心脏的大体及显微镜下观.ppt

1、心脏的大体及显微镜下观,Fuyuan zhang,正常心脏大体观,这是一个正常心脏的外形，心外膜看上去光滑而有光泽。心外膜脂肪的数量正常，左冠状动脉的前降支从主动脉根部延伸到心尖部。,正常主动脉瓣大体观,主动脉瓣显示三个 薄而精密的瓣叶组 织。其上可见冠状 动脉的开口。心内 膜光滑，其下可见红褐色的心肌组织。主动脉瓣上的主动脉壁显示光滑的增生的内膜组织，但无动脉粥样硬化的改变。,正常三尖瓣大体观,这是三尖瓣结构，瓣叶菲薄精密。和二尖瓣一样，瓣叶边缘也有细的腱索将其附着到下方室壁的乳头肌上。,正常心肌中倍显微镜下观,这是正常心肌纤维的纵轴观，可见中心排列的细胞核及细胞之间没有分界线，其中有些浅红

2、色的圆盘插入。,正常冠状动脉显微镜下观,这是正常冠状动脉，具有很大，光滑，没有阻塞的管腔，能为心肌提供充足的血液供应。,动脉粥样硬化性心血管疾病,冠状动脉粥样硬化性狭窄，显微镜下观,冠状动脉显示由于粥样硬化斑块的沉积导致官腔狭窄，严重的狭窄可导致心绞痛，心肌缺血和心肌梗塞（右下图）。,正常,冠状动脉栓塞后再通，显微镜下观,切面的冠状动脉显示陈旧性的栓塞，并有再通而形成两个小的狭窄通道。,冠状动脉伴钙化的粥样硬化，显微镜下观,这是冠状动脉严重狭 窄的表现，它的复杂 性在于其右下方有大 片的钙化区域，在苏 木素依红染色上显示蓝色。复合性的动脉粥样硬化包括钙化，血栓或出血。这些钙化会使得冠状动脉成形

3、很难成功。,冠状动脉阻塞性粥样硬化，显微镜下观,冠状动脉的远端显示 明显的狭窄，这种累 及到末端的病变是严 重动脉粥样硬化的典 型改变。在伴有糖尿病和高脂血症的病人，常可见到这种情况，会使搭桥手术十分困难。,冠状动脉近期的栓塞，显微镜下观,在新近发生狭窄的冠状动脉中可见粉红到红色的新鲜血栓。其中开放的，针形的区域是粥样硬化斑块的胆固醇间隙。,粥样硬化斑块，高倍显微镜下观,粥样硬化改变的高倍镜下观，可见许多的泡沫细胞，及少许的胆固醇结晶，和散在的深蓝色的炎性细胞。,主动脉伴有很少的脂质纹，大体标本,这是基本正常的人体主动脉的外观，表面十分光滑，仅见少许菲薄的黄色脂质条纹。,主动脉伴有脂肪条纹，大

4、体标本,白色箭头显示的是主动脉上最明显的脂肪条纹，还有其它的散在于主动脉的表面，脂肪条纹是动脉粥样硬化最早出现的改变。,主动脉不同程度的粥样硬化改变，大体标本,这三个主动脉显示 的是轻，中，重度的 动脉粥样硬化。最下 面最轻的动脉粥样硬 化仅显示散在的脂质斑块；中间的显示许多大的斑块；最上面严重动脉粥样硬化病变显示粥样硬化上广泛的溃疡出现。,主动脉-粥样硬化性主动脉，大体标本，CT片,这里是一个主动脉粥样硬化瘤的标本，在腹主动脉分叉处的上方形成球形的瘤体，但其体积增大到6-7厘米时，就很容易破裂。,腹部CT显示的是主动脉瘤，体积接近6厘米，这时其很容易破裂。,主动脉粥样硬化斑块，低倍显微镜下观

5、,显微镜下可见左侧大的粥样硬化斑块，其中包含许多的胆固醇结晶。左侧还可见溃疡及出血。,主动脉粥样硬化斑块，高倍显微镜下观,主动脉粥样硬化斑块的高倍镜下观，可见泡沫细胞及胆固醇结晶,主动脉溃疡性粥样硬化并发附壁血栓，大体标本,这是严重粥样硬化的主动脉，已经形成粥样硬化斑块的溃疡及附壁血栓。,肾脏的胆固醇栓子，中倍显微镜下观,冠状动脉中度粥样硬化，大体标本,一支冠状动脉纵形切 开，周围有心外膜脂 肪，这里心外膜的增 加是全身脂肪增加的 一部分。这里的冠状动脉仅显示轻度的粥样硬化，可见散在的黄色脂质斑块而没有狭窄。,冠状动脉严重粥样硬化，大体标本,这是从主动脉根部左侧发出的左冠状动脉，切开的为左前降

