Fatigue and New Murmur in a 15 year old after a Catheter Ablation Procedure

Fatigue and New Murmur in a 15 year old after a Catheter Ablation Procedure | 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 Fatigue and New Murmur in a 15 year old after a Catheter Ablation Procedure Hasna Khandekar, Soham Dasgupta, Christopher Johnsrude, Bahaaldin Alsoufi, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6465826/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 12 You are reading this latest preprint version Abstract Background: Infective endocarditis is an atypical complication of pediatric cardiac catheterization procedures including electrophysiology study and ablation. Case Presentation: A 15-year-old male with neurogenic bladder who had undergone catheter ablation to treat ventricular tachycardia was subsequently diagnosed with endocarditis, likely stemming from post-procedure Enterococcus faecalis urinary tract infection and requiring extensive cardiac surgery. Conclusion: Though infectious endocarditis is a rare complication of invasive cardiac procedures, especially in pediatric patients, there have been several cases where patients have been diagnosed with IE stemming from urinary tract infection. Therefore, specific attention to risk of post-procedure urinary tract infection including systemic involvement should be considered for selected patients in whom urinary catheter placement is anticipated. electrophysiology ablation infective endocarditis urinary tract infection urology Figures Figure 1 Figure 2 Introduction Complications from EP procedures are aberrant; infective endocarditis due to an EP procedure is even more rare. Nonetheless, there have been several cases documented of infective endocarditis originating from a urinary tract infection, which brings into question whether prophylactic antimicrobials should be considered in high-risk patients for urinary tract infections. Case Presentation A 15-year-old male with complex medical history including spina bifida, neurogenic bladder, and well-managed diabetes mellitus presents for follow-up in the pediatric electrophysiology (EP) clinic three months after catheter ablation procedure to treat idiopathic focal ventricular tachycardia. During the EP procedure under general anesthesia, 3-dimensional EP mapping confirmed the arrhythmia focus was in the non-coronary cusp of the aortic valve, and radiofrequency ablation (ABL) successfully eliminated ventricular tachycardia without acute complications. A post-procedure echocardiogram was normal. A Foley catheter placed uneventfully had been used throughout the 7-hour procedure, removed prior to extubating. He was discharged home the following morning after an unremarkable observation period. Three days post-procedure, however, he developed fever and was diagnosed with a urinary tract infection (UTI) by his primary care provider. Urine culture was positive for Enterococcus faecali s that was pan-sensitive to nitrofurantoin, ampicillin, and vancomycin. Of note, he was not known to have had a prior UTI, and urinalysis immediately before or after Foley placement was not performed. Initial antibiotic therapy included PO nitrofurantoin 100 mg twice daily for seven days, and his fever and dysuria resolved. However, the patient developed recurrent symptoms of dysuria four weeks later. Repeat urine testing was again positive for Enterococcus faecalis that was pan-sensitive to ampicillin, gentamicin, nitrofurantoin, and vancomycin, and he was again treated with nitrofurantoin, this time 100 mg twice a day for seven days. Although his symptoms improved with treatment, he endorsed malodorous urine a month later, at which point repeat urine culture off antibiotics had no growth. When presenting for routine post-ABL follow-up in EP clinic 2 weeks later, he endorses healed sites for percutaneous access and no palpitations but has been experiencing recent fatigue and worsening home glucose control. On exam, his axillary temperature is 96.9 F, pulse 131 bpm, blood pressure 113/43 mmHg, and respiratory rate 20 bpm. He appears diaphoretic, has bounding pulses, and a new grade 2/4 holodiastolic murmur is auscultated at the right upper sternal border. Electrocardiogram demonstrates sinus tachycardia with otherwise normal intervals and voltages. Echocardiogram reveals new echogenic masses on the aortic and mitral valves, severe aortic regurgitation, and mild mitral and tricuspid valve regurgitation. The patient was referred directly from clinic to the emergency department (ED) where workup was notable for an erythrocyte sedimentation rate of 63 mm/Hr (normal 0–20 mm/Hr), C-reactive protein of 8.7 mg/dL (normal < 0.5 mg/dL), Procalcitonin of 0.09 ng/mL (normal 0.1–0.5 ng/mL), white blood cell count of 7,350 µL 7.35 x 10 9 L (normal 