A cardiac abscess is a suppurative infection of the myocardium, endocardium, native or

prosthetic valve tissue. Similar to other abscesses, it develops either by dissemination from a
distant source such as bacteremia or sepsis or by direct extension of a pre-existing cardiac
infective focus. Infective endocarditis has long been identified as the main cause of the latter.
Although the incidence of cardiac abscesses continues to be investigated, it is presumably higher
than noted postmortem and is of great importance when deciding the prognosis and management
of patients. A single organism causes cardiac abscesses, usually Staphylococcus
aureus or Escherichia coli. Less typically, polymicrobial abscesses have been noted. [1],[2],[3]
Important complications of a cardiac abscess, whether alone or with valve tissue, are conduction
abnormalities on electrocardiogram (ECG). The incidence of perivalvular abscess among
patients with infective endocarditis is between 30% to 40%, with the aortic valve having a higher
predisposition than the mitral valve and annulus. Native aortic valve endocarditis, usually
located in a weak part of the annulus near the atrioventricular node (AV), clearly demonstrates
the anatomic predisposition and exemplifies why abscesses and heart block presents as frequent
sequelae.
Perivalvular abscesses are also more common with prosthetic valves. In this case, the annulus
instead of the leaflet is usually the primary site of infection. The degree of conduction disruption,
therefore, depends on the extent of the involvement of the conduction system and is more
commonly seen in perivalvular aortic abscesses. Additionally, the severe extension of
perivalvular infection can also result in extrinsic coronary compression, or disruption, leading to
an acute coronary syndrome. Thus far, only aortic valve involvement and current IV drug use
have been prospectively identified as independent risk factors for a perivalvular abscess. Any
patient with a cardiac abscess, regardless of all other factors, has an increased risk of
embolization, morbidity, and mortality.

Etiology
Cardiac abscesses are most commonly thought to occur primarily by the extent of a pre-existing
cardiac infection, as it is with the case of infective endocarditis (IE). Secondary causes of cardiac
abscess are believed to be due to bacteremia (persistent or transient) without a known cardiac
source, as well as susceptible heart tissue soon after myocardial infarction (MI), or prosthetic
valve disease, usually in the setting of bacteremia. Other less common predisposing factors may
be trauma, penetrating wounds, deep burns, infected transplanted hearts, infected sternal incision
site, pseudoaneurysm, HIV, or parasitic infections.
The following are organisms noted to be involved in cardiac abscess formation:
 Staphylococcus aureus
 Haemophilus species
 Enterococci
 Escherichia coli
  Beta-hemolytic streptococci
 Streptococcus pneumoniae
 Bacteroides species
 Parasitic organisms
 Hydatid cysts
 Miscellaneous
 In the preantibiotic and earliest antibiotic era, streptococci were the most frequent cause of IE,
responsible for 80% of the cases.25,26 Their relative importance has diminished over the years due to
the regression of rheumatic heart disease, better oral and dental care, simpler chemoprophylaxis and
decreased incidence of streptococcal bacteremia.20 The largest group in percent term is viridans
streptococci, among which S sanguis I and II, S mutans, S mitior, S salivarius, and S milleri are the
most important species causing endocarditis (in order of frequency).

Pathophysiology
The number one predisposing factor for a cardiac abscess is current or prior infective
endocarditis. The most common sites involved are the aortic valve, followed by the ventricular
septa, mitral valves, and papillary muscles. S. aureus, the most commonly involved causative
agent, is present in up to one-third of all cases and has even higher incidence in patients with
prosthetic valves.
Secondly, bacteremia becomes of significant importance although abscesses due to bacteremia
alone tend not to be large enough to cause death and have been reported as an incidental
postmortem finding in most papers.
The site of prior MI has also been documented as a predisposing risk factor for the development
of a cardiac abscess in patients in whom bacteremia is of concern. Such a scenario is plausible in
a patient with known prior infection undergoing an acute coronary syndrome or acquiring the
infection soon following an MI. It is also suspected that the presence of necrosis of muscle fibers
post-MI, in addition to inflammatory state and decreased perfusion with lack of blood flow,
increases myocardium susceptibility to this complication.

