Medical Care
Medical treatment includes the following:
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Antibiotics - Usually given for a prolonged period of time, and the choice of antibiotics depends on the organism(s) isolated from cultures
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Agents for stabilization of hemodynamic status.
Supportive treatment includes the following:
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Fluid and electrolyte balance
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Nutritional support.
Surgical Care
Once the diagnosis of myocardial abscess is made, the treatment of choice is surgical in nature. Appropriate procedures include the following:
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Open heart surgery
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Valve replacement
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Re-replacement of prosthetic valves
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Abscess evacuation.
Consultations
Myocardial abscess usually develops in patients who are generally very ill, with multiorgan system involvement and unremitting infective endocarditis. The expertise of several subspecialists is needed:
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Cardiologist
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Cardiovascular surgeon
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Infectious disease specialist
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Intensive care medicine and pulmonary medicine specialists
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Nephrologist
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Microbiologist/pathologist.
Diet
Patients with myocardial abscess often are critically ill. Supplementation of nutrition, either by the enteral or parenteral route, is very important.
Patients should be maintained without oral intake until a decision regarding surgical intervention has been made and surgery has been performed.
Postoperatively, gradual advancement in the diet is recommended.
Activity
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 deep venous thrombosis (DVT) and pulmonary embolization (PE).
Gradual increase in ambulation is recommended following surgical intervention.
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 usually are bedridden, with minimal activity. Frequently, such patients must receive prophylaxis to prevent development of DVT and PE.
Further Outpatient Care
Further outpatient care may include the following:
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Continuation of adjunctive therapy
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Anticoagulation therapy, in case of metallic prosthetic valve replacement
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Continuing antibiotic therapy
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Diuretic use with CHF
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Antiarrhythmic therapy for postoperative arrhythmias
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Aggressive antibiotic prophylaxis prior to minor surgeries.
Further Inpatient Care
Aggressive postoperative supportive therapy in patients with myocardial abscess includes the following:
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Agents for stabilization of hemodynamics
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Fluid and electrolyte balance
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Nutrition (parenteral or enteral).
Continuation of antibiotic therapy may be necessary. Patients still may require a prolonged 6-week course of antibiotic therapy.
Inpatient & Outpatient Medications
Medications include the following:
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Vancomycin
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Gentamicin
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Dopamine
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Diuretics
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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.
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Myocardial abscess. Transesophageal echocardiogram exhibiting aortic valvular endocarditis and aortic root abscess.
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Myocardial abscess. Complete heart block seen on a 12-lead electrocardiogram in a patient with myocardial abscess involving the prosthetic aortic valve ring.
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Myocardial abscess. Color Doppler imaging showing flow into the aortic root abscess.
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Myocardial abscess. Aortic valvular ring abscess seen by transesophageal echocardiography.
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Myocardial abscess (gross).
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Myocardial abscess (opened).
