JCU MB4 Term 1 Week 2 (MI)

1

Based on the picture, what is the diagnosis?

Healed MI


  Acute MI

  Old healed MI

  Atherosclerotic IHD

  Acute on chronic MI

  Bacterial endocarditis (SBE)


Note the thin anterior border with whitish scarring - no recent damage.

2

56-year-old with fatigue. Picture of heart shown. What is the diagnosis?

LV aneurysm post-MI


  Acute on chronic MI

  Atherosclerosis and MI

  Acute MI only

  Old MI and aneurysm

  Old MI and rupture

3

A 57-year-old man presents with a 4-hour history of chest pain radiating to his neck, with associated diaphoresis and dyspnoea. His CK-MB and troponin I are mildly elevated, and his ECG shows anterior wall ST elevations. He dies suddenly following a ventricular tachycardia/ventricular fibrillation arrest. The gross appearance of his heart is shown. What is the diagnosis?

Thrombosis of the LAD artery


  Acute MI (1 week)

  Unstable angina

  Stable plaque (>90%)

  Acute MI (1 day)

  Variable angina (Prinzmetal)


The picture shows thrombosis and occlusion of the LAD, which would lead to myocardial occlusion.

4

68-year-old man, found dead in his apartment picked up by paramedics. Image shows his myocardial biopsy. What is duration of his MI?

Biopsy of MI at less than 24 hours


  < 24 hours

  1-3 days

  3-7 days

  1-3 weeks

  

3 weeks


There are plenty of neutrophils, which means that 1-3 days is possible. However, there are still nuclei visible from the myocardium, which means that macrophages have not yet infiltrated; a very recent infarct is more likely.

KFP questions include: What type of plaque would be causing this (unstable, and how would it appear microscopically)? What is the final diagnosis (unstable angina vs MI vs SCD - SCD in this case)? What are the risk factors for his disease?

5

A 13-year-old girl develops malaise and fever, an irregular circular rash, and forearm subcutaneous nodules 3 weeks after a painful pharyngitis. A new heart murmur and friction run are heard. Her mitral valve anterior leaflet would appear as shown. What is your diagnosis?

ARF - Mitral valve vegetations


  Chronic RHD

  Bacterial endocarditis

  Acute rheumatic vegetations

  Congenital mitral floppy valve

  Thrombotic vegetations


The picture shows vegetations lining the border of the valve, and the history is consistent with Acute Rheumatic Fever. Infective vegetations would present with destruction of the valve and irregular yellowish-red vegetations in clumps.

6

An infant girl with a late systolic murmur has upper extremity pulses and blood pressures greater than in her lower extremities. She also has a webbed neck and short fourth metacarpals. If an autopsy were performed at this point, we might see a heart and great vessels as shown.

Coarctation of the aorta


  Coarctation of the aorta

  VSD

  PDA

  ASD

  Fallot's tetralogy


The picture and history are characteristic of coarctation of the aorta.

7

The image shows the myocardial biopsy of a treated MI. What is the diagnosis?

Biopsy of MI reperfusion haemorrhage


  Acute MI - 1 day

  Old MI - 6 weeks and haemorrhage

  Acute on chronic MI

  Acute MI and reperfusion

  MI at 1-3 weeks

8

The following picture shows a heart cross-section gross specimen at autopsy. What is the diagnosis?

Acute MI with thrombus


  Healed MI with aneurysm

  Acute MI with mural thrombus

  Acute MI with aneurysm

  Acute on chronic MI

  Acute MI with bacterial infection

9

52-year-old chest pain. Picture of post-mortem heart is shown. What is the most likely cause of death?

MI with wall rupture


  Cardiac tamponade

  Acute MI

  Ventricular aneurysm

  Mitral incompetence

  Thromboembolism


Aneurysm is a chronic complication of MI. Rupture followed by bleeding and cardiac tamponade is an acute complication (within 10 days).

10

68-year-old male. Picture shows myocardial biopsy. What is the duration of his MI?

MI biopsy at 1-3 weeks


  < 4 hours

  4-24 hours

  1-3 days

  1-3 weeks

  

3 weeks


Note the capillaries and macrophages (large cells). Myocardial tissue is all gone, removed by the granulation tissue (only necrotic tissue remains).

11

68-year-old recovering following an MI died suddenly while watching television on the 10th day. Myocardial biopsy is shown. What is the likely complication that caused his death?

