PICTURES

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TEXT="#080000"> <div> <I>PICTURES</I></div> <div> <IMG SRC="0bfc9cc0.jpg" border=0 width="457" height="460" ALIGN="BOTTOM" HSPACE="0" VSPACE="0">NORMAL CORONARY</div> <div> <IMG SRC="16b90610.jpg" border=0 width="400" height="353" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="16c66750.jpg" border=0 width="358" height="373" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="16db43b0.jpg" border=0 width="436" height="315" ALIGN="BOTTOM" HSPACE="0" VSPACE="0">Sino-Atrial Nodal Artery. </div> <div> <IMG SRC="0c3f4d60.jpg" border=0 width="500" height="470" ALIGN="BOTTOM" HSPACE="0" VSPACE="0">Coronary Arteries And Veins. </div> <div> <IMG SRC="16ec9390.jpg" border=0 width="457" height="313" ALIGN="BOTTOM" HSPACE="0" VSPACE="0">Anomalous Origin Of The Left Coronary. </div> <div> <IMG SRC="16fef0e0.jpg" border=0 width="495" height="270" ALIGN="BOTTOM" HSPACE="0" VSPACE="0">Coronary Ostial Stenosis</div> <div> <IMG SRC="170d0420.jpg" border=0 width="464" height="322" ALIGN="BOTTOM" HSPACE="0" VSPACE="0">Myocardial Bridge Over The Lad</div> <div> <IMG SRC="171c5270.jpg" border=0 width="453" height="295" ALIGN="BOTTOM" HSPACE="0" VSPACE="0">Coronary Obstruction Due To Fungi </div> <div> <IMG SRC="172f4730.jpg" border=0 width="500" height="371" ALIGN="BOTTOM" HSPACE="0" VSPACE="0">Vaso-Invasive Aspergillus Of The Coronary Artery </div> <bR> <div> <IMG SRC="0635ee00.gif" border=0 width="350" height="480" ALIGN="BOTTOM" HSPACE="0" VSPACE="0">VENTRICULAR ANEURYSM</div> <div> <IMG SRC="17384230.gif" border=0 width="388" height="291" ALIGN="BOTTOM" HSPACE="0" VSPACE="0">CORONARY THROMBOSIS</div> <div> <IMG SRC="09fb0440.gif" border=0 width="432" height="324" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <div> <IMG SRC="0a3b0710.gif" border=0 width="432" height="369" ALIGN="BOTTOM" HSPACE="0" VSPACE="0">MI ACUTE AND MASSIVE<IMG SRC="0a4b0440.gif" border=0 width="432" height="324" ALIGN="BOTTOM" HSPACE="0" VSPACE="0">OLD AND ACUTE MI</div> <div> <IMG SRC="0a5b0440.gif" border=0 width="432" height="324" ALIGN="BOTTOM" HSPACE="0" VSPACE="0">Healing Myocaridial <FONT SIZE="3" COLOR="#800000" FACE="Arial" >Infarct</FONT> </div> <div> •A higher power of a healing myocardial <FONT SIZE="3" COLOR="#800000" FACE="Arial" >infarct</FONT>. </div> <div> •Macrophages can be seen containing a dark pigment (arrow), which is probably hemosiderin because of the color and variation in particle size. </div> <div> •The red, wavy fibres are collagen and represent the scar tissue that will ultimately replace the dead myocardium. </div> <bR> <div> <IMG SRC="174f3760.gif" border=0 width="499" height="374" ALIGN="BOTTOM" HSPACE="0" VSPACE="0">COAGULATIVE NECROSIS</div> <div> <IMG SRC="175e0680.gif" border=0 width="480" height="360" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <div> CORONARY ARTERY OBSTRUCTION FROM A THROMBI GIVING WHAT YOU KNOW, DUE TO CAD MAY BE OR OTHER, TREATMENT BY PASS AND GRAFT</div> <bR> <div> <IMG SRC="0a0b0440.gif" border=0 width="432" height="324" ALIGN="BOTTOM" HSPACE="0" VSPACE="0">Healed anteroseptal myocardial <FONT SIZE="3" COLOR="#800000" FACE="Arial" >infarct</FONT> with mural thrombus </div> <div> •Outflow tract of left ventricle. Note: aortic valve; endocardial surface of interventricular septum marker by "asterisk"; posterior papillary muscle arising from posterior left ventricular wall (white arrow); anterolateral wall of left ventricle (black arrow) </div> <div> •Mural thrombus (green arrow) filling concavity resulting from thinning of septal wall by fibrotic healed <FONT SIZE="3" COLOR="#800000" FACE="Arial" >infarct</FONT>. </div> <bR> <div> <IMG SRC="0b470f30.gif" border=0 width="368" height="243" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="0b540f00.gif" border=0 