4.5–13.0 x 10 9 L) with neutrophilic predominance of 83.3% (normal 33–67%), and a ferritin level of 183.4 ng/mL (normal 15–83 ng/mL). Chest computed tomography angiogram revealed a small pericardial effusion with marked enlargement of the left atrium and ventricle, and no evidence of pulmonary septic emboli. Blood cultures were drawn, and he was admitted to the cardiac intensive care unit for empiric administration of vancomycin and ceftriaxone. On hospital day 2, blood cultures returned positive for Enterococcus faecalis , and he was transitioned to IV ampicillin and gentamicin. Per American Heart Association pediatric infectious endocarditis guidelines, large vegetations likely causing valvar dysfunction prompted referral for urgent cardiac surgery 1 . Intraoperatively, the aortic valve appeared substantially eroded with aneurysmal dilation of the non-coronary cusp, a large vegetation on the right coronary cusp, and a small perforation in the left coronary cusp. Deemed irreparable, the aortic valve was replaced with a 23 mm Resilia aortic bioprosthesis. There was a large vegetation and perforation of the anterior leaflet of the mitral valve and ruptured chordae of the posterior leaflet. Mitral valvuloplasty was ineffective, so the mitral valve was replaced with a 31 mm St. Jude Epic bioprosthesis. Inspection of the tricuspid valve revealed a single ruptured chordae, repaired primarily. Post-operative echocardiogram showed no perivalvar leaks, trivial aortic insufficiency, no mitral or aortic valve stenosis, and normal left and right ventricular systolic function. Histopathology of the aortic valve showed gram positive cocci along with fibrosis, acute and chronic inflammation and foci of calcification. Cultures from the aortic valve specimen obtained intra-operatively grew Enterococcus faecalis. All positive hospital-based blood cultures indicated susceptibility to ampicillin, gentamicin and vancomycin. The patient was treated with IV ampicillin and gentamycin for a total of 6 weeks per ID recommendations. All cultures after the day of cardiac surgery were negative and weekly bacterial serum PCR remained negative through completion of antibiotic therapy. He was discharged home on post-operative day 20. Repeat echocardiogram a week after discharge showed stable function of both bioprosthetic valves and the repaired tricuspid valve. After completion of his antibiotic regimen, his inflammatory markers were normal and repeat Karius testing was negative. He remains on chronic oral antibiotic prophylaxis per pediatric urology recommendations. Visual Summary (Table 1): Timeline Summary Day 1 Patient underwent EP study and cardiac ablation in RFCA in noncoronary cups of aortic valve. Foley catheter was placed during procedure. Patient was discharged a day after procedure Day 4 Evaluated at urgent care due to dysuria. Urine culture was positive for Enterococcus faecali s that was pan-sensitive to nitrofurantoin, ampicillin, and vancomycin. Discharged home with seven-day course of nitrofurantoin with symptom resolving. Day 32 Recurrent symptoms of dysuria and urine testing was obtained and positive for Enterococcus faecalis that was pan-sensitive to ampicillin, gentamicin, nitrofurantoin, and vancomycin. He was again treated with nitrofurantoin for seven days. Day 60 Patient endorsed malodorous urine a month later, at which point repeat urine culture off antibiotics had no growth. Day 74 Evaluated in EP clinic where patient was diaphoretic and found to have new murmur. Echo in clinic found to have new vegetation on the aortic and mitral valves, severe aortic regurgitation, and mild mitral and tricuspid valve regurgitation. Referred to emergency room for further workup. Lab workup notable for increase in inflammatory markers. CT angiogram revealed a small pericardial effusion with marked enlargement of the left atrium and ventricle, and no evidence of pulmonary septic emboli. Blood cultures were drawn, and he was admitted to the cardiac ICU for empiric administration of vancomycin and ceftriaxone. Day 75 Blood cultures returned positive for Enterococcus faecalis , and he was transitioned to IV ampicillin and gentamicin. Day 77 Due to findings of large vegetations causing valvar dysfunction, patient required surgical intervention. He required replacement of aortic and mitral valve, and repair of tricuspid valve. Histopathology of the aortic valve showed gram positive cocci along with fibrosis, acute and chronic inflammation and foci of calcification. Cultures from the aortic valve specimen obtained intra-operatively grew Enterococcus faecalis. All positive hospital-based blood cultures indicated susceptibility to ampicillin, gentamicin and vancomycin. Patient was treated with IV ampicillin and gentamycin for a total of 6 weeks. Day 97 He was