Diagnosis of Myocardial Abscess After Acute Myocardial Infarction by Transesophageal Echocardiography: Case Report and Short Review of Published Data

A 56-year-old man received thrombolysis for an anterior myocardial infarction after chest pain for 18 hours. Ten days later he was readmitted with fever and hemodynamic deterioration. Transesophageal echocardiography demonstrated a thin-walled cavity at the apex of the left ventricle. At operation he was found to have a myocardial abscess, and after excision and antibiotics his subsequent clinical course was uneventful. We review the echocardiographic diagnosis and clinical features of myocardial abscess complicating acute infarction. Presumed etiologic factors in our patient included late thrombolysis, mural thrombus, and poor dental hygiene leading to septicaemia.     

Cardiovascular effects and safety of dental anesthesia and dental interventions in patients with recent uncomplicated myocardial infarction

To determine the cardiovascular effects and safety of dental anesthesia and dental interventions in patients within three weeks of uncomplicated acute myocardial infarction, 40 patients were studied. Twenty patients, group 1, underwent injectable local dental anesthesia with 2% lidocaine and 1:100 000 epinephrine. Group 2, 20 patients, underwent vigorous dental prophylaxis (13 patients) or dental extraction (seven patients) after local anesthesia. Heart rate, blood pressure, electrocardiograms, and symptoms were monitored before, during, and after the dental intervention. There were no significant hemodynamic changes or complications related to dental anesthesia or the dental procedures. One patient experienced an asymptomatic, uncomplicated, self-limited, eight-beat run of ventricular tachycardia two hours after dental extraction. Limited dental anesthesia and dental interventions were well tolerated by these patients with recent myocardial infarction.     

Myocardial abscess due to Klebsiella pneumoniae complicating acute infarction

A case is described in which Klebsiella pneumoniae urosepsis associated with acute myocardial infarction resulted in myocardial abscess and papillary muscle rupture. The diagnosis was made during surgery for mitral valve replacement. The patient improved after therapy with cefotaxime; however, cardiac rupture occurred on the sixth postoperative day. The pathogenesis of myocardial abscess and the use of non-invasive techniques for diagnosis are discussed.     

Recurrent myocardial abscess during Streptococcus B endocarditis

The authors report a case of serious streptococcus B endocarditis with a myocardial abscess that recurred after surgery. Streptococcus B endocarditis is a rare disease which is characterized by a pronounced tropism of the organism for cardiac tissues, with severe cardiac valve mutilation and abscess formation in 40% of the cases. A myocardial abscess makes the prognosis worse and must be treated surgically during the acute phase of endocarditis. Modern imaging methods, notably trans-oesophageal two-dimensional echocardiography and computerized tomography should now be used to detect such abscesses.     

Aortic ring abscess following bacterial endocarditis of the aortic valve and aortic valve replacement

Valve replacement was performed in a 30-year-old male patient with acute aortic insufficiency due to bacterial endocarditis. During a routine examination three months later, an aortic ring abscess was found by echocardiography. In the following night, the patient was readmitted with acute anterior myocardial infarction. Coronary angiography showed a compression of the left coronary artery by the large ring abscess of the aortic valve. 48 hours after surgical revision of the aortic valve prosthesis and the ring abscess, the patient died due to pump failure.     

Septal myocardial abscess and infectious pericarditis in a case of bacterial endocarditis

A case of acute aortic valve endocarditis is reported, in which the complications of pericarditis and myocardial abscess were diagnosed clinically. Two dimensional and M-mode echocardiography showed large echo-free spaces and a marked thickening of the interventricular septum which had not been detected previously, suggesting pericardial effusion and myocardial abscess. This is the first case in Japan to our knowledge, in which the pericarditis and myocardial abscess were detected preoperatively and successfully treated surgically.     

Acute myocardial infarction and pyocholecystitis. Report of a case

The clinical data of a 43 year old male with acute myocardial infarction and acute abdominal syndrome on the 4th day after the onset of infarction is reported. During abdominal surgery, a gall bladder abscess was found and a cholecystectomy was performed, without abdominal or cardiac complications. This report emphasizes the rare association of these entities and that even in evolving myocardial infarction surgery can be performed with reasonable risk. The collaboration of cardiologist, surgeon and anesthesiologist is suggested.     

