台灣第一位女醫生 宋．伊利莎白

（Mrs. Dr. Elizabeth Christie

Ferguson）

血管與心臟
血管 與心臟
蔡坤寶 (Kun-Bow Tsai)
小港醫院病理科 治醫師
小港醫院病理科主治醫師
Tel: (07) 8036783 ext 3140
E-mail:
E mail: kbtsai@kmu.edu.tw
kbtsai@kmu edu tw
References
Robbins and Cotran Pathologic Basis of Disease
Rubin’s Pathology Clinicopathologic Foundations of Medicine
 (muscular artery)血管壁的構造
肌肉性動脈(muscular
肌肉性動脈 artery)血管壁的構造
內皮細胞
內膜

內彈性層 中膜

外膜

外彈性層

Robbins and Cotran Pathologic Basis of Disease

Regional specializations of the vasculature

(Elastic artery)

Robbins and Cotran Pathologic Basis of Disease

 Vascular wall

Robbins and Cotran Pathologic Basis of Disease

 Blood vessels

• Vascular Anomalies
• H
Hypertensive
i Vascular
V l DiDisease
• Arteriosclerosis
• Atherosclerosis
• Aneurysms and Dissection
• Vasculitis
• Veins and Lymphatics
• Vascular Tumors
 Arteriovenous fistula
(動靜脈性瘻管
動靜脈性瘻管))
• Abnormal communications between arteries
and veins
• Usually developmental defects,
defects, penetrating
injuries, inflammatory necrosis or rupture of
arterial
t i l aneurysm into
i t the
th adjacent
dj t vein
i
• Sometimes inducingg cardiac (high
(high-
g -output
output)
p )
failure, rupture and hemorrhage
Arteriovenous fistula of brain
(腦動靜脈性瘻管
腦動靜脈性瘻管))
thiin vascular wall thick vascular wall with
without internal elastic internal elastic lamina.
lamina.

El ti Van
Elastic V Gieson
Gi
Intimal thickeningg - a response
p to vascular injury
j y
(內膜增厚
內膜增厚—血管對損傷的反應)
管對損傷的反應)

Robbins and Cotran Pathologic Basis of Disease

 Hypertensive vascular disease
(高血壓性血管疾病
高血壓性血管疾病))
• Elevated blood pressure affecting the function
and structure of blood vessels, largely small
muscular arteries and arterioles
• Hyaline and hyperplastic arteriolosclerosis
causing wall thickening with luminal
narrowing
 Hyaline arteriolosclerosis
(透明狀小動脈血管硬化
透明狀小動脈血管硬化))
• Aged
Aged, H/T,
H/T DM
• Chronic hemodynamic and
metabolic
t b li stress
t
→Endothelial cell injury
→Leakage and hyaline
deposition
→Homogeneous, pink,
hyaline thickening of the
walls of arterioles with loss
of structural detail and
narrowing
i off the
h lumen
l
• Benign nephrosclerosis of Robbins and Cotran Pathologic
g
shrinking kidney Basis of Disease
 Hyperplastic arteriolosclerosis
(增殖性小動脈血管硬化
增殖性小動脈血管硬化))
• Acute and severe
hypertension (malignant
hypertension: diastolic Luminal
i
pressure > 110mm Hg)
obliteration
• Necrotizing
N ti i arteriolitis
arteriolitis:
t i liti :
fibrinoid deposits and
acute
t necrosis
i off vascular
l
wall
• Onion
Onion--skin, concentritic
concentritic,, PAS
laminated thickening of
R bbi andd Cotran
Robbins C t P th l i
Pathologic
the walls of arterioles with Basis of Disease
progressive narrowing of
the lumen
 Arteriosclerosis (動脈硬化
(動脈硬化))
• Atherosclerosis: formation of intimal fibrous
plaques with central grumous core rich in lipid primarily
in elastic ((aorta, carotid and iliac arties)) or large
g and
medium--sized muscular arteries (coronary and
medium
popliteal
p p arteries))
• Monckeberg medial calcific sclerosis: medial
calcification or ossification of medium
medium--sized
muscular arteries (femoral, tibial,
tibial, radial and ulnar
arteries) in persons older than 50 years old
• Arteriolosclerosis: hyaline and hyperplastic
arteriolosclerosis causing wall thickening with luminal
narrowing of small arteries or arterioles,
arterioles, associated
with H/T and DM
 Atherosclerosis (粥狀動脈硬化
(粥狀動脈硬化))
• Fatty streak: not raised,
raised lipid
lipid--filled foamy cells,
cells
lymphocytes and small amount of extracellular lipid
• Atheromatous plaque (fibrolipid plaque or
atheroma):
atheroma ): necrotic core composed of cellular debris,
extracellular
t ll l lipid
li id with
ith cholesterol
h l t l crystals
t l or clefts,
l ft
foamy cells, granulation tissue and covered by fibrous
cap
– Cells: smooth muscle cells, macrophages and other
leukocytes
– Connective extracellular matrix: collagen, elastic fibers,
fibers,
proteoglycans
– Intracellular and extracellular lipid
p deposits
p
• Most in abdominal aorta,
aorta, coronary arteries
Fatty
y streak in aorta ((脂肪條紋
脂肪條紋))

O ti off branch
Ostia b h vessels
l

Robbins and Cotran Pathologic Basis of Disease

Fatty streak from aorta of experimental
hypercholesterolemic rabbit

foam cells

Sudan red
Robbins and Cotran Pathologic Basis of Disease
Fibrofatty plaque of atherosclerosis
(動脈粥狀硬化纖維脂肪斑塊
動脈粥狀硬化纖維脂肪斑塊))

Intima

Rubin’s Pathology Clinicopathologic Foundations of Medicine

Complicated lesions of atherosclerosis
(動脈粥狀硬化複雜的
動脈粥狀硬化複雜的病灶 病灶)
病灶)

