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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3654_Библиотеки_им_академика_М_И_Перельмана
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Fig. 3.37 Diagram representing the right-sided ventricular septum
with the septomarginal trabecula, branching in two parts to wedge the
crista supraventricularis
G. Thiene and S. Rizzo
(d) With the fall of pulmonary arterial pressure after birth,
the pulmonary artery wall loses progressively elastic
lamellar units becoming attened like a vein, as to be
called in the past “arteria venosa.” To all effects, during
fetal life with the patency of the ductus arteriosus, the
pulmonary artery behaves like a second aorta.
Echo Transthoracic View
Tomographic cross sections of transthoracic two- dimensional
echo include long- and short-axis parasternal views and fourto ve-chamber apical views (Figs.3.38 and 3.39). They are
an excellent, noninvasive scan of cardiac valves.
The long-axis parasternal view beautifully explores both
inow and outow of the left ventricle, including aortic and
mitral valves with the entire apparatus (leaets, chordae tendineae, and papillary muscles). In addition, the pulmonary
infundibulum is well visible (Fig.3.40).
The short-axis parasternal tomographic sections may scan
the heart from apex to base including cross sections of both
ventricles and the apparatus of both atrioventricular valves
(Figs.3.41 and 3.42). The parasternal short axis at the base
of the heart beautifully discloses the aortic root, the pulmonary artery, and its bifurcation (Fig.3.43).
The apical four-chamber view in longitudinal tomographic
section allows to see both ventricles and atria, with the corresponding atrioventricular valves (Figs.3.44 and 3.45).
Fig. 3.38 Transducer position (subxiphoid, apical, parasternal long
axis) (illustration by Anna Rambaldo)
Fig. 3.39 Diagram with multiple tomographic sections (illustration by
Anna Rambaldo)
long axis view
mid ventricular section
of short axis view
3 Anatomy ofNative Heart Valves
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Diagram of long axis view
Parasternal long axis view
Anatomical specimen with
Fig. 3.40 Parasternal long-axis view left atrium, inow and outow left ventricle, aorta and pulmonary infundibulum. AA ascending aorta, LV left
ventricle, RV right ventricle, LA left atrium, MV mitral valve
Anatomical specimenDiagram Short axis view at the
Fig. 3.41 Parasternal short-axis view. Midventricular section with left and right ventricles, mitral and tricuspid valves. LV left ventricle; RV right
ventricle
Diagram of parasternal short axis View at the papillary muscle level
Fig. 3.42 Apical short axis, showing the papillary muscles of the mitral valve. IVS = interventricular septum; LV left ventricle; RV right
ventricle
Anatomical specimen
26
Anatomical specimen
Diagram of short axis view Parasternal short axis
Anatomical specimenDiagram Apical four chamber view
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Fig. 3.43 Parasternal short axis at the level of the great arteries’ root. Note the semilunar aortic valve and pulmonary artery bifurcation. AV ante-
rior valve; LA left atrium; PA pulmonary artery; RA right atrium; RV right ventricle
G. Thiene and S. Rizzo
Fig. 3.44 Apical four-chamber tomographic section. LA left atrium; LV left ventricle; MV mitral valve; RA right atrium; RV right ventricle; TV
tricuspid valve
By slightly enhancing the transducer, a ve-chamber view
may be obtained, namely, the four cardiac chambers plus the
left ventricular outow tract up to the ascending aorta
Moreover, from the apical longitudinal approach, a twochamber view (left atrium, mitral valve, left ventricle) may
be achieved (Fig.3.47).
(Fig.3.46).
3 Anatomy ofNative Heart Valves
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Fig. 3.45 Other apical
four-chamber tomographic
section. LA left atrium; LV left
ventricle; RA right atrium; RV
right ventricle
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Fig. 3.46 Five-chamber apical tomographic section
Fig. 3.47 Apical tomographic section with two-chamber view. LA left
atrium; LAAleft atrial appendages; LV left ventricle; MV mitral valve
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G. Thiene and S. Rizzo
Conduction System
The atrioventricular (AV) conduction system, discovered by
Tawara (Fig.3.48), is in close proximity to the cardiac valves.