Infective endocarditis presenting with ST segment elevation

Despite diagnostic and therapeutic advances, mortality and morbidity associated with infective endocarditis (IE) remains high. Congestive heart failure and complications such as septic embolization and aortic root abscess are the main causes. Although aortic root abscess is a common complication of IE involving the aortic valve, acute myocardial infarction (AMI) is a rare complication in patients with endocarditis, whether in the acute or later phase of infection. In most cases, the infarction is either anterior or anterolateral. To the best of the present authors' knowledge, only one case of infarction at a purely inferior site has been reported previously. In the present case, IE with an aortic root abscess presented clinically as an acute inferior wall myocardial infarction.     

Occult dental infection as a cause of fever of obscure origin.

Three patients with prolonged unexplained fevers were ultimately found to have deep-seated dental infection. After initial examination failed to elicit symptoms or signs of dental infection, and extensive in-hospital evaluation was nonproductive, dental consultation with roentgenograms provided the diagnosis. All three patients underwent dental extractions with periapical or peridontal debridement; following a brief postoperative febrile period, all three responded with defervescence, without subsequent recurrence of fever. These cases emphasize the importance of periapical and peridontal infection as causes of fever of obscure origin. The pathogenesis, characteristics and bacteriology of periapical abscess are discussed.     

Relationship between myocardial infarction and preinfarction angina: a histopathological study of coronary arteries in two sudden death cases employing serial section

Two patients who had previously experienced old myocardial infarction and who died suddenly after an attack of chest pain were examined and discussed. In both cases two of the three main coronary arteries showed severe stenosis with canalization. Ruptured atheromatous plaque was found in the unblocked coronary artery. Fibrin was already formed and surrounded the fractured intimal collagen fiber, foam cells, and cholesterin clefts, but a luminal thrombi had not yet been formed. Fresh occluding thrombi were formed at the site of the ruptured atheromatous plaque. Coronary thrombi containing abscess components such as foam cells, cholesterin clefts, and the fractured intimal collagen fiber were found in our preliminary study. These views support the supposition that this fracture between the lumen and the plaque might precede and be responsible for the formation of the thrombus and the onset of acute myocardial infarction. It was confirmed that the attack of preinfarction angina occurred at the time of the rupture of the atheromatous plaque. The rupture of the atheromatous plaque plays an important part as an initiating factor of peinfarction angina and myocardial infarction. Thus, it is necessary to examine coronary arteries by serial histopathological section method.     

Anaerobic myocardial abscess following myocardial infarction

An anaerobic myocardial abscess due to Bacteroides fragilis developed in a 60-year-old man when he had an acute myocardial infarction while recuperating from surgery for a paracolonic abscess. Anaerobic bacteremia is a common event and may lead to infection in areas of low oxygen tension far removed from the original portal of entry.     

Diagnosis and successful management of septal myocardial abscess: a complication of bacterial endocarditis

A case of acute enterococcal aortic valve endocarditis is presented in which the complication of a septal myocardial abscess was diagnosed clinically and successfully treated surgically. This represents the first instant, to our knowledge, in which the preoperative diagnosis of a myocardial abscess served as the indication for emergency cardiac surgical intervention in active endocarditis with successful outcome. The diagnostic parameters permitting clinical recognition of a myocardial abscess include the development of advancing degrees of atrioventricular and bundle branch block, and the finding of pericarditis or pericardial effusion in aortic valvular infections. Two additional findings were noted in the present case: echocardiographic evidence of septal thickening, and loss of septal Q waves on the electrocardiogram. Since myocardial abscesses do not respond to medical therapy, continuous electrocardiographic monitoring and frequent echocardiographic determinations are recommended in cases of active aortic valve endocarditis to permit early diagnosis and surgical management of this complication.     

Infective endocarditis complicated by abscess and perforation of mitral valve--a case report

A case of a 47-year-old male admitted to our department due to acute myocardial infarction, treated effectively with primary angioplasty, is presented. Three weeks earlier the patient was admitted to another hospital with a suspicion of infective endocarditis. Echocardiography performed in our department after the patient recovered from acute phase of MI revealed the presence of mitral valve abscess which caused valve perforation. The patient was transferred to another institution for cardiac surgery.     