width="320" height="240" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="0b640f00.gif" border=0 width="320" height="240" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="176e46b0.gif" border=0 width="484" height="363" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="0e4befb0.gif" border=0 width="446" height="251" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="177e8cf0.jpg" border=0 width="488" height="463" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="0e5f3240.gif" border=0 width="499" height="292" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="178e4250.jpg" border=0 width="484" height="293" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <div> <IMG SRC="0a1b0440.gif" border=0 width="432" height="324" ALIGN="BOTTOM" HSPACE="0" VSPACE="0">Subendocardial Posteroseptal Myocardial <FONT SIZE="3" COLOR="#800000" FACE="Arial" >Infarct</FONT> </div> <div> •Outflow tract of left ventricle. Note: aortic valve; endocardial surface of interventricular septum (aterisk); posterior papillary muscle arising from posterior wall (1 arrow); anterolateral wall of left ventricle (double asterisk). </div> <div> •Subendocardial scarring, a healed <FONT SIZE="3" COLOR="#800000" FACE="Arial" >infarct</FONT> of posterior wall of left ventricle, and apical portions of anterior wall and interventricular septum (2 arrows). </div> <bR> <bR> <div> <IMG SRC="0a6b0440.gif" border=0 width="432" height="324" ALIGN="BOTTOM" HSPACE="0" VSPACE="0">Malignant Lymphoma Invading Visceral Pericardium </div> <div> •View of posterior wall of heart with inferior border facing the lower corner on your right. </div> <div> •The middle band of fat from base to apex separating the visible ventricular red brown surface into 2 areas marks the posterior aspect of the IV septum with the RV above and the LV below. </div> <div> •Note the white lymphoma involving the surface of the atriums (arrow), and possibly the deeper myocardium. Cancers do not respect anatomical layers. </div> <div> <IMG SRC="0a7b0440.gif" border=0 width="432" height="324" ALIGN="BOTTOM" HSPACE="0" VSPACE="0">Left Ventricular Hypertrophy </div> <div> •Transverse section of the heart, viewed from below with anterior surface facing downward. </div> <div> •Note marked thickening of left ventricular to at least twice its normal maximum thickness of about 1.5 cm. Note the relatively moderate hypertrophy of the right ventricle. </div> <div> •Possible causes are hypertension, aortic stenosis or a cardiomyopathy, i.e., hypertrophy of the heart of unknown cause</div> <div> <IMG SRC="0a8b0440.gif" border=0 width="432" height="324" ALIGN="BOTTOM" HSPACE="0" VSPACE="0">Atrial Myxoma </div> <div> •This is a bisected myxoma measuring 4-5 cm in greatest diameter. The relatively smooth but nodular variegated surface is seen on the left, and the cut surface on the right. The cut surface has a mucoid glistening variegated appearence characteristic of myxomatous tumors. </div> <div> •This is a solid mass lesion, but some <FONT SIZE="3" COLOR="#800000" FACE="Arial" >cardiac</FONT> myxomas have a delicate papillary form similar to a sea anemone. The individual papillae can break off, embolize, and thereby call attention to the possible presence of a <FONT SIZE="3" COLOR="#800000" FACE="Arial" >cardiac</FONT> myxoma, among other possibilities</div> <div> <IMG SRC="0e9b0cf0.gif" border=0 width="432" height="207" ALIGN="BOTTOM" HSPACE="0" VSPACE="0">Emboli in Heart View of inflow tract of right ventricle, with the tricuspid valve visible along your right half of the upper margin of the image. </div> <div> •View is of left ventricular outflow tract showing aortic valve. Note posterior papillary muscle arising from posterior wall of left ventricle (1 arrow), and anterior papillary muscle arising from anterolateral wall (2 arrows). </div> <div> •The rest of the left ventricular wall is a