The AV node is located inside the triangle of Koch, consisting of the following sides: the tendon of Todaro (within
the crista dividens), the brous annulus of the septal tricuspid valve leaet, and the ostium of the coronary sinus
(Fig.3.49).
The AV node is a right-sided structure of the atrial septum
which lies just above the septal leaet of the tricuspid valve
(Fig.3.50).
The His bundle penetrates the central brous body
(Fig.3.51) and runs underneath the membranous septum, on
the crest of the ventricular septum, just in front of the anteroseptal commissure of the tricuspid valve (Fig.3.52); then, it
bifurcates upon the crest of the ventricular septum, dividing
into right and left branches (Fig.3.52).
The sinoatrial node is located at the junction of the superior vena cava and right atrium, quite far from the AV valves
and the aortic root.
The pulmonary and mitral valves do not have a relation
with the AV conduction system in the normal heart.
Membranous septum
Right coronary
aortic leaflet
Left bundle
branch
Fig. 3.48 The av conduction system, discovered by Tawara, seen from
the left ventricle
Cardiovascular Pathology, University of Padua-Italy
Fig. 3.49 The triangle of Koch: the av node is located in front of the
ostium of the coronary sinus. The His bundle penetrates the central
brous body and runs underneath the transilluminated membranous
septum
ab
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Fig. 3.50 The av node is
located on the right side of the
central brous body, below
the endocardium of the atrial
septum. It is quite far from the
mitral valve, just over the
tricuspid septal leaet (a).
Panoramic view and (b)
closeup of the av node
Fig. 3.51 (a) The His bundle
penetrates the central brous
body from the right side, far
from the mitral valve. (b)
Common His bundle on the
right side of the atrial septum,
fully surrounded by the
collagen of the central brous
body, close to the septal
leaet of the tricuspid valve
ab
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G. Thiene and S. Rizzo
a
b
Further Reading
Anderson RH, Becker AE.Cardiac anatomy. An integrated text and
color atlas. Edinburgh: Grover Medical Publishing, Churchill
Livingstone; 1986.
Anderson RH, Yen HS.The anatomy of the heart. Cordis International
SA Training & Development; 1995.
Ho SY.Anatomy of the mitral valve. Heart. 2002 Nov;88(Suppl 4):iv5–
10, 5iv.
Pistolesi GF, Thiene G, Casolo F. L’imaging diagnostico del cuore.
Cittadella: Edizioni libreria Cortina Verona; 1985.
Rajamannan NM. Cardiac valvular medicine. Chap. 19. London:
Springer-Verlag; 2012.
Taramasso M, Pozzoli A, Basso C, Thiene G, Denti P, Kuwata S,
Nietlispach F, Aleri O, Hahn RT, Nickenig G, Schofer J, Leon
MB, Reisman M, Maisano F. Compare and contrast tricuspid and
mitral valve anatomy: interventional perspectives for transcatheter
tricuspid valve therapies. EuroIntervention. 2018;13(16):1889–98.
Fig. 3.52 Relationship of the conduction system with the aortic and
tricuspid valve. (a) The His bundle runs and bifurcates under the membranous septum (transilluminated), in correspondence to the anteroseptal commissure of the tricuspid valve. (b) The His bundle is just below
(4–5mm) the commissure between the aortic right and posterior noncoronary semilunar cusps of the aorta
Aortic Valve
Time
Incidence
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Non Infections Pathology ofNative
Heart Valves
CristinaBasso andGaetanoThiene
4
Rheumatic Valve Disease
Rheumatic valve disease is still the leading cause of aortic
valve disease in developing countries, while it is declining in
the Western world in favor of degenerative forms (Fig.4.1).
