Acquired Ventricular Septal Defect Secondary to Aortic Valve Endocarditis

Acquired Ventricular Septal Defect Secondary to Aortic Valve Endocarditis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Acquired Ventricular Septal Defect Secondary to Aortic Valve Endocarditis Courtney Hanson, Maria Tibesar, Timothy Pansegrau Pansegrau This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5020960/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 11 Mar, 2025 Read the published version in Journal of Cardiothoracic Surgery → Version 1 posted 16 You are reading this latest preprint version Abstract Introduction : Infective endocarditis remains a deadly disease with an in-hospital mortality rate of around 20%. While ventricular septal defects (VSDs) have been linked to an increased risk of infective endocarditis, cases of acquired VSDs resulting from infective endocarditis are not well-documented in the literature. Our report highlights a rare case of acquired VSD that resulted directly from aortic valve endocarditis. Case Presentation : A 57-year-old male presented to an outside hospital with chest pain, shortness of breath, and low-grade fevers for the past seven days. Additionally, poor dentition was noted. Blood cultures detected gram-positive staphylococci and streptococcus anginosus. Due to concern for endocarditis, an order was placed for both a transthoracic echocardiogram (TTE) and transesophageal echocardiogram (TEE). Results showed aortic regurgitation, stenosis, and a mobile growth. The patient was managed with IV antibiotics until transferred. Upon arrival at our facility, TEE revealed a VSD that demonstrated left-to-right flow into the right ventricle. Due to the risk of cardiac decompensation and septic embolization, immediate surgical intervention was necessary. The aorta was opened, and the diseased aortic valve was excised. The necrotic septum was debrided and an acquired VSD the size of a quarter was identified. A pericardial patch was used to repair the VSD. Following debridement a mechanical aortic valve was placed. The patient was taken to ICU in a stable condition. However, several days following the procedure, the patient developed ongoing arrhythmia, and a permanent pacemaker was placed. Conclusions : It has been well-documented in literature that congenital VSDs are associated with an increased incidence of endocarditis. However, only a few cases have been documented where a VSD results directly from aortic valve endocarditis. This is the first recorded case of an adult in the U.S. with native aortic valve gram-positive staphylococci and streptococcus anginosus endocarditis resulting in a large acquired VSD. The condition was successfully diagnosed and treated with surgery. Successful treatment of post-operative arrhythmia with permanent pacemaker placement was achieved- a first for acquired VSD caused by infectious endocarditis. aquired ventricular septal defect endocarditis pacemaker aortic valve Figures Figure 1 Introduction With a rising incidence in the United States infective endocarditis remains a deadly disease with a mortality rate ranging from 17 to 36% 1 .Although congenital ventricular septal defects (VSDs) and congenital heart defects have been linked to an increased risk of infective endocarditis, 2 cases of acquired VSDs due to erosion through the myocardial tissue from infective endocarditis are not well-documented in the literature. 3 We present a case of an adult in the U.S. with native aortic valve gram-positive staphylococci and streptococcus anginosus endocarditis resulting in a large acquired VSD. The condition was successfully diagnosed and treated with surgery. This case also highlights a successful treatment of postoperative complete heart block with permanent pacemaker placement. Case Presentation A 57-year-old male patient with a known history of Hodgkin's Lymphoma status post chemotherapy and chest radiation in 2008, alcohol use disorder, and chronic tobacco use presented to an outside hospital with chest pain, shortness of breath, night sweats, and low-grade fevers, for the past 7 days. During the physical examination, a murmur was heard over the left sternal border. Additionally, poor dentition with several missing teeth was noted. The patient met the criteria for systemic inflammatory response syndrome. Blood cultures detected gram-positive staphylococci and streptococcus anginous. Initial