6、支，有严重的粥样硬化及广泛的钙化，末端有显著的狭窄。,冠状动脉粥样硬化斑块内出血，大体标本,这是冠状动脉粥样硬化合并出血到粥样硬化斑块内，这种急性出血可能导致冠状动脉管腔狭窄。,冠状动脉阻塞性粥样硬化病变，大体标本,冠状动脉的系列横 切面显示管腔的狭 窄，在左侧的近端 冠状动脉狭窄最严 重，通常粥样硬化病变在近端更为严重，那里动脉的血流速度很快。局灶性的病变越严重则PTCA或搭桥手术的效果更好。,心脏及冠状动脉前降支最近的栓塞，大体标本,心脏前面切开的左前降支冠状动脉，在管腔内可见新形成的深红色的血栓。在前降支冠状动脉分布的区域可见梗死的心肌。,冠状动脉新的栓塞，纵形切开，大体标本,在冠状动脉

7、纵形切 开面，可见冠状动 脉管腔中深红色的 血栓。冠状动脉管 腔中粥样硬化斑块使管腔显著狭窄，而血栓形成则使管腔完全闭塞。,心肌梗死,心脏，左心室，急性心肌梗塞，大体标本,这里左室纵形切开以显示大范围的急性心肌梗死。坏死的中心是黄色的坏死肌肉，周围是红色的充血区，仍存活的心肌为红褐色。,心脏，左心室和室间隔，心肌梗塞，大体标本,This cross section through the heart demonstrates the left ventricle on the left. Extending from the anterior portion and into the sept

8、um 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.,心肌，收缩带坏死，显微镜下观,The earliest change histologically seen with acute myocardial infarction in the first day is contraction ba

9、nd necrosis. The myocardial fibers are beginning to lose cross striations and the nuclei are not clearly visible in most of the cells seen here.,Note the many irregular darker pink wavy contraction bands extending across the fibers.,心肌，急性心肌梗塞，1-2天，高倍显微镜下观,This high power microscopic view of the myoc

10、ardium demonstrates an infarction of about 1 to 2 days in duration. The myocardial fibers have dark red contraction bands extending across them. The myocardial cell nuclei have almost all disappeared.,There is beginning acute inflammation. Clinically, such an acutemyocardial infarction is marked by

11、changes in the electrocardiogram and by a rise in the MB fraction of creatine kinase.,心肌，急性心肌梗塞，1-2天，显微镜下观,In this microscopic view of a recent myocardial infarction, there is extensive hemorrhage along with myocardial fiber necrosis with contraction bands and loss of nuclei.,心肌，急性心肌梗塞，3-4天，显微镜下观,Th

12、is myocardial infarction is about 3 to 4 days old. There is an extensive acute inflammatory cell infiltrate and the myocardial fibers are so necrotic that the outlines of them are only barely visible.,心肌，亚急性心肌梗塞，1-2周，显微镜下观,This is an intermediate myocardial infarction of 1 to 2 weeks in age. Note th

13、at there are remaining normal myocardial fibers at the top. Below these fibers are many macrophages along with numerous capillaries and little collagenization.,心脏，透壁心肌梗塞伴破裂及血心包，大体标本,One complication of a transmural myocardial infarction is rupture of the myocardium. This is most likely to occur in t

14、he 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 he

15、mo-pericardium can lead to tamponade.,心脏，透壁心肌梗塞伴破裂，大体标本,In cross section, the point of rupture of the myocardium is shown with the arrow. In this case, there was a previous myocardial infarction 3 weeks before, and another myocardial infarction occurred, rupturing through the already thin ventricula

16、r wall 3 days later.,心脏，远期的心肌梗塞，中倍显微镜下观,There is pale white collagen within the interstitium between myocardial fibers. This represents an area of remote infarction.,心脏，远期的心肌梗塞，低倍显微镜下观,The myocardium beneath the endocardial surface at the top demonstrates pale fibrosis with collagenization following

17、 healing of a subendocardial myocardial infarction.,心脏，远期的心肌梗塞，大体标本,The heart is opened to reveal the left ventricular free wall on the right and the septum in the center. There has been a remote myocardial infarction that extensively involved the anterior left ventricular free wall and septum. The

18、white appearance of the endocardial surface indicates the extensive scarring.,心脏，左室室壁瘤，大体标本,There has been a previous extensive transmural myocardial infarction involving the free wall of the left ventricle. Note that the thickness of the myocardial wall is normal superiorly, but inferiorly is only

19、a thin fibrous wall. The infarction was so extensive that, after healing, the ventricular wall was replaced by a thin band of collagen, forming an aneurysm. Such an aneurysm represents non-contractile tissue that reduces stroke volume and strains the remaining myocardium. The stasis of blood in the

