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What is the best management option for non-significant residual shunt after device closure of perimembranous ventricular septal defect: A case report based on the lessons from post-procedure endocarditis.
Medicine (Baltimore) 2019; 98(42):e17347M

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.

Authors+Show Affiliations

Department of Pediatric Cardiology, West China Second University Hospital, Sichuan University. The Cardiac Development and Early Intervention Unit, West China Institute of Women and Children's Health, West China Second University Hospital, Sichuan University.Department of Radiology, West China Hospital, Sichuan University.Department of Pediatric Cardiology, West China Second University Hospital, Sichuan University. The Cardiac Development and Early Intervention Unit, West China Institute of Women and Children's Health, West China Second University Hospital, Sichuan University. Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education Chengdu. Key Laboratory of Development and Diseases of Women and Children of Sichuan Province, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China.Department of Pediatric Cardiology, West China Second University Hospital, Sichuan University. The Cardiac Development and Early Intervention Unit, West China Institute of Women and Children's Health, West China Second University Hospital, Sichuan University. Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education Chengdu. Key Laboratory of Development and Diseases of Women and Children of Sichuan Province, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China.Department of Pediatric Cardiology, West China Second University Hospital, Sichuan University. The Cardiac Development and Early Intervention Unit, West China Institute of Women and Children's Health, West China Second University Hospital, Sichuan University. Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education Chengdu. Key Laboratory of Development and Diseases of Women and Children of Sichuan Province, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China.

Pub Type(s)

Case Reports
Journal Article

Language

eng

PubMed ID

31626092

Citation

Shao, Shuran, et al. "What Is the Best Management Option for Non-significant Residual Shunt After Device Closure of Perimembranous Ventricular Septal Defect: a Case Report Based On the Lessons From Post-procedure Endocarditis." Medicine, vol. 98, no. 42, 2019, pp. e17347.
Shao S, Luo C, Zhou K, et al. What is the best management option for non-significant residual shunt after device closure of perimembranous ventricular septal defect: A case report based on the lessons from post-procedure endocarditis. Medicine (Baltimore). 2019;98(42):e17347.
Shao, S., Luo, C., Zhou, K., Hua, Y., & Wang, C. (2019). What is the best management option for non-significant residual shunt after device closure of perimembranous ventricular septal defect: A case report based on the lessons from post-procedure endocarditis. Medicine, 98(42), pp. e17347. doi:10.1097/MD.0000000000017347.
Shao S, et al. What Is the Best Management Option for Non-significant Residual Shunt After Device Closure of Perimembranous Ventricular Septal Defect: a Case Report Based On the Lessons From Post-procedure Endocarditis. Medicine (Baltimore). 2019;98(42):e17347. PubMed PMID: 31626092.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - What is the best management option for non-significant residual shunt after device closure of perimembranous ventricular septal defect: A case report based on the lessons from post-procedure endocarditis. AU - Shao,Shuran, AU - Luo,Chunyan, AU - Zhou,Kaiyu, AU - Hua,Yimin, AU - Wang,Chuan, PY - 2019/10/19/entrez PY - 2019/10/19/pubmed PY - 2019/10/19/medline SP - e17347 EP - e17347 JF - Medicine JO - Medicine (Baltimore) VL - 98 IS - 42 N2 - 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. SN - 1536-5964 UR - https://www.unboundmedicine.com/medline/citation/31626092/What_is_the_best_management_option_for_non-significant_residual_shunt_after_device_closure_of_perimembranous_ventricular_septal_defect:_A_case_report_based_on_the_lessons_from_post-procedure_endocarditis L2 - http://dx.doi.org/10.1097/MD.0000000000017347 DB - PRIME DP - Unbound Medicine ER -