physical findings showed signs of congestive heart failure. Due to pressing concern for potential endocarditis, transthoracic echocardiogram (TTE) and transesophageal echocardiogram (TEE) were performed. Results showed aortic regurgitation, stenosis, and a mobile vegetation on the ventricular side of the valve that extended into the outflow tract. The patient was managed with antibiotics until transfer to a tertiary center. Upon arrival, an updated echocardiogram additionally revealed a large VSD that demonstrated left-to-right flow into the right ventricle. Due to the risk of cardiac decompensation and septic embolization, and size of the vegetation an immediate surgical intervention was deemed necessary. The patient underwent a median sternotomy, and the pericardium was opened. On cardiopulmonary bypass, the aorta was opened, and the diseased aortic valve was excised. The necrotic ventricular septum was visualized and a VSD, approximately the size of a 21mm valve sizer was identified. Pledgeted mattress sutures were placed circumferentially around the annulus, and slightly larger piece of the bovine pericardial patch was used to patch the VSD. Following complete debridement and removal of all calcium, a mechanical aortic valve was placed and secured in an annular position. Patient was weaned off cardiopulmaonary bypass and chest was closed. Three days following the procedure, the patient developed complete heart block, a known complication of VSD repair 4 and a permanent pacemaker was placed. The patient tolerated the surgery and procedure well and was discharged on post operative day 14. He followed up in clinic two weeks later and reported significant improvement in his symptoms. The most recent echocardiogram indicated a properly functioning mechanical aortic valve, a mildly dilated left ventricle, ejection fraction of 55–60% and a 2mm dehicense of the patch. Discussion The primary complications of infective endocarditis result from direct damage to cardiac tissue and function. Damage to cardiac valves may result in regurgitation, defective valve leaflets, myocardial abscesses and fistulas. Hemodynamic compromise often leads to the acute onset of heart failure, which is the leading cause of death in infective endocarditis cases 1 . Distant complications, such as septic emboli, metastatic infection, and immunologic phenomena can also complicate infective endocarditis. 1 In our case the VSD likely developed from bacterial erosion through the interventricular septum. There are only a few documented cases of this in literature. One case is a pediatric patient who had a known bicuspid aortic valve and aortic stenosis who developed Staphylococcus aureus endocarditis on the aortic and tricuspid valves. Subsequent exams discovered a new VSD that was repaired with a bovine patch. 5 Another paper discusses an acquired VSD in the setting of culture negative aortic valve endocarditis from a severe aortic regurgitation jet. 6 A second adult case describes an acquired VSD occurring in the setting of an aortic root abscess from a mechanical aortic valve. 7 Finally, a third adult case describes aortic and mitral valve endocarditis, left ventricular outflow tract septal abscess and VSD formation. 8 Our case is unique in that he had a native aortic valve and no pre-existing VSD. Our hypothesis is that the patient’s poor dental hygiene and subsequent transient bacteremia likely lead to aortic valve endocarditis and formation of VSD. 9 On initial TEE imaging, the ventricular septal defect was not seen, and as the disease progressed it was eventually seen on TEE at the center where he underwent surgical repair. This case represents successful surgical management with removal of necrotic tissue, VSD repair and aortic valve replacement. The case is also unique because after surgical repair he developed a complete heart block that required a permanent pacemaker implant. In our case, a direct insult to the interventricular septal tissue and patch placement likely disrupted the cardiac conduction system thus permanent pacemaker placement was necessary post-operatively. Given the risk of permanent damage to the electrical conduction system, permanent pacemaker placement should be considered in patients with acquired VSD repair because of infective endocarditis to optimize long term patient outcomes. Limitations This patient did not have previous echocardiograms prior to disease