discharged home on post-operative day 20. Day 104 Repeat echocardiogram showed stable function of both bioprosthetic valves and the repaired tricuspid valve. Day 111 Repeat inflammatory markers were normal and repeat Karius testing was negative after completion of antibiotics. He was started on chronic oral antibiotic prophylaxis per pediatric urology recommendations. Discussion and Conclusion Differential Diagnosis: The differential diagnosis of a diabetic teenager presenting with fatigue and poor glucose control is quite broad. In this case, however, the findings of a new diastolic murmur and new echocardiographic evidence of intracardiac masses with valvar insufficiency in a patient with neurogenic bladder who recently underwent interventional cardiac catheterization involving a Foley catheter, having experienced post-procedure UTI that appeared incompletely treated initially, narrows the list of likely diagnoses to infective endocarditis and infective thrombophlebitis. The actual diagnosis in this case is infective endocarditis. The Condition, Treatment and Management: Infective endocarditis (IE) most often results from bacteremia in the setting of disruption of the endocardial lining 2 . Acute IE presents as a fulminant febrile illness, as bacteria spread hematogenously and can damage multiple organs both via inflammation and direct invasive effects, including the heart, and can progress rapidly to death. In contrast, subacute endocarditis is generally more insidious, with a gradual clinical progression over weeks to months unless accelerated by complications such as a major embolic event or ruptured structure 3 . The annual rate of IE in the pediatric population is 0.3-3.0 per 100,000, and most common pathogens are Staphylococcus aureus and Streptococcus viridans 4 ; Enterococcus faecalis is an uncommon cause of IE. About 50–70% of pediatric IE cases occur in children with congenital heart defects 5 , but can also occur in patients that instead have immunodeficiency, diabetes mellitus, and/or indwelling central venous catheters 6 . Management of IE routinely requires a multidisciplinary approach, and includes aggressive antibiotic therapy, repeated surveillance for affected organ injury, and sometimes surgical intervention 7 . Performed under sterile conditions, cardiac catheterization procedures in general are very unlikely to cause infective endocarditis 8 . Since catheter-based EP/ABL procedures under general anesthesia in pediatric patients can last 4 hours or longer, a Foley catheter is often employed to avoid significant bladder distention from continuous IV fluids and medically induced urinary retention from drugs used by anesthesiologists, and to facilitate accurate measurement of intake/output during long complex procedures. These issues coupled with our patient’s neurogenic bladder prompted use of a Foley in this case. Our patient presented with an Enterococcus faecalis urinary tract infection a few days after the procedure, treated with seemingly adequate antibiotic therapy based on sensitivities, but the organism was still present on follow-up urine culture a month later. Since a “test of cure” urine culture was not obtained after initial antibiotic therapy, the repeat positive culture may have represented incomplete treatment, or perhaps a second infection. Subsequently, Enterococcus faecalis was found on blood culture when he presented three months post-procedure with subacute IE complicated by severe aortic insufficiency. We suspect that despite inserting the Foley using topical sterile technique, Enterococcus faecalis colonizing the distal urethra were mechanically translocated to the bladder, where delayed emptying from abnormal urodynamics predisposed to enhanced replication and long-standing UTI that was incompletely treated with antimicrobials to which Enterococcus seemed sensitive, culminating in hematogenous spread that reached the heart. After reviewing the post-operative pathology, it remained unclear if IE originated at the aortic non-coronary cusp where catheter ABL eliminated his VT, or elsewhere nearby. The first reported case of Enterococcus faecalis infective endocarditis after a catheter ablation procedure was in a 73-year-old immunosuppressed male receiving steroids for colonic tubular adenomas 9 , circumstances quite dissimilar to our 15-year-old patient. Contemporary pediatric EP procedures have a low incidence of complications, with IE being exceedingly rare 10 . While antimicrobial prophylaxis is not usually recommended for patients with neurogenic bladders, recent urologic guidelines recommend a short course of antibiotics in the peri-interventional period for invasive urological procedures to help prevent bacteremia 11 . Available guidelines for pediatric cardiac catheterization