心臟的大體及顯微鏡下觀

1、心臟的大體及顯微鏡下觀,Fuyuan zhang,正常心臟大體觀,這是一個(gè)正常心臟的外形，心外膜看上去光滑而有光澤。心外膜脂肪的數(shù)量正常，左冠狀動脈的前降支從主動脈根部延伸到心尖部。,正常主動脈瓣大體觀,主動脈瓣顯示三個(gè) 薄而精密的瓣葉組 織。其上可見冠狀 動脈的開口。心內(nèi) 膜

2、光滑，其下可見紅褐色的心肌組織。主動脈瓣上的主動脈壁顯示光滑的增生的內(nèi)膜組織，但無動脈粥樣硬化的改變。,正常三尖瓣大體觀,這是三尖瓣結(jié)構(gòu)，瓣葉菲薄精密。和二尖瓣一樣，瓣葉邊緣也有細(xì)的腱索將其附著到下方室壁的乳頭肌上。,正常心肌中倍顯微鏡下觀,這是正常心肌纖維的縱軸觀，可見中心排列的細(xì)胞核及細(xì)胞之間沒有分界線，其中有些淺紅色的圓盤插入。,正常冠狀動脈顯微鏡下觀,這是正常冠狀動脈，具有很大，光滑，沒有阻塞的管腔，能為心肌提供充足的血液供應(yīng)。

3、,動脈粥樣硬化性心血管疾病,冠狀動脈粥樣硬化性狹窄，顯微鏡下觀,冠狀動脈顯示由于粥樣硬化斑塊的沉積導(dǎo)致官腔狹窄，嚴(yán)重的狹窄可導(dǎo)致心絞痛，心肌缺血和心肌梗塞（右下圖）。,正常,冠狀動脈栓塞后再通，顯微鏡下觀,切面的冠狀動脈顯示陳舊性的栓塞，并有再通而形成兩個(gè)小的狹窄通道。,冠狀動脈伴鈣化的粥樣硬化，顯微鏡下觀,這是冠狀動脈嚴(yán)重狹 窄的表現(xiàn)，它的復(fù)雜 性在于其右下方有大

4、 片的鈣化區(qū)域，在蘇 木素依紅染色上顯示藍(lán)色。復(fù)合性的動脈粥樣硬化包括鈣化，血栓或出血。這些鈣化會使得冠狀動脈成形很難成功。,冠狀動脈阻塞性粥樣硬化，顯微鏡下觀,冠狀動脈的遠(yuǎn)端顯示 明顯的狹窄，這種累 及到末端的病變是嚴(yán) 重動脈粥樣硬化的典

5、 型改變。在伴有糖尿病和高脂血癥的病人，?？梢姷竭@種情況，會使搭橋手術(shù)十分困難。,冠狀動脈近期的栓塞，顯微鏡下觀,在新近發(fā)生狹窄的冠狀動脈中可見粉紅到紅色的新鮮血栓。其中開放的，針形的區(qū)域是粥樣硬化斑塊的膽固醇間隙。,粥樣硬化斑塊，高倍顯微鏡下觀,粥樣硬化改變的高倍鏡下觀，可見許多的泡沫細(xì)胞，及少許的膽固醇結(jié)晶，和散在的深藍(lán)色的炎性細(xì)胞。,主動脈伴有很少的脂質(zhì)紋，大體標(biāo)本,這是基本正常的人體主動脈的外觀，表面十分光滑，僅見少許菲

6、薄的黃色脂質(zhì)條紋。,主動脈伴有脂肪條紋，大體標(biāo)本,白色箭頭顯示的是主動脈上最明顯的脂肪條紋，還有其它的散在于主動脈的表面，脂肪條紋是動脈粥樣硬化最早出現(xiàn)的改變。,主動脈不同程度的粥樣硬化改變，大體標(biāo)本,這三個(gè)主動脈顯示 的是輕，中，重度的 動脈粥樣硬化。最下 面最輕的動脈粥樣硬 化僅顯示

7、散在的脂質(zhì)斑塊；中間的顯示許多大的斑塊；最上面嚴(yán)重動脈粥樣硬化病變顯示粥樣硬化上廣泛的潰瘍出現(xiàn)。,主動脈-粥樣硬化性主動脈，大體標(biāo)本，CT片,這里是一個(gè)主動脈粥樣硬化瘤的標(biāo)本，在腹主動脈分叉處的上方形成球形的瘤體，但其體積增大到6-7厘米時(shí)，就很容易破裂。,腹部CT顯示的是主動脈瘤，體積接近6厘米，這時(shí)其很容易破裂。,主動脈粥樣硬化斑塊，低倍顯微鏡下觀,顯微鏡下可見左側(cè)大的粥樣硬化斑塊，其中包含許多的膽固醇結(jié)晶。左側(cè)還可見潰瘍及出血。,