onset, making it difficult to rule out any congenital anomalies. However, intraoperative findings revealed necrotic tissue across the interventricular septum. The patient did not have history of a cardiac murmur, and earlier echocardiograms failed to show a significant left-to-right shunt across the interventricular septum. Therefore, an acquired VSD directly from infective endocarditis damage to the cardiac tissue was more likely. The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. Abbreviations VSD- ventricular septal defect TTE- transthoracic echocardiogram TEE- transesophageal echocardiogram Declarations Disclosure Statement The authors have nothing to disclose. Funding Statement The authors have no funding to disclose. Informed Consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. Corresponding Author Courtney M. Hanson [email protected] Author Contribution C.H. and M.T. wrote the main manuscript and assisted in patient managment T.P. managed patient care including surgical management References Fowler VG, Bayer AS, Baddor LM. In: Goldman L, Cooney K, editors. Goldman-Cecil Medicine. 27th ed. Elsevier; 2024. Zebua J, Nasution AN, Siregar AA, Hasan H. C54. Infective Endocarditis with Ventricular Septal Defect and Ruptured Sinus of Valsalva: A Case Report. Eur Heart J Supplements. 2021;23(SupplementF). suab124.053. Farooq W, Palatnic L, Fernandez SF. Complex Clinical Cases ACQUIRED VENTRICULAR SEPTAL DEFECT AS A COMPLICATION OF TRICUSPID VALVE INFECTIVE ENDOCARDITIS . Vol 83.; 2024. Andersen H, de Leval MR, Tsang VT, Elliott MJ, Anderson RH, Cook AC. Is Complete Heart Block After Surgical Closure of Ventricular Septum Defects Still an Issue? Ann Thorac Surg. 2006;82(3):948–56. 10.1016/j.athoracsur.2006.04.030 . Durden R, Turek J, Reinking B, Bansal M. Acquired ventricular septal defect due to infective endocarditis. Ann Pediatr Cardiol. 2018;11(1):100–2. 10.4103/apc.APC_130_17 . Darabant S, Oberton SB, Roldan LP, Roldan CA. Ventricular Septal Defect from Aortic Regurgitation Jet Lesion in Aortic Valve Infective Endocarditis. J Heart Valve Dis. 2016;25(2):150–2. De Caluwé E, Verwerft J. Complicated Infective Endocarditis of a Mechanical Aortic Valve due to Propionibacterium acnes. J Heart Valve Dis. 2016;25(3):364–8. Ishiekwene C, Ghitan M, Kuhn-Basti M, Chapnick E, Lin YS. Staphylococcus lugdunensis endocarditis with destruction of the ventricular septum and multiple native valves. IDCases. 2017;7:14–5. 10.1016/j.idcr.2016.10.011 . Veloso TR, Amiguet M, Rousson V, et al. Induction of experimental endocarditis by continuous low-grade bacteremia mimicking spontaneous bacteremia in humans. Infect Immun. 2011;79(5):2006–11. 10.1128/IAI.01208-10 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 11 Mar, 2025 Read the published version in Journal of Cardiothoracic Surgery → Version 1 posted Editorial decision: Revision requested 09 Oct, 2024 Reviews received at journal 02 Oct, 2024 Reviews received at journal 29 Sep, 2024 Reviewers agreed at journal 21 Sep, 2024 Reviews received at journal 20 Sep, 2024 Reviewers agreed at journal 20 Sep, 2024 Reviews received at journal 19 Sep, 2024 Reviewers agreed at journal 19 Sep, 2024 Reviewers agreed at journal 19 Sep, 2024 Reviews received at journal 19 Sep, 2024 Reviewers agreed at journal 19 Sep, 2024 Reviewers agreed at journal 19 Sep, 2024 Reviewers invited by journal 19 Sep, 2024 Editor assigned by journal 05 Sep, 2024 Submission checks completed at journal 05 Sep, 2024 First submitted to journal 02 Sep, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5020960","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":361358023,"identity":"06496aae-4165-47ca-a45a-dab87cb25f4e","order_by":0,"name":"Courtney Hanson","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+0lEQVRIiWNgGAWjYJADNgjF3sDAwMPAwNiAT+0BFC08B0jWIpGAXwt/e4/Z5487bBIbxA6wPfi5o07OXPKN2YM3DDayGw5g1yJx5ozxjINn0hIbpBPYDXvPHDa2nJ1jbjiHIc0YlxYDiRxjhoNth0Fa2CR42w4kbridYybNw3A4kYCW/2Atkn/b6hI33DwD0vKfkJYDYC3SvG3MiRtu8IC0HMCpReLMsWKGs23Jxm3SiW3Ssm2HjQ3OpJVJzjFINp6JQwt/e/Nmhso2O9l+6eRjkm/b6uQMjh/eJvGmwk62D4cWGHBsQ40IA/zKQcCesJJRMApGwSgYsQAAmbZblnjma6kAAAAASUVORK5CYII=","orcid":"","institution":"University of North Dakota","correspondingAuthor":true,"prefix":"","firstName":"Courtney","middleName":"","lastName":"Hanson","suffix":""},{"id":361358024,"identity":"3b58e608-27f9-438e-9e07-a8e24a9790a0","order_by":1,"name":"Maria