- Email: [email protected]
WHEN GUIDELINES FAIL, A CASE STUDY IN INFECTIVE ENDOCARDITIS AND PERIMEMBRANOUS VENTRAL SEPTAL DEFECT
1016 JACC April 5, 2016 Volume 67, Issue 13
FIT Clinical Decision Making WHEN GUIDELINES FAIL, A CASE STUDY IN INFECTIVE ENDOCARDITIS AND PERIMEMBRANOUS VENTRAL SEPTAL DEFECT Moderated Poster Contributions Pulmonary Hypertension and FIT Clinical Decision Making Moderated Poster Theater, Poster Area, South Hall A1 Saturday, April 02, 2016, 10:45 a.m.-10:55 a.m. Session Title: FIT Clinical Decision Making: Featured Moderated Poster Session Abstract Category: Congenital Heart Disease Presentation Number: 1129M-07 Authors: Mannu Nayyar, Bryan King, Nadish Garg, University of Tennessee Health Science Center, Memphis, TN, USA
Background: Updated American Heart Association (AHA)/American College of Cardiology (ACC) recommendations for infective endocarditis (IE) antibiotic prophylaxis have precluded the need for antibiotics in patients with ventricular septal defects (VSD).
Case: A 23 yr old woman with congenital small uncomplicated VSD presented to the ED 37 days post-partum complaining of fever, chills and fatigue. She appeared ill with tachycardia, a grade III/IV harsh systolic murmur in the aortic area and decreased bibasilar lung sounds. Blood cultures were positive for streptococcus viridans. Transthoracic echocardiogram (TTE) showed a large vegetation with severe pulmonary valve (PV) insufficiency, a small vegetation on aortic valve (AV) and a 5mm restrictive perimembranous VSD. Transesophageal echocardiogram showed the VSD color flow jet was directed at the PV. Bacteremia resolved with antibiotics however she developed congestive heart failure (CHF) with left ventricular (LV) dysfunction. The LV ejection fraction declined to 30% likely due to new aortic regurgitation. Decision Making: Decision was made to close the VSD, replace the pulmonic valve and replace the aortic valve. VSD was closed, however due to the relatively small size of the pulmonary artery and the aortic root, PV and AV replacement was not feasible. CHF responded well to medical therapy and she remains symptom-free several months later.
Conclusions: Current AHA/ACC guidelines do not recommend antibiotic prophylaxis for acyanotic uncomplicated VSDs without a history of IE. The relative risk of IE is as high as 3.3 in this subset of patients when compared to those who have undergone repair. It is important to consider that in infants with small patent ductus arteriosus with no evidence of left heart volume overload, current guidelines suggest it is reasonable to consider closure to eliminate the risk of endocarditis. Small VSD is associated with high velocity jets that damage the valve endothelium and predispose to IE as in our patient. This case highlights the fact that all congenital VSD should not be considered the same. Small VSD although hemodynamically insignificant can predispose to IE and thus should be considered for IE prophylaxis.
FIT Clinical Decision Making WHEN GUIDELINES FAIL, A CASE STUDY IN INFECTIVE ENDOCARDITIS AND PERIMEMBRANOUS VENTRAL SEPTAL DEFECT Moderated Poster Contributions Pulmonary Hypertension and FIT Clinical Decision Making Moderated Poster Theater, Poster Area, South Hall A1 Saturday, April 02, 2016, 10:45 a.m.-10:55 a.m. Session Title: FIT Clinical Decision Making: Featured Moderated Poster Session Abstract Category: Congenital Heart Disease Presentation Number: 1129M-07 Authors: Mannu Nayyar, Bryan King, Nadish Garg, University of Tennessee Health Science Center, Memphis, TN, USA
Background: Updated American Heart Association (AHA)/American College of Cardiology (ACC) recommendations for infective endocarditis (IE) antibiotic prophylaxis have precluded the need for antibiotics in patients with ventricular septal defects (VSD).
Case: A 23 yr old woman with congenital small uncomplicated VSD presented to the ED 37 days post-partum complaining of fever, chills and fatigue. She appeared ill with tachycardia, a grade III/IV harsh systolic murmur in the aortic area and decreased bibasilar lung sounds. Blood cultures were positive for streptococcus viridans. Transthoracic echocardiogram (TTE) showed a large vegetation with severe pulmonary valve (PV) insufficiency, a small vegetation on aortic valve (AV) and a 5mm restrictive perimembranous VSD. Transesophageal echocardiogram showed the VSD color flow jet was directed at the PV. Bacteremia resolved with antibiotics however she developed congestive heart failure (CHF) with left ventricular (LV) dysfunction. The LV ejection fraction declined to 30% likely due to new aortic regurgitation. Decision Making: Decision was made to close the VSD, replace the pulmonic valve and replace the aortic valve. VSD was closed, however due to the relatively small size of the pulmonary artery and the aortic root, PV and AV replacement was not feasible. CHF responded well to medical therapy and she remains symptom-free several months later.
Conclusions: Current AHA/ACC guidelines do not recommend antibiotic prophylaxis for acyanotic uncomplicated VSDs without a history of IE. The relative risk of IE is as high as 3.3 in this subset of patients when compared to those who have undergone repair. It is important to consider that in infants with small patent ductus arteriosus with no evidence of left heart volume overload, current guidelines suggest it is reasonable to consider closure to eliminate the risk of endocarditis. Small VSD is associated with high velocity jets that damage the valve endothelium and predispose to IE as in our patient. This case highlights the fact that all congenital VSD should not be considered the same. Small VSD although hemodynamically insignificant can predispose to IE and thus should be considered for IE prophylaxis.