876 VENTRICULAR SEPTAL DEFECT AND RIGHT-SIDED INFECTIVE ENDOCARDITIS

Abstract

Abstract Introduction Right-sided infective endocarditis (IE) accounts for 5-10% of IE cases; it is most frequently associated with intravenous drug abuse but can also be observed in patients with cardiac implantable electronic devices, central venous catheters or congenital heart diseases. Case report A 34-year-old female, with unrepaired perimembranous ventricular septal defect (VSD) and right ventricle and tricuspid valve (TV) IE with lung septic embolism treated conservatively with antibiotic therapy 16 years ago, was admitted to our hospital for persistent fever and cough unsuccessfully treated with empiric antibiotic therapy. She denied intravenous drug abuse and recent surgical or dental procedures. Blood cultures resulted positive for multi sensitive Staphylococcus lugdunensis, so antibiotic therapy with Oxacillin and Gentamicin was started. Suspecting IE, transesophageal echo (TEE) was performed and showed, inside VSD, a small fluctuating vegetation and, along the right side of the interventricular septum, next to the VSD, a voluminous hypomobile vegetation; septal and anterolateral TV leaflets appeared thickened and infiltrated by vegetations floating into the right atrium; at color-Doppler moderate TV regurgitation. A whole-body computed tomography showed right lung abscess and right kidney septic infarct. Endocarditis Team, considering hemodynamic stability and inflammatory biomarkers and surveillance blood cultures negativization, decided for medical therapy with echocardiographic follow-up. TEE performed at the end of antibiotic therapy demonstrated complete disappearance of the above described vegetations and surgical VSD closure was scheduled. Discussion Patients with unoperated small VSDs and without volume overload signs usually remain asymptomatic and do not require surgery; nevertheless, a small percentage of them develops problems later in life and IE represents one of the main concerns. Even if unrepaired VSD is associated with increased risk of IE compared with the general population, antibiotic prophylaxis is still recommended only for high-risk patients undergoing at-risk dental procedures, while non-specific oral and cutaneous hygiene measures should always be applied. Latest ESC Guidelines for the management of adult congenital heart disease state that in patients with no significant left to right shunt, but a history of repeated episodes of IE, VSD closure should be considered (IIa, C); it's still matter of debate whether closure should be performed after the first episode of IE. Conclusion IE should always be suspected in patients with VSD and persistent fever. Optimal oral and skin hygiene are effective prevention measures, while prophylactic antibiotic therapy is indicated only in selected cases. Surgery should be considered after repeated episodes of IE.