Tibesar","email":"","orcid":"","institution":"University of North Dakota","correspondingAuthor":false,"prefix":"","firstName":"Maria","middleName":"","lastName":"Tibesar","suffix":""},{"id":361358025,"identity":"fdbadc60-9f46-49c5-b221-e8086be60d8e","order_by":2,"name":"Timothy Pansegrau Pansegrau","email":"","orcid":"","institution":"Sanford Health","correspondingAuthor":false,"prefix":"","firstName":"Timothy","middleName":"Pansegrau","lastName":"Pansegrau","suffix":""}],"badges":[],"createdAt":"2024-09-03 00:52:55","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5020960/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5020960/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s13019-024-03244-2","type":"published","date":"2025-03-11T15:58:33+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":67174784,"identity":"92159e01-9ab4-494f-8c58-1e87519e85a9","added_by":"auto","created_at":"2024-10-22 04:46:18","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":156108,"visible":true,"origin":"","legend":"\u003cp\u003ePatient’s ventricular septal defect shown on echocardiogram.\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5020960/v1/f9b254fd76c103208148cd64.jpg"},{"id":78689107,"identity":"e8fc8c2d-5be6-42f4-9129-bf7c73feee4c","added_by":"auto","created_at":"2025-03-17 16:11:24","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":599757,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5020960/v1/4de8932b-243f-42db-9fa9-e47dcd93e187.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Acquired Ventricular Septal Defect Secondary to Aortic Valve Endocarditis","fulltext":[{"header":"Introduction","content":"\u003cp\u003eWith a rising incidence in the United States infective endocarditis remains a deadly disease with a mortality rate ranging from 17 to 36% \u003csup\u003e1\u003c/sup\u003e.Although congenital ventricular septal defects (VSDs) and congenital heart defects have been linked to an increased risk of infective endocarditis,\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e cases of acquired VSDs due to erosion through the myocardial tissue from infective endocarditis are not well-documented in the literature.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e We present a case of an adult in the U.S. with native aortic valve gram-positive staphylococci and streptococcus anginosus endocarditis resulting in a large acquired VSD. The condition was successfully diagnosed and treated with surgery. This case also highlights a successful treatment of postoperative complete heart block with permanent pacemaker placement.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA 57-year-old male patient with a known history of Hodgkin's Lymphoma status post chemotherapy and chest radiation in 2008, alcohol use disorder, and chronic tobacco use presented to an outside hospital with chest pain, shortness of breath, night sweats, and low-grade fevers, for the past 7 days. During the physical examination, a murmur was heard over the left sternal border. Additionally, poor dentition with several missing teeth was noted. The patient met the criteria for systemic inflammatory response syndrome. Blood cultures detected gram-positive staphylococci and streptococcus anginous. Initial physical findings showed signs of congestive heart failure. Due to pressing concern for potential endocarditis, transthoracic echocardiogram (TTE) and transesophageal echocardiogram (TEE) were performed. Results showed aortic regurgitation, stenosis, and a mobile vegetation on the ventricular side of the valve that extended into the outflow tract. The patient was managed with antibiotics until transfer to a tertiary center.\u003c/p\u003e \u003cp\u003eUpon arrival, an updated echocardiogram additionally revealed a large VSD that demonstrated left-to-right flow into the right ventricle. Due to the risk of cardiac decompensation and septic embolization, and size of the vegetation an immediate surgical intervention was deemed necessary. The patient underwent a median sternotomy, and the pericardium was opened. On cardiopulmonary bypass, the aorta was opened, and the diseased aortic valve was excised. The necrotic ventricular septum was visualized and a VSD, approximately the size of a 21mm valve sizer was identified. Pledgeted mattress sutures were placed circumferentially around the annulus, and slightly larger piece of the bovine pericardial patch was used to patch