8、主動脈粥樣硬化斑塊，高倍顯微鏡下觀,主動脈粥樣硬化斑塊的高倍鏡下觀，可見泡沫細(xì)胞及膽固醇結(jié)晶,主動脈潰瘍性粥樣硬化并發(fā)附壁血栓，大體標(biāo)本,這是嚴(yán)重粥樣硬化的主動脈，已經(jīng)形成粥樣硬化斑塊的潰瘍及附壁血栓。,腎臟的膽固醇栓子，中倍顯微鏡下觀,,冠狀動脈中度粥樣硬化，大體標(biāo)本,一支冠狀動脈縱形切 開，周圍有心外膜脂 肪，這里心外膜的增

9、 加是全身脂肪增加的 一部分。這里的冠狀動脈僅顯示輕度的粥樣硬化，可見散在的黃色脂質(zhì)斑塊而沒有狹窄。,冠狀動脈嚴(yán)重粥樣硬化，大體標(biāo)本,這是從主動脈根部左側(cè)發(fā)出的左冠狀動脈，切開的為左前降支，有嚴(yán)重的粥樣硬化及廣泛的鈣化，末端有顯著的狹窄。,冠狀動脈粥樣硬化斑塊內(nèi)出血，大體標(biāo)本,這是冠狀動脈粥樣硬化合并出血到粥樣硬化斑塊內(nèi)，這種急性出血可能導(dǎo)致冠狀動脈管腔狹窄。,冠狀動脈阻塞性粥樣硬化病變，大體標(biāo)

10、本,冠狀動脈的系列橫 切面顯示管腔的狹 窄，在左側(cè)的近端 冠狀動脈狹窄最嚴(yán) 重，通常粥樣硬化病變在近端更為嚴(yán)重，那里動脈的血流速度很快。局灶性的病變越嚴(yán)重則PTCA或搭橋手術(shù)的效果更好。,心臟及冠狀動脈前降支最近的栓塞，大體標(biāo)本,心臟前面切開的左前降支冠狀動脈，在管腔內(nèi)可見新形成

11、的深紅色的血栓。在前降支冠狀動脈分布的區(qū)域可見梗死的心肌。,冠狀動脈新的栓塞，縱形切開，大體標(biāo)本,在冠狀動脈縱形切 開面，可見冠狀動 脈管腔中深紅色的 血栓。冠狀動脈管 腔中粥樣硬化斑塊使管腔顯著狹窄，而血栓形成則使管腔完全閉塞。,,心肌梗死,心臟，左心室，急性心肌梗塞，

12、大體標(biāo)本,這里左室縱形切開以顯示大范圍的急性心肌梗死。壞死的中心是黃色的壞死肌肉，周圍是紅色的充血區(qū)，仍存活的心肌為紅褐色。,心臟，左心室和室間隔，心肌梗塞，大體標(biāo)本,This cross section through the heart demonstrates the left ventricle on the left. Extending from the anterior portion and into the septu

13、m 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，收縮帶壞死，顯微鏡下觀,The earliest cha

14、nge 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 visible in most of the c

15、ells 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，高倍顯微鏡下觀,This high power microscopic view of the myocardium demonstrates an infarction of about 1 to

16、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 acutemy

17、ocardial 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，顯微鏡下觀,In this microscopic view of a recent myocardial infarction, there is extensive

18、hemorrhage along with myocardial fiber necrosis with contraction bands and loss of nuclei.,心肌，急性心肌梗塞，3-4天，顯微鏡下觀,This myocardial infarction is about 3 to 4 days old. There is an extensive acute inflammatory cell infiltrat

19、e and the myocardial fibers are so necrotic that the outlines of them are only barely visible.,心肌，亞急性心肌梗塞，1-2周，顯微鏡下觀,This is an intermediate myocardial infarction of 1 to 2 weeks in age. Note that there are remaining nor

20、mal myocardial fibers at the top. Below these fibers are many macrophages along with numerous capillaries and little collagenization.,心臟，透壁心肌梗塞伴破裂及血心包，大體標(biāo)本,One complication of a transmural myocardial infarction is ruptur

21、e 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-inferio

22、r 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.,心臟，透壁心肌梗塞伴破裂，大體標(biāo)本,In cross section, the point of

23、 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

24、 3 days later.,心臟，遠(yuǎn)期的心肌梗塞，中倍顯微鏡下觀,There is pale white collagen within the interstitium between myocardial fibers. This represents an area of remote infarction.,心臟，遠(yuǎn)期的心肌梗塞，低倍顯微鏡下觀,The myocardium beneath the endocardial su

