Isolated Right-Sided Valvular Endocarditis in Non-Intravenous Drug Users

Infective endocarditis due to nasal septal perforation during home oxygen therapy

We report a case of infective endocarditis (IE) due to nasal septal perforation during Home oxygen therapy (HOT). A 64-year-old man with a history of interstitial pneumonia (IP) and on HOT was hospitalized for dyspnea. Methicillin-sensitive Staphylococcus aureus (MSSA) was repeatedly detected in blood cultures. Echocardiography revealed tricuspid valve vegetation and regurgitation. The patient was diagnosed with IE, according to the modified Duke criteria. A full-body examination revealed nasal septal perforation and MSSA was isolated from the nasal cavity. The patient was treated with cefazolin and clindamycin. However, he developed aspiration pneumonia and subsequently died. The portal of entry of MSSA was damaged nasal mucosa, caused by dryness and curettage of the dried nasal mucus during HOT. Nasal septal perforation, a potential complication of HOT, may cause severe bacterial infections. Consequently, diligent nasal care is crucial during HOT.

Management of isolated native tricuspid valve infective endocarditis by a multidisciplinary program: a single-center retrospective cohort study

Background

Isolated native tricuspid valve infective endocarditis remains a challenging disease to treat given the large number of patients with substance use disorder. There is limited data on the optimal treatment strategy and the impact of a multidisciplinary endocarditis program on outcomes for this population.

Objectives

To assess the clinical outcomes associated with management of native tricuspid valve infective endocarditis by a multidisciplinary team.

Design

Single-center, retrospective cohort study.

Methods

Patient cases were identified from the registry of the institutional multidisciplinary endocarditis team. Patients with left-sided endocarditis, multivalvular endocarditis, prosthetic tricuspid valves and cardiac implantable electronic devices were excluded.

Results

Between September 7th, 2021 and February 1st, 2024 72 consecutive patients with isolated native tricuspid valve infective endocarditis were identified. Sixty-six (91.7%) patients were managed medically. Five patients underwent percutaneous mechanical aspiration of tricuspid valve vegetations and one patient underwent tricuspid valve replacement during the index hospitalization. In-hospital mortality was 1.4% and 90-day mortality was 2.8%. Nineteen (26.4%) patients discharged before medically advised and 25% were re-admitted within 30 days. Ten (13.9%) patients underwent elective tricuspid valve replacements after outpatient follow-up.

Conclusion

Among 72 patients with isolated native tricuspid valve infective endocarditis managed by a multidisciplinary endocarditis program over a 2.5-year period, in-hospital, 90-day mortality and 1-year mortality were very low despite low rates of percutaneous mechanical aspiration and tricuspid valve surgery. Multidisciplinary follow-up can lead to elective tricuspid valve surgery in a delayed fashion.

Candida endocarditis: Update on management considerations

The rise in incidence rates of invasive candidiasis warrants an increase in attention and efforts toward preventing and treating this virulent infection. Cardiac involvement is one of the most feared sequelae and has a poor prognosis. Despite the introduction of several novel antifungal agents over the past quarter century, complications and mortality rates due to Candida endocarditis have remained high. Although fungal endocarditis has a mechanism similar to bacterial endocarditis, no specific diagnostic criteria or algorithm exists to help guide its management. Furthermore, recent data has questioned the current guidelines recommending a combined approach of antifungal agents with surgical valve or indwelling prostheses removal. With the emergence of multidrug-resistant Candida auris, a focus on improved prophylactic measures and management strategies is necessary.

A Novel Technique Debulking Vegetations in Tricuspid Endocarditis and Venacava Utilizing AngioVac Aspiration System

The AngioVac system (AngioDynamics Inc., Latham, NY) is used for the removal of commonly encountered intravascular material, such as thrombus or vegetations in the right atrium, right ventricle, superior vena cava, and inferior vena cava. Patients with high surgical risk having tricuspid endocarditis and superior vena cava thrombus can be treated with the AngioVac system, hence mitigating the risks for this patient population. We present a case series with the utilization of the AngioVac device to reduce the vegetation size and decrease the risk of emboli with effective antibiotic penetration. Transesophageal echocardiography shows a reduction in the size of the vegetations in all three cases with no postoperative complications. This case series demonstrates a novel technique debulking vegetations in tricuspid endocarditis and vena cava.

