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Presented by Ralph Hruban, M.D. and prepared by Joseph J. Maleszewski, M.D.
Case 1: This 60 some year old man with a history of aortic stenosis and coronary artery disease.
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Question 1 of 1
1. Question
Week 378: Case 1
This 60 some year old man with a history of aortic stenosis and coronary artery disease developed heart failure and had a left ventricular assist device inserted.images/jjm011209/case1a.jpg
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images/jjm011209/case1e.jpgCorrect
Answer: Hypertrophy and Replacement fibrosis
Histology: The heart muscle is remarkable for two changes. First, the nuclei of the myocytes are enlarged, hyperchromatic, and some have a “box car” appearance. Second, some myocytes are replaced by areas of fibrosis. In these areas one can appreciate pigment containing (lipofuscin) macrophages.
Discussion: The two changes seen in this heart are consistent with the patient’s clinical history. The changes of myocyte hypertrophy (enlarged hyperchromatic nuclei with a box car appearance) are consistent with myocyte hypertrophy induced by the patient’s aortic stenosis. Long-standing hypertension and a dilated cardiomyopathy would give the same changes. The second change, is that of replacement fibrosis (areas of fibrosis with lipofuscin containing macrophages) is consistent with small areas of remote ischemic injury (microinfarcts if you will) secondary to the patient’s coronary artery disease.
See: Endomyocardial biopsy plays a role in diagnosing patients with unexplained cardiomyopathy.
Reference(s):
– Ardehali H, Qasim A, Cappola T, Howard D, Hruban R, Hare JM, Baughman KL, Kasper EK. Am Heart J. 2004 May;147(5):919-23.Incorrect
Answer: Hypertrophy and Replacement fibrosis
Histology: The heart muscle is remarkable for two changes. First, the nuclei of the myocytes are enlarged, hyperchromatic, and some have a “box car” appearance. Second, some myocytes are replaced by areas of fibrosis. In these areas one can appreciate pigment containing (lipofuscin) macrophages.
Discussion: The two changes seen in this heart are consistent with the patient’s clinical history. The changes of myocyte hypertrophy (enlarged hyperchromatic nuclei with a box car appearance) are consistent with myocyte hypertrophy induced by the patient’s aortic stenosis. Long-standing hypertension and a dilated cardiomyopathy would give the same changes. The second change, is that of replacement fibrosis (areas of fibrosis with lipofuscin containing macrophages) is consistent with small areas of remote ischemic injury (microinfarcts if you will) secondary to the patient’s coronary artery disease.
See: Endomyocardial biopsy plays a role in diagnosing patients with unexplained cardiomyopathy.
Reference(s):
– Ardehali H, Qasim A, Cappola T, Howard D, Hruban R, Hare JM, Baughman KL, Kasper EK. Am Heart J. 2004 May;147(5):919-23.