procedures do not recommend routine antimicrobial prophylaxis for circumstances similar to those of our patient 8 . Lessons for the Clinician: In patients with or without pre-existing structural heart disease who present with fatigue and a new murmur after recent invasive cardiac procedures, infective endocarditis should be included on the initial differential diagnosis. Clinicians should have a low threshold for consulting infectious disease experts when treating infections with potentially aggressive pathogens such as Enterococcus faecalis , especially in patients who have undergone invasive cardiac procedures. Routine use of a Foley catheter in pediatric patients undergoing catheter-based cardiac interventions should be carefully weighed if there is any known pre-existing risk of urinary tract infection prior to or soon after the procedure. If a Foley is considered to be indicated for such patients, routine pre-procedure urinalysis, urine culture and/or empiric peri-procedure antimicrobial prophylaxis might also be considered. Abbreviations EP - electrophysiology ABL - radiofrequency ablation UTI - urinary tract infection ED - emergency department EKG - electrocardiogram PCR - polymerase chain reaction PO - per oral ICU - intensive care unit ID - infectious disease IE - infective endocarditis IV - intravenous VT - ventricular tachycardia Declarations Author Disclosure: None of the authors have any financial disclosures relevant to this article. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device. ● Ethics approval and consent to participate: Non-applicable ● Consent for publication Written informed consent for publication from patient's parents has been obtained. Consent was obtained for submission and publication from parent of child since he was 15 years old when case occurred and is still under the age of 18 at the time of submission. A signed copy is available upon request from the journal editors ● Availability of data and materials There is no research data to declare. Still images representing the 3D mapping during the electrophysiology study as well as the transthoracic echocardiogram confirming diagnosis of infective endocarditis are included in supplementary materials. A twelve-lead electrocardiogram is also available in supplementary materials demonstrating ventricular tachycardia with an outflow tract origin. Complete echocardiographic imaging is available for upload upon request. ● Competing Interests There are no competing interests with this submission. ● Funding Non-applicable ● Authors' contributions HK prepared the manuscript for submission to this journal. CJ and SD were the physicians who initially performed this patient’s electrophysiology study as well as ablation prior to his subsequent presentation. SD was responsible for choosing the images demonstrating the valvular damage from subacute bacterial endocarditis for inclusion in this report. LT was the primary physician caring for patient after initial surgical repair as well as oversaw formulation of manuscript with CJ, SD, and HK. BA was responsible for the surgical intervention after initial diagnosis and as part of evidence-based care for patient after ablation procedure. All authors have reviewed the final manuscript prior to submission. ● Acknowledgements No additional acknowledgements References McDonald EG, Aggrey G, Tarık Aslan A, et al. Guidelines for Diagnosis and Management of Infective Endocarditis in Adults: A WikiGuidelines Group Consensus Statement. JAMA Netw Open. 2023;6(7):e2326366. doi:10.1001/jamanetworkopen.2023.26366 Cox DA, Tani LY. Pediatric infective endocarditis: A clinical update. Pediatr Clin North Am. 2020;67:875-888. Vilcant V, Hai O. Bacterial Endocarditis. [Updated 2023 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470547/ Ann Maruncic, Meghan Zimmerman, Jenifer Glatz; Infective Endocarditis. Pediatr Rev October 2023; 44 (10): 601–603. https://doi.org/10.1542/pir.2022-005561 Vicent L, Luna R, Martínez-Sellés M. Pediatric Infective Endocarditis: A Literature Review. J Clin Med. 2022;11(11):3217. Published 2022 Jun 5. doi:10.3390/jcm11113217 Gupta S, Sakhuja A, McGrath E, Asmar B. Trends, microbiology, and outcomes of infective endocarditis in children during 2000-2010 in the United States. Congenital Heart Dis. 2017;12:196-201. Baddour LM, Wilson, WR, Bayer AS, Fowler VG, Tleyjeh IM, Rybak ML. Infective Endocarditis in Adults: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Scientific Statement for Healthcare Professionals from the American Heart Association. Circulation. 