Ventricular Septal Defect With Shunt From Left Ventricle to Right Atrium: Bacterial Endocarditis as a Complication

Abstract

During a two-year period we have seen six patients with malformations of the ventricular septum resulting in the shunting of blood between the left ventricle and the right atrium. Surgical closure of the defect has been successful in all. A history of bacterial endocarditis was established in two patients and strongly suspected in two others before operation. The surprisingly large number of patients with a malformation previously considered rare and the unusually high incidence of endocarditis as a complication prompted a review of the anatomical and clinical features of this anomaly.There have been 26 patients reported with left ventricular to right atrial shuntst on whom relatively complete clinical studies are available (Perry, Burchell, and Edwards, 1949;Stahlman et al., 1955;Kirby, Johnson, and Zinsser, 1957;Ferencz, 1957;Lynch et al., 1958;Gerbode et al., 1958;Kjellberg et al., 1959;Braunwald and Morrow, 1960;Levy and Lillehei, 1962). Symptoms were directly related to the amount of left-to-right shunting of blood with pulmonary vascular engorgement. These consisted of poor feeding in infancy and easy fatigue; tachypncea, pneumonia, and congestive heart failure were often noted. The usual findings on examination were a precordial thrill and loud systolic murmur along the lower left sternal border; a mid-diastolic apical rumble was heard in some patients.Chest radiography generally demonstrated cardiomegaly, pulmonary vascular engorgement, and in 15 of the 26 patients specific enlargement of the right atrium. The electrocardiogram was not diagnostic; an abnormal P wave was present in a few of the tracings. Except for one patient with a mean electrical axis of -90°, there were no reports of the axis being to the left or superiorly oriented. Cardiac catheterization demonstrated a left-to-right shunt at the level of the right atrium in all but 2 patients. The right atrial pressure was raised in 5 of the 9 patients in whom it was recorded.

Gerbode defect associated with blunt trauma in a dog

“…In human patients, congenital Gerbode defects are associated with evidence of pre-existing volume overload, such as right-sided chamber enlargement, dilation of the pulmonary artery or enlargement of the pulmonary veins. 10 No murmur was detected at the time of admission. However, a grade III/VI right-sided, systolic heart murmur, with a point of maximal intensity over the fifth intercostal space, was detected 15 h post-admission, and 3 h after the development of a ventricular arrhythmia.…”

Right-sided infective endocarditis in association with a left-to-right shunt complicated by haemoptysis and acute renal failure: a case report

“…Finally, ventricular septal defects complicated by endocarditis without haemodynamic significance are commonly treated conservatively with endocarditis prophylaxis to avoid further endocarditis episodes. Successful surgical management of small ventricular septal defects without haemodynamic significance after endocarditis has been reported in several cases [ 10 , 21 – 24 ].…”

Communication between the left ventricle and right atrium

“…In the case reported by Perry et al (1949), infection was present at two separate sites, namely the tricuspid valve and the wall of the right ventricle. Mellins et al (1964) recorded six patients with this defect, in two of whom there was unequivocal evidence of bacterial endocarditis, and in a further two circumstantial evidence. One of our patients had previously suffered from this complication but recovered rapidly following antibiotic therapy.…”

“…The shunt may thus be either solely from the left ventricle to the right atrium DIRECT VIA or at both ventricular and atrial levels. Mellins et al (1964) reviewed the 26 cases reported to that time and found that the indirect type was the more common (an incidence of 18 as opposed to eight of the direct type). Our experience has been to the contrary, inasmuch as in 10 out of our total of 15 patients the shunt was from the left ventricle directly to the right atrium.…”

“…A further two cases reported by Stahlman, Kaplan, Helmsworth, Clark, and Scott (1955) were diagnosed, as were all the preceding cases, at necropsy, and it was not until Kirby, Johnson, and Zinsser (1957) successfully closed a left ventricular/right atrial shunt that the diagnosis was established during the life of a patient, albeit at the time of operation. With increasing awareness of this entity and with more refined and precise methods of cardiac investigation by means of cardiac catheterization and angiocardiography, further cases have been diagnosed pre-operatively and have been successfully operated on (Gerbode, Hultgren, Melrose, and Osborn, 1958;Braunwald and Morrow, 1960;Levy and Lillehei, 1962;and Mellins, Cheng, Ellis, Jameson, Malm, and Blumenthal, 1964).…”