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1、心脏的大体及显微镜下观,Fuyuan zhang,正常心脏大体观,这是一个正常心脏的外形，心外膜看上去光滑而有光泽。心外膜脂肪的数量正常，左冠状动脉的前降支从主动脉根部延伸到心尖部。,正常主动脉瓣大体观,主动脉瓣显示三个 薄而精密的瓣叶组 织。其上可见冠状 动脉的开口。心内 膜光滑，其下可见红褐色的心肌组织。主动脉瓣上的主动脉壁显示光滑的增生的内膜组织，但无动脉粥样硬化的改变。,正常三尖瓣大体观,这是三尖瓣结构，瓣叶菲薄精密。和二尖瓣一样，瓣叶边缘也有细的腱索将其附着到下方室壁的乳头肌上。,正常心肌中倍显微镜下观,这是正常心肌纤维的纵轴观，可见中心排列的细胞核及细胞之间没有分界线，其中有些浅红
2、色的圆盘插入。,正常冠状动脉显微镜下观,这是正常冠状动脉，具有很大，光滑，没有阻塞的管腔，能为心肌提供充足的血液供应。,动脉粥样硬化性心血管疾病,冠状动脉粥样硬化性狭窄，显微镜下观,冠状动脉显示由于粥样硬化斑块的沉积导致官腔狭窄，严重的狭窄可导致心绞痛，心肌缺血和心肌梗塞（右下图）。,正常,冠状动脉栓塞后再通，显微镜下观,切面的冠状动脉显示陈旧性的栓塞，并有再通而形成两个小的狭窄通道。,冠状动脉伴钙化的粥样硬化，显微镜下观,这是冠状动脉严重狭 窄的表现，它的复杂 性在于其右下方有大 片的钙化区域，在苏 木素依红染色上显示蓝色。复合性的动脉粥样硬化包括钙化，血栓或出血。这些钙化会使得冠状动脉成形
3、很难成功。,冠状动脉阻塞性粥样硬化，显微镜下观,冠状动脉的远端显示 明显的狭窄，这种累 及到末端的病变是严 重动脉粥样硬化的典 型改变。在伴有糖尿病和高脂血症的病人，常可见到这种情况，会使搭桥手术十分困难。,冠状动脉近期的栓塞，显微镜下观,在新近发生狭窄的冠状动脉中可见粉红到红色的新鲜血栓。其中开放的，针形的区域是粥样硬化斑块的胆固醇间隙。,粥样硬化斑块，高倍显微镜下观,粥样硬化改变的高倍镜下观，可见许多的泡沫细胞，及少许的胆固醇结晶，和散在的深蓝色的炎性细胞。,主动脉伴有很少的脂质纹，大体标本,这是基本正常的人体主动脉的外观，表面十分光滑，仅见少许菲薄的黄色脂质条纹。,主动脉伴有脂肪条纹，大
4、体标本,白色箭头显示的是主动脉上最明显的脂肪条纹，还有其它的散在于主动脉的表面，脂肪条纹是动脉粥样硬化最早出现的改变。,主动脉不同程度的粥样硬化改变，大体标本,这三个主动脉显示 的是轻，中，重度的 动脉粥样硬化。最下 面最轻的动脉粥样硬 化仅显示散在的脂质斑块；中间的显示许多大的斑块；最上面严重动脉粥样硬化病变显示粥样硬化上广泛的溃疡出现。,主动脉-粥样硬化性主动脉，大体标本，CT片,这里是一个主动脉粥样硬化瘤的标本，在腹主动脉分叉处的上方形成球形的瘤体，但其体积增大到6-7厘米时，就很容易破裂。,腹部CT显示的是主动脉瘤，体积接近6厘米，这时其很容易破裂。,主动脉粥样硬化斑块，低倍显微镜下观
5、,显微镜下可见左侧大的粥样硬化斑块，其中包含许多的胆固醇结晶。左侧还可见溃疡及出血。,主动脉粥样硬化斑块，高倍显微镜下观,主动脉粥样硬化斑块的高倍镜下观，可见泡沫细胞及胆固醇结晶,主动脉溃疡性粥样硬化并发附壁血栓，大体标本,这是严重粥样硬化的主动脉，已经形成粥样硬化斑块的溃疡及附壁血栓。,肾脏的胆固醇栓子，中倍显微镜下观,冠状动脉中度粥样硬化，大体标本,一支冠状动脉纵形切 开，周围有心外膜脂 肪，这里心外膜的增 加是全身脂肪增加的 一部分。这里的冠状动脉仅显示轻度的粥样硬化，可见散在的黄色脂质斑块而没有狭窄。,冠状动脉严重粥样硬化，大体标本,这是从主动脉根部左侧发出的左冠状动脉，切开的为左前降
6、支，有严重的粥样硬化及广泛的钙化，末端有显著的狭窄。,冠状动脉粥样硬化斑块内出血，大体标本,这是冠状动脉粥样硬化合并出血到粥样硬化斑块内，这种急性出血可能导致冠状动脉管腔狭窄。,冠状动脉阻塞性粥样硬化病变，大体标本,冠状动脉的系列横 切面显示管腔的狭 窄，在左侧的近端 冠状动脉狭窄最严 重，通常粥样硬化病变在近端更为严重，那里动脉的血流速度很快。局灶性的病变越严重则PTCA或搭桥手术的效果更好。,心脏及冠状动脉前降支最近的栓塞，大体标本,心脏前面切开的左前降支冠状动脉，在管腔内可见新形成的深红色的血栓。在前降支冠状动脉分布的区域可见梗死的心肌。,冠状动脉新的栓塞，纵形切开，大体标本,在冠状动脉
7、纵形切 开面，可见冠状动 脉管腔中深红色的 血栓。冠状动脉管 腔中粥样硬化斑块使管腔显著狭窄，而血栓形成则使管腔完全闭塞。,心肌梗死,心脏，左心室，急性心肌梗塞，大体标本,这里左室纵形切开以显示大范围的急性心肌梗死。坏死的中心是黄色的坏死肌肉，周围是红色的充血区，仍存活的心肌为红褐色。,心脏，左心室和室间隔，心肌梗塞，大体标本,This cross section through the heart demonstrates the left ventricle on the left. Extending from the anterior portion and into the sept
8、um is a large recent myocardial infarction. The center is tan with surrounding hyperemia. The infarction is “transmural“ in that it extends through the full thickness of the wall.,心肌，收缩带坏死，显微镜下观,The earliest change histologically seen with acute myocardial infarction in the first day is contraction
