Ventricular septal defect with secondary left ventricular-to-right atrial shunt is associated with a higher risk for infective endocarditis and a lower late chance of closure

Predictive Scoring System for Spontaneous Closure of Infant Ventricular Septal Defect: The P-VSD Score

Ventricular septal defect (VSD) is a common congenital heart disease. However, consensus on the utility of echocardiography in predicting spontaneous closure (SC) of VSD remains lacking. This study aimed to identify and validate significant predictors of SC through a predictive scoring system. This retrospective study included medical records of 712 echocardiography instances performed on 304 patients diagnosed with VSD from 2016 to 2020 in their first year of life. A novel scoring system for predicting the SC of VSD was developed and validated using another dataset from different hospitals. Of the 304 patients, 215 (70.7%) had perimembranous (PM) VSDs and 89 had muscular (29.3%) VSDs. The median follow-up periods were 36.2 (interquartile range [IQR], 13-59) months and 13.7 9 (IQR, 5-37.4) days for PM and muscular VSDs, respectively. The overall SC rate during follow-up was 29.3%. Pulmonary hypertension (HTN), concomitant left ventricle (LV)-right atrium (RA) shunt, VSD size to aortic valve (AV) annulus size ratio, and left ventricular end-diastolic dimension (LVEDD) z-score were significant risk factors affecting SC of VSD. The "P-VSD" score, a new scoring system, demonstrated an area under the curve for predictability of 0.769. Pulmonary HTN, concomitant LV-RA shunt, LVEDD z-score, and VSD size-to-AV annulus size ratio at diagnosis were significantly associated with non-SC VSD after infancy. The P-VSD score can predict the SC of VSD in clinical settings and simplify the identification and appropriate management of high-risk patients.

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

BACKGROUND

Infective endocarditis has a relevant clinical impact due to its high morbidity and mortality rates. Right-sided endocarditis has lower complication rates than left-sided endocarditis. Common complications are multiple septic pulmonary embolisms, haemoptysis, and acute renal failure. Risk factors associated with right-sided infective endocarditis are commonly related to intravenous drug abuse, central venous catheters, or infections due to implantable cardiac devices. However, patients with congenital ventricular septal defects might be at high risk of endocarditis and haemodynamic complications.

CASE PRESENTATION

In the following, we present the case of a 23-year-old man without a previous intravenous drug history with tricuspid valve Staphylococcus aureus endocarditis complicated by acute renal failure and haemoptysis caused by multiple pulmonary emboli. In most cases, right-sided endocarditis is associated with several common risk factors, such as intravenous drug abuse, a central venous catheter, or infections due to implantable cardiac devices. In this case, we found a small perimembranous ventricular septal defect corresponding to a type 2 Gerbode defect. This finding raised the suspicion of a congenital ventricular septal defect complicated by a postendocarditis aneurysmal transformation.

CONCLUSIONS

Management of the complications of right-sided infective endocarditis requires a multidisciplinary approach. Echocardiographic approaches should include screening for ventricular septal defects in patients without common risk factors for tricuspid valve endocarditis. Patients with undiagnosed congenital ventricular septal defects are at high risk of infective endocarditis. Therefore, endocarditis prophylaxis after dental procedures and/or soft-tissue infections is highly recommended. An acquired ventricular septal defect is a very rare complication of infective endocarditis. Surgical management of small ventricular septal defects without haemodynamic significance is still controversial.

Ruptured Sinus of Valsalva Aneurysm and Gerbode Defects: Patient and Procedural Selection: the Key to Optimising Outcomes

PURPOSE OF REVIEW

In this review, we reflect on the historical background, clinical features and imaging techniques used to assess Gerbode defects and sinus of Valsalva aneurysms. We aim to review the evolution of treatment strategies and the progression towards less invasive management for these conditions.

RECENT FINDINGS

While transthoracic echocardiography is often diagnostic, transesophageal echocardiography (2D and 3D) has improved our understanding of these defects and allowed us to more accurately define their anatomy. Cardiac MRI provides improved assessment of the physiological impact of defects by quantifying shunt volume. Transcatheter techniques are currently vying with surgery as the mainstay of treatment. New insights are being discovered regarding diagnostic modalities and treatment pathways. Defining criteria for patient selection for catheter or surgical therapy is essential when deciding on the optimum intervention for the individual patient.