History and Physical

Depending on the acuity of presentation (acute versus subacute IE), as well as the location of
cardiac abscess and the overall state of a patient with bacteremia, the following are
possible history and physical exam findings.
History
Highly variable, vague symptoms are common. An acute presentation is more toxic; whereas, a
subacute patient presents with a more indolent complaint. Depending on conduction abnormality,
symptoms related to heart block of any degree may be present.
 Fever, subjective or objective
  Anorexia
 Myalgias
 Headache
 Dyspnea
 Joint pain
 Rashes
 Cough
 Chest pain
Physical Exam
The possible complications of the most common causative etiology of IE, as well as
complications of a cardiac abscess alone. One must keep in mind that the absence of these
findings does not rule out IE as the findings are not sufficiently sensitive or specific for this
disease process.
 Fever
 Signs and symptoms of heart failure: S3, JVD, crackles
 Signs and symptoms of valvular insufficiency: usually systolic murmurs related to the
tricuspid valve, mitral valve, or aortic valve. Diastolic murmurs are possible, and more
common if dealing with a patient with prosthetic valve endocarditis and perivalvular leak
or disease.
 Focal neurologic complaints due to emboli
 Back pain associated with osteomyelitis
 Petechia, nonspecific
 Subungal or splinter hemorrhages, linear lesions of nailbeds
 Osler nodes, painful subcutaneous nodules most commonly on hands
 Janeway lesions, non-tender lesions of palms or soles
 Roth spots, retinal hemorrhages on fundoscopic exam
 Splenomegaly

Evaluation
Tests to consider include:
 Blood and urine studies
 Blood cultures
  Echocardiography; transthoracic versus transesophageal (TEE), with TEE being more
sensitive and specific as well as recommended for the initial assessment of any patient
with a suspected perivalvular disease
 Continuous electrocardiographic monitoring; new atrioventricular block has a positive
predictive value of 88% for abscess formation but low 45% sensitivity.
Always keep in mind that it is in the realm of possibility to obtain negative cultures and still have
a cardiac abscess. For example, a patient whose initial evaluation demonstrated bacteremia
with, initially, no physical signs of IE or cardiac conduction deficit may receive intravenous (IV)
antibiotics before a further workup, and therefore, cultures may not be reliable. Additionally, if
cultures are not drawn properly, the likelihood of positive results decreases significantly.

Treatment / Management
Intravenous antibiotics should be administered in a timely fashion once a patient is suspected of
IE or a cardiac abscess. Empiric broad-spectrum antibiotics until further characterization of
infective species should be monitored for at least 6 weeks of therapy in this patient
population. [9]
Surgery consult and the time of surgical intervention is of high importance when approaching a
patient with a cardiac abscess. There is increased morbidity and mortality in patients in whom
surgery is delayed. Thus early surgery is recommended. Surgery for these patients aims toward
the eradication of the infection and correction of hemodynamic abnormalities.
However, some patients with periannular extension of infection or myocardial abscess could
potentially be treated without surgical intervention. These patients include:
 Patients with smaller (less than 1 cm) abscesses
 Patients who do not have complications of heart block, an echocardiographic progression
of abscess during antibiotic therapy
 Patients who do not have valvular dehiscence or insufficiency
It is recommended that patients who do not undergo surgery are monitored closely with serial
TEE repeated at 2, 4, and 8 weeks after completion of antibiotic therapy.

Complications
 Heart block
 Arrhythmias
 Congestive heart failure
 Stroke
 Multiple organ failure
 Acute respiratory distress syndrome
 Death
Postoperative and Rehabilitation Care
 These patients often require 6 to 8 weeks of parenteral antibiotic therapy. They also need
deep vein thrombosis (DVT) prophylaxis. Those with a prosthetic valve may require oral
anticoagulants.
 Because the patients are critically ill, nutrition is essential.
 To help prevent muscle atrophy and DVT, an exercise program is also recommended.

Deterrence and Patient Education

Prophylaxis against infective endocarditis

Pearls and Other Issues

Prophylaxis remains a longstanding subject in the matter of prevention of IE or cardiac abscess.
Thus far, prophylaxis is mostly based on observational studies and, in fact, places such as the
United Kingdom no longer endorse antibiotic prophylaxis for dental procedures to prevent IE,
the leading source of the cardiac abscess.
One point against prophylaxis is the fact that tooth brushing has been proven to cause bacteremia
and, therefore, makes it difficult to assess the rare versus high magnitude transient bacteremia
and its effect on IE and its sequelae. For this reason, the United States and European countries
have agreed that the use of prophylaxis is reserved only for those at "highest risk."
On that same matter, the widespread use of antibiotics for the prevention and treatment of IE and
abscesses could potentially create a setting where there will be an increased incidence of
polymicrobial infection and antibiotic resistance, especially in immunocompromised patients.
Furthermore, the risk of drug-related adverse effects increases with prolonged drug exposure. In
the case of antibiotic therapy, vestibular, auditory, and nephrotoxic adverse effects are of major
concern. These adverse effects require close monitoring and an expert team in the management
of IE and its complications; these are, unfortunately, not widely available.