Right-Side Endocarditis: A Typical Presentation in an Atypical Patient

Right-side endocarditis (RSE) is a well-defined clinical entity, rarer than left-side endocarditis. Known risk factors include intravenous drug use or the presence of medical devices. The most frequently affected valve is the tricuspid valve. In most cases, medical treatment is enough. Surgical treatment is reserved for failed medical therapy or in the presence of large vegetations. Although there is a high recurrence rate in intravenous drug users (IDU), RSE has a generally good prognosis. We present the case of a 70-year-old male with no known previous diseases other than alcohol abuse. He was admitted with fever, cough, hemoptysis and a weight loss of 8 kg in two months. Chest X-ray revealed two images of condensation, one in the right pulmonary base and another in the superior right lobe. A computerized tomography of the thorax revealed a subsegmental pulmonary embolism. The patient refused hospitalization and was discharged medicated with levofloxacin and apixaban. In ambulatory, there was a decrease in size of the lesions but with a new lesion in the right hemithorax. Two months after the first episode, the patient is admitted with the same symptoms. The transthoracic echocardiogram showed a 20cm vegetation in the tricuspid valve. He was admitted to the hospital and received treatment with penicillin and gentamicin after isolation of Streptococcus mitis in the blood cultures. Surgical treatment was needed after a weak response to antibiotics, with a good evolution.

Transient complete heart block: a case report of a rare complication of tricuspid valve infective endocarditis

Background

Right-sided tricuspid valve (TV) endocarditis can be difficult to identify and may be under-recognized in the absence of traditional risk factors. While generally identified with aortic valve pathology, infective endocarditis that extends beyond the leaflets of the TV have been reported to cause conduction disease.

Case summary

We present the case of a 63-year-old patient who presented with haemodynamically unstable complete heart block requiring temporary venous pacemaker support. Despite the absence of traditional risk factors or significant valvular disease on transthoracic echocardiogram, she was found to be persistently bacteraemic and subsequent transoesophageal echocardiogram identified large vegetation on the septal leaflet of the TV. Conduction disease was noted to reverse with antibiotic therapy and resolution of bacteraemia.

Discussion

Although rare, right-sided endocarditis involving the triangle of Koch may present with conduction disease due to local inflammation and mechanical compression. Conduction disease associated with right-sided disease appears to be readily reversible with medical therapy and temporary device support may be appropriate in the acute setting.

Multi-valvular infective endocarditis from Gemella morbillorum

Gemella morbillorum is increasingly implicated in infectious endocarditis. Our patient presented with anaemia and renal failure with evidence of infarcts and embolic disease. He was found to have endocarditis with an organism that could not speciate with standard culture methods requiring matrix assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF) for identification and susceptibilities. While involvement of mitral and aortic valves can be expected with Gemella, he had rare involvement of the pulmonic valve in a structurally normal heart. Although bacteriological cure was achieved, due to the locally destructive nature of Gemella, he ultimately required valve replacements for heart failure resolution. Workup for commonly implicated pathologies associated with G. morbillorum led to suspicion of gastrointestinal malignancy with findings of occult bleeding prompting an ongoing evaluation. With improved access to advanced diagnostics, G. morbillorum has been increasingly identified in infectious endocarditis. Given its destructive nature, it is important for clinicians to consider this organism is difficult to identify isolates.

Extensive right-sided infectious endocarditis due to Streptococcus pneumoniae

Streptococcus pneumoniae is a rare cause of infectious endocarditis. Most cases have an acute and aggressive evolution, with a high mortality rate. We report the case of a 36-year-old man, with a history of unrepaired ventricular septal defect, who came to the emergency department with fever, cough and asthenia with 3 months of evolution. Blood cultures were positive for Streptococcus pneumoniae Echocardiogram showed large vegetation on septum, free wall and outflow tract of the right ventricle. Thoracic CT revealed septic pulmonary embolism. Antimicrobial therapy and surgical treatment was performed and the patient presented a favourable evolution.