dilated interventricular septum , which shows a flattening of the trabeculae carnae, characteristic of dilatation. </div> <bR> <div> <IMG SRC="0aab0440.gif" border=0 width="432" height="324" ALIGN="BOTTOM" HSPACE="0" VSPACE="0">Acute myocaridial <FONT SIZE="3" COLOR="#800000" FACE="Arial" >Infarct</FONT> </div> <div> •This is a higher power view of the previous case. </div> <div> •Note the excellent preservation of the PMN's and the fragmentation and smudging of the muscle fibers characteristic of coagulative necrosis. </div> <div> <IMG SRC="0abb0440.gif" border=0 width="432" height="324" ALIGN="BOTTOM" HSPACE="0" VSPACE="0">Subendocardial Fibrosis </div> <div> •View of superior surface of transverse section with the anterior surface facing downward. </div> <div> •Note the small subendocardial scars indicated by the 2 arrows</div> <bR> <div> <IMG SRC="0acb09e0.gif" border=0 width="432" height="414" ALIGN="BOTTOM" HSPACE="0" VSPACE="0">Embolus in Right Ventricle </div> <div> •View of inflow tract of right ventricle, showing right atrium, tricuspid valve, and right ventricle. </div> <div> •Note huge obstructive embolus (arrow) jammed into trabeculae carnae and carnae and folded into the shape of a letter "U". It is 1 cm in diameter and 8 cm in length, corresponding to the size of some leg veins, which can be larger. </div> <div> •The dark space marked "asterisk" is the opening into the outflow tract leading to the pulmonary valve and trunk. </div> <div> <IMG SRC="0adb0400.gif" border=0 width="432" height="320" ALIGN="BOTTOM" HSPACE="0" VSPACE="0">Subendocardial Hemorrhages </div> <div> •View of outflow tract of left ventricle. The antero- lateral LV wall with the anterior papillary muscle is is retracted to the right above the posterior wall with its papillary muscle. </div> <div> •The exposed endocardial surface below the aortic valve is the left side of the IV septum. </div> <div> •Note the subendocardial hemorrhages (arrows), and the excessively dilated left ventricle. </div> <div> •Causes of hemorrhages include shock, sepsis, clotting deficiencies and thrombocytopenia of any cause. </div> <bR> <bR> <div> <IMG SRC="0aeb0440.gif" border=0 width="432" height="324" ALIGN="BOTTOM" HSPACE="0" VSPACE="0">Thrombus in Left Atrium </div> <div> •View of the inflow tract of the left ventricle showing a big left atrium, a stenotic mitral valve, and the upper left ventricle showing the anterior and posterior papillary muscles. </div> <div> •Note the severe mitral stenosis due to a healed rheumatic valvulitis with thickened valve cusps and chordae tendinae. The large cusp with thick chordae tendinae attached to the posterior papillary muscle is the anterior valvular leaflet. </div> <div> •The huge thrombus (2 arrows), which shows outer older light tan layers is arising out of the auricular appendage</div> <div> <IMG SRC="0e6b0d60.gif" border=0 width="432" height="214" ALIGN="BOTTOM" HSPACE="0" VSPACE="0">VEGETATION</div> <bR> <div> <IMG SRC="0e7b0170.gif" border=0 width="432" height="279" ALIGN="BOTTOM" HSPACE="0" VSPACE="0">Acute Infective Endocarditis involving Tricuspid Valve </div> <div> •View is of the inflow tract of the right ventricle showing the tricuspid valve. </div> <div> •Note the thin plaque like vegetation outlined by 2 arrows, and that it has extended onto the underlying ventricular endocardium. This is a fully developed bacterial endocarditis, which could be missed on an echocardiogram</div> <div> <IMG SRC="0b1b0440.gif" border=0 width="432" height="324" ALIGN="BOTTOM" HSPACE="0" VSPACE="0">Mitral Valve Prosthesis </div> <div> •View is of the outflow tract of the left ventricle with the aortic valve above, and the undersurface of the mitral valve orifice below (arrow) with a prosthesis. These serve to replace either severely stenotic valves due to rheumatic fever, or prolapsed valves