I i
Intima

M di
Media

Rubin’s Pathology Clinicopathologic Foundations of Medicine

 Atherosclerosis in the aorta

Complicated
Fibrous p
plaque
q atheroma

Robbins and Cotran Pathologic Basis of Disease

Atherosclerosis (粥狀動脈硬化
(粥狀動脈硬化))

fibrous cap

ti core
necrotic

Cholesterol clefts
 Pathogenesis of
atherosclerosis
h l i

Robbins and Cotran Pathologic Basis of Disease

 Major risk factors for atherosclerosis
(粥狀動脈硬化的主要危險因子
粥狀動脈硬化的主要危險因子))
• Non
Non--modifiable
Increasing age
Male
l gender
d
Family history
Genetic abnormalities
• Modifiable
Hyperlipidemia: hypercholesterolemia, low
Hyperlipidemia: low--density
lipoprotein (LDL) cholesterol.
cholesterol.
Hypertention
Cigarette smoking
Diabetes
I fl
Inflammation:
i C-reactive protein (CRP)
Robbins and Cotran Pathologic Basis of Disease
 健康飲食44建議
最新美國飲食指南出爐！ 健康飲食

• 糖攝取量小於每日總熱量10％
糖攝取量小於每日總熱量10 ％
• 飽和脂肪小於每日總熱量10
飽和脂肪小於每日總熱量 10％
％
• 2300毫克
鈉攝取量小於每日2300
鈉攝取量小於每日 毫克
• 若有喝酒攝取適量酒精

用超級食物戰勝疾病
陳惟華醫師－提升治癒力 ‧ 健康再升級
https://today.line.me/TW/article/3fa34bb58c215aaf1b960ab1b49a59
d9b48454427e74d72ee26c96c1e720a573?openExternalBrowser=1
Nature history of atherosclerosis
(動脈粥狀硬化的自然病史)

Robbins Pathologic Basis of Disease

Atherosclerotic plaque rupture in coronary artery
(冠狀動脈粥狀硬化斑塊
冠狀動脈粥狀硬化斑塊破裂 破裂))
Without thrombus Wi h thrombosis
With h b i
Pl
Plaque rupture
t

Plaque rupture
Robbins and Cotran Pathologic Basis of Disease
 Sites of severe atherosclerosis
(嚴重 動脈粥狀硬化好發的位置))
嚴重動脈粥狀硬化好發的位置

Rubin’s Pathology Clinicopathologic Foundations of Medicine

 Vulnerable and stable atherosclerotic plaque
(易損
易損及穩定的 動脈粥狀硬化斑塊))
及穩定的動脈粥狀硬化斑塊

Thin fibrous caps, large Thickened and densely

lipid cores, and greater collagenous fibrous caps
inflammation with minimal inflammation
Robbins and Cotran Pathologic Basis of Disease
 Aneurysms and dissection
(動脈瘤及剝離
動脈瘤及剝離))
• Aneurysm: localized
localized, abnormal dilation of a
vessel (most commonly in aorta or heart)
• Dissection (dissecting aneurysm): blood
dissecting and creating a cavity within the
vessel (aorta) wall
True and false aneurysms
(真實
真實與 假動脈瘤))
與假動脈瘤

Robbins and Cotran Pathologic Basis of Disease

 The location of aneurysms
(各種動脈瘤好發部位)

Rubin’s Pathology Clinicopathologic Foundations of Medicine

 Aortic aneurysms (主動脈瘤
(主動脈瘤)
主動脈瘤)
• Saccular (balloon
(balloon--like), cylindroid or fusiform
dilation due to destruction of tunica media
secondary to atherosclerosis in thin and
weakened arterial wall
• Most frequently in abdominal aorta
aorta,, usually
below the renal arteries and above the
bifurcation
• Atheromatous
Ath t ulcer
l coveredd by
b murall
thrombus
Abdominal aortic aneurysm (腹主動脈瘤
(腹主動脈瘤))

Thrombus

Rupture

Robbins and Cotran Pathologic Basis of Disease

 Aortic dissection
((dissecting
g hematoma,, 主動脈剝離
主動脈剝離))
• Intima tear→ dissection of aortic media
b t
between th
the middle
iddl andd outer
t thi
thirds
d
→b blood
ood re-
ree-rupture
up u e into
o thee lumen
u e oof aorta
o
due to distal intimal tear with a new channel
(double--barreled aorta)
(double
→ or rupture of the dissection into the
pericardial, pleural or peritoneal cavity with
massive hemorrhage and death
• Hypertension, cystic medial degeneration
(CMD) Marfan
(CMD), M f syndrome d
 Aortic dissection (主動脈剝離
主動脈剝離))

Intimal Atherosclerosis
tear
Intramural
hematoma

Robbins and Cotran Pathologic Basis of Disease

 Dissecting aneurysm

Virtual Slidebox Department of Pathology The University of Iowa

 Dissecting aneurysm

False
Intima
True Dissection

Elastic Van Gieson

 Aortic dissection (主動脈剝離)
(
DeBakey’s type I Type II Type III

Robbins and Cotran Pathologic Basis of Disease

 M f syndrome
Marfan d (馬凡氏症候群
馬凡氏症候群))
• Autosomal dominant inheritance disorder of
connective tissue
• Skeletal abnormalities:
abnormalities: tall with long extremities,
dobule--jointed with lax ligment in the hand and feet,
dobule feet
dolichocephalic,, prominent supraorbital ridges,
dolichocephalic
kyphosis,, scoliosis,
kyphosis scoliosis pectus excavatum
excavatum,, or pigeon-
pigeon-breast
deformity
• Ocular change : bilateral subluxation
s bl ation or dislocation of
lens (Ectopia
(Ectopia lentis)
lentis)
• Cardiovascular lesions:
lesions: mitral valve proplapse and
aortic dissection
 M di l degeneration
Medial d ti (中膜
中膜變性
變性))
Marfan syndrome Normal

