Evaluation of Excised Cardiac Valves



Evaluation of Excised Cardiac Valves


Allen P. Burke, M.D.



General Considerations

A gross photograph generally provides significantly more information than do histologic sections or long gross descriptions. However, histologic evaluation is essential in ruling out endocarditis, which may not always be grossly obvious.

The distinction between valve replacement and repair should be made. In general, aortic valves and stenotic mitral valves are replaced, and insufficient mitral valves are either repaired or replaced.


Aortic Valve

For replaced aortic valves, the number of tissue fragments and intact leaflets should be described, as well as intact (fused) commissures, raphes, and calcification. With any valve, roughened areas, vegetations, and perforations should be sectioned to exclude endocarditis (Table 171.1). The most common conditions encountered are degenerative calcific aortic stenosis (trileaflet somewhat more common than bileaflet), followed by insufficient valves (trileaflet or bileaflet) that look relatively normal, and postinflammatory (rheumatic) valve disease. Depending on the population, aortic valve endocarditis may be a relatively common diagnosis and is generally known prior to surgery (Table 171.2).


Mitral Valve

Mitral valves are frequently repaired, especially in cases of regurgitation, most frequently for prolapse. In such cases, only a fragment of the posterior leaflet may be encountered. For stenotic valves (usually a result of postinflammatory mitral valve disease and rarely calcific mitral valve disease), the valve is typically replaced. For the mitral valve, the chordae tendineae should be described, as they are important to distinguish prolapse (thin, elongated) from rheumatic disease (thickened, fused) (Table 171.3). Mitral valves that have been previously operated that have been previously infected may also show thickened chordae. Common conditions requiring mitral valve replacement are presented in Table 171.4.








TABLE 171.1 Gross Findings, Aortic Valve, Surgical Specimensa









Intact valve ______________________________________ Intact separate leaflets ______________________________________ Fragmented ______________________________________


Number of leaflets: Three ______________________________________ Two ______________________________________ One ______________________________________ Indeterminate ______________________________________


Fused commissures (0,1,2,3) ______________________________________


Bicuspid valves: presence of raphe ______________________________________ angle of conjoint cusp (if fused) ______________________________________


Fibrosis (absent, mild, marked) ______________________________________


Calcification (mild, nodular) ______________________________________


Free edge of valve (rolled edges, fibrotic, normal)


Vegetations ______________________________________ Perforations ______________________________________ Fenestrations ______________________________________


Examples of diagnoses:b




  • Degenerative calcific sclerosis/stenosis, trileaflet valve



  • Degenerative calcific sclerosis/stenosis, bicuspid valve



  • Degenerative calcific sclerosis/stenosis, indeterminate number of leaflets



  • Bicuspid valve, changes consistent with insufficiency (often with aneurysm repair)



  • Trileaflet valve, changes consistent with insufficiency (sometimes with aneurysm repair)



  • Postinflammatory (rheumatic) valve disease (primarily stenotic/insufficient)



  • Infectious endocarditis



  • Unicuspid/unicommissural valve (teardrop shape)



  • Nonspecific fibrosis, indeterminate



  • Focal calcification, indeterminate (may rarely cause insufficiency instead of stenosis)


aGross photography is recommended and eliminates the need for long gross descriptions.

b Access to operative report and surgeon’s description is very helpful.



Tricuspid and Pulmonary Valves

The tricuspid valve is often repaired for the treatment of insufficiency, generally in the setting of pulmonary hypertension. Usually, no tissue is excised, and a C-shaped annuloplasty device is placed.

In cases of infectious endocarditis involving the tricuspid valve, which generally occurs in intravenous drug addicts, the valve may be resected, if there is significant destruction of the leaflets (see Chapter 177).

The pulmonary valve is repaired or replaced, often with right ventricular outflow tract reconstruction, in children with tetralogy of Fallot. Adults may have revisions of right ventricular outflow procedures decades after the initial surgery, and portions of native valve, prosthetic valve, transannular patch, or conduit may be removed during surgery (see Chapter 140).


Vegetations

In some patients, only a vegetation from a valve is removed (vegetectomy). Most of these are infectious endocarditis, and histologic
examination will show fibrin thrombus with entrapped neutrophils, and often bacteria. Occasionally, marantic (sterile) vegetations are removed, and histology shows bland fibrin thrombus. Another form of vegetation is represented by papillary fibroelastoma, which may be removed without incising the underlying valve leaflet (see Chapter 176).

Only gold members can continue reading. Log In or Register to continue

Related posts:

  1. Pediatric Interstitial Lung Disease and Hermansky-Pudlak Syndrome
  2. Pulmonary Capillaritis
  3. Small Cell Carcinoma
  4. Lymphoepithelioma-Like Carcinoma

Stay updated, free articles. Join our Telegram channel
Tags:
Aug 19, 2016 | Posted by in CARDIOLOGY | Comments Off on Evaluation of Excised Cardiac Valves

Full access? Get Clinical Tree
Get Clinical Tree app for offline access