2015;132(15):1435-1486. PACES/HRS Expert Consensus Statement on the Use of Catheter Ablation in Children and Patients with Congenital Heart Disease. Heart Rhythm Society. Accessed July 17, 2024. https://www.hrsonline.org/guidance/clinical-resources/paceshrs-expert-consensus-statement-use-catheter-ablation-children-and-patients-congenital-heart Ahmad S, Cutrone M, Ikram S, Yousaf S, Yousaf A. The First Reported Case of Post-Atrioventricular Node Ablation Enterococcus Faecalis Bacteremia in a Patient With Colonic Tubular Adenomas and Chronic Steroid Use. Cureus. 2021 Dec 20;13(12):e20549 Gupta A, Perera T, Ganesan A, et al. Complications of catheter ablation of atrial fibrillation. Circulation: Arrhythmia and Electrophysiology. 2013;6(6):1082-1088. doi:10.1161/circep.113.000768 Pannek J, Wöllner J. Management of urinary tract infections in patients with neurogenic bladder: challenges and solutions. Res Rep Urol. 2017;9:121-127. Published 2017 Jul 11. doi:10.2147/RRU.S113610 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 08 Jul, 2025 Reviews received at journal 09 Jun, 2025 Reviews received at journal 09 Jun, 2025 Reviews received at journal 08 Jun, 2025 Reviewers agreed at journal 06 Jun, 2025 Reviewers agreed at journal 03 Jun, 2025 Reviewers agreed at journal 30 May, 2025 Reviewers invited by journal 30 May, 2025 Editor assigned by journal 26 May, 2025 Editor invited by journal 09 May, 2025 Submission checks completed at journal 08 May, 2025 First submitted to journal 08 May, 2025 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. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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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-6465826","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":464827515,"identity":"f6d3da37-a36d-4115-ba20-8775d1f92d7f","order_by":0,"name":"Hasna Khandekar","email":"","orcid":"","institution":"University of Louisville","correspondingAuthor":false,"prefix":"","firstName":"Hasna","middleName":"","lastName":"Khandekar","suffix":""},{"id":464827516,"identity":"53068bde-b2d6-4d78-9a99-76a1c74dfe8e","order_by":1,"name":"Soham Dasgupta","email":"","orcid":"","institution":"Norton Children’s Hospital, University of Louisville","correspondingAuthor":false,"prefix":"","firstName":"Soham","middleName":"","lastName":"Dasgupta","suffix":""},{"id":464827517,"identity":"9dafe95f-cceb-4815-9e52-ce3f58b1dd53","order_by":2,"name":"Christopher Johnsrude","email":"","orcid":"","institution":"Norton Children’s Hospital, University of Louisville","correspondingAuthor":false,"prefix":"","firstName":"Christopher","middleName":"","lastName":"Johnsrude","suffix":""},{"id":464827518,"identity":"ebc48a70-6532-4c35-b0b8-088645605cb7","order_by":3,"name":"Bahaaldin Alsoufi","email":"","orcid":"","institution":"Norton Children’s Hospital, University of Louisville","correspondingAuthor":false,"prefix":"","firstName":"Bahaaldin","middleName":"","lastName":"Alsoufi","suffix":""},{"id":464827519,"identity":"bcb3d76f-8595-4ed8-932a-fec948d5a53d","order_by":4,"name":"Lauren Talley","email":"data:image/png;base64,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","orcid":"","institution":"Norton Children’s Hospital, University of Louisville","correspondingAuthor":true,"prefix":"","firstName":"Lauren","middleName":"","lastName":"Talley","suffix":""}],"badges":[],"createdAt":"2025-04-16 18:23:07","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6465826/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6465826/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":83893906,"identity":"03415a6f-8f77-4d0e-ac7a-82b6533c028d","added_by":"auto","created_at":"2025-06-04 08:33:42","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":943402,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eA:\u003c/strong\u003e 12 lead EKG in a 15 year old patient with ventricular tachycardia, demonstrating wide complex tachycardia consistent with outflow tract origin and ventricular-atrial dissociation (see leads II and III).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eB\u003c/strong\u003e: 3-D mapping images in right anterior oblique and posterior-anterior views created during EP study, showing the aortic root and ascending aorta relative to the right atrium and coronary sinus (mesh). Small area in red shows the tachycardia focus mapped to the non-coronary cusp of the aortic valve. The white tags represent the site of successful radiofrequency ablation. The yellow tags represent where the Bundle of His was recorded in the right heart.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6465826/v1/d66c53da06fd2b5c877debb6.png"},{"id":83893907,"identity":"c0ece2c2-3614-4f36-ac39-4b78f49a4031","added_by":"auto","created_at":"2025-06-04 08:33:42","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":830486,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eA: \u003c/strong\u003eEchocardiogram image (parasternal long axis) demonstrating a mobile vegetation (8 X 16 mm) originating from the malformed aortic valve leaflet, here prolapsed below the valve.