Percutaneous closure of congenital Gerbode defect using Nit-Occlud® Lê VSD coil

We present a case report about percutaneous closure of a congenital Gerbode defect using Nit-Occlud^® Lê VSD coil. The patient was referred to our hospital with a diagnosis of ventricular septal defect (VSD) and severe pulmonary arterial hypertension. But transthoracic echocardiography revealed a communication between the left ventricle (LV) and the right atrial (RA), called Gerbode defect. Catheterization confirmed the shunt from the LV to the RA. We successfully closed the defect with a VSD coil. After uneventful 6 mo follow-up, the patient was out of dyspnea, the symptom urged him to have medical attention. This case report is to discuss the diagnosis and percutaneous treatment approach for this rare congenital heart disease.

Evaluation of Ventricular Septal Defect with Special Reference to the Spontaneous Closure Rate, Subaortic Ridge, and Aortic Valve Prolapse II

The medical records of 2283 patients with ventricular septal defect (VSD) were reviewed to determine spontaneous closure, left ventricular-to-right atrial shunt, subaortic ridge, and aortic valve prolapse. One thousand eight hundred and twenty-three patients had been followed 1 month to 26 years (median 4 years) by echocardiography. Most of 460 patients could not be followed due to transportation of the institution. VSD was perimembranous in 68.8% (1255), trabecular muscular in 21.7% (395), muscular outlet in 6% (109), muscular inlet in 2.6% (48), and doubly committed subarterial in 0.9% (16). Defect size was classified in 66.8% (1218) as small, in 15.7% (286) as moderate, and in 17.5% (319) as large. VSD closed spontaneously in 18.8% (343 of 1823 patients) by ages 40 days to 24.9 years (median, 1.8 years). One hundred fifty-seven of 1255 perimembranous defects (12.5%) and 167 of 395 trabecular muscular defects (42%) closed spontaneously (p < 0.001). Defect size became small in 306 (16.8%) of patients with VSD at a median of 2.5 years. Aneurysmal transformation was detected in 32.9% (600), left ventricular-to-right atrial shunt in 9.7% (176), subaortic ridge in 2.6% (48) of 1823 patients who were followed. In 381 (20.9%) of the 1823 patients, the VSD had been closed by a surgical or transcatheter technique. Surgery is required in one-fifth of patients with subaortic ridge or aortic valve prolapse. In conclusion, isolated VSDs are usually benign abnormalities that tend to shrink and close spontaneously.

Transcatheter closure of left ventricle to right atrial communication using cera duct occluder

Left ventricle—right atrial communication could be congenital (Gerbode defect) or acquired as a complication of surgery or infective endocarditis and leads to volume overloading of pulmonary circulation. Two types, direct and indirect types are known depending on the involvement of septal tricuspid leaflet. Transcatheter closure of this defect is feasible and appears an attractive alternative to surgical management. Various devices like Amplatzer duct occluder I, II, Muscular ventricular septal defect device etc. have been used to close this defect. We report two patients, a preteen boy with direct left ventricle-right atrial communication as post operative complication and an adult female with indirect communication who underwent transcatheter closure with Cera duct occluder (Lifetech Scientific (Shenzhen), China).

Transcatheter Closure of Perimembranous Ventricular Septal Defects with Left Ventricular to Right Atrial Shunt

During the development of so-called aneurysmal transformation of perimembranous ventricular septal defects (pmVSD), tricuspid valve (TV) morphology and function may be altered resulting in left ventricular (LV) to right atrial (RA) shunting. The feasibility and outcome of interventional closure of these pmVSD has not been investigated so far. Interventional closure of pmVSD associated with mild to moderate LV-to-RA shunt was performed in four patients (aged 6.5-12.5 years). pmVSD were closed under fluoroscopic guidance by establishing an arteriovenous wire loop via a femoral artery and advancing the delivery sheath from a femoral vein. Before device release (or withdrawal if necessary), residual shunting across the device and TV valve function was investigated by transthoracic echocardiography and LV angiography. pmVSD sizes of 4, 5.5, 8 and 8.5 mm were closed with a 4/4 and 6/6 Amplatzer duct occluder II and an 8- and 10-mm Amplatzer muscular VSD occluder device, respectively. There were no or only minor residual postinterventional LV-to-RA shunts. No atrioventricular blocks were observed during a mean follow-up of 12.5 months (range 6.5-17 months). Transthoracic echocardiography indicated that the elimination of the VSD jet pushing the antero-superior TV leaflet open is the key mechanism for LV-to-RA shunt reduction after transcatheter pmVSD closure. Interventional closure in pmVSD associated with mild to moderate indirect LV-to-RA shunting is feasible and results in significant reduction in or elimination of LV-to-RA shunting.