Elastin fragmentation

Robbins and Cotran Pathologic Basis of Disease

 V
Vasculitis
liti (血管炎
(血管炎))
• Inflammation of vessel walls.
• Fever, myalgias,
myalgias, arthralgias,
arthralgias, and malaise, or local
manifestations of downstream tissue ischemia
• Systemic necrotizing vasculitides:
vasculitides: most affect small
vessels,
l suchh as arterioles,
i l venules
venules,
l , andd capillaries
ill i
(designated small vessel vasculitis),
vasculitis), but several types
affect aorta and medium-
medium-sized vessels
Vascular sites typically involved with
the more common forms of vasculitis

Robbins and Cotran Pathologic Basis of Disease

 Pathogenesis of noninfectious vasculitis
(非感染性血管炎的致病因
非感染性血管炎的致病因))
• Immune complex
p deposition
p
– SLE, Arthus phenomenon, serum sickness,
– Drug hypersensitivity vasculitis .
– Vasculitis secondary to infections
• Antineutrophil
A i hil cytoplasmic
l i antibodies
ib di (ANCA)
– Anti-
Anti-proteinase-
proteinase-3 ((PR3 ANCA, cytoplasmic -ANCA) :
PR3--ANCA,
granulomatosis with polyangiitis (Wegener
granulomatosis))
granulomatosis
– Anti
Anti--myeloperoxidase (MPO ANCA,, perinuclear -
MPO--ANCA
ANCA) : microscopic polyangiitis and Churg
Churg--
Strauss syndrome
• Anti antibodies:: Kawasaki disease
Anti--endothelial cell antibodies
• Autoreactive T cells
 Vasculitis (血管炎
血管炎))
• Giant cell (temporal) arteritis:
arteritis: a focal chronic,
granulomatous inflammation,, mainly
g y of the temporal
p
arteries
• Takayasu arteritis
arteritis:: an inflammatory disease affecting the
aorta and its major branches
• Polyarteritis nodosa
nodosa:: an acute necrotizing vasculitis
• Wegener granulomatosis:
granulomatosis: a vasculitis of the respiratory
tract and kidney
• Kawasaki disease (mucocutaneous
(mucocutaneous lymph node
syndrome): a childhood vasculitis that targets coronary
arteries
• Buerger
B di
disease: a peripheral
i h l vascular l disease
di off smokers
k
• Churg
Churg--Strauss syndrome: a systemic vasculitis of young
patients
i with
i h asthma
h
Rubin’s Pathology Clinicopathologic Foundations of Medicine
 Varicose veins (靜脈曲張
(靜脈曲張))
• Abnormally dilated, tortuous veins produced
by prologed increased intraluminal pressure
• Superficial vein of legs predominantly
• Esophageal varices (食道靜脈曲張
食道靜脈曲張)) and anal
hemorrhoid (痔瘡(痔瘡)
痔瘡)
• Variation in the thickness of the vein wall
caused by dilation or compensatory
hypertrophy of the smooth muscle
muscle, subintimal
fibrosis, thrombosis, elastic tissue
degeneration or spotty calcification
(p
phlebosclerosis))
phlebosclerosis
Varicose veins and stasis ulcer (鬱滯性皮膚潰瘍
(鬱滯性皮膚潰瘍))

Robbins and Cotran Rubin’s Pathology Clinicopathologic

Pathologic Basis of Disease Foundations of Medicine
Esophageal varices (食管靜脈曲張
食管靜脈曲張))
 Esophageal varices (食管靜脈曲張
食管靜脈曲張))

Virtual Slidebox Department of Pathology The University of Iowa

 External hemorrhoid ((外痔
外痔))
Hemorrhoids are classified as internal or external
depending on which side of the dentate line they
are located. These hemorrhoids are external.

rectum

anus
Virtual Slidebox Department of Pathology The University of Iowa
 Mixed hemorrhoid (混合痔瘡
(混合痔瘡))
columnar epithelium Squamous
of rectum epithelium of anus

iinternal
t l
External
hemorrhoid
hemorrhoid

Virtual Slidebox Department of Pathology The University of Iowa

Classification of vascular tumors and tumor-
tumor-like
conditions (血管腫瘤
(血管腫瘤或類似 或類似腫瘤 腫瘤狀況 狀況的分類的分類))
• Benign neoplasms and conditions
– Hemangioma:
Hemangioma: capillary hemangioma
hemangioma,, cavernous
hemangioma,, pyogenic granuloma
hemangioma
Lymphangioma:
y p g
– Lymphangioma : capillary
p y lymphangioma,
lymphangioma
y p g , cavernous
lymphangioma (cystic hygroma
hygroma))
– Glomus tumor
– Vascular ectasia:
ectasia: nevus flammeus
flammeus,, hereditary hemorrhagic
telangiectasis,, spider telangiectasia
telangiectasis
– Reactive vascular proliferation: bacillary angiomatosis
• Intermediate
Intermediate--grade neoplasms
neoplasms:: Kaposi sarcoma,
hemangioendothelioma
• Malignant neoplasms: angiosarcoma
angiosarcoma,, hemangiopericytoma
Hemangioma of the tongue (舌頭血管瘤
(舌頭血管瘤))

Robbins and Cotran Pathologic Basis of Disease

Cavernous hemangioma (海綿狀血管瘤)
 Kaposi sarcoma (KS,卡波西氏肉瘤
(KS,卡波西氏肉瘤))
• Vascular neoplasm caused by human herpesvirus 8 (HHV8)
that is highly associated with acquired immunodeficiency
syndrome
• Four forms based on population demographics and risks:
– Classic KS: a disorder of older men, not associated with
HIV infection.
– Endemic i African
Af i KS
KS:
S: in
i HIVseronegative
i individuals
i di id l
younger than age 40 (an indolent or aggressive course;): a
particularly severe form with prominent lymph node and
visceral involvement in prepubertal children (poor
pprognosis,
g , almost 100% mortalityy within 3 yyears).
)
– Transplant
Transplant--associated KS: an aggressive course that
characteristically involves lymph nodes, mucosa, and
viscera; often regress with attenuation immunosuppression
– AIDS
AIDS--associated (epidemic) KS: the most common HIV- HIV-
related
l d malignancy,
li i
involves
l lymph
l h nodes
d & disseminates
di i t
widely to viscera, most p’t die of opportunistic infections
 Progressive
g gross
g and microscopic
p
stages of cutaneous Kaposi sarcoma
Patch Plaque Nodule

