Ann Thorac Surg 2001;71:1360-1361
© 2001 The Society of Thoracic Surgeons
Case report
Myocardial abscess with contained rupture: successful repair
David G. Harris, FCS(SA)a,
Gawie J. Rossouw, FCS(SA)a
a Department of Cardiothoracic Surgery, Tygerberg Hospital, Cape Town, South Africa
Accepted for publication September 14, 2000.
Address reprint requests to Dr Harris, Department of Cardiothoracic Surgery, Suite A2, Tygerberg Hospital, Cape Town, 7505, South Africa
e-mail: dghrrs{at}aol.com
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Abstract
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Spontaneous rupture of the heart from myocardial abscess is a rare occurrence. Most cases of spontaneous cardiac rupture are due to myocardial infarction. We present a case of a contained rupture of the heart in a patient with staphylococcal septicemia. Although cultures from the pericardial space were negative the macroscopic and clinical picture was compatible with an abscess.
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Introduction
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Myocardial abscesses have been reported in 0.2% to 1.5% of autopsies. Most have occurred as a complication of generalized sepsis or endocarditis [1]. Rarely an abscess may develop at the site of an acute myocardial infarction or within a cardiac aneurysm. Multiple small abscesses are often found in generalized septicemia. Most are diagnosed postmortem. A myocardial abscess is usually silent and not clinically evident, as its presence may be obscured by the accompanying picture of severe sepsis [1]. Occasionally the systemic infection may respond to appropriate antibiotics; however serious or fatal complications may ensue as the result of a residual myocardial abscess. We describe a case of a contained rupture of an abscess that was successfully explored and repaired.
A 17-year-old African man was admitted with acute renal failure after the administration of an unknown substance through an enema by his traditional healer. Initial urea and creatinine were 108 mmol/L and 2200 mmol/L respectively. Hemodialysis was performed for 18 days, by which time renal function had recovered. Renal biopsy revealed acute tubular necrosis and interstitial nephritis.
Two days after stopping dialysis the patient developed a fluctuating fever; C-reactive protein rose from 10 µg/mL on admission to 255 µg/mL. Clinically he had pneumonia and bilateral pleural effusions. Staphylococcus aureus was cultured in urine (> 100,000 organisms/mL) and blood; pleural fluid cultures were negative. The organism was sensitive to vancomycin and cloxacillin and the patient was treated with these antibiotics for 10 days. The fever persisted at this stage and C-reactive protein remained elevated at 88 µg/mL. A pericardial friction rub was noted and an echocardiogram confirmed a loculated fluid collection that was presumed to be purulent (Fig 1). Aspiration was negative.
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Fig 1. Echocardiogram depicting intrapericardial collection adjacent to the left atrioventricular groove (A and B). Note thickening of the adjacent myocardium.
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Surgical drainage was performed through a small left anterior thoracotomy, as a residual pleural effusion was also present. The pleural space was entered and 600 mL of straw-colored fluid was drained, which produced no growth. The pericardium obviously contained a fluid collection and was opened anterior to the phrenic nerve. The pericardium was partially adhered to the anterior cardiac surface, and a lateral collection of 200 mL of old blood was drained. In the atrioventricular groove the cardiac muscle appeared inflamed and thickened, and a clotted blood collection was present posteriorly. At this stage the patient started coughing and an abrupt hemorrhage occurred from this area, located in the distribution of the obtuse marginal artery and approximately 3 cm below the atrioventricular groove. The thoracotomy was enlarged and the defect was sutured with multiple 3-0 polypropylene sutures reinforced with pericardial pledgets. The tissue appeared extremely fragile; however hemostasis was successful. The obtuse marginal vessel could not be visualized during the suture placement in this area because of inflammatory changes on the heart surface. The patient was extubated in the operating room and made an uncomplicated recovery. He was treated with oral cloxacillin for another 2 weeks. Fluid and tissue cultures from the pericardium and follow-up blood cultures were negative. He was discharged home 2 weeks after surgery. At 6 months he remained well and chest roentgenogram was normal. Repeat echocardiography and further follow-up were not done.
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Comment
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Myocardial abscesses are usually small and multiple but may be large and solitary [1]. There is a definite predilection for the valve ring area at the atrioventricular junction to be a site of such abscesses. This could be due to direct extension from the valve or this area may be more susceptible, as the fibrous skeleton is relatively avascular. An abscess has been shown to occur well away from the valve ring [2]. In cases associated with cardiac aneurysm it could be assumed that the spread is directly from mural endocarditis, as the coronaries supplying the abscess site in 2 cases were completely occluded in both [3]. Abscesses associated with myocardial infarction have had primary septic foci such as urinary tract infection, osteomyolitis, diverticular abscess, and cellulitis. A ruptured myocardial abscess in a patient with severe burns and staphylococcal septicemia was diagnosed at autopsy. The patient had intractable sepsis and cardiac failure, and the authors recommend that patients developing these signs undergo echocardiography [4].
Most common organisms are Staphylococcus aureus, Streptococcus pneumoniae, gram-negative bacteria (Escherichia coli, Klebsiella), Streptococcus viridans, and Salmonellae species [1–3]. Organisms grown from infarcts include S aureus, Clostridium perfringens, E coli, Proteus mirabilis, and Pseudomonas. Staphylococcus aureus and Candida species are most common in patients with endocarditis. Anaerobic abscesses are rare, are usually associated with myocardial infarcts, and may be related to the low oxygen tension in the area. Echocardiographic features associated with abscesses include wall thickening and honeycomb appearance, with fistulous tracts that may drain into the pericardium.
Perforation into the pericardial cavity or into a cardiac chamber is rare; in a review of 632 cases of spontaneous rupture of the heart only 3 were due to abscess [5]. Most cases of cardiac rupture are due to myocardial infarction [6]. Three types of rupture have been recognized: (1) "blow-up" rupture, probably not amenable to surgery; (2) small rupture or leak through a friable aneurysm; and (3) chronic rupture with formation of a false aneurysm [6]. Surgical repair is possible with good long-term results. Our patient appeared to have had a blow-up rupture that likely remained contained by pericardial adhesions.
Surgical repair of a myocardial abscess has been performed [7], but we have found no previous reports of successful repair of a ruptured abscess.
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References
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Rawls W.J., Shuford W.H., Logan W.D., Hurst J.W., Schlant R.C. Right ventricular outflow tract obstruction produced by a myocardial abscess in a patient with tuberculosis. Am J Cardiol 1968;21:738-745.[Medline]
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Bashour T., Kabbani S.S., Ellertson D.G., Crew J., Hanna E.S. Surgical salvage of heart rupture. Report of two cases and review of the literature. Ann Thorac Surg 1983;36:209-213.[Abstract]
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Egan T.M., Maitland A., Sinave C., Pollick C., David T.E. Myocardial abscess in a patient with AIDS-related complex: pericardial patch repair. Ann Thorac Surg 1990;49:481-482.[Abstract]
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Abstract
Introduction