Acquired left ventricle-to-right atrium shunt: clinical implications and diagnostic dilemmas

BACKGROUND

The acquired left ventricle-to-right atrium (LV-RA) shunt (Gerbode defect) is rare but it can sometimes be a critical condition. The diagnosis is quite challenging largely due to its exotic anatomic features and diagnostic difficulties. This study aims to present the clinical features and diagnostic solutions of this rare lesion.

METHODS

Data source was based on a comprehensive literature retrieval of acquired LV-RA shunts of 1990-2014.

RESULTS

Most of the acquired LV-RA shunts are of either a postoperative or an infective etiology. Transthoracic echocardiography showed a 62.2% accurate diagnosis, 13.4% inclusive diagnosis, 9.8% missed diagnosis, and 14.5% misdiagnosis rate. The accurate diagnostic rate of transthoracic echocardiography was significantly lower than that of the transesophageal echocardiography or cardiac catheterization. The LV-RA shunts are often misinterpreted as mitral regurgitation, pulmonary hypertension, tricuspid regurgitation, Valsalva aneurysm rupture, and subaortic/high perimembrane/residual ventricular septal defect. Surgical, interventional, and conservative treatments were applied in 57.8, 24.4, and 17.8% patients, respectively. Prognosis showed an event-free survival of 85%, a comorbidity of 9.1%, and a mortality of 13.6%.

CONCLUSIONS

A high jet detected in the right atrium with uncertain origin and course has to appeal to additional diagnostic techniques including transesophageal echocardiography, cardiac catheterization, or cardiac magnetic resonance imaging for differential diagnoses. Small restrictive shunts are preferred with conservative treatments, high-risk patients are candidates of interventional therapy, and the patients with unstable hemodynamics warrant an open heart surgery. Careful operative maneuver, good control of intracardiac infection, preservation of heart function, etc., are mandatory for the prevention of the development of an acquired LV-RA shunt.

A new scoring system for spontaneous closure prediction of perimembranous ventricular septal defects in children

Background

Perimembranous ventricular septal defect (PMVSD) is a congenital heart aberration, which is surgically treated by patch or device closure, but also can heal without operation as spontaneous closure (SC).

Methods

We analyzed data from 1873 PMVSD patients admitted to our hospital during September 2001 and December 2009, in order to establish a Cox regression model for PMVSD SC probability prediction (derivative cohort). Initial contact age, ventricular septal defect (VSD) diameter, shunt flow, aneurysmal tissue of the ventricular membranous septum (ATVMS) development, associated complications, and left ventricular end-diastolic dimension (LVDD) were analyzed for correlations with SC. The derived scoring system based on the coefficients of the model was developed and applied to another cohort with 382 PMVSD patients to evaluate the validity for SC probability forecast (validation cohort).

Results

Multivariate Cox regression analysis revealed that SC of PMVSD was associated with age at first contact, defect size, diffuse shunt flow, ATVMS formation, associated complication, as well as increased LVDD, which were used to establish a new scoring system. The area under the receiver operating characteristic (ROC) curve of our predictive scaling was 0.831 (95% CI 0.804–0.858, p<0.001) in the derivative cohort. The scoring system also accurately predicted SC with an area under the ROC curve of 0.863 (95% CI 0.785–0.941, p<0.001) in the validation cohort.

Conclusion

Our scoring system using factors affecting SC can predict the probability of SC in PMVSD patients.

Left ventricular to right atrial shunt (Gerbode defect): congenital versus acquired

Introduction

Congenital left ventricular to right atrial (LV-RA) shunt (Gerbode defect) is rare, while acquired LV-RA shunt has been increasingly reported. As yet, systematically incorporated data of the LV-RA shunt have not been presented.

Aim

To present the clinical features, diagnostic challenge and management strategies of congenital and acquired LV-RA shunts.