with severe insufficiency. </div> <div> •The sclerotic white thick bands below the valve are fibrotic chordae tendinae characteristic of a healed rheumatic valvulitis with stenosis</div> <div> <IMG SRC="0b2b0440.gif" border=0 width="432" height="324" ALIGN="BOTTOM" HSPACE="0" VSPACE="0">Calcification of Aortic Valve with Stenosis </div> <div> •This is an excised stenotic aortic valve replaced by a prosthesis. It is the complete native valve. </div> <div> •The valve is very deformed by severe calcific stenosis. </div> <div> •Only 2 cusp like structures can be identified, markedly thickened by nodular and granular calcific aggregates. </div> <div> •Two causes are possible. One is a congenital bicuspid aortic valve deformed by degenerative calcific stenosis. The other is a healed rheumatic valvulitis with marked degenerative changes due to hemodynamic injury and possibly acquired degenerative calcific stenosis as well</div> <div> <IMG SRC="0bea5360.jpg" border=0 width="421" height="310" ALIGN="BOTTOM" HSPACE="0" VSPACE="0">Healed Transmural <FONT SIZE="3" COLOR="#800000" FACE="Arial" >Infarct</FONT> (Masson Trichrome</div> <bR> <div> <IMG SRC="179007e0.jpg" border=0 width="512" height="382" ALIGN="BOTTOM" HSPACE="0" VSPACE="0">Mural Thrombus</div> <div> <IMG SRC="17ad55e0.jpg" border=0 width="469" height="350" ALIGN="BOTTOM" HSPACE="0" VSPACE="0">Myocardial Aneurysm</div> <div> <IMG SRC="17bea800.jpg" border=0 width="490" height="384" ALIGN="BOTTOM" HSPACE="0" VSPACE="0">Myocardial Aneurysm</div> <bR> <div> <B>coronary artery disease - definition:</b><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> Stenotic arteriosclerotic coronary artery disease is a narrowing of the coronary arteries caused by atherosclerosis that, when sufficiently severe, limits the flow of blood to the myocardium (heart muscle). In its most severe form, it occludes the coronary arteries.<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <B>coronary bypass surgery - history:</b><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> Early surgical attacks to treat coronary heart disease include the direct implantation of the internal mammary artery into the myocardium by Vineberg and Miller in 1951. Largely overlooked is the first operation for coronary artery disease in which the internal mammary artery was directly anastomosed to the LAD-coronary artery by Kolesov in Leningrad in 1964. In May 1967 Favoloro and Effler, at Cleveland Clinic, started reversed saphenous vein bypass grafting.<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <B>what is a coronary artery bypass graft ?</b><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="627" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" ALIGN="BOTTOM" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER HEIGHT= 279 WIDTH="291"><div> <IMG SRC="06879830.gif" border=0 width="121" height="131" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="067fa8a0.gif" border=0 width="250" height="138" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> </tD> <tD VALIGN=CENTER WIDTH="329"><div> Aortocoronary bypass surgery means that one or more bypass grafts are implanted between the aorta and the coronary blood vessel. If occlusive vascular disease limits the blood flow to the heart, the bypass graft bridges the occluded or diseased heart blood vessel (coronary artery) and brings new blood to the heart. Saphenous veins (from the leg) or arteries (like the IMA = internal mammary artery) are commonly used as grafts for coronary bypass surgery.