the VSD. Following complete debridement and removal of all calcium, a mechanical aortic valve was placed and secured in an annular position. Patient was weaned off cardiopulmaonary bypass and chest was closed. Three days following the procedure, the patient developed complete heart block, a known complication of VSD repair\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e and a permanent pacemaker was placed. The patient tolerated the surgery and procedure well and was discharged on post operative day 14. He followed up in clinic two weeks later and reported significant improvement in his symptoms. The most recent echocardiogram indicated a properly functioning mechanical aortic valve, a mildly dilated left ventricle, ejection fraction of 55\u0026ndash;60% and a 2mm dehicense of the patch.\u003c/p\u003e"},{"header":"Discussion","content":" \u003cp\u003eThe primary complications of infective endocarditis result from direct damage to cardiac tissue and function. Damage to cardiac valves may result in regurgitation, defective valve leaflets, myocardial abscesses and fistulas. Hemodynamic compromise often leads to the acute onset of heart failure, which is the leading cause of death in infective endocarditis cases\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. Distant complications, such as septic emboli, metastatic infection, and immunologic phenomena can also complicate infective endocarditis.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn our case the VSD likely developed from bacterial erosion through the interventricular septum. There are only a few documented cases of this in literature. One case is a pediatric patient who had a known bicuspid aortic valve and aortic stenosis who developed \u003cem\u003eStaphylococcus aureus\u003c/em\u003e endocarditis on the aortic and tricuspid valves. Subsequent exams discovered a new VSD that was repaired with a bovine patch.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e Another paper discusses an acquired VSD in the setting of culture negative aortic valve endocarditis from a severe aortic regurgitation jet.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e A second adult case describes an acquired VSD occurring in the setting of an aortic root abscess from a mechanical aortic valve.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e Finally, a third adult case describes aortic and mitral valve endocarditis, left ventricular outflow tract septal abscess and VSD formation. \u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eOur case is unique in that he had a native aortic valve and no pre-existing VSD. Our hypothesis is that the patient\u0026rsquo;s poor dental hygiene and subsequent transient bacteremia likely lead to aortic valve endocarditis and formation of VSD.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e On initial TEE imaging, the ventricular septal defect was not seen, and as the disease progressed it was eventually seen on TEE at the center where he underwent surgical repair. This case represents successful surgical management with removal of necrotic tissue, VSD repair and aortic valve replacement.\u003c/p\u003e \u003cp\u003eThe case is also unique because after surgical repair he developed a complete heart block that required a permanent pacemaker implant. In our case, a direct insult to the interventricular septal tissue and patch placement likely disrupted the cardiac conduction system thus permanent pacemaker placement was necessary post-operatively. Given the risk of permanent damage to the electrical conduction system, permanent pacemaker placement should be considered in patients with acquired VSD repair because of infective endocarditis to optimize long term patient outcomes.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eLimitations\u003c/strong\u003e \u003cp\u003eThis patient did not have previous echocardiograms prior to disease onset, making it difficult to rule out any congenital anomalies. However, intraoperative findings revealed necrotic tissue across the interventricular septum. The patient did not have history of a cardiac murmur, and earlier echocardiograms failed to show a significant left-to-right shunt across the interventricular septum. Therefore, an acquired VSD directly from infective endocarditis damage to the cardiac tissue was more likely.