Robbins Pathologic Basis of Disease

 Kaposi sarcoma (卡波西氏肉瘤
(卡波西氏肉瘤))

Coalescent red- Plump spindle cells

p rple macules
purple mac les in nodular form
and plaques
Robbins and Cotran Pathologic Basis of Disease
 Angiosarcoma (血管肉瘤
血管肉瘤))

CD31
involving the dense clumps of atypical cells
right ventricle lining distinct vascular lumens
Robbins and Cotran Pathologic Basis of Disease
 Percutaneous coronaryy intervention
(經皮冠狀動脈介入治療
經皮冠狀動脈介入治療))

https://www.youtube.com/watch?v=S9AqBd4RExk
 Restenosis after angioplasty and stenting
(血管成形術與
血管成形術與血管支架術後再狹窄血管支架術後再狹窄))

stent wires

residual yellow
atherosclerotic plaque Movat stain
Residual yyellow atherosclerotic A thickened neointima
plaque and a new, tan-white separating and overlying
concentric intimal lesion inside the stent wires which
of that plaque. encroaches on the lumen
Robbins and Cotran Pathologic Basis of Disease
 Summary
• Pathogenesis and risk factors of atherosclerosis
• Aneurysms and dissection
• Hypertensive vascular disease
• Pathogenesis of noninfectious vasculitis
• Varicose veins 食物加減吃 - 韓柏檉
• Vascular tumors

https://www.youtube.com/watch?v=vdf
https://www youtube com/watch?v=vdf
8AzqDOfA&t=284s
 The heart
• Heart Failure
• Congenital Heart Disease
• Ischemic
i Heart Disease
i
• Arrhythmias
• Hypertensive Heart Disease
• Valvular Heart Disease
• Cardiomyopathies
• Pericardial Disease
• Tumors of the Heart
• C di T
Cardiac Transplantation
l t ti
 Changes in the aging heart
(心臟隨著年紀老化所產生的變化
心臟隨著年紀老化所產生的變化))
Chambers: increased left atrial cavity size, decreased left
ventricular cavity size, sigmoid-shaped ventricular septum
Valves: aortic valve calcific deposits, mitral valve annular
calcific deposits, fibrous thickening of leaflets, buckling of
mitral leaflets toward the left atrium, Lambl excrescences
Epicardial coronary arteries: tortuosity, increased cross-
sectional luminal area, calcific deposits, atherosclerotic
plaque
l
Myocardium: increased mass, increased subepicardial fat,
b
brown atrophy,
h lipofuscin
li f i deposition,
d i i basophilic
b hili
degeneration, amyloid deposits
A
Aorta: dil d ascending
dilated di aorta with i h rightward
i h d shift,
hif
elongated (tortuous) thoracic aorta, sinotubular junction
calcific deposits,
deposits elastic fragmentation and collagen
accumulation, atherosclerotic plaque
 Mechanisms of cardiovascular
dysfunction (心臟
(心臟血管
血管功能不良
功能不良的機制 的機制))

• Pumpp failure
• Flow obstruction
• Reg
Regur gitant flow
urgitant
• Shunted flow
• Disorders
Di d off cardiac
di conduction
d ti
• Rupture of the heart or a major vessel
 Cardiac hypertrophy (心臟肥大
(心臟肥大))

• 350 to 600 gm (up to approximately two times normal)

in pulmonary hypertension and ischemic heart
disease
• 400 to 800 gm (up to two to three times normal) in
systemic hypertension,
hypertension, aortic stenosis
stenosis,, mitral
regurgitation,, or dilated cardiomyopathy
regurgitation
• 600 to 1000 gm (three or more times normal) in
hypertrophic
yp p cardiomyopathy
y p y or aortic
regurgitation
 Left ventricular hypertrophy (左心室肥大)

Pressure Normal Volume

(concentric) (dilated)
hypertrophy
yp p y hypertrophy
yp p y
Robbins and Cotran Pathologic Basis of Disease
Left ventricular hypertrophy (左心室肥大)
Normal Hypertrophied
yp p
myocardium myocardium

Increases in both cell size

and nuclear size in the
hypertrophied myocytes.
Robbins and Cotran Pathologic Basis of Disease
Causes and consequences of cardiac hypertrophy
(心臟肥大
心臟肥大的原因和結的原因和結果 果)

Robbins and Cotran Pathologic Basis of Disease

Left--sided heart failure (左心衰竭
Left (左心衰竭))
• Causes: IHD, hypertension, aortic or mitral
valvular diseases, primary myocardial
diseases
di
• Heart: myocyte hypertrophy and variable
degrees of interstitial fibrosis
• Lung: pulmonary congestion and edema,
heart
failure cells,
cells, p
pleural effusions
• Brain
Brain:: hypoxic encephalopathy due to
h
hypoperfusion
f i
 Right-
Right
g -sided heart failure ((右心衰竭
右心衰竭))
右心衰竭
• Usual cause: secondary consequence of left- left-
sided heart failure
• Isolated
I l t d right-
right
i ht-sided
id d heart
h t failure:
failure
f il : pulmonary
l
yp
hypertension (cor p
pumonale))
pumonale
• Liver: passive congestion (congestive
h
hepatomegaly),
hepatomegaly
t l ),
) centrilobular
t il b l necrosis i , andd
cardiac cirrhosis
• Congestive splenomegaly
• Ascites
Ascites,, ankle (pedal) and pretibial edema,
edema,
anasarca
 Frequency of congenital cardiac malformations
(先天性心臟發育
先天性心臟發育異常的 異常的發生率 發生率))
Incidence per Million
Malformation Live Births %
Ventricular
V t i l septalt l defect
d f t 4482 42
Atrial septal defect 1043 10
P l
Pulmonary stenosis
t i 836 8
Patent ductus arteriosus 781 7
Tetralogy of Fallot 577 5
Coarctation of aorta 492 5
Atrioventricular septal defect 396 4
Aortic stenosis 388 4
Transposition of great arteries 388 4
Truncus arteriosus 136 1
Total anomalous pulmonary 120 1
venous connection
Tricuspid
p atresia 118 1
TOTAL 9757
Robbins and Cotran Pathologic Basis of Disease
 Congenital cardiac malformations
(先天性心臟發育
先天性心臟發育異常 異常))
• Malformations causingg a left-
left
f -to
to--right
g shunt
• Malformations causing a right
right--to
to--left shunt
• Malformations causing an obstruction
Congenital
C it l heart
h t disease
di (先天性心臟病))
(先天性心臟病