Isolated Native Tricuspid Valve Endocarditis in a Nonintravenous Drug User

Infective endocarditis (IE) is a disease characterized by high morbidity and mortality. IE was first described in the mid-16th century. Right-sided infective endocarditis (RSIE) represents 5% to 10% of all IE episodes in adults. RSIE can be divided into three groups according to the underlying risk factors: intravenous drug users (IDUs), cardiac device carriers, and the “three noes” group (no left-sided IE, no IDUs, and no cardiac devices). Tricuspid valve endocarditis in nonintravenous drug users can occur in a variety of conditions including congenital heart disease, intracardiac devices, central venous catheters, and immunologically debilitated patients. Due to the rareness of isolated native nonrheumatic tricuspid valve endocarditis, here, we like to present an 18-year-old male from rural Ethiopia with the diagnosis of isolated native tricuspid valve endocarditis that was treated and cured.

Bacterial co-infections and superinfections in COVID-19: a case report of right heart infective endocarditis and literature review

Coronavirus disease of 2019 (COVID-19) is a worldwide pandemic with significant morbidity and mortality. Patients with severe forms of the disease are usually managed in the Intensive Care Unit (ICU), where they can develop secondary infections particularly bacterial, favored by prolonged intubation and central venous catheterization (CVC), hence increasing the disease’s mortality. Infectious endocarditis (IE) represents a rare and severe cardiovascular complication in patients with CVC. We report the case of a patient admitted to the ICU for an acute respiratory distress syndrome (ARDS) due to COVID19. Her management included intubation and mechanical ventilation, CVC and treatment with Hydroxychloroquine and azithromycin, and echocardiography findings were unremarkable. On the 10th day of onset, the patient developed septic shock and both echocardiography and blood cultures were in favor of A positive diagnosis of tricuspid valve infective endocarditis, accordingly to the modified Duke criteria. Specific treatment was started with a good clinical evolution. Our case outlines the difficulty of management of bacterial co-infections and superinfections in COVID-19 ICU patients, and particularly rare infections such as right-heart IE, which usually require a multidisciplinary approach and coordination between intensivits, cardiologists and infectiologists.

Characteristics and outcomes of patients with right-sided endocarditis undergoing cardiac surgery

Background

There has been an increasing incidence of right-sided infective endocarditis (RSIE) due to the global rise of intravenous drug use (IVDU) and an increasing number of implantable cardiac electronic devices and central venous catheters. Our aim was to investigate differences in the clinical presentation, microbiological findings and prognosis of patients undergoing surgery for RSIE compared to left-sided infective endocarditis (LSIE).

Methods

Relevant clinical data of all 432 consecutive patients undergoing valve surgery for infective endocarditis (IE) at our institution between January 2009 and December 2018 were retrospectively analyzed. Acquired data included patients' demographic and preoperative comorbidities, manifestation of IE according to the recently modified Duke Criteria, perioperative data and relevant clinical outcomes.

Results

A total of 403 patients (93.3%) underwent surgery for LSIE and twenty-nine patients (6.7%) for RSIE. Eleven patients with RSIE (37.9%) showed a concomitant left-sided infection. Compared to LSIE, RSIE patients were significantly younger [47.5 (40.4-69.3) vs. 65.1 (53.7-74.6); P=0.008] and presented with less comorbidities such as hypertension (41.4% vs. 65.3%; P=0.010) and coronary artery disease (6.9% vs. 29.0%; P=0.010). Rates of IVDU (34.5% vs. 4.5%; P<0.001), human immunodeficiency virus (HIV) (10.3% vs. 1.7%; P=0.023) and hepatitis C virus (HCV) infection (24.1% vs. 5.2%; P=0.001) were greater in RSIE. The proportion of Staphylococcus aureus IE was significantly higher in RSIE compared to LSIE (37.9% vs. 21.1%; P=0.035). 30-day mortality was 6.9% after surgery for RSIE compared to 14.6% after operation for LSIE (P=0.372).

Conclusions

Patients undergoing surgery for RSIE compared to LSIE presented with a higher rate of pulmonary septic emboli, more Staphylococcus aureus infections and larger vegetations. Larger multicenter prospective trials are needed to provide more reliable data on the clinical profile of these patients, in order to determine optimal surgical management.

Comparison of Clinical Characteristics and Prognosis in Patients with Right- and Left-sided Infective Endocarditis

OBJECTIVE

Right-sided endocarditis (RSE) accounts for 5%-10% of all cases of infective endocarditis (IE) and frequently has different etiological, pathogenetic, and clinical presentations compared with left-sided endocarditis (LSE). The aims of this study were to evaluate the epidemiologic and clinical characteristics and prognosis of RSE patients and to compare them with those of LSE patients. This study's importance relates to the local understanding of RSE and LSE, since Israeli demographics are different compared to the Unites States and Europe with regard to intravenous drug abuse and rheumatic valvular disease prevalence.