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eThe authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eVSD- ventricular septal defect\u003c/p\u003e\n\u003cp\u003eTTE- transthoracic echocardiogram\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTEE- transesophageal echocardiogram\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eDisclosure Statement\u003c/h2\u003e\n\u003cp\u003eThe authors have nothing to disclose.\u003c/p\u003e\u003ch2\u003eFunding Statement\u003c/h2\u003e \u003cp\u003eThe authors have no funding to disclose.\u003c/p\u003e \u003ch2\u003eInformed Consent\u003c/strong\u003e \u003cp\u003eThe authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal.\u003c/p\u003e \u003ch2\u003eCorresponding Author\u003c/strong\u003e \u003cp\u003eCourtney M. Hanson [email protected]\u003c/p\u003e \u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eC.H. and M.T. wrote the main manuscript and assisted in patient managment T.P. managed patient care including surgical management\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eFowler VG, Bayer AS, Baddor LM. In: Goldman L, Cooney K, editors. Goldman-Cecil Medicine. 27th ed. Elsevier; 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZebua J, Nasution AN, Siregar AA, Hasan H. C54.\u0026emsp;Infective Endocarditis with Ventricular Septal Defect and Ruptured Sinus of Valsalva: A Case Report. Eur Heart J Supplements. 2021;23(SupplementF). suab124.053.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFarooq W, Palatnic L, Fernandez SF. \u003cem\u003eComplex Clinical Cases ACQUIRED VENTRICULAR SEPTAL DEFECT AS A COMPLICATION OF TRICUSPID VALVE INFECTIVE ENDOCARDITIS\u003c/em\u003e. Vol 83.; 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAndersen H, de Leval MR, Tsang VT, Elliott MJ, Anderson RH, Cook AC. Is Complete Heart Block After Surgical Closure of Ventricular Septum Defects Still an Issue? Ann Thorac Surg. 2006;82(3):948\u0026ndash;56. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.athoracsur.2006.04.030\u003c/span\u003e\u003cspan address=\"10.1016/j.athoracsur.2006.04.030\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDurden R, Turek J, Reinking B, Bansal M. Acquired ventricular septal defect due to infective endocarditis. Ann Pediatr Cardiol. 2018;11(1):100\u0026ndash;2. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.4103/apc.APC_130_17\u003c/span\u003e\u003cspan address=\"10.4103/apc.APC_130_17\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDarabant S, Oberton SB, Roldan LP, Roldan CA. Ventricular Septal Defect from Aortic Regurgitation Jet Lesion in Aortic Valve Infective Endocarditis. J Heart Valve Dis. 2016;25(2):150\u0026ndash;2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDe Caluw\u0026eacute; E, Verwerft J. Complicated Infective Endocarditis of a Mechanical Aortic Valve due to Propionibacterium acnes. J Heart Valve Dis. 2016;25(3):364\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIshiekwene C, Ghitan M, Kuhn-Basti M, Chapnick E, Lin YS. Staphylococcus lugdunensis endocarditis with destruction of the ventricular septum and multiple native valves. IDCases. 2017;7:14\u0026ndash;5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.idcr.2016.10.011\u003c/span\u003e\u003cspan address=\"10.1016/j.idcr.2016.10.011\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVeloso TR, Amiguet M, Rousson V, et al. Induction of experimental endocarditis by continuous low-grade bacteremia mimicking spontaneous bacteremia in humans. Infect Immun. 2011;79(5):2006\u0026ndash;11. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1128/IAI.01208-10\u003c/span\u003e\u003cspan address=\"10.1128/IAI.01208-10\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"aquired ventricular septal defect, endocarditis, pacemaker, aortic valve","lastPublishedDoi":"10.21203/rs.3.rs-5020960/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5020960/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e \u003cb\u003eIntroduction\u003c/b\u003e: Infective endocarditis remains a deadly disease with an in-hospital mortality rate of around 20%. While ventricular septal defects (VSDs) have been linked to an increased risk of infective endocarditis, cases of acquired VSDs resulting from infective endocarditis are not well-documented in the literature. Our report highlights a rare case of acquired VSD that resulted directly from aortic valve endocarditis.