D. Thomas et al., CARDIAC AND EXTRACARDIAC ABSCESSES IN INF ECTIVE ENDOCARDITIS, Archives des maladies du coeur et des vaisseaux, 86(12), 1993, pp. 1825-1835
Cardiac abscesses are observed in 20 to 30 % of cases of infective end
ocarditis and in at least 60 % of prosthetic valve endocarditis. The a
ortic valve ring is more frequently affected than the mitral valve rin
g. A cavity contiguous with a cardiac chamber forming a pseudo-aneuris
m or a closed purulent collection, the abscess may extend to the neigh
bouring cardiac structures or to the ascending aorta. This extension m
ay cause conduction defects, abnormal communications between the cardi
ac chambers, pericardial disease and, exceptionally, myocardial ischae
mia, complications which are clinical signs of abscess formation in pa
tients with infective endocarditis. The presence of a cardiac abscess
is a poor prognostic factor in infective endocarditis. The diagnosis m
ust be made at an early stage when surgical treatment is optimal. The
most valuable investigation is transoesophageal echocardiography with
a sensitivity of over 80 % and a specificity of about 95 %. This inves
tigation has become practically routine in all patients with endocardi
tis in order to diagnose abscesses at an early stage, especially in ca
ses of aortic or prosthetic valve endocarditis. Information about the
site, size and extension of the abscess may be obtained and existing o
r potential complications may be envisaged with a view to surgery. Oth
er imaging diagnostic techniques, such as angiography, CT scanning and
nuclear magnetic resonance imaging have a number of disadvantages and
are not more sensitive than transoesophageal echocardiography. Surgic
al techniques depend on the site and extension of the abscess. They ar
e sutured or closed with dacron or pericardial patches after having be
en cleaned and filled with formolated resorcin glue. The valvular pros
thesis is inserted either in anatomical position or in a sub or suprac
oronary dacron tube necessitated by the perivalvular extension of the
infectious lesions. These complex procedures may require associated co
ronary reimplantation or revascularisation when the coronary ostia are
affected. The highest operative mortality is observed in prosthetic v
alve endocarditis with abscess and extra-annular prosthetic implants.
The risk of secondary valvular dehiscence, often recurrent, is much hi
gher when there is an abscess at operation. Extracardiac abscesses in
cases of infective endocarditis are mainly observed in the cerebral an
d/or splenic territories. They may become the main problem, especially
cerebral abscesses, but they rarely require surgery.