25、rface at the top demonstrates pale fibrosis with collagenization following healing of a subendocardial myocardial infarction.,心臟，遠(yuǎn)期的心肌梗塞，大體標(biāo)本,The heart is opened to reveal th

26、e left ventricular free wall on the right and the septum in the center. There has bee

27、n 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 scarring.,心臟，左室室壁瘤，大體標(biāo)本,There has bee

28、n 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

29、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 strain

30、s the remaining myocardium. The stasis of blood in the aneurysm predisposes to mural thrombosis.,心臟，左室室壁瘤，大體標(biāo)本,A cross section through the heart reveals a ventricular aneurysm with a very thin wall at

31、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.,心臟，冠狀動脈搭橋移植血管，大體標(biāo)本,This patient underwent coronary artery byp

32、ass 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"

33、fashion just to the right of this to branches of the circumflex artery. A white temporary pacing wire extends from the mid left surface.,,動脈剝脫,主動脈，弓部剝脫，大體標(biāo)本,箭頭處為撕脫的部位,在主動脈瓣上7cm。該病人的主動脈瓣膜上及大血管近端有顯著的動脈粥樣硬化改變。此例為主動脈剝離。,心臟

34、，剝脫伴中膜撕裂，低倍顯微鏡下觀,顯微鏡下觀，主動脈上的撕裂處（箭頭部位）越過了內(nèi)膜，血流也沿著內(nèi)膜剝離（星形處）。,血心包及心包填塞，大體標(biāo)本,主動脈剝離可以導(dǎo)致血心包，大量的出血會引起心包填塞,主動脈，剝脫，大體標(biāo)本,主動脈縱形切開，顯示很局限的主動脈剝離。紅褐色的血栓位于主動脈切面的兩側(cè)，包繞主動脈。內(nèi)膜的撕裂處在左側(cè)，導(dǎo)致主動脈形成雙腔。,主動脈，剝脫，顯微鏡下觀,剝離達(dá)到了動脈的肌層。在任何情況下，主動脈的剝離都是非常緊急的狀

35、態(tài)，可以隨時(shí)導(dǎo)致死亡。血流可以沿著主動脈的上下剝離主動脈。沿著,大血管的剝離可能導(dǎo)致頸動脈的閉塞，有時(shí)也可以剝離到冠狀動脈，并導(dǎo)致它們的閉塞。,頸動脈，剝脫伴壓迫,主動脈剝脫出血，導(dǎo)致頸動脈的壓塞。血流也可以剝脫到冠狀動脈。所以主動脈剝脫的病人可以有嚴(yán)重的胸痛的癥狀（遠(yuǎn)端剝脫）或中風(fēng)的癥狀（頸動脈剝脫）或心肌缺血的癥狀（冠狀動脈剝脫）。,主動脈，剝脫，顯微鏡下觀,顯微鏡下觀，顯示紅色的血栓壓迫主動脈管腔。,主動脈，剝脫，Marfan氏

36、綜合征，大體標(biāo)本,這是在Marfan綜合癥的患者發(fā)生的主動脈剝脫，剛好在主動脈根部的上方。撕裂貫穿主動脈，血心包及心包填塞在幾分鐘內(nèi)發(fā)生。,二尖瓣脫垂，浮動瓣膜，Marfan氏綜合征，大體標(biāo)本,這還是在上例Marfan綜合癥患者，顯示的是二尖瓣。二尖瓣的瓣葉臃長，最左邊的而且向上球囊樣突起。這是典型的二尖瓣脫垂伴浮動瓣葉。支持瓣葉的腱索變長變細(xì)。,二尖瓣脫垂，浮動瓣膜，Marfan氏綜合征，大體標(biāo)本,This view of the m

37、itral valve in a patient with Marfan's 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

38、 area of discoloration.,主動脈，囊性中層壞死，Marfan氏綜合征，粘蛋白染色，,,蜘蛛樣指Marfan氏綜合征，大體,The hand at the left is that of a young woman with Marfan's syndrome, while the hand at the right is a normal male. Both persons were of the sam

39、e height, 188 cm. However, note that the hand at the left demonstrates arachnodactyly.,,感染性心內(nèi)膜炎,主動脈瓣，感染性心內(nèi)膜炎，大體標(biāo)本,This is infective endocarditis. The aortic valve demonstrates a large, irregular, reddish tan vegetation.V

40、irulent organisms, such as Staphylococcus aureus, produce an "acute" bacterial endocarditis, while some organisms such as Streptococcus viridans produce a "subacute" bacterial endocarditis.,主動脈瓣，感染性心內(nèi)

