eMedicine Specialties > Infectious Diseases > Cardiovascular and Intravascular Infections

Myocardial Abscess: Follow-up

Author: Vibhuti N Singh, MD, MPH, FACC, FSCAI, Director, Suncoast Cardiovascular Center; Chair, Cardiology Division and Cath Labs, Department of Medicine, Bayfront Medical Center; Clinical Assistant Professor, Division of Cardiology, University of South Florida College of Medicine
Coauthor(s): Kul Aggarwal, MD, FACC, Professor of Clinical Medicine, Department of Internal Medicine, Division of Cardiology, University of Missouri School of Medicine; Chief, Cardiology Section, Harry S Truman Veterans Hospital; Rakesh K Sharma, MD, FACC, Adjunct Associate Professor of Medicine and Cardiology; University of Arkansas for Medical Sciences, Medical Center of South Arkansas; Jamshid Shirani, MD, FACC, FAHA, Consulting Staff, Director of Cardiovascular Fellowship Program, Department of Medicine, Division of Cardiology, Geisinger Medical Center; Joel A Strom, MD, ME, Professor of Internal Medicine, Chemical and Biomedical Engineering, and Honors College, University of South Florida; Mingquan Suksanong, MD, Clinical Assistant Professor, Department of Medicine, Division of Infectious Diseases and Tropical Medicine, University of South Florida School of Medicine; Consulting Staff, Department of Medicine, Bayfront Medical Center
Contributor Information and Disclosures

Updated: Aug 27, 2009

Follow-up

Further Inpatient Care

  • Aggressive postoperative supportive therapy in patients with myocardial abscess includes the following:
    • Agents for stabilization of hemodynamics
    • Fluid and electrolyte balance
    • Nutrition (parenteral or enteral)
  • Continuation of antibiotic therapy may be necessary. Patients may still require a prolonged 6-week course of antibiotic therapy.

Further Outpatient Care

  • Continuation of adjunctive therapy
  • Anticoagulation therapy, in case of metallic prosthetic valve replacement
  • Continuing antibiotic therapy
  • Diuretic use with CHF
  • Antiarrhythmic therapy for postoperative arrhythmias
  • Aggressive antibiotic prophylaxis prior to minor surgeries

Inpatient & Outpatient Medications

  • Vancomycin
  • Gentamicin
  • Dopamine
  • Diuretics
  • Anticoagulants

Transfer

  • Patients with infective endocarditis usually exhibit rapid deterioration, and they may require transfer to a tertiary care facility for a diagnostic workup and open heart surgery. Such patients must be transported via an Advanced Cardiac Life Support ambulance staffed with well-trained and experienced paramedics.

Deterrence/Prevention

  • Prompt and effective treatment of infective endocarditis is required.
  • A high index of suspicion and early recognition of the changes that suggest development of myocardial abscess are necessary.
  • Regular prophylaxis for subacute bacterial endocarditis, with preoperative antibiotics according to the recommendations of the American Heart Association, is necessary.
  • Critically ill patients with myocardial abscess and infective endocarditis are usually bedridden, with minimal activity. Frequently, such patients must receive prophylaxis to prevent development of DVT and PE.

Complications

  • Myocardial perforation
  • Significant clinical deterioration
  • Worsening CHF
  • Worsening heart sounds and murmurs
  • New-onset valvular regurgitation (100% of cases)11
  • Poor response to antibiotics
  • Development of conduction defects or progression of heart block, such as bundle-branch block and atrioventricular block (45%)2
  • Sudden onset of complete heart block or Mobitz type II block (highly specific)
  • Type of valve involvement, eg, aortic valve endocarditis (40%-85%)
  • Miscellaneous
    • Severe recurrent ventricular arrhythmias
    • Pericarditis (uncommon)
    • Infection of the prosthetic valves
    • Right-sided endocarditis in patients with congenital heart disease

Prognosis

  • With early diagnosis and prompt surgical treatment, patients improve rapidly.
  • Without surgical intervention, the prognosis worsens very significantly.

Patient Education

  • Educate patients regarding their condition, and emphasize the importance of prophylaxis.
  • For excellent patient education resources, visit eMedicine's Infections Center and Heart Center. Also, see eMedicine's patient education articles Abscess and Antibiotics.

Miscellaneous

Medicolegal Pitfalls

  • Myocardial abscess is still recognized infrequently, particularly in the setting of complicated infective endocarditis, in which it has been found in as many as a third of cases. Early detection is of paramount importance to the course of treatment and prognosis.
  • Clinicians should have a high index of suspicion, and they should proceed aggressively in patients with infective endocarditis who exhibit signs of rapid deterioration and a complicated course, such as new-onset conduction defects, CHF, valvular regurgitation, pericarditis, protracted course of illness, or failure to eradicate septicemia despite an adequate antibiotic regimen.

