MANUSCRIPT
We describe a case of late infective endocarditis (IE), after
percutaneous closure of a patent foramen ovale (PFO) in an intravenous
drug abuser.
A 31-year-old man presented with worsening fever and cough associated
with left knee swelling not responsive to steroid therapy. His past
medical history included intravenous drug abuse and Human
Immunodeficiency Virus (HIV) infection for which he was on
anti-retroviral therapy. At the age of 22, he underwent percutaneous PFO
closure with an Amplatzer device (AGA Medical, Golden Valley, Minnesota,
USA) subsequent to an embolic stroke.
On physical examination, there was a widely harsh vesicular murmur with
right basal hypophonesis, tachycardia and swelling on the right knee
with functional impotence.
A Methicillin-sensitive Staphylococcus Aureus was isolated from blood
cultures. Magnetic resonance and Computed Tomography examinations showed
spots of infective emboli disseminated throughout the body, the lungs
and multiple abscess collections with necrotic core in the left leg.
A trans-esophageal echocardiography was then performed (Fig.1A), showing
multiple formations on the right side of the inter-atrial septum in an
area corresponding to the previously implanted closure device and
floating into the right atrium up to the tricuspid orifice (maximum size
5 x 0.6 cm). This large vegetation engaged in the tricuspid valve during
each systole of the cardiac cycle. The left side of the inter-atrial
septum appeared free from vegetations and fully covered by a thin layer
of endothelium.
He was started on a target intravenous antibiotic therapy with
piperacillin/tazobactam and teicoplanin, which was switched to
daptomycin and amikacin due to persistent fever.
Considering the dimensions of the vegetation and the embolic events, the
patient was then referred for cardiac surgery for Amplatzer® removal and
subsequent repair of the atrial defect.
Consent of the patients was obtained.
After a median sternotomy, cardiopulmonary bypass and cardioplegic
cardiac arrest, an extensive vegetation of 4.5 cm, including the
previously implanted device (Fig.1B-C), was removed through a right
atrial approach. The remaining inter-atrial defect was repaired with an
autologous pericardial patch and operation completed in the usual
fashion.
The postoperative course was uneventful, with regression of symptoms and
progressive reduction of the disseminated abscess collections. The
patient completed his course of antibiotic therapy and discharged home.
At 6-months, he was free from symptoms and echocardiographic
investigation was unremarkable.
There are 26 cases of IE on atrial septal occluders described in
literature. Out of those, 15/26 were positioned to repair Ostium
Secundum defects and 11/26 for PFO’s1.
Infective endocarditis is
relatively rare after percutaneous inter-atrial septal defect closure
but it can lead to several complications2 and It is
reported to be more frequent early after the
procedure1.
It has been previously described a percutaneous atrial septal defect
closure performed in a 6 years old boy who eventually became a drug
addict later in his life and developed an infective endocarditis which
involved both the left and the right side of the septal
occluder3.
The present case describes the late occurrence of infective endocarditis
nine years after a percutaneous closure of PFO in an adult HIV positive
drug abuser patient.
Considering the increase of drug abuse in developed countries, it is
mandatory to observe this group of patients, with intense inpatient drug
rehabilitation and psychological support, close and lifelong follow-up,
customized treatment of other infectious diseases with a more aggressive
approach and significant financial support in order to ensure patient
therapy, accessibility and compliance.
In addition, given the high risk associated with drug addiction
lifestyle, especially in HIV positive cases, it may be considered a
multidisciplinary team approach to discuss a surgical approach, possibly
minimally invasive, as an alternative to treat these defects and fully
explain the available options to these patients.
Funding source: none
BIBLIOGRAPHY
1. Amedro P, Soulatges C, Fraisse A. Infective endocarditis after device
closure of atrial septal defects: Case report and review of the
literature. Catheter Cardiovasc Interv . 2017;89(2):324-334.
doi:10.1002/ccd.26784
2. Verma SK, Tobis JM. Explantation of patent foramen ovale closure
devices: A multicenter survey. JACC Cardiovasc Interv .
2011;4(5):579-585. doi:10.1016/j.jcin.2011.01.009
3. La Sala MS, Zohourian H, McKeown J, Snyder S. Late bacterial
endocarditis in an intravenous drug user with an Amplatzer Septal
Occluder. Texas Hear Inst J . 2020;47(4):311-314.
doi:10.14503/THIJ-18-6903
Figure 1. Echocardiographic and operative images
Pre-operative trans-esophageal echocardiographic findings of the large
vegetation (arrowheads) adherent to the body of the Amplatzer (AMP)
projecting into the right atrium. RA: Right Atrium, RV: Right
Ventricle. B) Surgical view of the vegetation (arrowheads)
from right atrial approach. SVC: Superior Vena Cava, ICV Inferior Vena
Cava and TV: Tricuspid Valve. C) Surgical sample of the
vegetation (arrowheads) removed with the Amplatzer (AMP).