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• W2069924320 abstract "HomeCirculationVol. 125, No. 6Residual Shunt After Ductus Arteriosus Occluder Implantation Complicated by Late Endocarditis Free AccessBrief ReportPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessBrief ReportPDF/EPUBResidual Shunt After Ductus Arteriosus Occluder Implantation Complicated by Late Endocarditis Christophe Saint-André, JD, Xavier Iriart, MD, Hopewell Ntsinjana, MD and Jean-Benoît Thambo, MD Christophe Saint-AndréChristophe Saint-André From the Department of Cardiology, Department of Pediatric Cardiology, Bordeaux University Hospital, Bordeaux, France (C.S.-A., X.I., J.-B.T.), and Health Sciences Faculty, University of the Witwatersrand, Johannesburg, South Africa (H.N.). Search for more papers by this author , Xavier IriartXavier Iriart From the Department of Cardiology, Department of Pediatric Cardiology, Bordeaux University Hospital, Bordeaux, France (C.S.-A., X.I., J.-B.T.), and Health Sciences Faculty, University of the Witwatersrand, Johannesburg, South Africa (H.N.). Search for more papers by this author , Hopewell NtsinjanaHopewell Ntsinjana From the Department of Cardiology, Department of Pediatric Cardiology, Bordeaux University Hospital, Bordeaux, France (C.S.-A., X.I., J.-B.T.), and Health Sciences Faculty, University of the Witwatersrand, Johannesburg, South Africa (H.N.). Search for more papers by this author and Jean-Benoît ThamboJean-Benoît Thambo From the Department of Cardiology, Department of Pediatric Cardiology, Bordeaux University Hospital, Bordeaux, France (C.S.-A., X.I., J.-B.T.), and Health Sciences Faculty, University of the Witwatersrand, Johannesburg, South Africa (H.N.). Search for more papers by this author Originally published14 Feb 2012https://doi.org/10.1161/CIRCULATIONAHA.111.024521Circulation. 2012;125:840–842We report the case of a 20-year-old woman who had percutaneous closure of a patent ductus arteriosus (PDA) with a 17-mm Rashkind occluder when she was 4 years of age. A small residual shunt was noted on color-flow Doppler echocardiography immediately after the procedure and at 6-month follow-up. Because of the lack of hemodynamic complications, no additional intervention was performed.Sixteen years later, she presented with recurrent bilateral bronchopneumonia that required antibiotic treatment. Chest radiography during the third episode showed a right bronchopneumonia (Figure 1). At that time, new treatment with amoxicillin and clavulanic acid was given for 10 days, but fever persisted despite this course of antibiotics.Download figureDownload PowerPointFigure 1. Chest radiograph showed right upper lobe consolidation suggestive of infective bronchopneumonia (arrow). The Rashkind occluder device is visible in the duct area (dotted arrow).Results of the physical examination showed blood pressure of 110/70 mm Hg, pulse of 92 bpm, temperature of 38.5°C, and pale appearance. There were no other examination findings except a continuous murmur below the left clavicle.Laboratory workup revealed C-reactive protein 152 mg/L, leukocytes 17 300/mm3, hemoglobin 12.3 g/dL, and hematocrit 35%, which suggested persistent infection. Six hemocultures were positive for Streptococcus acidominimus.A hypothesis of infection at the occluder site was confirmed by transthoracic and transesophageal echocardiograms, which showed a 5×8-mm vegetation on the left pulmonary artery with attachment to the Rashkind occluder (Figure 2; online-only Data Supplement Movie I) and another vegetation on the main pulmonary artery (online-only Data Supplement Movie II) along the persistent left-to-right shunt (online-only Data Supplement Movie III). Furthermore, a chest computed tomography scan showed septic emboli in both lung fields (Figure 3). An incidental finding was made of a filling defect in the proximal left pulmonary artery, closely related to the occluder device (Figure 4).Download figureDownload PowerPointFigure 2. Transesophageal echocardiography showed mobile vegetation (arrow) in the left pulmonary artery attached to the occluder. DA indicates descending aorta; LPA, left pulmonary artery.Download figureDownload PowerPointFigure 3. Contrast-enhanced computed tomography (lung window) showed bilateral peripheral consolidations suggestive of infective pneumonia (arrows).Download figureDownload PowerPointFigure 4. Computed tomography angiography showed a filling defect in the proximal left pulmonary artery closely related to the Rashkind occluder device (arrow). A, Sagittal multiplanar reconstruction view. B, Coronal oblique left pulmonary artery view. C, Axial oblique left pulmonary artery view. D, Axial view.The origin of this infection was not found. Descaling had been performed 4 months earlier with antibiotic prophylaxis with 2 g of amoxicillin. Results of a dental checkup performed during hospitalization were normal.Intravenous antibiotic treatment consisted of amoxicillin and gentamycin for 2 weeks, then amoxicillin alone for 2 more weeks. After 1 week of treatment, C-reactive protein decreased to normal levels. A follow-up transesophageal