The acute rheumatic valvulitis consists of noninfective
small vegetations (verrucae) arising on the contact border of
the cusps. The acute inammation consists of a granulomatous phenomenon including “owl” cells (Aschoff) and “spider cells” (Aničkov), without perforation or fraying of the
leaets. The organization of such vegetations leads to cusp
brous thickening and retraction (Fig.4.2) with commissural
fusion (Fig. 4.3), a feature which is considered pathognomonic of the disease.
In the chronic stage, presence of vascularization at histology is the marker of previous rheumatic valvulitis (Fig.4.2),
since normal valves are not vascularized. Calcication of the
cusps is another consequence of rheumatic valve disease
(Fig.4.4).
As far as the pathophysiologic consequence, aortic stenosis occurs when commissural fusion predominates (Fig.4.3),
whereas incompetence originates when cusp retraction prevails (Fig.4.2).
The combination of the two (commissural fusion and
cusp retraction) accounts for aortic steno-incompetence.
Chronic regurgitation leads to traumatic reaction of the
subaortic septal endocardium with swallow nest formation,
which is considered a pathognomonic gross hallmark of
rheumatic aortic valve incompetence.
Nowadays, valve disease due to primary dystrophic calcication is by far the main cause of aortic stenosis (Fig.4.4).
C. Basso · G. Thiene (*)
Department of Cardiac, Thoracic, Vascular Sciences and Public
Health, University of Padua Medical School, and Cardiovascular
Pathology Unit, University Hospital of Padua, Padua, Italy
e-mail: cristina.basso@unipd.it; gaetano.thiene@unipd.it
Rheumatic valve disease
Degenerative valve disease
Emerging valve disease
Fig. 4.1 The diagram shows the decline of rheumatic valve pathology
and the increase of degenerative one, as current trend of aortic valve
disease in the developed countries
It is easily distinguishable from rheumatic stenosis, because
of coarse intrinsic calcic deposits in the absence commissural fusion. The calcium deposits may be so exuberant to
appear as nodular cauliower-like excrescences (Figs. 4.5
and 4.6).
Calcication may involve the membranous septum and
the His bundle bifurcation, with onset of AV block.
The dystrophic calcic phenomenon of the aortic valve is
frequently associated with calcication of the mitral ring
(Fig.4.5) and atherosclerotic disease of the aorta (Fig.4.6).
Aortic valve stenosis implies systolic overload with ventricular hypertrophy (Fig. 4.7) and myocardial blood ow
discrepancy, even in the absence of obstructive coronary
artery disease. It is the cause of subendocardial myocardial
ischemia, with myocytolysis and brosis (Fig.4.8).
The term atherosclerotic aortic stenosis was used in the
past; however, atheromasia of the aortic cusps is rare.
Another frequent cause of calcic aortic stenosis is the
bicuspid aortic valve, a congenital defect silent until adult-
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
G. Thiene et al. (eds.), Pathology of Cardiac Valve Disease, https://doi.org/10.1007/978-3-031-35498-4_4
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C. Basso and G. Thiene
Fig. 4.2 (a) Drawing normal
aortic valve. (b) Drawing
rheumatic aortic
incompetence. (c) Rheumatic
aortic valve incompetence:
note the thickened and
retracted cusps (d)
vascularization at histology
ac
bd
Fig. 4.3 Rheumatic aortic
stenosis with commissural
fusion. (a) Drawing. (b)
Surgical pathology specimen
abc
Fig. 4.4 Senile aortic stenosis by dystrophic calcication (a). Note the absence of commissural fusion (b). The histology shows nodular intrinsic
calcication, in the absence of inammation or neovascularization (c)
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Fig. 4.5 Senile aortic valve
stenosis (a) associated with
dystrophic calcication of the
mitral annulus (b)
ab
abc
Fig. 4.6 Senile aortic valve stenosis by dystrophic calcication (a) associated with severe atherosclerosis of the aorta (b). Close-up (c)
Fig. 4.7 Senile aortic valve
stenosis (a) with concentric
left ventricular hypertrophy
(b)
ab
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