What is the best management option for non-significant residual shunt after device closure of perimembranous ventricular septal defect

Abstract

Rationale:Non-significant residual shunt is a relatively common complication after device closure of perimembranous ventricular septal defects (Pm-VSD). Lifelong antibiotic prophylaxis has been recommended in guidelines to avoid infectious endocarditis (IE) if residual shunt remains. Clinicians, however, rarely follow it in their practice and regular follow-up was the most common option since post-procedure IE after transcatheter closure of PmVSD is rarely reported. We firstly described a case of IE after transcatheter closure of PmVSD with modified symmetrical double-disk device with a residual shunt, highlighting the need for reassessing the prognostic implications of post-procedure non-significant residual shunt and the most appropriate treatment strategy.Patient concerns:A 3-year old female received transcatheter closure of PmVSD sized 5.0 mm on left ventricular angiography with an 8-mm modified symmetric double-disk occluder (SHAMA) owing to a history of recurrent lower respiratory tract infections. Post-procedure echocardiography documented a non-significant residual shunt, but no additional interventions were performed. Two months post procedure, the child was re-admitted into our department with a complaint of persistent fever up to 41°C for 11 days and nonresponse to 1-week course of amoxicillin.Diagnoses:The diagnosis of post procedure IE was established since a vegetation (13 × 9 mm) was found to be attached to the tricuspid valve and the occluder, and Staphylococcus aureus was isolated from all three-blood cultures.Interventions:After 6 weeks of vancomycin treatment, the vegetation disappeared with no sign of valvular dysfunction. Three weeks after discharge, a second device was implanted to abolish persistent residual flow.Outcomes:Unfortunately, the child was ultimately transferred to surgical department due to severe hemolysis after the second device implantation. The occluders were removed and the VSD was closed with a pericardial patch. Tricuspid valvuloplasty was also performed and the following course was uneventful.Lessons:For non-significant residual shunt after device closure of PmVSD, implantation of a second device or surgical repair may be a better and more satisfactory alternative compared with lifelong antibiotic prophylaxis or no interventions, since associated IE can indeed occur despite its rarity and the risk of antibiotic-associated adverse events may outweigh the benefits.

Infective Endocarditis among Pediatric Patients with Prosthetic Valves and Cardiac Devices: A Review and Update of Recent Emerging Diagnostic and Management Strategies

“…The device was removed, the defect was surgically repaired, and no other complications occurred. In addition, patients received prolonged antibiotic treatment (Figure 8) [69][70][71][72][73].…”

Emerging Concepts on Infection of Novel Cardiac Implantable Devices

“…Six cases of VSD closure device-related infective endocarditis (IE) have been reported in the literature so far (Table 2 ) [ 4 , 60 , 61 , 62 , 63 , 64 ], which included the Amplatzer® device (2/6, 33%), Nit-Occlud® (3/6, 50%), and modified symmetric double-disk occluder (SHAMA) (1/6, 16%). VSD-related IE is mostly a pediatric condition.…”