</div> </tD> </tR> </TABLE></div> <bR> <div> <B>coronary artery bypass surgery</b><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="628" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" ALIGN="BOTTOM" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER HEIGHT= 268 ><NOBR><div> <IMG SRC="069b7dc0.gif" border=0 width="183" height="220" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <bR> </NOBR></tD> <tD VALIGN=CENTER WIDTH="204"><div> After thoracotomy<FONT SIZE="3" COLOR="#808080" FACE="Arial" > (opening of the chest)</FONT> the left IMA <FONT SIZE="3" COLOR="#808080" FACE="Arial" >(internal mammary artery)</FONT> is harvested. Simultaneously, a segment of the saphenous vein <FONT SIZE="3" COLOR="#808080" FACE="Arial" >(vein of the leg)</FONT> is prepared for the aorto- coronary bypass operation. Intraoperative photo (<B>left</b>) showing the heart and the harvested IMA. Photo on the <B>right</b> <FONT SIZE="3" COLOR="#808080" FACE="Arial" >(white circle)</FONT> showing the IMA being prepared for bypass grafting.</div> </tD> <tD VALIGN=CENTER><NOBR><div> <IMG SRC="06bb6dc0.gif" border=0 width="182" height="220" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <bR> </NOBR></tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 325 ><NOBR><div> <IMG SRC="06ab5dc0.gif" border=0 width="181" height="220" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <bR> <bR> <bR> </NOBR></tD> <tD VALIGN=CENTER WIDTH="204"><div> After induction of extra- corporeal circulation the aorta is x-clamped, the coronary arteries are exposed, opened and the IMA is anastomosed (sutured) into the coronary artery. Intraoperative photo (<B>left</b>) showing the anastomosis of the IMA to the coronary artery. Photo on the <B>right</b> showing the IMA-bypass to the coronary artery <FONT SIZE="3" COLOR="#808080" FACE="Arial" >(LAD)</FONT>, now supplying arterial blood to the heart muscle - bypassing the occluded coronary artery.</div> </tD> <tD VALIGN=CENTER><NOBR><div> <IMG SRC="06cb5dc0.gif" border=0 width="181" height="220" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> </NOBR></tD> </tR> </TABLE></div> <bR> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="629" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" ALIGN="BOTTOM" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER HEIGHT= 226 WIDTH="154"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="226" ALIGN="bottom" WIDTH="154" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=CENTER><NOBR><div> <IMG SRC="06e09c60.gif" border=0 width="265" height="198" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> </NOBR></tD> <tD VALIGN=CENTER><NOBR><div> <IMG SRC="06f84dc0.gif" border=0 width="132" height="220" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> </NOBR></tD> <tD VALIGN=CENTER WIDTH="154"><div> Demonstrating additional vein grafting: <B>left:</b> coronary artery is exposed (<FONT SIZE="3" COLOR="#FF0000" FACE="Arial" ><-</FONT>), the vein prepared (<FONT SIZE="3" COLOR="#00FF00" FACE="Arial" >-></FONT>). <B>middle:</b> the vein is sutured into the coronary artery. <B>right:</b> the bypass is finished (<FONT SIZE="3" COLOR="#00FF00" FACE="Arial" >-></FONT>).</div> </tD> </tR> </TABLE></div> <bR> <div> <IMG SRC="07086dc0.gif" border=0 width="134" height="220" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <div> <U>Acute Anterior Myocardial Infarction see more ekg on my wife web or usmle cardio [</U><A HREF="http://ibenayache.homestead.com" TARGET="_top" TITLE="http://ibenayache.homestead.com"><U><U>ibenayache.homestead.com</U></U></A><U>]</U></div> <div> <B>A 63 year old woman with 10 hours of chest pain and sweating.</b></div> <div>  <A NAME="top"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><IMG SRC="09137b20.gif" border=0 width="823" height="434" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <div> <B>Acute anterior myocardial infarction</b></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">ST elevation in the anterior leads V1 - 6, I and aVL </b></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">reciprocal ST depression in the inferior leads </b></div> <bR> <bR> <bR> </td> </tr></table></body>