41、膜炎，大體標(biāo)本,The more virulent bacteria causing 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

42、 are being destroyed. Portions of the vegetation can break off and become septic emboli,主動脈瓣，感染性心內(nèi)膜炎，血管造影片,This angiogram demonstrates the aortic arch and great vessels. An embolus from a cardiac valvular vegetation from

43、 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 an

44、d/or abscess.,感染性心內(nèi)膜炎波及到心肌，大體標(biāo)本,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

45、 is extending into to underlying myocardium.,二尖瓣，感染性心內(nèi)膜炎并發(fā)瘺管到右心，大體標(biāo)本,Here, infective endocarditis on the mitral valve has spread into the septum all the way to the tricuspid valve, producing a fistula.,感染性心內(nèi)膜炎，顯微鏡下觀,Micr

46、oscopically, 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 ve

47、getation can break off and embolize.,感染性心內(nèi)膜炎，顯微鏡下觀,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 relativ

48、ely avascular, so high dose antibiotic therapy is needed to eradicate the infection.,感染性心內(nèi)膜炎病人的甲下線形出血，大體,,感染性心內(nèi)膜炎病人的甲下線形出血，大體,Another small linear splinter hemorrhage is seen here subungually on the left thumb of a patie

49、nt with infective endocarditis and blood culture positive for Staphylococcus aureus.,,非感染性心內(nèi)膜炎,非細(xì)菌性栓塞性心內(nèi)膜炎，大體標(biāo)本,The small pink vegetation on the rightmost cusp margin represents the typical finding with non-bacterial thr

50、ombotic endocarditis (or so-called "marantic endocarditis"). This is,non-infective. It tends to occur in persons with a hypercoagulable state (Trousseau's syndrome, a paraneoplastic syndrome associated wi

51、th malignancies) and in very ill persons.,非細(xì)菌性栓塞性心內(nèi)膜炎，大體標(biāo)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.,非細(xì)菌性栓塞性心內(nèi)膜

52、炎，顯微鏡鏡下觀,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.

53、Such bland vegetations are typical of the non-infective forms of endocarditis.,Libman包囊心肌內(nèi)膜炎（二尖瓣風(fēng)濕性瓣膜炎）,Here are flat, pale tan, spreading vegetations over the mitral valve surface and even on the chordae tendineae. Thi

54、s 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 pati

55、ents 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，急性風(fēng)濕性贅生物，大體標(biāo)本,The small

56、 verrucous vegetations seen 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 area

57、s of endocardial inflammation. Such verrucae are too small to cause serious cardiac problems.,二尖瓣，風(fēng)濕性狹窄，大體標(biāo)本,The heart has been sectioned to reveal the mitral valve as seen from above in the left atrium. The mitral valve

58、 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, then aortic alone, then mi

59、tral, aortic, and tricuspid together.,,心包炎,嚴(yán)重的心包炎，圖解,,纖維性心包炎，圖解,This diagram depicts the appearance of a fibrinous pericarditis. The red-pink squiggly lines extending from the epicardial surface into the yellow fluid rep

60、resent the strands of fibrin. This type of pericarditis is typical of uremia with renal failure, underlying myocardial infarction, and acute rheumatic carditis.,纖維性心包炎，大體標(biāo)本,A window of adherent pericardium has been opene

61、d 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.,纖維性心包炎，大體標(biāo)本,This is an exampl

62、e of a fibrinous pericarditis. The surface appears roughened from the normal glistening appearance by the strands of pink-tan fibrin.,纖維性心包炎，大體標(biāo)本,The epicardial surface of the heart shows a shaggy fibrinous exudate. This

63、 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. Th

64、e 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.,纖維性心包炎，顯微鏡下觀,Microscopically, the pericardia

65、l surface 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，大體標(biāo)本,The pericarditis he

66、re 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

67、 be called "hemopericardium".,出血性心包炎，大體標(biāo)本,The surface of the heart with hemorrhagic pericarditis demonstrates a roughened and red appearance. Hemorrhagic pericarditis is most likely to occur with metastatic tum

68、or and with tuberculosis (TB). TB can also lead to a granulomatous pericarditis that may calcify and produce a "constrictive" pericarditis.,,心肌炎,心臟，微膿腫，大體標(biāo)本,The epicardial surface of the heart is smooth and gli

69、stening, but there are small scattered pinpoint yellowish microabscesses. (Higher magnification in next photo).,心臟，微膿腫，大體標(biāo)本,This magnification of the preceding photograph shows the small yellowish pinpoint microabscesses

70、 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 arter