Very late-onset endocarditis complicated by non-significant aortic regurgitation after device closure of perimembranous ventricular septal defect

Tang C, Zhou K, Hua Y, Wang C.Medicine (Baltimore). 2020 May;99(19):e20120. doi: 10.1097/MD.0000000000020120.PMID: 32384490



Introduction: Aortic regurgitation (AR) was recognized as a major, but rare complication after device closure for perimembranous ventricular septal defects (PmVSD). Most of them are temporary and non-significant. Infectious endocarditis (IE) is another extremely rare post-procedure complication of PmVSD. Theoretically, AR could increase risk for post-interventional IE. However, no cases have been documented thus far. We firstly described a case of very late-onset IE associated with non-significant AR after transcatheter closure of PmVSD with modified symmetrical double-disk device, underscoring the need for reassessing long-term prognostic implications of non-significant post-procedure AR after PmVSD occlusion and the most appropriate treatment strategy.

Patient concerns: A 15-year old male received transcatheter closure of a 6.4 mm sized PmVSD with a 9-mm modified symmetric double-disk occluder (SHAMA) 11 years ago in our hospital. A new-onset mild eccentric AR was noted on transthoracic echocardiography (TTE) examination 1-year post procedure, without progression and heart enlargement. At this time, the child was admitted with a complaint of persistent fever for 16 days and nonresponse to 2-weeks course of amoxicillin and cefoxitin.

Diagnosis: The diagnosis of post-procedure IE was established since a vegetation (14 × 4 mm) was found to be attached to the tricuspid valve, an anechoic area (8 × 7 mm) on left upper side of ventricular septum and below right aortic sinus, and severe eccentric AR as well as the isolation of Staphylococcus aureus from all three-blood cultures.

Interventions: Treatment with vancomycin was initially adopted. However, surgical interventions including removal of vegetation, abscess and occluder, closure of VSD with a pericardial patch, tricuspid valvuloplasty, and aortic valvuloplasty were ultimately performed because of recurrent fever and a new-onset complete atrioventricular block 12-days later. The child continued with antibiotic therapy up to six weeks post operation.

Outcomes: The child’s temperature gradually returned to normal with alleviation of AR (mild) and heart block (first degree). The following course was uneventful.

Conclusion: Late-onset IE could occur following device closure of PmVSD and be associated with post-procedure AR. For non-significant AR after device closure of PmVSD, early surgical intervention could be an alternative for reducing the aggravation of aortic valve damage and the risk of associated IE.


Figure 1 (A) Parasternal long-axis views on TTE 10 years post device closure showed mild eccentric AR. (B) Short-axis views on TEE 11 years post device closure revealed vegetation attached to TV (red arrow), an anechoic area below right aortic sinus (black arrow), continuity between aorta and anechoic area (purple arrow) and severe eccentric AR. AR = aortic regurgitation, TEE = transesophageal echocardiography, TTE = transthoracic echocardiography.