Two-dimensional echocardiographic diagnosis of acquired right ventricular outflow obstruction due to external cardiac compression

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109 5, Part 1

Brief

Communications

I 109

Two-dimensional echocardiographic diagnosis of myocardial abscess complicating ventricular septal defect JesusVargas-Barron, M.D., Gheorghe Pop, M.D., CandaceKeirns, M.D., Fause Attie, M.D., and Jose Esquivel-Avila, M.D. Mexico City, Mexico

The site of mechanical trauma of a jet lesion from a left-to-right shunt is susceptible to complication with infection. Recently we reported a casein which pulmonary endarteritis developed at the site of mechanical trauma from a patent ductus arteri0sus.l The formation of a myocardial abscesscan be an unusual complication of infective endocarditis or the result of an overwhelming septicemia.2We report a caseof endocarditis secondary to the trauma of a jet lesion from a left-to-right shunt from a ventricular septal defect (VSD). The findings of a twodimensionalechocardiographicstudy (2DE) suggestedthe presence of a myocardial abscess,later corroborated at surgery and necropsy. A 2-month-old male infant was admitted to this hospital with respiratory distress and fever. He had originally been hospitalized 20 days after birth becauseof dyspnea, fatigue, and fever. At that time acyanotic congenital heart diseasewasdiagnosed.Treatment wasstarted with antibiotics, digitalis, and furosemide. The patient was referred to this hospital becauseof deterioration, On admissionhe was critically ill with fever. His lungs were clear, and examination of the precordial area revealed a holosystolic thrill and murmur over the midprecordium with a diastolic murmur in the pulmonary area. The liver was notably enlarged and peripheral pulseswere bounding. The ECG indicated biventricular hypertrophy and the chest x-ray showed cardiomegaly and increased pulmonary vascular markings. Enterobacter grew out from blood on three occasions,and urinary sediment was abnormal. The day after admission,we studied the patient with 2DE and pulsed Doppler. A VSD was visualized and flow through the defect was registered by Doppler. In the parasternal short-axis view abnormal echoeswere apparent on the anterior wall of the right ventricular outflow tract opposite the VSD. The right anterior wall itself was thickened with an acoustic impedance which produced a “honeycomb” appearance(Fig. 1). It was not possibleto visualize normal motion of the pulmonic valve. A Doppler study with samplevolume at the level of the pulmonary artery registered diastolic retrograde flow consistent with pulmonary regurgitation. The echocardiographicfindings, together with the infant’s clinical status and paraclinical results, suggestedendocarditis with right-sided vegetations. Thickening of the right anterior wall with the From the Departments of Echocardiography Instituto National de Cardiologia Ignacio Reprint requests: Dr. Jesus Vargas-Barron, phy, Institute National de Cardiologia Mexico, D.F. 14080, Mexico.

and Chavez.

Pediatric

Department Ignacio Chavez,

Cardiology

of EchocardiograJuan Badiano

1,

Fig. 1. Two-dimensional parasternal short-axis view at the level of aortic valve demonstrating myocardial abscess on the right ventricular anterior wall (arrows). Infective vegetations adhering to the wall are apparent. LA = left atrium; RA = right atrium; TV = tricuspid valve; A0 = aorta; PV = pulmonic valve; PA = pulmonary artery.

Fig. 2. Computerized axial tomography scan with intravenous contrast medium showsthickening of right ventricular free wall (square), apparently causedby abscess. Contrast medium fills a greatly reduced right ventricular cavity (black arrows).

“honeycomb” appearanceled to the suspicion of a myocardial abscess.A computerized axial tomography (CAT) scanperformed 4 days later supported the diagnosisof an abscess,which now appearedto drain into the pericardial cavity (Fig. 2). This last finding led to a second 2DE, which likewise indicated rupture of the abscessinto the pericardium (Fig. 3). Based on the findings of the noninvasive studies, surgery was scheduled for the following day. A myocardial abscesswas found in the anterior wall of the right ventricle which drained into the pericardial cavity. The abscesswas evacuated. The postoperative course was characterized by low cardiac output and persistent septicemia;the infant died 3 days after surgery.