9、band necrosis. The myocardial fibers are beginning to lose cross striations and the nuclei are not clearly visible in most of the cells seen here.,Note the many irregular darker pink wavy contraction bands extending across the fibers.,心肌，急性心肌梗塞，1-2天，高倍显微镜下观,This high power microscopic view of the my
10、ocardium demonstrates an infarction of about 1 to 2 days in duration. The myocardial fibers have dark red contraction bands extending across them. The myocardial cell nuclei have almost all disappeared.,There is beginning acute inflammation. Clinically, such an acute myocardial infarction is marked
11、by changes in the electrocardiogram and by a rise in the MB fraction of creatine kinase.,心肌，急性心肌梗塞，1-2天，显微镜下观,In this microscopic view of a recent myocardial infarction, there is extensive hemorrhage along with myocardial fiber necrosis with contraction bands and loss of nuclei.,心肌，急性心肌梗塞，3-4天，显微镜下观
12、,This myocardial infarction is about 3 to 4 days old. There is an extensive acute inflammatory cell infiltrate and the myocardial fibers are so necrotic that the outlines of them are only barely visible.,心肌，亚急性心肌梗塞，1-2周，显微镜下观,This is an intermediate myocardial infarction of 1 to 2 weeks in age. Note
13、 that there are remaining normal myocardial fibers at the top. Below these fibers are many macrophages along with numerous capillaries and little collagenization.,心脏，透壁心肌梗塞伴破裂及血心包，大体标本,One complication of a transmural myocardial infarction is rupture of the myocardium. This is most likely to occur i
14、n the first week between 3 to 5 days following the initial event, when the myocardium is the softest. The white arrow marks the point of rupture in this anterior-inferior myocardial infarction of the left ventricular free wall and septum. Note the dark red blood clot forming the hemopericardium. The
15、 hemo-pericardium can lead to tamponade.,心脏，透壁心肌梗塞伴破裂，大体标本,In cross section, the point of rupture of the myocardium is shown with the arrow. In this case, there was a previous myocardial infarction 3 weeks before, and another myocardial infarction occurred, rupturing through the already thin ventric
16、ular wall 3 days later.,心脏，远期的心肌梗塞，中倍显微镜下观,There is pale white collagen within the interstitium between myocardial fibers. This represents an area of remote infarction.,心脏，远期的心肌梗塞，低倍显微镜下观,The myocardium beneath the endocardial surface at the top demonstrates pale fibrosis with collagenization following healing of a subendocardial myocardial infarction.,心脏，远期的心肌梗塞，大体标本,The heart is opened to reveal the left ventricular free wall on the right and the septum in the center. There has been a remote
