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Pathobiology of Thrombosis

Overview of thrombosis Abnormal hemostasis leads to thrombus formation. Thrombosis in either the arterial or the venous system is a leading cause of significant morbidity and mortality. When thrombosis occurs in the arterial system, myocardial infarction and stroke may occur, whereas thrombosis in the venous system results in venous thromboembolic disease. Thrombosis and thrombotic-related events are among the most common causes of mortality in the Western…

Pathobiology of Aortic Aneurysms

Aortic aneurysms (AAs) can develop in either the thoracic or the abdominal aorta, termed thoracic aortic aneurysm (TAA) ( Fig. 7.1 ) or abdominal aortic aneurysm (AAA) ( Fig. 7.2 ), respectively. AAs are further subclassified according to their specific location in the thoracic (ascending aorta, aortic arch, descending aorta) or abdominal (suprarenal or infrarenal) aortic segments ( Fig. 7.3 ). Although this classification may appear…

Pathobiology of Atherosclerosis

Knowledge of the pathobiology of atherosclerosis has continued to evolve at a rapid pace. Previously regarded as a mainly segmental disease, we now increasingly appreciate the condition’s diffuse nature. The traditional clinical focus on atherosclerosis has emphasized coronary artery disease. The attention of physicians in general and of cardiovascular specialists in particular now embraces other arterial beds, including the peripheral and cerebrovascular arterial circulations. Formerly considered…

Vascular Pharmacology

Therapeutic intervention is optimized when we understand the normal physiological signaling processes that are disrupted by a disease process, the abnormal molecular and cellular mechanisms driving disease pathogenesis, and the pharmacological profile of the intervention. Indeed, the majority of vascular drugs act as replacement therapy to augment endogenous protective signaling processes or as reversal therapy to block or reduce the abnormal activity of pathological mediators or…

Normal Mechanisms of Vascular Hemostasis

Hemostasis occurs in response to vessel injury. The clot is essential both for the prevention of blood loss and the initiation of the wound repair process. When there is a lesion present in the blood vessel, the response is rapid, highly regulated, and localized. If the process is not balanced, abnormal bleeding or nonphysiological thrombosis, can result. In cardiovascular disease, the formation of abnormal thrombus at…

Vascular Smooth Muscle

The centrality of vascular smooth muscle cells (VSMCs) to normal functioning of the cardiovascular system has led to decades of intensive research into the physical, cellular, and molecular mechanisms regulating VSMC biology. VSMCs are the major cell type within the enclosed vascular continuum; they are primarily responsible for adaptations necessary for repeated cycles of contraction and relaxation resulting from cardiac-driven pulsatile blood flow. VSMCs maintain contractile…

The Endothelium

In 1839, the German physiologist Theodor Schwann became the first to describe a “thin, but distinctly perceptible membrane” that he observed as part of the capillary vessel wall that separated circulating blood from tissue. The cellular monolayer that formed this membrane would later be named the endothelium ; however, the term endothelium did not appear until 1865 when it was introduced by the Swiss anatomist Wilhelm…

Vascular Embryology and Angiogenesis

In simple terms, the cardiovascular system consists of a sophisticated pump (i.e., the heart) and a remarkable array of tubes (i.e., the blood and lymphatic vessels). Arteries and arterioles (the efferent blood vessels in relation to the heart) deliver oxygen, nutrients, paracrine hormones, blood and immune cells, and many other products to the capillaries, small-caliber, thin-walled vascular tubes. These substances are then transported through the capillary…

Valvular heart disease in pregnancy

Key points Pregnancy increases cardiac output and intravascular volume, which increases gradients across stenotic lesions and can exacerbate heart failure in patients with severe valvular stenosis. Intravascular volume increases in the immediate postpartum period, and high-risk patients require 48 to 72 hours of close monitoring after delivery. The risk of cardiovascular events ranges between 5% and 70% for women with heart disease. Women with higher New…

Management of bioprosthetic valve degeneration

Key points The choice of surgical valve replacement or transcatheter valve-in-valve (VIV) implantation for bioprosthetic valve failure depends on careful consideration of patient characteristics and surgical valve and anatomic parameters by a multidisciplinary heart valve team. Clinical outcomes after a transcatheter VIV procedure differ from those after a native valve transcatheter aortic valve implantation; with VIV, there are fewer mechanical complications and lower rates of mortality,…