Brief

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Communications

Fig. 3. Two-dimensional parasternal short-axis view at the level of the great arteries reveals increasein the size and extension of myocardial abscess.Shaded area of diagram correspondsto abscesswith fistular tracts draining into pericardial cavity (arrows) and echo-free spaces created by necrosis of myocardial tissue. Pulmonary artery is dilated. Abbreviations as in Fig. 1.

American

May, 19i35 Heart Journal

myocardial abscesswas in closeproximity to the vegetations (Fig. 4); microabscesses were also found in the right ventricular wall as well as evidence of purulent epicarditis. Myocardial abscessis a relatively rare entity which is practically never diagnosedantemortem.*,,’ Cardiac scintigraphy hasbeen suggestedasa method for detecting and localizing abscesses.4.” In our casethe larger diameter of the abscessmade its identification with 2DE and computer scanpossible.The echocardiographicimageof myocardial abscessin the right anterior wall, characterized by thickening of the wall with an acoustic impedanceproducing a honeycomb appearanceand echo-free spacesresulting from necrosisof myocardial tissue, is very similar to the image described in a case of a right-sided cardiac tumor.6 Should such a tumor becomeinfected, differential diagnosis would be difficult. 2DE can be useful in the antemortem identification of myocardial abscess,a finding not described before in the literature with this technique. REFERENCES 1. Vargas-Barron

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J, Attie F, Buendia A, Keirns C, EsquivelAvila J: Echocardiographic recognition of pulmonary endarteritis in patent ductus arteriosus. AM HEART J 109:368,1985. Kim HS, Weilbacher DG, Lie JT: Myocardial abscesses. Am J Clin Path01 70:18, 1978. Abela GS, Majmudar B, Felner JM: Myocardial abscesses unassociated with infective endocarditis. South Med J 74:432, 1978. Thakur ML, Cleman RE, Welch MJ: Indium-111 labeled leucocytes for the localization of abscesses: Preparation, analysis, tissue distribution and comparison with gallium-67 citrate in dogs. J Lab Clin Med 89:2?7, 1977. Gross R. Rothkonf M. Chmel H: Mvocardial abscess caused by Stre&ococ& Aga&tiae: Successful diagnosis and treatment. South Med J 74:1001, 1981. Lucas EM, Stelzer P: Echocardiographic demonstration of right atria1 rupture in a patient with right-sided cardiac tumor. Chest 83:921. 1983.

Traumatic presenting

aorto-right ventricular fistula with a diastolic murmur

Richard J. Haskell, M.D., William J. French, M.D., and Daniel P. Harley, M.D. Torrance, Calif.

Specimen from autopsy showing VSD (lower with large infective vegetations directly opposite arrow). The intraparietal abscessextends laterally from the vegetations. RV = right ventricle. Fig.

4.

arrow) (upper

The postmortem study revealed a perimembranousVSD and destruction of the greater part of the pulmonic valve. In the right ventricular cavity beneath the valve, vegetations implanted opposite the defect were present. The

Intracardiac fistulas may be a sequelaeof penetrating cardiac injuries.’ The vast majority of these communications are ventricular septal defects,*but occasionallythere may be fistulous tracts betweentwo great vesselsor from a great vesselto a cardiac chamber.3There have been few reports of traumatic aorto-right ventricular fistula that were definitively diagnosedprior to surgery.4This report From the Division of Cardiology, Department of Medicine and Cardiothoracic Surgery, Department of Surgery, Harbor-UCLA Center. Reprint Division

requests: William J. French, M.D., Harbor-UCLA Medical of Cardiology, 1000 W. Carson, Torrance, CA 90509.

Division of Medical Center,