Left to right shunts (late cyanosis)

• Ventricular septal defect (VSD)
• Atrial septal defect (ASD)
• Patent ductus arterisus (PDA)
• Atrioventricular Septal Defect (AVSD)
Congenital heart disease (left to right shunts)
先天性心臟病(左到右的分流)

Robbins and Cotran Pathologic Basis of Disease

Ventricular septal defect (VSD,
(VSD, 心室中隔缺損
心室中隔缺損))
• Types of VSDs
– Membranous VSD: 90%
– Infundibular VSD
– Within muscular septum
• 50% of small muscular VSDs: spontaneous close
• Membranous or infundibular VSD: usually large
defects
• Right ventricular hypertrophy and pulmonary
hypertension:: present from birth
hypertension
• Irreversible pulmonary vascular disease leading to
shunt reversal,
reversal, cyanosis, and death
Ventricular septal defect (membranous type)
膜型心室中隔缺損
膜型 心室中隔缺損

Robbins and Cotran Pathologic Basis of Disease

Congenital
C it l heart
h t disease
di (先天性心臟病))
(先天性心臟病
Right to left shunt (early cyanosis)
• Tetralogy
T t l off Fallot
F ll t (TOF)
• Transposition of the Great Arteries (TGA)
• Truncus Arteriosus
• Tricuspid Atresia
• Total Anomalous Pulmonary Venous
Connection (TAPVC)
Tetralogy of Fallot (法洛氏四合症
法洛氏四合症))

Right ventricular hypertrophy

Rubin’s Pathology Clinicopathologic Foundations of Medicine
 T t l
Tetralogy off Fallot
F ll t (TOF,
(TOF 法洛氏四合症
法洛氏四合症))
• Ventricular septal defect (VSD)
• Over
Over--riding of aorta: aortic valve overriding
the defect of the VSD
• Subpulmonary stenosis:
stenosis: obstruction to right
ventricular outflow due to narrowing of the
infundibulum accompanied by pulmonary
valvular stenosis
• Right ventricular hypertrophy (RVH):
enlarged "boot-
"boot-shaped" heart
Congenital heart disease (先天性心臟病
(先天性心臟病))

Obstructive congenital
g anomalies
• Coarctation of aorta
• Pulmonary stenosis and atresia
• Aortic
A ti stenosis
t i and
d atresia
t i
Coarctation of aorta （主動脈縮窄）

Robbins and Cotran Pathologic Basis of Disease

Coarctation of aorta （主動脈縮窄）

• Coarctation of the aorta with a PDA:

PDA:
delivery of unsaturated blood through the
ductus arteriosus producing cyanosis
localized to the lower half of the body, not
survive the neonatal period
• Coarctation of the aorta without a PDA:
most asymptomatic
 Ischemic heart diseases
(IHD, 缺血性心臟病
缺血性心臟病))
• Coronary
C artery di
disease (CAD)
(CAD): reduced
d d blood
bl d
flow due to obstructive atherosclerotic lesions in
the epicardial coronary arteries.
• Atherosclerotic plaque (over 90%), coronary
emboli, myocardial vessel inflammation, or
vascular spasm
• Clinical manifestations: myocardial infarction,
angina pectoris,
pectoris chronic IHD with heart failure,
failure
sudden cardiac death (SCD)
 Angina
g p
pectoris （心絞痛）
• Paroxysmal and recurrent attacks of substernal or
precordial
di l chest
h t discomfort
di f t causedd by
b transient
i t (15
(15
seconds to 15 minutes)
minutes) myocardial ischemia that is
insufficient to induce myocyte necrosis
• Stable or typical angina: most common,
common, due to chronic
atherosclerosis,, relieved by rest or
stenosing coronary atherosclerosis
nitroglycerin
• Prinzmetal or variant angina:
angina: uncommon, caused by
coronary artery spasm
• Unstable or crescendo angina: caused by disruption of
an atherosclerotic plaque with partial thrombosis,
prolonged duration (>20 min),
min) increasing frequency
 Coronary artery pathology in ischemic heart
disease (缺血性心臟病之冠狀動脈病理
(缺血性心臟病之冠狀動脈病理))
Plaque
q Plaque-associated
q
Syndrome Stenosis disruption thrombus
Stable angina >75% No No

