutive autopsies. These cases were then categorized based on their system of origin and further subclassified into specific primary site categories. As well, the type of cardiac tissue affected was noted in 193 cases (72.6%). RESULTS: The 266 autopsy cases involving cardiac neoplasms represented 2.33% of the total number of autopsies. Among the 266 cases, two neoplasms were primaries, while 264 were metastatic in origin. Metastatic cardiac neoplasms most frequently metastasized from the respiratory system, followed (in order of decreasing frequency) by the hematopoietic, gastrointestinal, breast and genitourinary systems. A minority of metastatic cardiac neoplasms were found to have spread from other systems. Cardiac neoplasms most frequently involved the pericardium, followed (in order of decreasing frequency) by the myocardium, epicardium and endocardium. CONCLUSIONS: There were 132 times more metastatic cardiac neoplasms than primary cardiac neoplasms found in the present study. The most common sites of metastatic origin were the lungs, bone marrow (leukemia/multiple myeloma), breasts and lymph nodes (lymphoma). Leukemias were more prevalent in the present study than in previous studies. The pericardium was the tissue that was most frequently affected by metastatic cardiac neoplasms.