Material and methods

The data source was based on a comprehensive literature retrieval of the LV-RA shunt in the period 1990–2013.

Results

In comparison with the acquired Gerbode defect, the congenital Gerbode defect group of patients were younger and were associated more often with additional congenital disorders. Previous cardiac surgery and infective endocarditis were the two major aetiologies of the occurrence of the acquired shunts. Paravalvular abscess was associated in 10.2% and atrioventricular block in 13.6% of the acquired group patients. Transoesophageal echocardiography showed a higher diagnostic accuracy, lower missed diagnosis and lower inclusive diagnosis rates, in comparison to transthoracic echocardiography, but the misdiagnosis rates of the two modalities did not differ from each other. Four (4.5%) of the acquired group patients were complicated by atrioventricular block following surgical or interventional closure of the shunt. Eight (9.1%) patients died in the acquired group, but no patient died in the congenital group.

Conclusions

The diagnosis of an LV-RA shunt is quite challenging, especially in the context of coexisting abnormalities including an additional intracardiac shunt, tricuspid regurgitation, pulmonary artery hypertension and infective endocarditis, which have to be carefully differentiated from the shunt by further investigations. A better control of infective complications and careful manoeuvres during surgery may help to keep the LV-RA-sensitive septum intact.

Changing spectrum of infective endocarditis in children: a 30 years experiences from a tertiary care center in Taiwan

BACKGROUND

The epidemiology of infective endocarditis (IE) changes with the medical advances. This study aimed to evaluate the trends in a pediatric cohort.

METHODS

From hospital database (1983-2011), patients <18 years who fulfilled the modified Duke criteria of IE were identified.

RESULTS

We enrolled 112 patients (M/F 57/55) with 116 IE episodes. About 86 patients (74.1%) had preexisting cardiac lesions and 23 patients (19.6%) were immunocompromised hosts. Prior dental procedure was noted in 12 (10.3%) patients, including 4 with simple ventricular septal defect. The overall mortality was 10.7%. The risk factors included vegetations in both ventricles (odds ratio = 7.81, P = .019) and prior use of broad-spectrum antibiotics (odds ratio = 3.75, P = .055). Approximately one-third of the patients (29.3%) required surgical intervention. We identified an increasing trend in the proportion of hospital-acquired IE (from 12% during 1983-1991 to 39% during 2002-2011), and the spectrum of offending pathogens showed a trend for fewer Streptococcus species, more Staphylococcus aureus and increased pathogen diversity. The leading pathogens were Gram-negative bacilli in hospital-acquired IE and Streptococcus species in community-acquired IE. Hospital-acquired IE was associated with younger age, a higher proportion of immunocompromised patients, a history of central line indwelling and higher mortality. In contrast, more surgical intervention and embolic events occurred in community-acquired IE patients.

CONCLUSIONS

The mortality of pediatric IE remains high. Dental procedures were noted in one-tenth of the patients. Although increased S. aureus-caused episodes and pathogen diversity were noted, Streptococcus species remain the most common pathogen.

Clinical utility of the ventricular septal defect diameter to aorta root diameter ratio to predict early childhood developmental defects or lung infections in patients with perimembranous ventricular septal defect

BACKGROUND

Ventricular septal defect (VSD) is the most frequent type of congenital heart disease. Conventional methods to evaluate VSD size and severity are both invasive and cumbersome to perform. We investigated whether the ratio between the diameter of the defect and the aortic root diameter (DVSD/DAR) would accurately reflect the degree of shunted blood and the severity of VSD in children with perimembranous VSD.

METHODS

We recruited 987 children with perimembranous VSD (pmVSD) and used color Doppler echocardiography to calculate DVSD/DAR. 987 healthy children were recruited as control group. The pmVSD group was further stratified into four groups according to age (1 to 4 y) and again into four groups according to the DVSD/DAR ratio: children whose DVSD/DAR was 1/5 to <1/4, 1/4 to <1/3, 1/3 to 1/5, or 1/2 to <2/3 were assigned to groups A, B, C, and D, respectively. Height, weight, infection scores and systemic-pulmonary circulation ratio (QP/QS ratio) were compared among groups A, B, C and D. Then the relationship between the DVSD/DAR ratio and height, weight, QP/QS ratio, infection score were analysed by linear regression analysis.

