Native cardiac valves

Background

Cardiac valves may be received in the laboratory after artificial valve replacement surgery for congenital and acquired conditions that have resulted in valve dysfunction.1-4 See the reference provided (Recommendations for processing cardiovascular surgical pathology specimens)2 for more detail on clinical scenarios associated with cardiac valve surgery.

Record the patient identifying information and any clinical information supplied together with the specimen description as designated on the container. See overview page for more detail on identification principles.

Fresh tissue received
  • No
    • Non-routine fixation (not formalin), describe.
  • Yes
    • Special studies required, describe.
    • Ensure samples are taken prior to fixation.

Fresh specimens should be carefully examined for any thrombi or vegetations. If identified, a piece of the material should be submitted for microbiological evaluation.1-3 Note that swabs are not useful for microbiological culture and that molecular biological studies may also be required.2

Intraoperative consultation
  • Not performed
  • Performed, describe type and result
    • Frozen section
    • Imprints
    • Other, describe

See general information for more detail on specimen handling procedures.

Inspect the specimen and dictate a macroscopic description.

External InspectionBack to top


Orientate and identify the anatomical features of the specimen.

Orientation markers

Record additional orientation or designation provided by operating clinician:

  • Absent
  • Present
    • Method of designation (e.g. suture, incision)
    • Featured denoted

Photographs of both inflow and outflow valve surface can be helpful.1

Describe the following features of the specimen:

Procedure

Record as stated by the clinician.

Options
  • Cardiac valve, state whether excision or repair, if known
    • Aortic
    • Mitral
    • Tricuspid
    • Pulmonary
  • Other, describe

Specimen integrity

  • Intact valve cusps
  • Incomplete cusps/fragmented material

Anatomical components included (more than one may apply) and specimen dimensions (mm)

  • Total specimen, in three dimensions 1-4
  • Each cusp valve leaflet, in three dimensions, free edge x free edge to cut-edge (valve ring) x thickness 1
  • Other, specify

Specimen description 1,2

  • Number of cusp leaflets

Commissures

  • Absent
  • Present
    • Number
    • Fused (Yes/No)

Annual tissue/valve ring

  • Absent
  • Present
    • Measurement (circumference in mm)

Calcification

  • Absent
  • Present
    • Number of cusps involved and size of deposits (maximum dimension in mm)

Vegetation(s)/thrombus(i)

  • Absent
  • Present
    • Number, location(s) and size (maximum dimension in mm)

Scarring/thickening

  • Absent
  • Present
    • Number of or specific valves involved, if known

Atrioventricular valves

Chordae

  • Absent
  • Present, describe
    • Normal
    • Abnormal
      • Fused
      • Shortened or elongated/muscular
      • Regular/irregular
      • Ruptured

Papillary muscle

  • Absent
  • Present
    • Intact with smooth surgical cut or ruptured
    • Attenuated e.g. scarred/hypertrophied

Semilunar valves

  • Raphe
    • Absent
    • Present
  • Fenestrations/perforations
    • Absent
    • Present
      • Number, size (max. dimension in mm) and location of each
More detail

Floppy mitral valve is the result of myxoid change which may be evident as thickening and translucency macroscopically.4

A raphe is the area of failed cusp separation present in a congenitally bicuspid valve as a ridge from the base of the cusps at the aortic wall extending toward the free margin of the valve cusps.2 It can be distinguished from the more common acquired cusp fusion where fibrocalcification extends all the way through to the free margin.2

DissectionBack to top


Decalcification of the whole specimen may be necessary prior to sectioning if the valve is calcified.2

Section transversely at 5mm intervals perpendicular to the valve ring and free edge.1

Section all fused commissures and raphes. Section papillary muscle if present.1

Internal InspectionBack to top


Not required.

ProcessingBack to top


Submit all sections of cusp tissue for processing.

Standard protocols for special stains required for cardiac valve specimens should be available.  Care should be taken to conserve tissue in case ancillary studies are required. 

Special stain protocol example4
  • Alcian blue Periodic Acid Schiff +/- diastase (AB PAS+/-D) to distinguish neutral from acid mucopolysaccharides
  • Elastic Verhoeff Van Gieson (EVG) or Alcian Blue EVG for elastin

Record details of each cassette.

An illustrated block key similar to the one provided may be useful.

Acknowledgements

Prof Tony Thomas for his contribution in reviewing and editing this protocol.

Block allocation key

Cassette id
Site
No. of pieces
A
Cardiac valve  

ReferencesBack to top


  1. Veinot JP. Native Cardiac Valve Pathology. Surgical Pathology Clinics. 2012;5(2):327-52.
  2. Stone JR, Basso C, Baandrup UT, Bruneval P, et al. 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. Cardiovasc Pathol. 2012;21(1):2-16.
  3. Thiene G and Basso C. Pathology and pathogenesis of infective endocarditis in native heart valves. Cardiovasc Pathol 2006;15(5):256-263.
  4. Boyle JJ, Rassl DM, Neil D, Suvarna K and Doran H. Tissue Pathways for Cardiovascular Pathology, The Royal College of Pathologists, London, 2008.