Serial myocardial lactate metabolic changes after intracoronary thrombolysis in evolving myocardial infarction

To ascertain whether early intracoronary reperfusion (less than 3 hours) preserves aerobic myocardial metabolism in acute myocardial infarction, serial changes in trans-cardiac lactate extraction after intracoronary thrombolysis were examined in 35 patients with acute anteroseptal myocardial infarction. Eight patients without intracoronary reperfusion served as controls. In the chronic phase, we also observed abnormally contracting myocardial segments as an index of infarct size and the regional ejection fraction as an index of chronic regional cardiac function. In the early reperfusion group (less than 3 hours; 15 cases), positive lactate extraction was restored; there were small abnormally-contracting segments and a high regional ejection fraction. However, the intermediate reperfusion group (3-5 hours; 10 cases) had sustained anaerobic lactate extraction, large abnormally-contracting segments and a low regional ejection fraction. The late reperfusion (greater than 5 hours; 10 cases) group showed apparent aerobic lactate extraction, but had large abnormally-contracting segments and a low regional ejection fraction. Thus, early reperfusion preserves aerobic lactate metabolism and good ventricular function in the chronic phase.     

Serial myocardial lactate metabolic changes after intracoronary thrombolysis in evolving myocardial infarction

To investigate whether early reperfusion (less than or equal to 3 hours) preserves aerobic myocardial metabolism in acute myocardial infarction, we examined serial changes in trans-cardiac lactate extraction after thrombolysis in 43 patients with acute antero-septal myocardial infarction. In the chronic phase, we also determined abnormally contracting segments as an index of infarct size and regional ejection fraction as an index of chronic regional cardiac function. In the early reperfusion group (less than or equal to 3 hours), positive lactate extraction was restored and there were small abnormally contracting segments and a high regional ejection fraction. The intermediate reperfusion group (3-5 hours), however, had sustained anaerobic lactate extraction, large abnormally contracting segments and a low regional ejection fraction. The late reperfusion (greater than 5 hours) group showed apparently aerobic lactate extraction, but had large abnormally contracting segments and a low regional ejection fraction. Thus, early reperfusion preserves aerobic lactate metabolism and good chronic ventricular function.     

Asymptomatic myocardial abscess

This report describes a rare case of an asymptomatic myocardial abscess which was not associated with infective endocarditis but was diagnosed to be a tumor and treated by open-heart surgery. A 69-year-old patient without a history of endocarditis or myocardial infarction was submitted to invasive cardiac diagnostics after an embolic event in the brachial artery. Investigation revealed an "intracardiac tumor" and the patient subsequently underwent open-heart surgery. After cardiotomy the suggested tumor was found in the posterior wall of the left atrium adjacent to the mitral ring, appearing as a circumscribed, indurated, and plane area. After incision for biopsy, a cheesy pus emptied from a cavity. The tissue sections showed an intramural myocardial abscess. Because of the extent, location and the character of the abscess, the cavity was closed after rinsing using mattress sutures. The postoperative course was uncomplicated. This report demonstrates that in suspected cardiac tumors a myocardial abscess should be considered in any differential diagnosis despite the rarity of the event, since the diagnosis of the myocardial abscess is not an absolute indication for surgical intervention.     

The effects of practolol on the dysrhythmias complicating acute ischemic heart disease

The cardioselective beta-adrenoceptor blocking agent practolol was used in the management of ventricular and supraventricular dysrhythmias associated with acute myocardial Infarction in 134 patients, and in the management of these dysrhythmias in 19 patients with acute myocardial ischemia. Practolol was frequently effective in controlling ventricular dysrhythmias which occurred within the first 24 hours after the onset of symptoms of acute myocardial infarction. It was also effective in controlling the ventricular dysrhythmias which occurred after resuscitation from ventricular fibrillation. It was of particular value when therapeutic doses of lidocaine had been ineffective. Practolol was much less effective in controlling ventricular dysrhythmias which occurred more than 24 hours after acute infarction. Atrial fibrillation and atrial flutter were infrequently abolished by practolol in undigitalized patients after acute myocardial infarction. There was no correlation between the effectiveness of practolol and the blood concentration of the drug. One adverse effect of practolol was the occurrence of sinus bradycardia with or without an increase in the frequency of ventricular ectopic beats. Bradycardia was sometimes accompanied by hypotension. Severe hypotension occasionally occurred in the absence of bradycardia.     