20、aneurysm predisposes to mural thrombosis.,心脏，左室室壁瘤，大体标本,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.,心脏，冠状动

21、脉搭桥移植血管，大体标本,This patient underwent coronary artery bypass grafting with autogenous vein (saphenous vein) grafts. The largest of these runs down the center of the heart to anastomose with the left anterior descending artery distally.,Another graft extends in a Y fashion just to the right of this to

22、branches of the circumflex artery. A white temporary pacing wire extends from the mid left surface.,动脉剥脱,主动脉，弓部剥脱，大体标本,箭头处为撕脱的部位,在主动脉瓣上7cm。该病人的主动脉瓣膜上及大血管近端有显著的动脉粥样硬化改变。此例为主动脉剥离。,心脏，剥脱伴中膜撕裂，低倍显微镜下观,显微镜下观，主动脉上的撕裂处（箭头部位）越过了内膜，血流也沿着内膜剥离（星形处）。,血心包及心包填塞，大体标本,主动脉剥离可以导致血心包，大量的出血会引起心包填塞,主动脉，剥脱，大体标本,主动脉纵形切开，显

23、示很局限的主动脉剥离。红褐色的血栓位于主动脉切面的两侧，包绕主动脉。内膜的撕裂处在左侧，导致主动脉形成双腔。,主动脉，剥脱，显微镜下观,剥离达到了动脉的肌层。在任何情况下，主动脉的剥离都是非常紧急的状态，可以随时导致死亡。血流可以沿着主动脉的上下剥离主动脉。沿着,大血管的剥离可能导致颈动脉的闭塞，有时也可以剥离到冠状动脉，并导致它们的闭塞。,颈动脉，剥脱伴压迫,主动脉剥脱出血，导致颈动脉的压塞。血流也可以剥脱到冠状动脉。所以主动脉剥脱的病人可以有严重的胸痛的症状（远端剥脱）或中风的症状（颈动脉剥脱）或心肌缺血的症状（冠状动脉剥脱）。,主动脉，剥脱，显微镜下观,显微镜下观，显示红色的血栓压迫主动

24、脉管腔。,主动脉，剥脱，Marfan氏综合征，大体标本,这是在Marfan综合症的患者发生的主动脉剥脱，刚好在主动脉根部的上方。撕裂贯穿主动脉，血心包及心包填塞在几分钟内发生。,二尖瓣脱垂，浮动瓣膜，Marfan氏综合征，大体标本,这还是在上例Marfan综合症患者，显示的是二尖瓣。二尖瓣的瓣叶臃长，最左边的而且向上球囊样突起。这是典型的二尖瓣脱垂伴浮动瓣叶。支持瓣叶的腱索变长变细。,二尖瓣脱垂，浮动瓣膜，Marfan氏综合征，大体标本,This view of the mitral valve in a patient with Marfans syndrome depicts a flop

25、py mitral valve. The leaflet on the lower left has ballooned upward and the prolapse has resulted in contusion of the top of the leaflet, with a red black area of discoloration.,主动脉，囊性中层坏死，Marfan氏综合征，粘蛋白染色，,蜘蛛样指Marfan氏综合征，大体,The hand at the left is that of a young woman with Marfans syndrome, while

26、the hand at the right is a normal male. Both persons were of the same height, 188 cm. However, note that the hand at the left demonstrates arachnodactyly.,感染性心内膜炎,主动脉瓣，感染性心内膜炎，大体标本,This is infective endocarditis. The aortic valve demonstrates a large, irregular, reddish tan vegetation.Virulent organ

27、isms, such as Staphylococcus aureus, produce an acute bacterial endocarditis, while some organisms such as Streptococcus viridans produce a subacute bacterial endocarditis.,主动脉瓣，感染性心内膜炎，大体标本,The more virulent bacteria causing the acute bacterial form of infective endocarditis can lead to serious des

28、truction, as shown here in the aortic valve. Irregular reddish tan vegetations overlie valve cusps that are being destroyed. Portions of the vegetation can break off and become septic emboli,主动脉瓣，感染性心内膜炎，血管造影片,This angiogram demonstrates the aortic arch and great vessels. An embolus from a cardiac v

29、alvular vegetation from the left side of the heart can travel out the systemic circulation. Shown here is a septic embolus from infective endocarditis travelling up the left common carotid artery, which could result in a cerebral infarction and/or abscess.,感染性心内膜炎波及到心肌，大体标本,In this case, the infecti

30、ve 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.,二尖瓣，感染性心内膜炎并发瘘管到右心，大体标本,Here, infective endocarditis on the mitral valve has spread into the

31、 septum all the way to the tricuspid valve, producing a fistula.,感染性心内膜炎，显微镜下观,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