Unstable angina Variable Frequent Nonocclusive, often

with
i h thromboemboli
th b b li
Transmural Variable Frequent Occlusive
myocardial
di l
infarction
S b d
Subendocardial
di l Variable
V i bl V i bl
Variable Widely
Wid l variable,
i bl may beb
myocardial absent, partial/complete,
infarction or lysed
Sudden death Usually Frequent Often small platelet
severe aggregates or thrombi
and/or thromboemboli
Robbins and Cotran Pathologic Basis of Disease
 Myocardial infarction（心肌梗塞）
infarction（心肌梗塞）
心肌梗塞
• The vast majority of Mis caused by acute
coronary artery thrombosis: i due
d to disruption
i i
of
o ppreexisting
ee s g atherosclerotic
e osc e o c plaque
p que
• 10% of Mis in the absence of occlusive
atherosclerotic vascular disease: mostly
attributable to coronary artery vasospasm or to
embolization from mural thrombi (e.g., in the
setting
i off atrial
i l fibrillation)
fib ill i ) or valve
l vegetations.
vegetations
t ti .
Time of onset of keyy events in ischemic
cardiac myocytes
(心肌細胞缺血後
心肌細胞缺血後主要情況的開始時間主要情況的開始時間))
Feature Time
Onset of ATP depletion seconds
Loss of contractilit
contractility < 2 min
ATP reduced
To 50% of normal 10 min
To 10% off normall 40 mini
Irreversible cell injury 20
20-- 40 min
Microvascular injury > 1 hr

Robbins and Cotran Pathologic Basis of Disease

Progression of myocardial necrosis after coronary
artery occlusion (冠狀動脈阻塞後心肌壞死的
(冠狀動脈阻塞後心肌壞死的進展 進展))

Robbins and Cotran Pathologic Basis of Disease

Distribution of myocardial ischemic necrosis correlates with
the location and nature of decreased perfusion (心肌細胞缺
(心肌細胞缺
血壞死的分布和
血壞死的 分布和血 液灌流減少的部位與特性的關係)
血液灌流減少的部位與特性的關係)

Robbins and Cotran Pathologic Basis of Disease

Evolution of morphologic changes in myocardial
infarction (心肌梗塞型態上變化的
(心肌梗塞型態上變化的進展 進展))
Time Gross features Light
g microscope
p
0-1/2 hr None None
1/2--4 hr
1/2 None Usually none; variable waviness
4-12 hr Occasional mottling Beginning necrosis, hemorrhage
12--24hr
12 Dark mottling Ongoing necrosis, neutrophils
1-3 d M
Mottling
ttli withith yellow-
yellow
ll - Coagulation
C l ti necrosis i with
ith loss
l off
tan infarct center nuclei & striations, neutrophils
3-7 d Hyperemic border,
border Disintergration of myofibers and
central softening early phagocytosis of dead cells
7-10 d Depressed
p red
red--tan Earlyy formation of fibrovascular
margins granulation tissue
10--14 d
10 Red
Red--gray borders Granulation tissue with new vessels
and collagen deposition
2-8 wk Gray
Gray--white scar Increased collagen, decreased cells
>2 mo Scarring complete Dense collagenous scar
Acute myocardial infarct (急性心肌梗塞)
(
Necrosis

Rupture
p
Scar
TTC
Robbins and Cotran Pathologic Basis of Disease
Myocardial infarction (心肌梗塞
心肌梗塞))
One day 3 to 4 days

7 to 10 days Granulation tissue

Robbins and Cotran Pathologic Basis of Disease

Myocardial infarction and repair (心肌梗塞
(心肌梗塞與修復
與修復))
dense collagenous scar

Robbins and Cotran Pathologic Basis of Disease

 Complications
p of myocardial
y
infarction (心肌梗塞的合併症
心肌梗塞的合併症))

Rupture of the
Anterior ventricular septum
p
rupture

Robbins and Cotran Pathologic Basis of Disease

Complications of myocardial infarction
(心肌梗塞的合併症)

Ventricular aneurysm

Rubin’s Pathology Clinicopathologic Foundations of Medicine

 The causes and outcomes of ischemic heart
disease (IHD) (缺血性心臟病
缺血性心臟病的 的原因和結
原因和結果 果)

Robbins and Cotran Pathologic Basis of Disease

Sudden Cardiac Death (SCD,
(SCD 心臟性猝死
心臟性猝死))
• The mechanism of SCD: most often a lethal
arrhythmia
• Marked coronary atherosclerosis with a
critical (>75% cross-
cross-sectional area) stenosis
involving one or more of the three major vessels:
in 80% to 90% of SCD victims
• Acute
A te plaque
l e disruption
di ti (50%),
(50%) AMI (25%)
• Myocardial ischemia
ischemia--induced irritability that
initiates malignant ventricular arrhythmias
(ventricular
t i l fibrillation)
fibrillation
fib ill ti )
Hypertensive heart disease (高血壓性心臟病
(高血壓性心臟病))
Systemic (left-sided) Pulmonary (right-sided)

pacemaker

Marked
M k d concentric
t i Marked dilation,
dilation
thickening of left thickened free wall, and
ventricular wall yp p
hypertrophied trabeculae
in right ventricle
Robbins and Cotran Pathologic Basis of Disease
Valvular heart disease (瓣膜性心臟疾病
(瓣膜性心臟疾病))
• Valvular degeneration caused by
calcification
• Myxomatous
y degeneration
g ((mitral valve
prolapse))
prolapse
• Rheumatic heart disease
• Infective endocarditis
• Non
Non--infective vegetations
g
Etiologies of acquired heart valve disease ((後天瓣膜性心臟疾病的病原學
後天瓣膜性心臟疾病的病原學))
Mitrall Stenosis
Mit St i Aortic
A ti Stenosis
St i
Rheumatic heart disease Rheumatic heart disease
Senile calcific aortic stenosis
Mitral Regurgitation Calcification of congenitally
deformed valve
Ab
Abnormalities
li i off Leaflets
L fl & Commissures
C i
Postinflammatory scarring Aortic Regurgitation
I f i endocarditis
Infective d di i Rh
Rheumatic
i heart
h disease
di
Mitral valve prolapse
Drugs (Fen-phen)
Abnormalities of Tensor Apparatus Aortic Disese
Rupture
p of ppapillary
p y muscle Degenerative
g aortic dilation
Papillary muscle dysfunction (fibrosis) Syphilitic aortitis
Rupture of chordae tendineae Ankylosing spondylitis
Ab
Abnormalities
li i off LV and/or
d/ Annulus
A l Rheumatoid
h id arthritis
hii
LV enlargement (myocarditis, dilated Marfan syndrome
cardiomyopathy)
Calcification of mitral ring
Robbins and Cotran Pathologic Basis of Disease
Calcific valvular degeneration (鈣化性瓣膜退化)
(