MATERIAL AND METHODS

A retrospective cohort study of 215 patients with infective endocarditis was performed. The primary outcome was in-hospital mortality. The secondary outcomes were duration of hospitalization, recurrent hospitalization, recurrent infective endocarditis, and one-year mortality.

RESULTS

Of the 215 patients in the study, 176 had LSE and 39 had RSE. The RSE patients were younger than the LSE patients (48.1±18.9 years versus 61.8±17.0 years, P<0.001). The most common pathogen in both groups was Staphylococcus aureus, which occurred more in the RSE group (51%) versus the LSE group (19%). In-hospital mortality was lower among patients with RSE (2.6% versus 17%, P<0.037).

CONCLUSIONS

Our study demonstrated an increasing percentage of RSE compared to LSE among patients with IE. Pacemaker lead infection has become the leading cause of RSE in intravenous drug users (IVDU), although less common in Southern Israel. The etiological and clinical differences between RSE and LSE are noteworthy. Patients with RSE have a better prognosis than those with LSE.

Right-sided infective endocarditis in patients with uncorrected ventricular septal defect and patent ductus arteriosus: Two case reports

Uncorrected left-to-right shunt congenital heart defect is a predisposing factor for infective endocarditis (IE), especially right-sided IE which has different clinical manifestations and complications from left-sided IE. Prompt diagnosis by means of transthoracic echocardiography and timely antibiotics management for IE are encouraged to prevent multiorgan failure and fatal pulmonary embolism.

Outcome and prognostic factors of patients with right-sided infective endocarditis requiring intensive care unit admission

Background

Right-sided infective endocarditis (RSIE) is an uncommon diagnosis accounting for less than 10% of cases of infective endocarditis. Optimal management for severely ill patients with RSIE remains challenging because few studies reported on management and outcome. The goal of our study was to determine outcome and associated prognostic factors in a population of ICU patients with a diagnosis of definite, active and severe RSIE.

Methods

We performed a retrospective study in 10 French ICUs between January 2002 and December 2012. Main outcome was mortality at 30 days after ICU admission. Significant variables associated with 30-days mortality in the bivariate analysis were included in a logistic regression analysis.

Results

A total of 37 patients were studied. Mean age was 47.9 ± 18.4 years. Mean SAPS II, SOFA score and Charlson comorbidity index were 32.4 ± 17.4, 6.3 ± 4.4 and 3.1 ± 3.4, respectively. Causative pathogens, identified in 34 patients, were mainly staphylococci (n = 29). The source of endocarditis was a catheter related infection in 10 patients, intravenous drug abuse in 8 patients, cutaneous in 7 patients, urinary tract related in one patient and has an unknown origin in 7 patients. Vegetation size was higher than 20 mm for 14 patients. Valve tricuspid regurgitation was classified as severe in 11 patients. All patients received initial appropriate antimicrobial therapy. Aminoglycosides were delivered in combination with β-lactam antibiotics or vancomycin in 22 patients. Surgical procedure was performed in 14 patients. Eight patients (21.6%) died within 30 days following ICU admission. One independent prognostic factor was identified: use of aminoglycosides was associated with improved outcome (OR = 0.1; 95%CI = 0.0017–0.650; p = 0.007).

Conclusion

Mortality of patients with RSIE needing ICU admission is high. Aminoglycosides used in combination with β-lactam or vancomycin could reduce 30 days mortality.

Physiopathological approach to infective endocarditis in chronic hemodialysis patients: left heart versus right heart involvement

Infectious endocarditis (IE), a complication that is both cardiac and infectious, occurs frequently and is associated with a heavy burden of morbidity and mortality in chronic hemodialysis patients (CHD). About 2-6% of chronic hemodialysis patients develop IE and the incidence is 50-60 times higher among CHD patients than in the general population. The left heart is the most frequent location of IE in CHD and the different published series report a prevalence of left valve involvement varying from 80% to 100%. Valvular and perivalvular abnormalities, alteration of the immune system, and bacteremia associated with repeated manipulation of the vascular access, particularly central venous catheters, comprise the main factors explaining the left heart IE in CHD patients. While left-sided IE develops in altered valves in a high-pressure system, right-sided IE on the contrary, generally develops in healthy valves in a low-pressure system. Right-sided IE is rare, with its incidence varying from 0% to 26% depending on the study, and the tricuspid valve is the main location. Might the massive influx of pathogenic and virulent germs via the central venous catheter to the right heart, with the tricuspid being the first contact valve, have a role in the physiopathology of IE in CHD, thus facilitating bacterial adhesion? While the physiopathology of left-sided IE entails multiple and convincing mechanisms, it is not the case for right-sided IE, for which the physiopathological mechanism is only partially understood and remains shrouded in mystery.

