John P. Veinot

2011 consensus statement on endomyocardial biopsy from the Association for European Cardiovascular Pathology and the Society for Cardiovascular Pathology.

The Association for European Cardiovascular Pathology and the Society for Cardiovascular Pathology have produced this position paper concerning the current role of endomyocardial biopsy (EMB) for the diagnosis of cardiac diseases and its contribution to patient management, focusing on pathological issues, with these aims: • Determining appropriate EMB use in the context of current diagnostic strategies for cardiac diseases and providing recommendations for its rational utilization • Providing standard criteria and guidance for appropriate tissue triage and pathological analysis • Promoting a team approach to EMB use, integrating the competences of pathologists, clinicians, and imagers.

Recommendations for processing cardiovascular surgical pathology specimens: a consensus statement from the Standards and Definitions Committee of the Society for Cardiovascular Pathology and the Association for European Cardiovascular Pathology

With the advent of molecular subclassification of diseases, much consideration should be given to the proper processing of cardiovascular surgical pathology specimens to maximize patient care. Such specimens include endomyocardial biopsies, cardiac myectomy specimens, cardiac apical core segments, resected cardiac valves, pericardial biopsies, resected segments of aorta, cardiac tumors, vascular stents, vascular grafts, cardiac devices, resected veins, arterial biopsies including temporal artery biopsies and hearts removed during cardiac transplantation. In this report, the Standards and Definitions Committee of the Society for Cardiovascular Pathology and the Association for European Cardiovascular Pathology present consensus guidelines for the gross description, sectioning, processing, and staining of these specimens. This report is presented to aid pathologists, pathology assistants, and clinicians in maximizing the diagnostic utility of cardiovascular surgical pathology specimens for enhanced patient care.

Mechanical characterization of human aortas from pressurization testing and a paradigm shift for circumferential residual stress.

Material properties needed for accurate stress analysis of the human aorta are still incompletely known, especially as many reports have ignored the presence of residual stresses in the aortic wall. To contribute new material regarding these issues, we carried out measurements and pressurization testing on ascending, thoracic and abdominal aortic samples from 24 human subjects aged 38-77 years, and evaluated the opening angle describing the circumferential residual stress level present in the aorta. We determined material constants for the aorta by gender, anatomic location and age group, according to a simple phenomenological constitutive model. The unpressurized aortic radius positively correlated with age, and the circumferential and longitudinal stretch ratios under systemic pressure negatively correlated with age, confirming the known enlargement and stiffening of the aorta with aging. The opening angle was measured to range from a minimum of 89° to above 360° for extreme cases. For given aortic dimensions and material properties, analysis of the in vivo circumferential and longitudinal mural stress distributions indicated a profound influence of the opening angle. For instance, in the thoracic aorta of males aged 38-66, opening angles in the range of 0° to 80° (resp. 60°) may equalize the gradient of in vivo circumferential (resp. longitudinal) stress between the inner and outer layers of the aorta, as commonly expected; however, opening angles above 160° (resp. 120°) may cause the gradient of circumferential (resp. longitudinal) stress to reverse and increase compared to the case without residual stress, putting the maximum stresses toward the adventitia instead of the intima. Even though the analysis of the aortic wall excluded possible longitudinal residual stresses as well as material inhomogeneities, such as constitutive differences between the intimal, medial and adventitial layers, the experimental data reported herein are important to aortic modeling at large and the better understanding of aortic pathophysiology in particular.

Cholesterol Efflux Capacity, Carotid Atherosclerosis, and Cerebrovascular Symptomatology

Objective—To investigate the association of cholesterol efflux capacity with carotid atherosclerosis and cerebrovascular disease. Approach and Results—Patients with high-grade carotid stenosis (n=154) were recruited from Vascular Surgery clinics and 9 healthy controls from the McGill University Health Network, Montreal, Canada. Cerebrovascular symptomatology history was obtained. Stenosis was assessed by carotid ultrasound. Fasting blood samples were collected and depleted of apolipoprotein B particles by polyethylene glycol precipitation from serum. Cholesterol efflux was determined by incubating apolipoprotein B–depleted serum in cAMP-stimulated J774 cells for 6 hours. Carotid specimens were classified by 2 vascular pathologists using the American Heart Association atheromatous plaque classification. Differences in efflux were assessed according to (1) stenosis, (2) American Heart Association classification, and (3) cerebrovascular symptomatology. Normalized efflux was significantly lower in patients with carotid atherosclerosis compared with controls (0.97±0.16 versus 1.5±0.46; P<0.0001). Efflux was inversely associated with stenosis; the odds ratio for 80% to 99% versus 50% to 79% stenosis of tertile 1 (lowest) versus tertile 3 (highest) of efflux was 3.78 (95% confidence interval, 1.18–12.06) after adjusting for age, sex, low-density lipoprotein, and high-density lipoprotein. There were significant differences in cholesterol efflux between American Heart Association fibroatheroma (Va, 0.91±0.13), mainly calcific (Vb, 0.97±0.15), and mainly fibrotic (Vc, 1.03±0.21; P=0.05). There were no significant differences in efflux according to symptomatology. Conclusions—Cholesterol efflux capacity is inversely associated with increasing carotid stenosis and is associated with more advanced carotid plaque morphology, suggesting that cholesterol efflux capacity may be a biomarker for severity of carotid atherosclerotic burden. Whether therapies targeting high-density lipoprotein quality could be useful for stabilizing carotid atherosclerosis needs to be assessed.