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eB: \u003c/strong\u003eEcho image (apical 4 chamber) demonstrating a different vegetation (7.8 X 11 mm) on the anterior leaflet of the mitral valve.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6465826/v1/7040217bec63df5caa124160.png"},{"id":83895328,"identity":"82e20206-09b8-4cf4-8e92-bf37870ba374","added_by":"auto","created_at":"2025-06-04 08:41:47","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2526413,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6465826/v1/52612610-79b4-4669-95c6-db67292c845b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Fatigue and New Murmur in a 15 year old after a Catheter Ablation Procedure","fulltext":[{"header":"Introduction","content":"\u003cp\u003eComplications from EP procedures are aberrant; infective endocarditis due to an EP procedure is even more rare. Nonetheless, there have been several cases documented of infective endocarditis originating from a urinary tract infection, which brings into question whether prophylactic antimicrobials should be considered in high-risk patients for urinary tract infections.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA 15-year-old male with complex medical history including spina bifida, neurogenic bladder, and well-managed diabetes mellitus presents for follow-up in the pediatric electrophysiology (EP) clinic three months after catheter ablation procedure to treat idiopathic focal ventricular tachycardia. During the EP procedure under general anesthesia, 3-dimensional EP mapping confirmed the arrhythmia focus was in the non-coronary cusp of the aortic valve,\u003c/p\u003e\n\u003cp\u003eand radiofrequency ablation (ABL) successfully eliminated ventricular tachycardia without acute complications. A post-procedure echocardiogram was normal. A Foley catheter placed uneventfully had been used throughout the 7-hour procedure, removed prior to extubating. He was discharged home the following morning after an unremarkable observation period. Three days post-procedure, however, he developed fever and was diagnosed with a urinary tract infection (UTI) by his primary care provider. Urine culture was positive for \u003cem\u003eEnterococcus faecali\u003c/em\u003es that was pan-sensitive to nitrofurantoin, ampicillin, and vancomycin. Of note, he was not known to have had a prior UTI, and urinalysis immediately before or after Foley placement was not performed. Initial antibiotic therapy included PO nitrofurantoin 100 mg twice daily for seven days, and his fever and dysuria resolved. However, the patient developed recurrent symptoms of dysuria four weeks later. Repeat urine testing was again positive for \u003cem\u003eEnterococcus faecalis\u003c/em\u003e that was pan-sensitive to ampicillin, gentamicin, nitrofurantoin, and vancomycin, and he was again treated with nitrofurantoin, this time 100 mg twice a day for seven days. Although his symptoms improved with treatment, he endorsed malodorous urine a month later, at which point repeat urine culture off antibiotics had no growth.\u003c/p\u003e\n\u003cp\u003eWhen presenting for routine post-ABL follow-up in EP clinic 2 weeks later, he endorses healed sites for percutaneous access and no palpitations but has been experiencing recent fatigue and worsening home glucose control. On exam, his axillary temperature is 96.9 F, pulse 131 bpm, blood pressure 113/43 mmHg, and respiratory rate 20 bpm. He appears diaphoretic, has bounding pulses, and a new grade 2/4 holodiastolic murmur is auscultated at the right upper sternal border. Electrocardiogram demonstrates sinus tachycardia with otherwise normal intervals and voltages. Echocardiogram reveals new echogenic masses on the aortic and mitral valves, severe aortic regurgitation, and mild mitral and tricuspid valve regurgitation.\u003c/p\u003e\n\u003cp\u003eThe patient was referred directly from clinic to the emergency department (ED) where workup was notable for an erythrocyte sedimentation rate of 63 mm/Hr (normal 0\u0026ndash;20 mm/Hr), C-reactive protein of 8.7 mg/dL (normal\u0026thinsp;\u0026lt;\u0026thinsp;0.5 mg/dL), Procalcitonin of 0.09 ng/mL (normal 0.1\u0026ndash;0.5 ng/mL), white blood cell count of 7,350 \u0026micro;L 7.35 x 10\u003csup\u003e9\u003c/sup\u003e L (normal 4.5\u0026ndash;13.0 x 10\u003csup\u003e9\u003c/sup\u003e L) with neutrophilic predominance of 83.3% (normal 33\u0026ndash;67%), and a ferritin level of 183.4 ng/mL (normal 15\u0026ndash;83 ng/mL). Chest computed tomography angiogram revealed a small pericardial effusion with marked enlargement of the left atrium and ventricle, and no evidence of pulmonary septic emboli. Blood cultures were drawn, and he was admitted to the cardiac intensive care unit for empiric