fusion (raphe)
A: degenerative calcific aortic stenosis
g y
B: calcific aortic stenosis on a congenitally
bicuspid valve
Robbins and Cotran Pathologic Basis of Disease
 Rheumatic fever (風濕熱
(風濕熱))
• Acute,
Acute immunologically mediated
mediated,, multisystem
inflammatory disease
• Group
Group--A β hemolytic streptococcal pharyngitis
• Major manifestation:
manifestation: migratory polyarthritis
of large joints, carditis,
carditis, subcutaneous nodules,
erythema marginatum of the skin skin, Sydenham
chorea
• Non
Non--specific signs and symptoms: fever,
arthralgia and elevated acute
acute--phase reactants
Acute rheumatic heart disease (急性風濕性心臟病)

Robbins and Cotran Pathologic Basis of Disease

 Rheumatic heart disease (風濕性心
風濕性心臟臟病)
• Deforming fibrotic valvular
al lar disease (particularly
partic larl
mitral stenosis)
stenosis)
• Aschoff bodies
bodies:: swollen eosinophilic collagen
surrounded
d d by
b lymphocytes
l h t ((primarily
i il T cells),
ll )
occasional pplasma cells,, and p
plumpp
macrophages (Anitschkow
(Anitschkow cells, "caterpillar
cells") multinucleated Aschoff giant cells
cells"), cells,, and
central necrosis
Rheumatic heart disease (風濕性心臟病)
Mitral Aschoff body
vegetations
g

Mitral stenosis Neovascularization

Robbins and Cotran Pathologic Basis of Disease

 Four major forms of vegetative endocarditis
(四種主要增殖性心內膜炎類型)

RHD: rheumatic heart disease

IE: infective endocarditis
NBTE non
NBTE: non--bacterial
b t i l thrombotic
th b ti endocarditis
d diti
LSE: Libman
Libman--Sacks endocarditis in SLE
Robbins and Cotran Pathologic Basis of Disease
 Infective endocarditis ((IE))
(感染性心內膜炎
感染性心內膜炎))
• Infective vegetation on endocardium or valve
with destruction of leaflets (most commonly in
aortic and mitral valves)
• Acute IE (2020--30 %): necrotizing and destructive
l i
lesions, by
b staphylococcus
t h l aureus,
aureus, intravenous
i
drug abusers.
• Subacute IE (50 50--60 %): insidious infections of
deformed valves , byy Streptococcus
p viridans (oral
cavity flora)
flora)
• Complication: valvular destruction,
destruction ring abscess
of myocardium, systemic emboli (septic infarct)
 Bacterial infective endocarditis (細菌感染性心內膜炎)

A: vegetations on mitral valve (SBE)

B: destruction & ring abscess on bicuspid aortic valve (AE)
Robbins and Cotran Pathologic Basis of Disease
Infective (bacterial) endocarditis
Diagnostic
g criteria for infective endocarditis
診斷感染性心內膜炎的準則
Pathologic Criteria
• Microorganisms,
Microorganisms demonstrated by culture
or histologic examination, in a vegetation,
embolus from a vegetation,
vegetation or intracardiac
abscess
• Histologic confirmation of active
eendocarditis
doc d s in vege
vegetation
o or
o intracardiac
c d c
abscess

Robbins and Cotran Pathologic Basis of Disease

 Nonbacterial thrombotic endocarditis
(非細菌性
細菌性血栓 心內膜炎))
血栓心內膜炎
• Deposition of small masses of fibrin, platelets,
platelets, and
other
h blbloodd components on the
h leaflets
l fl off theh cardiac
di
valves
• Sterile (no microorganisms)
• Debilitated (cancer or sepsis) patients: marantic
endocarditis
• Sterile vegetations,
vegetations nondestructive
nondestructive,, and small (1 to 5
mm), and along the line of closure of the leaflets or
cusps
 Nonbacterial thrombotic endocarditis
(非細菌性
細菌性血栓 心內膜炎))
血栓心內膜炎
Thrombotic
Th b ti vegetations
t ti Bland thrombus, with
along the line of closure virtually no inflammation
of the mitral valve in the valve cusp
leaflets

(Thrombus)

(Cusp)
l
loosely
l attached
tt h d
Robbins and Cotran Pathologic Basis of Disease
Complications of cardiac valve prostheses
(人
人工心
人工 心臟瓣膜的瓣膜的併發症 併發症))
• Thrombosis/thromboembolism
Thrombosis/thromboembolism
• Anticolagulant--related hemorrhage
Anticolagulant
• P
Prosthetic
h i valve
l endocarditis
d di i
• Structural deterioration (intrinsic): wear,
fracture, poppet failure in ball valves, cuspal tear,
calcification
• Inadequate
q healing
g (p
((paravalvular
pparavalvular leak),
) exuberant
healing (obstruction), hemolysis
Thrombosis of a mechanical prosthetic valve
機械性瓣膜產生血栓))
(機械性瓣膜產生血栓

Robbins and Cotran Pathologic Basis of Disease

Calcification with secondary tearing of a
porcine
i bioprosthetic
bi th ti heart
h t valve
l
(豬的生物性瓣膜
豬的生物性瓣膜鈣化而 鈣化而破 破損)

