1、心脏的大体及 显微镜下观 Fuyuan zhang 正常心脏大体观 n 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 n 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 n 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 n 这是正常心肌纤维的纵轴观，可见中心 排列
2、的细胞核及细胞之间没有分界线， 其中有些浅红色的圆盘插入。 正常冠状动脉显微镜下观 n 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。 n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 n 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 n 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 n 这是冠状动脉严重狭 n 窄的表现，它的复杂 n 性在于其右下方有大 n 片的钙化区域，在苏
3、n 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 n 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 n 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
4、细胞 。 主动脉伴有很少的脂质纹，大 体标本 n 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，大体标 本 n 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 n 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 n 这里是一个主 动脉
5、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 n 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 n 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 n 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
6、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 n 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 n 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
7、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 n 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 n 在冠状动脉纵形切 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。 n心肌梗死 心脏，左心室，急性心肌梗塞 ，大体标本 n 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
8、 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 n 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 “tr
9、ansmural“ in that it extends through the full thickness of the wall. 心肌，收缩带坏死，显微镜下 观 n The earliest change histologically seen with acute myocardial infarction in the first day is contraction band necrosis. The myocardial fibers are beginning to lose cross striations and the nuclei are not clearly v
10、isible 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 n This high power microscopic view of the myocardium demonstrates an infarction of about 1 to 2 days in duration. The myocardial fibers have dark re
11、d contraction bands extending across them. The myocardial cell nuclei have almost all disappeared. There is beginning acute inflammation. Clinically, such an acute myocardial infarction is marked by 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
12、 ，显微镜下观 n 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 n This myocardial infarction is about 3 to 4 days old. There is an extensive acute inflammatory c
13、ell 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 n This is an intermediate myocardial infarction of 1 to 2 weeks in age. Note that there are remaining normal myocardial fibers at the top. Below these fibers are many m
14、acrophages 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 n 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
15、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 hemo- pericardium can lead to tamponade. 心脏，透壁心肌梗塞伴破裂， 大体标本 n In cross section, the poin
16、t 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 ventricular wall 3 days later. 心脏，远期的心肌梗塞，中倍 显微镜下观 n There is pale white collagen within the
17、 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 n The myocardium beneath the endocardial surface at the top demonstrates pale fibrosis with collagenization following healing of a subendocardial myocardial infarction. 心脏，远期的心肌梗塞，大体 标本 The hea
18、rt 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 white appearance of the endocardial surface indicates the extensive scarrin
19、g. 心脏，左室室壁瘤，大体标本 n 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 a thin fibrous wall. The infarction was so extensive that, after healing,
20、 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 aneurysm predisposes to mural thrombosis. 心脏，左室室壁瘤，大体标本 n A cross section
21、 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，冠状动脉搭桥移植血管 ，大体标本 n This patient underwent coronary artery bypass grafting
22、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 branches of the circumflex artery. A white temporary pacing wire e
23、xtends from the mid left surface. n动脉剥脱 主动脉，弓部剥脱，大体标本 n 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 n 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 n 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 n 主动脉纵形切开 ，显示很局限的 主动脉剥离。红 褐色的血栓位于 主动脉切面的两 侧，包绕
24、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。以剥离到冠状动脉，并导致它们的闭塞。 颈动脉，剥脱伴压迫 n 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）。
25、主动脉，剥脱，显微镜下观 n 显微镜下观，显示红色的血栓压迫主动脉管腔 。 主动脉，剥脱， Marfan氏综合 征，大体标本 n 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 n 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 n This view of the mit
26、ral valve in a patient with Marfans syndrome depicts a floppy 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 n The hand a
27、t the left is that of a young woman with Marfans syndrome, while 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. n n感染性心内 膜炎 主动脉瓣，感染性心内膜炎， 大体标本 n This is infective endocarditis. The aortic valv
28、e 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. 主动脉瓣，感染性心内膜炎， 大体标本 n The more virulent bacteria cau
29、sing the acute bacterial form of infective endocarditis can lead to serious destruction, 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 n This ang
30、iogram demonstrates the aortic arch and great vessels. An embolus from a cardiac valvular 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
31、 a cerebral infarction and/or abscess. 感染性心内膜炎波及到心肌， 大体标本 n 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. 二尖瓣，感染性
32、心内膜炎并发 瘘管到右心，大体标本 n Here, infective endocarditis on the mitral valve has spread into the septum all the way to the tricuspid valve, producing a fistula. 感染性心内膜炎，显微镜下观 n Microscopically, the valve in infective endocarditis demonstrates friable vegetations of fibrin and platelets (pink) mixed with inf
33、lammatory cells and bacterial colonies (blue). The friability explains how portions of the vegetation can break off and embolize. 感染性心内膜炎，显微镜下观 n 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. Val
34、ves are relatively avascular, so high dose antibiotic therapy is needed to eradicate the infection. 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 n Another small linear splinter hemorrhage is seen here subungually on the left thumb of a patient with infective endocarditis and blood culture positive for
35、Staphylococcus aureus. n非感染性心 内膜炎 非细菌性栓塞性心内膜炎，大 体标本 n The small pink vegetation on the rightmost cusp 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
36、state (Trousseaus syndrome, a paraneoplastic syndrome associated with malignancies) and in very ill persons. 非细菌性栓塞性心内膜炎，大 体标本 n 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 n
37、 The valve is seen on the left, and a bland vegetation is seen on the right. It appears pink because it is composed 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
38、肌内膜炎（二 尖瓣风湿性瓣膜炎） n Here are flat, pale tan, spreading vegetations over the mitral valve surface and even on the chordae 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 endocar
39、ditis. These vegetations appear in about 4% of SLE patients and rarely cause problems because they are not large and 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 n The small verrucous vegetations se
40、en along the closure line of this mitral valve are associated with acute rheumatic fever. These warty vegetations average 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
41、体标 本 n The heart has been sectioned to reveal the mitral valve as seen from above in the left atrium. The mitral valve demonstrates 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
42、, then aortic alone, then mitral, aortic, and tricuspid together. n心包炎 严重的心包炎，图解 纤维性心包炎，图解 n This diagram depicts the appearance 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 pericard
43、itis is typical of uremia with renal failure, underlying myocardial infarction, and acute rheumatic carditis. 纤维性心包炎，大体标本 n 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
44、pericarial sac. This is typical for a fibrinous pericarditis. 纤维性心包炎，大体标本 n This is an example of a fibrinous pericarditis. The surface appears roughened from the normal glistening appearance by the strands of pink-tan fibrin. 纤维性心包炎，大体标本 n The epicardial surface of the heart shows a shaggy fibrinou
45、s exudate. This is another example of fibrinous pericarditis. This appearance has often been called a “bread and butter“ pericarditis, but 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 “fri
46、ction 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 n Microscopically, the pericardial surface here shows strands of pink fibrin extending outward. There is underlying inflammation. Eventually, the fibrin can be organized and cleared, though sometim
47、es adhesions may remain. 出血性心包炎，大体标本 n 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“. n
48、出血性心包炎，大体标本 n The surface of the heart with hemorrhagic pericarditis demonstrates a roughened and red appearance. Hemorrhagic pericarditis is most likely to occur with metastatic tumor and with tuberculosis (TB). TB can also lead to a granulomatous pericarditis that may calcify and produce a “constr
49、ictive“ pericarditis. n心肌炎 心脏，微脓肿，大体标本 n The epicardial surface of the heart is smooth and glistening, but there are small scattered pinpoint yellowish microabscesses. (Higher magnification in next photo). 心脏，微脓肿，大体标本 n 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 ou