Special Concerns

  • Summary
    • Myocardial abscess is an important clinical condition with high rates of morbidity and mortality unless it is diagnosed and surgically treated in a prompt manner. Although diagnosis of this condition was difficult in the past and most cases were found at surgery or autopsy, it has now been tremendously facilitated by advancements in noninvasive diagnostic modalities.
    • Myocardial abscess can now be detected antemortem, owing to the availability of multiple diagnostic modalities, many noninvasive. The availability of TTE and TEE,111 In radionuclide scintigraphy, CT scan, and MRI has tremendously simplified the diagnosis and management of myocardial abscess.
    • The diagnostic modality of choice is TEE because of its high sensitivity and fairly adequate specificity. Do exclude myocardial abscess without first performing a TEE. Other diagnostic modalities are helpful as second-line tests.
    • Once the diagnosis is made, prompt surgical intervention is almost always required to improve prognosis.
 


More on Myocardial Abscess

Overview: Myocardial Abscess
Differential Diagnoses & Workup: Myocardial Abscess
Treatment & Medication: Myocardial Abscess
Follow-up: Myocardial Abscess
Multimedia: Myocardial Abscess
References
Further Reading
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Keywords

myocardial abscess, myocardial sepsis, cardiac abscess, bacterial endocarditis, infective endocarditis, IE, endocardial abscess, suppurative endocarditis, infectious myocarditis, heart infection, heart valve infection, valve infection, prosthetic valve infection, perivalvular infection, cardiac conduction system infection

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Contributor Information and Disclosures

Author

Vibhuti N Singh, MD, MPH, FACC, FSCAI, Director, Suncoast Cardiovascular Center; Chair, Cardiology Division and Cath Labs, Department of Medicine, Bayfront Medical Center; Clinical Assistant Professor, Division of Cardiology, University of South Florida College of Medicine
Vibhuti N Singh, MD, MPH, FACC, FSCAI is a member of the following medical societies: American College of Cardiology, American College of Physicians, American Heart Association, American Medical Association, and Florida Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Kul Aggarwal, MD, FACC, Professor of Clinical Medicine, Department of Internal Medicine, Division of Cardiology, University of Missouri School of Medicine; Chief, Cardiology Section, Harry S Truman Veterans Hospital
Kul Aggarwal, MD, FACC is a member of the following medical societies: American College of Cardiology and American College of Physicians
Disclosure: Nothing to disclose.

Rakesh K Sharma, MD, FACC, Adjunct Associate Professor of Medicine and Cardiology; University of Arkansas for Medical Sciences, Medical Center of South Arkansas
Rakesh K Sharma, MD, FACC is a member of the following medical societies: American College of Cardiology, American College of International Physicians, American College of Physicians, American Heart Association, and American Medical Association
Disclosure: Nothing to disclose.

Jamshid Shirani, MD, FACC, FAHA, Consulting Staff, Director of Cardiovascular Fellowship Program, Department of Medicine, Division of Cardiology, Geisinger Medical Center
Jamshid Shirani, MD, FACC, FAHA is a member of the following medical societies: American Association for the Advancement of Science, American College of Cardiology, American College of Physicians, American Federation for Medical Research, American Heart Association, American Society of Echocardiography, and Association of Subspecialty Professors
Disclosure: Nothing to disclose.

Joel A Strom, MD, ME, Professor of Internal Medicine, Chemical and Biomedical Engineering, and Honors College, University of South Florida
Joel A Strom, MD, ME is a member of the following medical societies: American College of Cardiology, American Heart Association, American Society of Echocardiography, and Sigma Xi
Disclosure: Merck, Inc. Own stock None; Abbott Labs, Inc. own stock None; Medtronic own stock None; General Electric own stock None

Mingquan Suksanong, MD, Clinical Assistant Professor, Department of Medicine, Division of Infectious Diseases and Tropical Medicine, University of South Florida School of Medicine; Consulting Staff, Department of Medicine, Bayfront Medical Center
Disclosure: Nothing to disclose.

Medical Editor

Craig T Basson, MD, PhD, FAHA, FACC, Gladys and Roland Harriman Professor of Medicine, Weill Cornell Medical College; Director, Cardiovascular Research, Greenberg Division of Cardiology, Department of Medicine, The New York Presbyterian Hospital
Craig T Basson, MD, PhD, FAHA, FACC is a member of the following medical societies: American College of Cardiology and American Heart Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

John L Brusch, MD, FACP, Assistant Professor of Medicine, Harvard Medical School; Consulting Staff, Department of Medicine and Infectious Disease Service, Cambridge Health Alliance
John L Brusch, MD, FACP is a member of the following medical societies: American College of Physicians and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

CME Editor

Eleftherios Mylonakis, MD, Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital
Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD, Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital
Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

 
 
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