A 54 year old man, hospitalised for thoraco-abdominal pain resulting from a septicemia which gives positive hemocultures for streptococcus D Bovis, is diagnosed to have a splenic abscess which will require splenectomy. At the same time, an endocarditis develops and gets worse, with auriculo-ventricular blockade and, especially, major aortic insufficiency, which is the cause of death by a brutal and massive pulmonary oedema. In the progression of an endocarditis, the occurrence of a splenic abscess, primary localisation of the initial septicemia or the secondary of an arterial septic embolism, is a rare contingency compared to the frequency of splenomegaly or splenic infarction: less than 2 percent of the cases in the literature. This very atypical and exceptional case serves as a reminder, on the one hand, of the diagnostic inadequacy of echocardiography which cannot visualise vegetation in the course of progressive endocarditis, and, on the other, of the prognostic importance of auriculoventricular blockade in septal and aortic endocardial lesions.

Since the early reports on the incidence of mechanical complications of acute myocardial infarction (AMI) assessed by echocardiography published in the 1980s, the management of patients with AMI has changed considerably, in particular with the progressive development of early revascularisation.The aim of this multicentre study was to assess the incidence of mechanical complications of AMI in the reperfusion era. Nine-hundred and eight consecutive patients were included. Echocardiography was performed on admission and at discharge. Seventy-eight percent of patients were revascularised at the acute phase.The following incidence rates of mechanical complications were observed: mitral regurgitation 28%, secondary to left ventricular (LV) remodelling (43%) or papillary muscle dysfunction (57%); pericardial effusion 6.6%, more frequent after anterior AMI and associated with a lower ejection fraction (EF); LV thrombus 2.4%, mainly after anterior AMI and associated with a lower EF (38 ± 10% vs. 48 ± 12%; p < 0.001); early infarct expansion 4%; septal rupture 0.6%; and acute free wall rupture 0.8%. The following factors were independently associated with the occurrence of mechanical complications by multivariate logistic regression analysis: lack of early revascularisation (OR 3.48, 95%CI 1.36-8.95; p < 0.001), LV-EF < 50% (OR 1.95, 95%CI 1.42-2.67; p < 0.001), Killip class >II (OR 1.91, 95%CI 1.27-2.87; p < 0.002) and age ≥ 70 years (OR 1.42, 95%CI 1.03-1.97; p < 0.03).This study demonstrates the favourable prognostic influence of early revascularisation as shown by the low incidence of mechanical complications after AMI, and underlines the persistent relationship between the development of these complications and depressed LV function.Depuis les premières études ayant évalué l’incidence des complications mécaniques de l’infarctus du myocarde (IDM) récent et publiées dans les années quatre-vingts, la prise en charge des patients victimes d’un IDM a considérablement changé, avec en particulier le développement progressif de la revascularisation précoce.Le but de cette étude multicentrique est d’évaluer l’incidence de ces complications mécaniques de l’IDM récent à l’ère de la reperfusion. Neuf cent huit patients consécutifs ont été inclus (78% de revascularisation précoce).Les complications mécaniques suivantes ont été observées: insuffisance mitrale 28% (secondaire au remodelage ventriculaire gauche dans 43% des cas ou par dysfonction de pilier dans 57% des cas), épanchement péricardique 6.6% (plus fréquent après IDM antérieur et/ou associé à une fraction d’éjection basse), thrombus intra ventriculaire gauche 2.4%, en particulier après IDM antérieur avec fraction d’éjection basse (38 ± 10% vs. 48 ± 12%; p < 0.001), expansion précoce de la zone nécrosée 4%, rupture septale 0.6% et rupture pariétale 0.8%. En analyse multivariée, les paramètres suivants ont été identifiés comme facteurs indépendants associés à la survenue de ces complications mécaniques: absence de revascularisation précoce, (OR 3.48, IC95% 1.36-8.95; p < 0.001), fraction d’éjection < 50% (OR 1.95, IC95% 1.42-2.67; p < 0.001), classe de Killip > II (OR 1.91, IC95% 1.27-2.87; p < 0.002), et âge ≥ 70 ans (OR 1.42, IC95% 1.03-1.97; p < 0.03).Cette étude confirme le rôle pronostique favorable de la revascularisation précoce comme en atteste la fréquence actuellement très faible des complications mécaniques de l’IDM récent ainsi que la persistance de la relation entre la survenue de ces complications et la dysfonction ventriculaire gauche.

Two cases of interventricular septal rupture (VSR) in elderly patients (71 and 74 years) occurring at the 5th and 12th day of primary postero-inferior myocardial infarction, were reported. The diagnosis was made at 2D echocardiography and confirmed at catheterisation with coronary angiography. Good surgical results were obtained after operation 72 and 12 hours after VSR (9th and 12th infarct days, respectively): the first patient had a good outcome with a 2 year follow-up, but the second patient died in the 55th postoperative day, of renal failure. The authors underline the value of 2D echo in the management of acute myocardial infarction and in the detection of VSR. In addition, the advances in intensive care and surgical techniques allow early and complete cure of cardiac lesions with a low hospital mortality and significant functional improvement, even in the elderly patient.

The authors report 3 cases of post-infarction left ventricular aneurysm with localised rupture into the pericardium. The patients (3 men aged 54, 58 and 67 years old) had left ventricular aneurysms (2 anterior, I posterior) which ruptured early, between the second and tenth week. All presented with cardiogenic shock. The diagnosis was made by 2D echocardiography (I case) or by pericardial aspiration and angiography (2 cases). Good results were obtained by surgical evacuation of the hemopericardium and resection of the ventricular aneurysm with a follow-up of 3 to 12 months. The rarity of these cases is underlined: only three other similar cases appear to have been previously reported.