RESULTS

Compared to age-matched children without VSD (the controls), the mean height and weight of children in the pmVSD group were lower, and heights and weights were negatively correlated with the DVSD/DAR ratio. This ratio was significantly reduced in groups C and D compared to control group (both P<0.05). Infection scores of groups A and B were significantly higher only in the one-year-old subgroup, but were significantly higher in groups C and D for all ages compared to the control group (both P<0.05). QP/QS ratio of group C and D were higher than group A and group B (all P<0.05). Moreover, QP/QS ratio of group D for all ages were more than 2. In addition, linear regression analysis revealed that the DVSD/DAR ratio negatively correlated with height and weight and positively correlated with the QP/QS ratio and infection score.

CONCLUSIONS

Our results suggest that the DVSD/DAR ratio accurately reflects the growth and pulmonary infection rates in children with pmVSD. This ratio, therefore, may be a useful additional reference index to predict the consequences of pmVSD.

Infective endocarditis in children without underlying heart disease

BACKGROUND/PURPOSE

Although pre-existing heart disease is the main predisposing factor for pediatric infective endocarditis (IE), cases of IE in children without underlying heart disease have been increasingly reported. This study reviews the clinical and laboratory characteristics of pediatric IE patients with and without underlying heart disease, and presents the unique features of patients with no apparent pre-existing heart disease.

METHODS

Children who were admitted to our hospital from January 1991 to April 2011 and met the Modified Duke criteria for definite or possible IE were retrospectively analyzed. Clinical characteristics and laboratory data were collected by chart review.

RESULTS

Forty-seven patients with a total of 48 episodes of IE were enrolled. Of these patients, 31 children (64.6%) had congenital heart disease (CHD), six (12.5%) had non-CHD chronic disease, and eleven (22.9%) were previously healthy adolescents. Five patients with non-CHD chronic conditions acquired infection from central catheter: two methicillin-resistant Staphylococcus aureus (MRSA), two Candida albicans and one coagulase-negative Staphylococcus (CoNS). The microbial pathogens in 11 previously healthy individuals were Streptococcus viridans (n = 3), methicillin-sensitive S. aureus (MSSA, n = 2), Haemophilus parainfluenzae (n = 2), Staphylococcus lugdunensis (n = 1), Enterococcus (n = 1), and Diphtheroid (n = 1). In total, five of 17 non-CHD patients were infected with S. aureus (two MRSA and three MSSA) and the vegetations in these five patients were detected in the right side of the heart (tricuspid valve or right atrium). The average interval between onset of symptoms and diagnosis of IE in the CHD and previously healthy groups was 18 and 31 days, respectively. Patients in the previously healthy group were older and more often required surgical interventions for removal of vegetation.

CONCLUSION

Over one-third (35.4%) of cases of IE in children occurred in patients without pre-existing cardiac disease. Early identification of these patients is critical and requires a high index of suspicion. The pathogenesis of IE in previously healthy individuals is still uncertain, but previous skin infection or dental problems may contribute to potential risk.

A rare type of Gerbode defect

A Gerbode defect is a left ventricle to right atrial communication. The type I defect (direct, acquired) results in a direct shunt through the atrioventricular part of membranous septum, while a type II (indirect, congenital) defect results in an indirect shunt through a perimembranous ventricular septal defect (VSD) and a defect in the septal tricuspid valve leaflet. We report a rare type of Gerbode defect wherein a small perimembranous VSD is completely covered by an elongated sail-like anterior tricuspid leaflet forming an aneurysm and directing the shunt into right atrium.

Are all ventricular septal defects created equal?

The authors report the occurrence of infective endocarditis in a 32-year-old man with a ventricular septal defect and a left ventricular-to-right-atrial shunt who adhered to the revised 2007 American Heart Association guidelines for infective endocarditis. The patient had received antibiotic prophylaxis prior to multiple previous dental procedures. At a recent dental evaluation for fillings, he was informed that he no longer needed prophylaxis. Fatigue and fevers developed 1 week later, and he was treated with an oral course of ciprofloxacin. The symptoms recurred, and blood cultures grew Streptococcus viridans. A 7-mm vegetative mass was seen on the septal leaflet of the tricuspid valve during transesophageal echocardiography. This report raises the concern that patients with ventricular septal defects and left ventricular-to-right-atrial shunts are at higher risk for endocarditis and may require antibiotic prophylaxis.