\u003c/p\u003e \u003cp\u003e \u003cb\u003eCase Presentation\u003c/b\u003e: A 57-year-old male presented to an outside hospital with chest pain, shortness of breath, and low-grade fevers for the past seven days. Additionally, poor dentition was noted. Blood cultures detected gram-positive staphylococci and streptococcus anginosus. Due to concern for endocarditis, an order was placed for both a transthoracic echocardiogram (TTE) and transesophageal echocardiogram (TEE). Results showed aortic regurgitation, stenosis, and a mobile growth. The patient was managed with IV antibiotics until transferred.\u003c/p\u003e \u003cp\u003eUpon arrival at our facility, TEE revealed a VSD that demonstrated left-to-right flow into the right ventricle. Due to the risk of cardiac decompensation and septic embolization, immediate surgical intervention was necessary. The aorta was opened, and the diseased aortic valve was excised. The necrotic septum was debrided and an acquired VSD the size of a quarter was identified. A pericardial patch was used to repair the VSD. Following debridement a mechanical aortic valve was placed. The patient was taken to ICU in a stable condition. However, several days following the procedure, the patient developed ongoing arrhythmia, and a permanent pacemaker was placed.\u003c/p\u003e \u003cp\u003e \u003cb\u003eConclusions\u003c/b\u003e: It has been well-documented in literature that congenital VSDs are associated with an increased incidence of endocarditis. However, only a few cases have been documented where a VSD results directly from aortic valve endocarditis. This is the first recorded case of an adult in the U.S. with native aortic valve gram-positive staphylococci and streptococcus anginosus endocarditis resulting in a large acquired VSD. The condition was successfully diagnosed and treated with surgery. Successful treatment of post-operative arrhythmia with permanent pacemaker placement was achieved- a first for acquired VSD caused by infectious endocarditis.\u003c/p\u003e","manuscriptTitle":"Acquired Ventricular Septal Defect Secondary to Aortic Valve Endocarditis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-10-22 04:46:13","doi":"10.21203/rs.3.rs-5020960/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-10-09T08:15:25+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-10-02T04:43:08+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-09-30T02:43:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"138990949105972405038642017270039370176","date":"2024-09-21T13:32:28+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-09-20T09:40:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"119555592465443598660042361818063375707","date":"2024-09-20T09:08:41+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-09-19T20:44:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"130836094939686439614329340976535472816","date":"2024-09-19T20:24:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"115630293772614197780400573396320927087","date":"2024-09-19T14:50:06+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-09-19T14:48:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"57048388369596614968704033859368957411","date":"2024-09-19T14:17:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"305610123383150968837400707661251031212","date":"2024-09-19T14:17:01+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-09-19T14:09:50+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-09-05T10:16:39+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-09-05T10:14:32+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Cardiothoracic Surgery","date":"2024-09-03T00:51:32+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3889ff87-cc4c-42e4-831d-5c9ec7581382","owner":[],"postedDate":"October 22nd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-03-17T16:05:26+00:00","versionOfRecord":{"articleIdentity":"rs-5020960","link":"https://doi.org/10.1186/s13019-024-03244-2","journal":{"identity":"journal-of-cardiothoracic-surgery","isVorOnly":false,"title":"Journal of Cardiothoracic Surgery"},"publishedOn":"2025-03-11 15:58:33","publishedOnDateReadable":"March 11th, 2025"},"versionCreatedAt":"2024-10-22 04:46:13","video":"","vorDoi":"10.1186/s13019-024-03244-2","vorDoiUrl":"https://doi.org/10.1186/s13019-024-03244-2","workflowStages":[]},"version":"v1","identity":"rs-5020960","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5020960","identity":"rs-5020960","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}