Superficial femoral artery nitinol stent in a patient with nickel allergy

We present a case of a patient who developed a systemic allergic reaction following placement of a nitnol stent in the superficial femoral artery for claudication symptoms. Shortly after, he was tested for contact dermatitis and found to have a severe reaction to nickel. His symptoms of severe itch and generalized rash resolved within days following stent explantation and reconstruction with a vein graft. The epidemiology and clinical significance of nickel allergy and the concomitant use of nickel-alloy stents are discussed.

Diagnostic use of the endomyocardial biopsy: a consensus statement

The Association for European Cardiovascular Pathology and the Society for Cardiovascular Pathology created a task force to write a consensus document on when and how endomyocardial biopsy is of help for clinicians in the diagnosis and treatment of patients with heart failure, arrhythmias, and cardiac masses. Endomyocardial biopsy is the gold standard for a definitive diagnosis in disease entities like myocarditis, cardiac allograft rejection, and infiltration/storage myocardial disorders. Use of molecular biology techniques is mandatory to obtain specific information on etiology and pathogenesis and should be carried out as an investigation complementary to histology and immunohistochemistry. Given the complexity of these investigations, endomyocardial biopsy should be performed in or in collaboration with cardiac pathology referral centers, where the whole armamentarium of pathological investigation is available, including molecular techniques. Optimal use of the endomyocardial biopsy requires clinicopathologic correlations.

Endomyocardial biopsy—when and how?

Endomyocardial biopsy is a commonly performed useful procedure utilized for the evaluation of cardiac tissue. Biopsy may be used to monitor transplant rejection, but it has many other applications including the evaluation of myocarditis, cardiomyopathy, chest pain, arrhythmia, and secondary involvement by systemic diseases. Drug toxicity may be evaluated and neoplasms may be biopsied. Recent developments include advances in myocardial and viral molecular biology and advances in image or electrophysiology guided biopsy. The utility of endomyocardial biopsy is reviewed with consideration of these advances.

AECVP and SCVP 2009 Recommendations for Training in Cardiovascular Pathology

Cardiovascular disease is of continuing importance as the result of a growing burden of risk factors in both developing and developed countries and the increasing number of elderly people worldwide. The recruitment and training of a new generation of Cardiovascular Pathologists is crucial to sustaining clinical excellence and to advancing our knowledge of cardiovascular disease. These pathologists will also have a key role in undergraduate and postgraduate training. In 2005 a task force of the Society for Cardiovascular Pathology published a document on the role of Cardiovascular Pathology as subspecialty of Anatomical Pathology (Pathological Anatomy). The 2005 report emphasized the need for a core curriculum and structured learning for residents and fellows in Cardiovascular Pathology. This new consensus statement on training is the result of collaboration between Cardiovascular Pathology Societies based in Europe and North America. It includes a detailed curriculum and describes three levels of expertise that can be developed.

Infective Endocarditis Presenting as ST-Elevation Myocardial Infarction: An Angiographic Diagnosis

While systemic embolic events occur with relative frequency in infective endocarditis (IE), coronary embolization remains an uncommon cause of ST elevation myocardial infarction. Herein we report a case of ventricular fibrillation and anterior ST elevation myocardial infarction occurring in a patient initially presenting with septic shock. Angiography proved diagnostic for IE of a native bicuspid aortic valve complicated by root abscess and left anterior descending artery occlusion. Histologic examination of the embolectomy specimen from the left anterior descending artery confirmed the presence of thrombus and bacteria. The present case highlights difficulties in identifying and managing patients with coronary embolism of vegetations from IE.

Tropheryma whipplei aortic valve endocarditis without systemic Whipple's disease

Culture-negative endocarditis is most often the result of prior antimicrobial therapy. Tropheryma whipplei is the etiologic agent of Whipples disease, which is typically characterized by diarrhea, weight loss, and intra-abdominal lymphadenopathy. We present the case of a 48-year-old male with Whipples endocarditis of the aortic valve who did not develop signs of systemic Whipples disease. Our patient was treated with a regimen that included ceftriaxone for 6 weeks prior to his cardiac surgery, yet valve pathology demonstrated abundant T. whipplei, suggesting that a prolonged antibiotic course is necessary for the treatment of Whipples endocarditis.