Robbins and Cotran Pathologic Basis of Disease

 Cardiomyopathies (心肌病變
心肌病變))
• Heart
H di
disease resulting
l i from
f a primary
i
abnormalityy in the myocardium
y
• Dilated cardiomyopathy (DCM): progressive cardiac
dilation and contractile (systolic) dysfunction, most
common (90%)
• Hypertrophic
H t hi cardiomyopathy
di th (HCM):
(HCM) myocardial di l
hypertrophy, abnormal diastolic filling and, intermittent
ventricular
t i l outflow
tfl obstruction,
b t ti idiopathic
idi thi
hypertrophic subaortic stenosis or hypertrophic
obstructive
b i cardiomyopathy
di h
• Restrictive cardiomyopathy:
y p y: decrease in ventricular
cardiomyopathy
compliance,, resulting in impaired ventricular filling
compliance
during diastole, least prevalent
 Myocardial disease

Robbins and Cotran Pathologic Basis of Disease

Major causes of myocarditis (心肌炎
心肌炎的 主要原因))
的主要原因
Infections
Viruses (e.g.,
(e g coxsackievirus,
coxsackievirus ECHO,
ECHO influenza,
influenza HIV
HIV,
cytomegalovirus), Chlamydiae (e.g., C. psittaci),
Rickettsiae (e.g.,
(e g R. typhi typhus fever)
R typhi, fever),
Bacteria (e.g., Corynebacterium diphtheriae, Neisseria
meningococcus Borrelia (Lyme disease),
meningococcus, disease) Fungi (e.g.,
(e g
Candida), Protozoa (e.g., Trypanosoma Chagas disease,
toxoplasmosis),
p ), Helminths ((e.g.,
g , trichinosis))
Immune-Mediated Reactions
Postviral Poststreptococcal (rheumatic fever),
Postviral, fever) Systemic
lupus erythematosus, Drug hypersensitivity (e.g.,
methyldopa , sulfonamides), Transplant rejection
Unknown
Sarcoidosis Giant cell myocarditis
Sarcoidosis,
Robbins and Cotran Pathologic Basis of Disease
Hypersensitivity (drug) myocarditis （過敏性心肌炎）
E i
Eosinophils
hil and d mononuclear
l inflammatory
i fl t cells
ll

Robbins and Cotran Pathologic Basis of Disease

 Causes of pericarditis (心包膜炎 的原因))
心包膜炎的原因
Infectious Agents
Viruses, Pyogenic bacteria, Tuberculosis,
Fungi,
g , Other p
parasites
Presumably Immunologically Mediated
Rheumatic fever,
fever Systemic lupus
erythematosus, Scleroderma, Postcardiotomy,
P t
Postmyocardial
di l infarction
i f ti (Dressler)
(D l )
syndrome, Drug hypersensitivity reaction
Miscellaneous
Myocardial infarction, Uremia, Following
cardiac surgery, Neoplasia, Trauma, Radiation

Robbins and Cotran Pathologic Basis of Disease

Acute suppurative pericarditis
（急性化膿性心包膜炎）
extension from a pneumonia

Robbins and Cotran Pathologic Basis of Disease

 Myxoma (黏液瘤
(黏液瘤))
• Most common primary
p y cardiac tumor in adult
• 90% in atria ( left : right = 4 : 1)
• Globular, papillary, gelatinous mass usually arising
from the fossa ovalis in the atrial septum
• Stellate or globular myxoma ("lepidic
("lepidic")") cells,
endothelial cells,
cells smooth muscle cells,
cells and
undifferentiated cells embedded within an abundant
acid
id mucopolysaccharide
l h id ground d substance
bt andd
covered on the surface by endothelium
 Left atrial myxoma （左心房的黏液瘤）

A pedunculated Abundant amorphous extracellular

lesion arising from the matrix contains scattered
region of fossa ovalis multinucleate myxoma cells
and extending into the (arrowheads) and abnormal vessel-
mitral valve orifice. like formations (arrow).
Robbins and Cotran Pathologic Basis of Disease
Complication of cardiac transplantation
(心臟移植的併發症
心臟移植的併發症))
• Allograft rejection : classic cellular rejection
characterized
h i d by
b interstitial
i i i l lymphocytic
i
inflammationo wwith myocyte
yocy e damage
d ge
• Allograft arteriopathy:
arteriopathy: most important long-
long-term
limitation for cardiac transplantation.
• Infection and malignancies
malignancies,, particularly Epstein
Epstein--
Barr virus-
virus-associated B-B-cell lymphomas
 Complications of heart transplantation
(Cardiac allograft rejection: lymphocytic infiltrate
associated with cardiac myocyte damage)

Robbins and Cotran Pathologic Basis of Disease

 Complications of heart transplantation
(Allograft arteriopathy
arteriopathy:: severe diffuse concentric
intimal thickening producing critical stenosis)
stenosis)

Internal elastic lamina

Movat pentachrome
Robbins and Cotran Pathologic Basis of Disease
 Summary
• Mechanisms of cardiovascular dysfunction
• C
Congenital
it l cardiac
di malformations
lf ti
• Coronaryy artery
y ppathology
gy in ischemic heart disease
• Morphologic changes in myocardial infarction
• Disorders predisposing to cor pulmonale
• Major causes of acquired heart valve disease
• Diagnostic criteria for infective endocarditis
• Cardiomyopathy and indirect myocardial dysfunction
• Major causes of myocarditis
• Myxoma
• Complication of cardiac transplantation
 2017 年最具前瞻性的 10 項醫療創新科技
10. 可讓人體吸收的新型心臟支架（Bioabsorbable Stents）
心臟血管支架挽救許多人的性命，但目前的材料只要置
入人體中，血管支架就會永遠留在體內，可能會阻礙血
流並導致血栓的發生。因此醫療發展的終極目標是希望
讓支架在任務完成後由人體吸收。2016 年 7 月，第一支
可讓人體吸收的新型心臟支架受到 FDA 的認證，此支架
的材料為可溶解的聚合物，當支架置入體內擴張血管，
兩年後會由身體吸收。雖然到目前為止只有一款支架經
FDA 認證，但不久的將來市面上將出現更多的新型心臟
支架，並且帶來高達 20 億美元的產值。

https://www.youtube.com/watch?v=pDdis6zfeUo

https://www.youtube.com/results?search_query=Top+10+Medical+Innovations+2017