32、 vegetation can break off and embolize.,感染性心内膜炎，显微镜下观,Here is a valve with infective endocarditis. The blue bacterial colonies on the lower left are extending into the pink connective tissue of the valve. Valves are relatively avascular, so high dose antibiotic therapy is needed to eradicate the inf

33、ection.,感染性心内膜炎病人的甲下线形出血，大体,感染性心内膜炎病人的甲下线形出血，大体,Another small linear splinter hemorrhage is seen here subungually on the left thumb of a patient with infective endocarditis and blood culture positive for Staphylococcus aureus.,非感染性心内膜炎,非细菌性栓塞性心内膜炎，大体标本,The small pink vegetation on the rightmost cusp

34、 margin represents the typical finding with non-bacterial thrombotic endocarditis (or so-called marantic endocarditis). This is,non-infective. It tends to occur in persons with a hypercoagulable state (Trousseaus syndrome, a paraneoplastic syndrome associated with malignancies) and in very ill perso

35、ns.,非细菌性栓塞性心内膜炎，大体标本,Here is another marantic vegetation on the leftmost cusp. These vegetations are rarely over 0.5 cm in size. However, they are very prone to embolize.,非细菌性栓塞性心内膜炎，显微镜镜下观,The valve is seen on the left, and a bland vegetation is seen on the right. It appears pink because it is comp

36、osed of fibrin and platelets. It displays about as,much morphologic variation as a brown paper bag. Such bland vegetations are typical of the non-infective forms of endocarditis.,Libman包囊心肌内膜炎（二尖瓣风湿性瓣膜炎）,Here are flat, pale tan, spreading vegetations over the mitral valve surface and even on the cho

37、rdae tendineae. This patient has systemic lupus erythematosus. Thus, these vegetations that can be on any valve or even on endocardial surfaces are consistent with Libman-Sacks endocarditis. These,vegetations appear in about 4% of SLE patients and rarely cause problems because they are not large and

38、 rarely embolize. Note also the thickened, shortened, and fused chordae tendineae that represent remote rheumatic heart disease.,二尖瓣，急性风湿性赘生物，大体标本,The small verrucous vegetations seen along the closure line of this mitral valve are associated with acute rheumatic fever. These warty vegetations avera

39、ge only a few millimeters and form along the line of valve,closure over areas of endocardial inflammation. Such verrucae are too small to cause serious cardiac problems.,二尖瓣，风湿性狭窄，大体标本,The heart has been sectioned to reveal the mitral valve as seen from above in the left atrium. The mitral valve dem

40、onstrates the typical fish mouth shape with chronic rheumatic scarring. Mitral valve is most often affected with rheumatic heart disease,followed by mitral and aortic together, then aortic alone, then mitral, aortic, and tricuspid together.,心包炎,严重的心包炎，图解,纤维性心包炎，图解,This diagram depicts the appearance

41、 of a fibrinous pericarditis. The red-pink squiggly lines extending from the epicardial surface into the yellow fluid represent the strands of fibrin. This type of pericarditis is typical of uremia with renal failure, underlying myocardial infarction, and acute rheumatic carditis.,纤维性心包炎，大体标本,A wind

42、ow 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.,纤维性心包炎，大体标本,This is an example of a fibrinous pericarditis. The surf

43、ace appears roughened from the normal glistening appearance by the strands of pink-tan fibrin.,纤维性心包炎，大体标本,The epicardial surface of the heart shows a shaggy fibrinous exudate. This is another example of fibrinous pericarditis. This appearance has often been called a bread and butter pericarditis, b

44、ut you would have to drop your buttered bread on the carpet to really get this effect. The fibrin often results in the the finding on,physical examination of a friction rub as the strands of fibrin on epicardium and pericardium rub against each other.,纤维性心包炎，显微镜下观,Microscopically, the pericardial su

45、rface here shows strands of pink fibrin extending outward. There is underlying inflammation. Eventually, the fibrin can be organized and cleared, though sometimes adhesions may remain.,出血性心包炎，大体标本,The pericarditis here not only has fibrin, but also hemorrhage. Thus, this is called a hemorrhagic peri

46、carditis. It is really just fibrinous pericarditis with hemorrhage. Without inflammation, blood in the pericardial sac would be called hemopericardium.,出血性心包炎，大体标本,The surface of the heart with hemorrhagic pericarditis demonstrates a roughened and red appearance. Hemorrhagic pericarditis is most lik

47、ely to occur with metastatic tumor and with tuberculosis (TB). TB can also lead to a granulomatous pericarditis that may calcify and produce a constrictive pericarditis.,心肌炎,心脏，微脓肿，大体标本,The epicardial surface of the heart is smooth and glistening, but there are small scattered pinpoint yellowish mic

48、roabscesses. (Higher magnification in next photo).,心脏，微脓肿，大体标本,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.,