Prosthetic heart valves

Key points The need for heart valve replacement surgery marks a major milestone in the natural history of valve disease and mandates establishment of a schedule for clinical and echocardiographic surveillance. Surgical repair, especially for primary mitral regurgitation, is preferred whenever anatomically feasible and when supported by the experience of the surgeon. Valve replacement surgery substitutes a nonimmunogenic foreign body for the native valve. Hemodynamic performance…

Infective endocarditis

Key points Infective endocarditis (IE) is a subacute or acute infection of a heart valve, endocardial surface, prosthetic valve or material, or cardiac implantable electronic device (CIED). Despite improvements in IE diagnosis and treatment, in-hospital mortality has not decreased and persists at almost 20%. Changes in the epidemiology, including older patients, more health care–associated infections, and more infections of CIEDs, reflect worsening host factors that may…

Pulmonic valve disease in adults

Key points Congenital valvular pulmonic stenosis (PS) that is mild in severity is well tolerated and has a benign natural history. Balloon angioplasty is the first-line treatment for severe valvular PS, especially for doming pulmonic valves. Double-chambered right ventricle is an uncommon form of right ventricular outflow tract obstruction in which the right ventricle is divided into a proximal high-pressure and a distal low-pressure chamber. Surgical…

Diseases of the tricuspid valve

Key points Tricuspid regurgitation (TR) is most frequently functional, not related to primary tricuspid leaflet pathology but secondary to another disease process that produces right ventricular dilation, distortion of the subvalvular apparatus, tricuspid annular dilation, or a combination of these. Severe TR due to a flail leaflet is associated with adverse outcomes favoring early surgical repair. TR negatively impacts clinical outcome and survival, regardless of left…

Intraoperative echocardiography for mitral valve surgery

Key points Mitral regurgitation (MR) and mitral stenosis (MS) may result from abnormalities of the mitral valvular complex—leaflets, annulus, chordae, and papillary muscles—and the left atrium and ventricle. Intraoperative echocardiography is a vital diagnostic technique for mitral valve (MV) surgery and is recommended for all valve repair procedures. Three-dimensional (3D) echocardiography, with or without color Doppler, may aid the clinician in localizing valvular pathology before and…

Imaging guidance of transcatheter mitral valve procedures

Key points The field of structural heart disease interventions is expanding rapidly. Advances in cardiac imaging are playing a central role in patient selection, imaging guidance, and follow-up of patients undergoing transcatheter mitral valve procedures (TCMVPs). Three-dimensional transesophageal echocardiography has become the fundamental technique for imaging guidance of TCMVP. Advances in heart and mitral valve modeling and echocardiographic-fluoroscopic (echo/fluoro) fusion imaging have enhanced the applicability of…

Transcatheter mitral valve repair and replacement

Key points The risks of surgery for severe mitral regurgitation (MR) in elderly patients and those with medical comorbidities, particularly with consideration of patient preference for quick recovery, have stimulated attempts to develop less invasive solutions. Unlike the extensive toolbox available to the mitral surgeon, transcatheter approaches are much more limited and often are able to address only a single major element of the dysfunctional valve…

Surgical mitral valve repair and replacement

Key points The mitral valve is a complex, three-dimensional assembly of independent anatomic components, including the annulus, leaflets and commissures, chordae tendineae, papillary muscles, and left ventricle. Abnormalities (lesions with etiologic implications) in any of these components may cause alteration in closure (i.e., dysfunction) against left ventricular (LV) pressure and consequently mitral regurgitation (MR) or mitral stenosis (MS). Although rheumatic disease remains the most common cause…

Secondary (functional) mitral regurgitation in ischemic and dilated cardiomyopathy

Key points Grading of mitral regurgitation (MR) severity by echocardiography should not be based on visual inspection of the color Doppler MR jet, but rather on integration of multiple qualitative and quantitative parameters. Secondary MR is dynamic, changing during systole in a biphasic pattern, and often varying dramatically with changes in loading conditions. Any degree of secondary MR is associated with an adverse prognosis; however, LV…