Surgical case of isolated pulmonary valve endocarditis in a patient without predisposing factors

We report a case of isolated pulmonary valve endocarditis in a 47-year-old woman without predisposing factors. She had episodes of low-grade fever and non-productive cough and was initially diagnosed with bacterial pneumonia. With antibiotic treatment, her condition improved transiently, but she had repeated respiratory events. Forty days after her first visit, she complained of severe dyspnea. Echocardiography revealed a large vegetation adhering to the pulmonary valve and she was diagnosed with isolated pulmonary valve endocarditis. Surgical treatment was selected because antibiotic treatment was not effective. The main pulmonary artery was transected above the annulus and the infected valve was excised. To avoid contact of the prosthetic valve with the infected pulmonary annulus, a stentless bioprosthesis was interposed between the transected parts of the pulmonary trunk. Two years after the surgery, the patient is stable with no sign of infection.

Gemella morbillorum endocarditis of pulmonary valve:a case report

Background

Pulmonary valve infective endocarditis is a rare finding for endocarditis. Infective endocarditis caused by Gemella morbillorum remains a scanty occurrence.

Case presentation

This is a case reported of a 28-year-old Chinese male with endocarditis caused by pulmonary valve infection of Gemella morbillorum associated with congenital ventricular septal defect, atrial septal defect and double-chambered right ventricle. The patient presented with fever, shortness of breath, progressively worsening exertional fatigue, dyspnea and weight loss for 3 months. The diagnosis was made with transthoracic echocardiogram, blood cultures, and post-operative pathology. The patient developed congestive heart failure and was managed with aggressive antibiotic therapy followed by surgery. He underwent replacement of the pulmonary valve with an aortic bioprosthetic valve, repair of ventricular septal defect and atrial septal defect, reconstruction of the right ventricular outlflow tract, and excision of vegetations. His postoperative recovery was uneventful. No bacteria were isolated from the excised tissues. He was asymptomatic without recurrence at 3-month follow-up.

Conclusions

The rare pathogen such as Gemella morbillorum can be the cause of infective endocarditis and timely surgical repair is necessary if the infection is refractory or there is progression of congestive heart failure under antibiotic cover.

Isolated Streptococcus agalactiae tricuspid endocarditis in elderly patient without known predisposing factors: Case report and review of the literature

Group B streptococcal (GBS) tricuspid infective endocarditis is a very rare clinical entity. It affects intravenous drug users, pregnant, postpartum women, and the elderly. We report the case of a 68-year-old patient without known predisposing factors who presented a GBS tricuspid endocarditis treated by penicillin and aminoglycosides with no response. The patient was operated with a good evolution. Our case is the 25th reported in the literature. GBS disease is increasing in the elderly and is mainly associated to comorbid conditions. Tricuspid infective endocarditis with Group B streptococcus predominantly presents as a persistent fever with respiratory symptoms due to pulmonary embolism. Therefore, it requires a medicosurgical treatment and close follow-up.

Clinical classification and prognosis of isolated right-sided infective endocarditis