administration of vancomycin and ceftriaxone. On hospital day 2, blood cultures returned positive for \u003cem\u003eEnterococcus faecalis\u003c/em\u003e, and he was transitioned to IV ampicillin and gentamicin. Per American Heart Association pediatric infectious endocarditis guidelines, large vegetations likely causing valvar dysfunction prompted referral for urgent cardiac surgery\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eIntraoperatively, the aortic valve appeared substantially eroded with aneurysmal dilation of the non-coronary cusp, a large vegetation on the right coronary cusp, and a small perforation in the left coronary cusp. Deemed irreparable, the aortic valve was replaced with a 23 mm Resilia aortic bioprosthesis. There was a large vegetation and perforation of the anterior leaflet of the mitral valve and ruptured chordae of the posterior leaflet. Mitral valvuloplasty was ineffective, so the mitral valve was replaced with a 31 mm St. Jude Epic bioprosthesis. Inspection of the tricuspid valve revealed a single ruptured chordae, repaired primarily. Post-operative echocardiogram showed no perivalvar leaks, trivial aortic insufficiency, no mitral or aortic valve stenosis, and normal left and right ventricular systolic function. Histopathology of the aortic valve showed gram positive cocci along with fibrosis, acute and chronic inflammation and foci of calcification. Cultures from the aortic valve specimen obtained intra-operatively grew \u003cem\u003eEnterococcus faecalis.\u003c/em\u003e All positive hospital-based blood cultures indicated susceptibility to ampicillin, gentamicin and vancomycin.\u003c/p\u003e\n\u003cp\u003eThe patient was treated with IV ampicillin and gentamycin for a total of 6 weeks per ID recommendations. All cultures after the day of cardiac surgery were negative and weekly bacterial serum PCR remained negative through completion of antibiotic therapy. He was discharged home on post-operative day 20. Repeat echocardiogram a week after discharge showed stable function of both bioprosthetic valves and the repaired tricuspid valve. After completion of his antibiotic regimen, his inflammatory markers were normal and repeat Karius testing was negative. He remains on chronic oral antibiotic prophylaxis per pediatric urology recommendations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eVisual Summary\u003c/strong\u003e (Table 1):\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Taba\" border=\"1\" class=\"fr-table-selection-hover\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTimeline\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSummary\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDay 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePatient underwent EP study and cardiac ablation in RFCA in noncoronary cups of aortic valve. Foley catheter was placed during procedure. Patient was discharged a day after procedure\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDay 4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEvaluated at urgent care due to dysuria. Urine culture was positive for \u003cem\u003eEnterococcus faecali\u003c/em\u003es that was pan-sensitive to nitrofurantoin, ampicillin, and vancomycin. Discharged home with seven-day course of nitrofurantoin with symptom resolving.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDay 32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRecurrent symptoms of dysuria and urine testing was obtained and positive for \u003cem\u003eEnterococcus faecalis\u003c/em\u003e that was pan-sensitive to ampicillin, gentamicin, nitrofurantoin, and vancomycin. He was again treated with nitrofurantoin for seven days.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDay 60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePatient endorsed malodorous urine a month later, at which point repeat urine culture off antibiotics had no growth.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDay 74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEvaluated in EP clinic where patient was diaphoretic and found to have new murmur. Echo in clinic found to have new vegetation on the aortic and mitral valves, severe aortic regurgitation, and mild mitral and tricuspid valve regurgitation. Referred to emergency room for further workup. Lab workup notable for increase in inflammatory markers. CT angiogram revealed a small pericardial effusion with marked enlargement of the left atrium and ventricle, and no evidence of pulmonary septic emboli. Blood cultures were drawn, and he was admitted to the cardiac ICU for empiric administration of vancomycin and ceftriaxone.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDay 75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBlood cultures returned positive for \u003cem\u003eEnterococcus faecalis\u003c/em\u003e, and he was transitioned to IV ampicillin and gentamicin.