Enhancing Healthcare Team Outcomes

A myocardial abscess is a life-threatening disorder of the endocardium, and early recognition and
initiation of treatment are necessary for patient survival. In the majority of cases, a myocardial
abscess is a complication of endocarditis that either involves native or prosthetic valves.
However, a myocardial abscess can also occur in many other settings including infective
endocarditis, trauma, suppurative pericarditis, infected transplanted heart, HIV, and parasitic
infections. The condition carries a very high mortality ranging from 30% to 75% without
treatment. To reduce the morbidity and mortality of this disorder, it is imperative that a
structured approach is developed to make an early diagnosis and begin
treatment.[10] Myocardial abscess tends to occur in critically ill patients with multiorgan
involvement in the face of a severe case of infective endocarditis.[11] Thus, the following
multidisciplinary team of healthcare professionals is recommended:
 Cardiologist to monitor for complications like heart block, septal perforation
  Cardiovascular surgeon for debridement, replacement of the valve
 Infectious disease specialist to ensure that the patient is on the right antibiotics
 Intensive care medicine and pulmonary medicine specialists to monitor the patients
 Nephrologist to dialyze the patients when the patient has renal failure
 Laboratory technology/pathologist to determine the type of organisms and cause; it is
important to note that many patients have negative blood cultures due to prior
administration of antibiotics
 Nurses to educate the patient and family on hand washing and endocarditis prophylaxis
 Physical therapist to improve muscular activity and lessen the risk of deep vein
thrombosis
 Dietitian to ensure that failure to thrive does not develop; patients are extremely ill and
often require food supplementation, either entirely or parenterally
 Pharmacist to monitor the antibiotic therapy which may extend for several months; many
patients with prosthetic valves may be on oral anticoagulants and need monitoring of
their coagulation parameters; these patients may also be on diuretics to treat heart failure
and antiarrhythmic drugs
8.2.2 Perivalvular extension in infective endocarditis

Perivalvular extension of IE is the most frequent cause of uncontrolled infection and is

associated with a poor prognosis and high likelihood of the need for surgery. Perivalvular
complications include abscess formation, pseudoaneurysms and fistulae (defined
in Table 11).223,224

Perivalvular abscess is more common in aortic IE (10–40% in NVE)3,225–227 and is

frequent in PVE (56–100%).3,6 In mitral IE, perivalvular abscesses are usually
located posteriorly or laterally.228 In aortic IE, perivalvular extension occurs most
frequently in the mitral-aortic intervalvular fibrosa.229 Serial echocardiographic
studies have shown that abscess formation is a dynamic process, starting with
aortic root wall thickening and extending to the development of fistulae.229 In one
study, the most important risk factors for perivalvular complications were
prosthetic valve, aortic location and infection with CoNS.230

Pseudoaneurysms and fistulae are severe complications of IE and are frequently associated with
very severe valvular and perivalvular damage.213,231–233 The frequency of fistula formation in IE
has been reported to be 1.6%, with S. aureus being the most commonly associated organism
(46%).233

Despite high rates of surgery in this population (87%), hospital mortality remains high
(41%).213,233,234 Other complications due to major extension of infection are less frequent and may
include ventricular septal defect, third-degree atrio-ventricular block and acute coronary
syndrome.223,224,234

Perivalvular extension should be suspected in cases with persistent unexplained fever or new
atrio-ventricular block. Therefore an electrocardiogram should be performed frequently during
continuing treatment, particularly in aortic IE. TOE, MSCT and PET/CT103 are particularly useful
for the diagnosis of perivalvular complications, while the sensitivity of TTE is <50%225–228 (see
section 5). Indeed, perivalvular extension is frequently discovered on a systematic TOE.
However, small abscesses can be missed, even using TOE, particularly those in a mitral location
when there is co-existent annular calcification.