MI biopsy at 1-3 weeks


  Severe arrhythmia

  Myocardial rupture

  Aneurysm formation

  Conduction block

  Vasovagal (e.g. television)


This must be an acute complication. The likely complication is cardiac tamponade following myocardial rupture.

12

A 30-year-old intravenous drug user with 2-day history of fever is found to have coarse systolic and diastolic murmurs, splenomegaly, and nail be splinter haemorrhages. His CK-MB is elevated. He experiences sudden cardiac arrest. His aortic valve at autopsy is shown. Why did he die?

Endocardial vegetations


  Septicaemia

  Haemorrhage

  Aneurysm of aorta

  MI

  Thromboembolism


While the picture shows extensive descruction characteristic of infective endocarditis (also consistent with the history) which could lead to septicaemia, the elevated CK-MB and sudden death point to myocardial infarction as the primary cause of death. In this case, it is likely caused by blockage of the coronary sinus due to the bacterial vegetations.

13

The picture shows a myocardial biopsy post-MI. What is the duration of the MI?

MI biopsy 1-3 days


  < 4 hours

  4-24 hours

  1-3 days

  1-3 weeks

  

3 weeks


Note plenty of neutrophils and oedema. The myocardial fibres are still intact but no nuclei.

14

The picture shows a myocardial biopsy post-MI (stained blue for collagen). What is the duration of the MI?

MI biopsy (late)


  < 4 hours

  4-24 hours

  1-3 days

  1-3 weeks

  

3 weeks


The high amount of collagen indicates extensive scarring, consistent with a healing or late MI.

15

72-year-old male, congestive cardiac failure. What is the complication indicated by the pale patches?

MI with aneurysm and fibrosis


  Endocardial fibrosis

  Old healed MI

  Ventricular aneurysm

  Mitral incompetence

  Mural thrombosis


This picture also shows a ventricular aneurysm (thin wall).

16

62-year-old with chronic IHD. What is the complication shown in the image?

LV aneurysm


  Old healed MI

  LV aneurysm

  Mural thrombosis

  Acute on chronic MI

  Cardiac tamponade

17

A 45-year-old man with a 6-year history of progressive exertional dyspnoea is found by echocardiography to have an ejection fraction 28% (normal is 50-60%) with systolic dysfunction and mitral regurgitation. His native heart after cardiac transplantation is shown. What is the diagnosis?

Dilated Cardiomyopathy


  Bacterial endocarditis (mitral valve)

  Hypertrophic cardiomyopathy

  LV aneurysm

  Toxic cardiomyopathy

  Dilated cardiomyopathy


The presentation is very characteristic of dilated cardiomyopathy, which is also the commonest form of cardiomyopathy. The marked dilation of the heart is readily visible in the image. Hypertrophic cardiomyopathy would have presented with a history of hypertension with cardiac failure as well as more hypertrophy than dilation in the gross specimen.

18

The picture shows a myocardial biopsy post-MI. What is the duration of the MI?

MI biopsy over 3 weeks


  < 4 hours

  4-24 hours

  1-3 days

  1-3 weeks

  

3 weeks


Note that there are no blood vessels, only inflammatory cells indicating late healing MI.

19

62-year-old CHD. What is the complication shown in the image?

Healed MI with aneurysm and thrombus


  Old healed MI

  Old MI & aneurysm & thrombus

  Old MI & mural thrombus

  Acute on chronic MI

  Acute on old MI & thrombus


Note the whitish scar in the posterior and septal regions indicating an old healed MI. The obvious posterior dilatation is consistent with the appearance of an aneurysm. A clot is clearly visible within the cavity.

20

A 48-year-old woman with a 5-year history of worsening orthpnoea is found on examination to have atrial fibrillation and a rumbling diastolic murmur with opening snap. The gross appearance of her heart at surgical valve replacement is shown. What are the possible complications?

Mitral Valve Stenosis


  Pedal oedema

  LV rupture

  Aneurysm

  Myocardial infarction

  Pulmonary oedema


The picture shows severe mitral stenosis, of which the commonest complications are pulmonary oedema and cardiac failure.

21

The picture shows a myocardial biopsy post-MI. What is the duration of the MI?

MI biopsy less than 24 hours


  < 4 hours

  4-24 hours

  1-3 days

  1-3 weeks

  

3 weeks


Note contraction bands and scarce nuclei. Inflammatory cells have not yet entered the myocardium.