Serum glucagon and insulin levels and their relationship to blood glucose values in patients with acute myocardial infarction and acute coronary insufficiency

Fasting serum glucagon, insulin and glucose levels were determined in 25 patients with acute myocardial infarction 1 day after their admission to the hospital and, in most instances, once again at a later date. Two control groups were used, one with coronary insufficiency but without myocardial infarction (10 patients) and the other without clinically recognizable coronary artery disease (12 patients). Serum glucagon levels were significantly higher in the patients with acute myocardial infarction on admission (121.6 ± 15.3 pg/ml) than in the other two groups and highest in patients with acute myocardial infarction and cardiogenic shock (239.3 ± 31 pg/ml, p < 0.001). Glucagon levels were elevated even in the three patients with cardiogenic shock who were not receiving catecholamines. Serum glucose values were also significantly higher in patients with acute myocardial infarction (155 ± 13.9 mg/100 ml), but serum insulin levels were not significantly different from those in patients with coronary insufficiency. These data suggest that the hyperglycemia of patients with acute myocardial infarction may be in part due to hyperglucagonemia.     

Prognostic value of a persistently positive technetium-99m stannous pyrophosphate myocardial scintigram after myocardial infarction.

Technetium-99m stannous pyrophosphate myocardial scintigrams were obtained in 138 clinically stable patients 32.7 +/- 47.3 weeks (range 6 to 260) after acute myocardial infarction. Of the 138 patients, 74 (54 percent) had a persistently positive scintigram. Patients with such a scintigram were more likely to have severe angina pectoris, compensated congestive heart failure, anterior location of acute myocardial infarction, Q waves and S-T segment elevation in the electrocardiograms, cardiomegaly, left ventricular dyssynergy (dyskinesia or global dyssynergy), and an ejection fraction of less than 50 percent. During a follow-up period of 11.6 +/- 6.9 months after scintigraphy, 42 percent of the patients with a persistently positive scintigram had either a cardiac death, a nonfatal myocardial infarction, unstable angina pectoris or decompensated congestive heart failure compared with 13 percent of the patients with a negative scintigram (P less than 0.001). Of the 14 patients with cardiac death, 13 (93 percent) had a persistently positive scintigram. A persistently positive scintigram not only was the best single predictor of cardiac death and combined end points, but also added significantly to the predictive ability of the other clinical variables, including age, location of acute myocardial infarct, clinical status, electrocardiographic findings, and chest X-ray findings. It is concluded that technetium-99m stannous pyrophosphate myocardial scintigraphy has prognostic value in patients after acute myocardial infarction.     

Electrophysiologic consequences of experimental acute ischemia superimposed on healed myocardial infarction in cats

Electrophysiologic studies were carried out in 61 cats studied 2 to 4 months after healing of experimental myocardial infarction, 38 cats studied 90 to 120 minutes after an acute myocardial infarction, and 24 cats in which acute myocardial infarction was superimposed on a 2 to 4 month old healed myocardial infarction (AMI/HMI). The frequency and grade of spontaneous arrhythmias, and the ability to induce sustained ventricular activity in tissue bath, were similar in the cats with acute and those with healed myocardial infarction, but greater in those with acute infarction superimposed on healed infarction. Spontaneous ventricular arrhythmias occurred in 42 percent of the cats with acute infarction, in 31 percent of those with healed infarction, and 62 percent of those with acute infarction superimposed on healed infarction. Similarly, sustained ventricular activity initiated by premature stimuli in tissue bath was achieved in 67 percent of the isolated hearts with acute infarction superimposed on healed infarction compared with 34 percent of the hearts with acute and 33 percent of those with healed infarction. The correlation between spontaneous arrhythmias and inducibility of sustained ventricular activity in tissue bath was significant in all three groups, but attained the highest level of significance in the hearts with healed infarction and those with healed and superimposed infarction.The duration of transmembrane action potentials at 90 percent repolarization (APD₉₀), recorded from surviving cells overlying an acute infarct, was shorter than that of those recorded from normal cells in the same heart. In contrast, APD₉₀ values recorded from surviving cells overlying areas of healed infarction were longer than APD₉₀ values of normal cells. Refractory periods tended to parallel action potential durations, particularly in hearts with healed or healed with superimposed acute infarction. The greatest degree of dispersion of action potential duration and refractory periods was observed in the latter hearts, which also had the greatest incidence of spontaneous arrhythmias and of inducibility of sustained ventricular activity in tissue bath.It is concluded that healing of surviving cells after myocardial infarction leaves in its wake long-term electrophysiologic cell abnormalities. These may interact with a new acute ischemic event to cause greater electrophysiologic instability than observed with acute infarction in the absence of previously injured tissue.