echocardiogram was performed, which showed no regression of either lesion. Surgical removal of the vegetation and concomitant ligation of the PDA were undertaken. Subsequent culture of the Rashkind device yielded no bacterial growth.It is widely agreed that PDAs with evidence of left-sided heart volume overload should be closed, but less evidence exists concerning the management of nonsignificant residual shunts after percutaneous occluder implantation. To the best of our knowledge, this is the first case of late endocarditis reported after percutaneous PDA occlusion with a residual shunt. The pathophysiology is proposed to be the same as that of native endocarditis, with endothelial damage resulting from mechanical lesions provoked by turbulent blood flow across the PDA, but the risk is clearly increased by the exogenous prosthesis.1 Even though native PDA endocarditis is well known, there are limited data on device-related endocarditis. Previous animal studies revealed no increased risk of endocarditis between device-implanted subjects and control subjects after injection with bacteria-contaminated serum.2The prevalence of a residual shunt after PDA percutaneous occlusion has been reported in 14% of patients after 6 months.3 This case reports the first infective endocarditis on a PDA occluder with residual shunt and highlights the need for long-term follow-up in case of residual shunt. Even though the risk of endocarditis requires further evaluation, implantation of a second device is a satisfactory means of abolishing persistent residual flow and should be considered if flow persists beyond 6 months.4DisclosuresNone.FootnotesThe online-only Data Supplement is available with this article at http://circ.ahajournals.org/lookup/suppl/doi:10.1161/CIRCULATIONAHA.111.024521/-/DC1.Correspondence to Christophe Saint-André, JD, Department of Cardiology, Bordeaux University Hospital, Avenue de Magellan, 33600, Pessac, France. E-mail [email protected]frReferences1. Guidelines on the prevention, diagnosis, and treatment of infective endocarditis. Eur Heart J. 2009; 30:2185–2186.MedlineGoogle Scholar2. Latson LA, McManus BM, Doer C, Kilzer K, Cheatham JP. Endocarditis risk of the USCI PDA umbrella for transcatheter closure of patent ductus arteriosus. Circulation. 1994; 90:2525–2528.LinkGoogle Scholar3. Allen HD, Beekman RH, Garson A, Hijazi ZM, Mullins C, O'Laughlin MP, Taubert KA. Pediatric therapeutic cardiac catheterization: a statement for healthcare professionals from the Council on Cardiovascular Disease in the Young, American Heart Association [published correction appears in Circulation. 1998;97:2375]. Circulation. 1998; 97:609–625.LinkGoogle Scholar4. Huggon IC, Tabatabaei AH, Qureshi SA, Baker EJ, Tynan M. Use of a second transcatheter Rashkind arterial duct occluder for persistent flow after implantation of the first device: indications and results. Br Heart J. 1993; 69:544–550.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Di Filippo S (2020) Clinical outcomes for congenital heart disease patients presenting with infective endocarditis, Expert Review of Cardiovascular Therapy, 10.1080/14779072.2020.1768847, 18:6, (331-342), Online publication date: 2-Jun-2020. Yilmazer M and Meşe T (2020) Infective endocarditis developing early after percutaneous closure of a patent ductus arteriosus in a child using the Amplatzer Duct Occluder II, Cardiology in the Young, 10.1017/S1047951120000542, 30:4, (591-593), Online publication date: 1-Apr-2020. El‐Saiedi S, Elshedoudy S, El‐Sisi A, Hanna B, Fattouh A and Hijazi Z (2019) Transcatheter closure of residual patent ductus arteriosus, Catheterization and Cardiovascular Interventions, 10.1002/ccd.28338, 95:1, (78-82), Online publication date: 1-Jan-2020. Szatmári V (2017) Incidence of postoperative implant-related bacterial endocarditis in dogs that underwent trans-catheter embolization of a patent ductus arteriosus without intra- and post-procedural prophylactic antibiotics, Veterinary Microbiology, 10.1016/j.vetmic.2017.05.023, 207, (25-28), Online publication date: 1-Aug-2017. Baltimore R, Gewitz M, Baddour L, Beerman L, Jackson M, Lockhart P, Pahl E, Schutze G, Shulman S and Willoughby R (2015) Infective Endocarditis in Childhood: 2015 Update, Circulation, 132:15, (1487-1515), Online publication date: 13-Oct-2015. Elder R and Baltimore R (2015) The Changing Epidemiology of Pediatric Endocarditis, Infectious Disease Clinics of North America, 10.1016/j.idc.2015.05.004, 29:3, (513-524), Online publication date: 1-Sep-2015. AOKI T, SUNAHARA H, SUGIMOTO K, ITO T, KANAI E and FUJII Y (2015) Infective endocarditis of the aortic valve in a Border collie dog with patent ductus arteriosus, Journal of Veterinary Medical Science, 10.1292/jvms.14-0384, 77:3, (331-336), . February 14, 2012Vol 125, Issue 6 Advertisement Article InformationMetrics © 2012 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.111.024521PMID: 22331922 Originally publishedFebruary 14, 2012 PDF download Advertisement SubjectsCongenital Heart DiseaseDevelopmental BiologyPulmonary Hypertension" @default.
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