Late (>12months post implantation) bacterial endocarditis (SBE) following ASD closure by trans-catheter approach is rare. SBE prophylaxis is recommended for 6-12 months, to allow full endothelialization. We present a patient with ASD occluder endocarditis and review of the literature.
A 16-year-old obese male who underwent trans-catheter PDA coil-occlusion and ASD closure by Amplatzer-device at 4-years of age presented with 5 days of severe frontal headaches. He was afebrile, tachycardic, tachypneic, and normotensive with no other heart-related findings. CRP was markedly elevated and blood culture yielded intermediately resistant Streptococcus pneumoniae, subtype 17f (not included in the vaccine). A transesophageal echocardiogram showed a hypermobile 1X1.5cm mass at the lower edge of the ASD occluder in the left atrium without residual shunt. Brain C.T was normal. The patient underwent a vegetectomy and extraction of the occluder, followed by ASD closure. The device was well endothelized. PCR from the vegetation yielded S.pneumoniae. The patient received 6 weeks of antibiotics (Linezolide+Ceftriaxone) and fully recovered.
Discussion:
7 cases of late SBE of ASD occluders have been published. Only two in children. The organism was MRSA in 3, MSSA in two, unknown in two. Only our patient had pneumococcal endocarditis, which is a rare cause of SBE (~5%). In only two patients (including ours), the device was fully endothelized. A risk factor for endocarditis seem to be incomplete device endothelization. Although rare, late infective endocarditis of ASD occluders must be considered and mandates a long term follow-up and a high index of suspicion in patients with intracardiac-devices.