From an epidemiologic point of view, right-sided infective endocarditis (RSIE) affects different types of patients: intravenous drug users (IDUs), cardiac device carriers (pacemakers and implantable automatic defibrillators), and the "3 noes" endocarditis group: no left-sided, no IDUs, no cardiac devices. Our objective is to describe and compare the clinical profile and outcome of these groups of patients. Every episode of infective endocarditis (IE) consecutively diagnosed in 3 tertiary centers from 1996 to 2012 was included in an ongoing multipurpose database. We assessed 85 epidemiologic, clinical, echocardiographic, and outcome variables in patients with isolated RSIE. A bivariated comparative analysis between the 3 groups was conducted.Among 866 IE episodes, 121 were classified as isolated RSIE (14%): 36 IDUs (30%), 65 cardiac device carriers (54%), and 20 "3 noes" group (16%). IDUs were mainly young men (36 ± 7 years) without previous heart disease, few comorbidities, and frequent previous endocarditis episodes (28%). Human immunodeficiency virus infection was frequent (69%). Cardiac device carriers were older (66 ± 15 years) and had less comorbidities (34%). Removal of the infected device was performed in 91% of the patients without any death. The "3 noes" endocarditis group was composed mainly by middle-age men (56 ± 18 years), health care related infections (50%), and had many comorbidities (75%). Whereas Staphylococcus aureus were the most frequent cause in IDUs (72% vs 34% in device carriers and 34% in the "3 noes" group, P = 0.001), coagulase negative Staphylococci predominated in the device carriers (58% vs 11% in drug users and 35% in the "3 noes", P < 0.001). Significant differences in mortality were found (17% in drug users, 3% in device carriers, and 30% in the "3 noes" group; P < 0.001). These results suggest that RSIE should be separated into 3 groups (IDUs, cardiac device carriers, and the "3 noes") and considered as independent entities as there are relevant epidemiologic, clinical, microbiological, echocardiographic, and prognostic differences among them.

Right-sided infective endocarditis presenting with purpuric skin rash and cardiac failure in a patient without fever

We describe the case of a 70-year-old woman who presented with symptoms of cardiac failure, and was found on clinical examination to have a purpuric rash over her lower extremities. Further evaluation of cardiac failure revealed tricuspid regurgitation with two large tricuspid valve vegetations. Blood cultures yielded a growth of Streptococcus viridans. She was treated with an intravenous ceftriaxone and gentamicin and made a complete recovery with resolution of the rash.

Right-sided infective endocarditis: surgical management

Right-sided infective endocarditis (RSIE) accounts for 5-10% of all cases of infective endocarditis and is predominantly encountered among injecting drug users (IDUs). RSIE diagnosis requires a high index of suspicion as respiratory symptoms predominate. Prognosis of isolated RSIE is favourable, and most cases (70-80%) resolve following antibiotic administration. Surgical intervention is indicated in patients with persistent infection that does not respond to antibiotic therapy, recurrent pulmonary emboli, intractable heart failure and if the size of a vegetation increases or persists at >1 cm. Techniques can be divided into 'prosthetic' (valve replacement or prosthetic annular implantation) or 'non-prosthetic' ones (Kay's or De Vega's annuloplasty, bicuspidalization or valvectomy). In IDUs who run a high risk of complications, vegetectomy and valve repair, avoiding artificial material should be considered as the first line of surgical management as is associated with better late survival.

Recommendations for the practice of echocardiography in infective endocarditis

Echocardiography plays a key role in the assessment of infective endocarditis (IE). It is useful for the diagnosis of endocarditis, the assessment of the severity of the disease, the prediction of short- and long-term prognosis, the prediction of embolic events, and the follow-up of patients under specific antibiotic therapy. Echocardiography is also useful for the diagnosis and management of the complications of IE, helping the physician in decision-making, particularly when a surgical therapy is considered. Finally, intraoperative echocardiography must be performed in IE to help the surgeon in the assessment and management of patients with IE during surgery. The current 'recommendations for the practice of echocardiography in infective endocarditis' aims to provide both an updated summary concerning the value and limitations of echocardiography in IE, and clear and simple recommendations for the optimal use of both transthoracic and transoesophageal echocardiography in IE.

A case of intra-cardiac right-sided mural infective endocarditis associated with ventricular septal defect despite prophylactic antibiotics: a case report

Bacterial endocarditis secondary to jet lesions from congenital heart disease is not uncommon, and has been reported on numerous occasions in the literature. These cases usually involve one or more cardiac valves. Our case is that of isolated intracardiac right-sided mural infective endocarditis associated with ventricular septal defect. Importantly, this patient had preceding dental work treated with antibiotic prophylaxis. This case highlights bacteraemia secondary to dental instrumentation versus routine oral hygiene. His presentation was predominantly that of respiratory symptoms and sepsis, and he was culture negative throughout his admission. The lesion was detailed on echocardiography and transoesophageal echocardiography, and treated conservatively. He has subsequently been referred for VSD closure.