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDay 77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDue to findings of large vegetations causing valvar dysfunction, patient required surgical intervention. He required replacement of aortic and mitral valve, and repair of tricuspid valve. Histopathology of the aortic valve showed gram positive cocci along with fibrosis, acute and chronic inflammation and foci of calcification. Cultures from the aortic valve specimen obtained intra-operatively grew \u003cem\u003eEnterococcus faecalis.\u003c/em\u003e All positive hospital-based blood cultures indicated susceptibility to ampicillin, gentamicin and vancomycin. Patient was treated with IV ampicillin and gentamycin for a total of 6 weeks.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDay 97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHe was discharged home on post-operative day 20.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDay 104\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRepeat echocardiogram showed stable function of both bioprosthetic valves and the repaired tricuspid valve.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDay 111\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRepeat inflammatory markers were normal and repeat Karius testing was negative after completion of antibiotics. He was started on chronic oral antibiotic prophylaxis per pediatric urology recommendations.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e"},{"header":"Discussion and Conclusion","content":"\u003ch2\u003eDifferential Diagnosis:\u003c/h2\u003e\u003cp\u003eThe differential diagnosis of a diabetic teenager presenting with fatigue and poor glucose control is quite broad. In this case, however, the findings of a new diastolic murmur and new echocardiographic evidence of intracardiac masses with valvar insufficiency in a patient with neurogenic bladder who recently underwent interventional cardiac catheterization involving a Foley catheter, having experienced post-procedure UTI that appeared incompletely treated initially, narrows the list of likely diagnoses to infective endocarditis and infective thrombophlebitis. The actual diagnosis in this case is infective endocarditis.\u003c/p\u003e\u003ch3\u003eThe Condition, Treatment and Management:\u003c/h3\u003e\u003cp\u003eInfective endocarditis (IE) most often results from bacteremia in the setting of disruption of the endocardial lining\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. Acute IE presents as a fulminant febrile illness, as bacteria spread hematogenously and can damage multiple organs both via inflammation and direct invasive effects, including the heart, and can progress rapidly to death. In contrast, subacute endocarditis is generally more insidious, with a gradual clinical progression over weeks to months unless accelerated by complications such as a major embolic event or ruptured structure\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eThe annual rate of IE in the pediatric population is 0.3-3.0 per 100,000, and most common pathogens are Staphylococcus aureus and Streptococcus viridans\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e; \u003cem\u003eEnterococcus faecalis\u003c/em\u003e is an uncommon cause of IE. About 50–70% of pediatric IE cases occur in children with congenital heart defects\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e, but can also occur in patients that instead have immunodeficiency, diabetes mellitus, and/or indwelling central venous catheters\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. Management of IE routinely requires a multidisciplinary approach, and includes aggressive antibiotic therapy, repeated surveillance for affected organ injury, and sometimes surgical intervention\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003ePerformed under sterile conditions, cardiac catheterization procedures in general are very unlikely to cause infective endocarditis\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. Since catheter-based EP/ABL procedures under general anesthesia in pediatric patients can last 4 hours or longer, a Foley catheter is often employed to avoid significant bladder distention from continuous IV fluids and medically induced urinary retention from drugs used by anesthesiologists, and to facilitate accurate measurement of intake/output during long complex procedures. These issues coupled with our patient’s neurogenic bladder prompted use of a Foley in this case. Our patient presented with an \u003cem\u003eEnterococcus faecalis\u003c/em\u003e urinary tract infection a few days after the procedure, treated with seemingly adequate antibiotic therapy based on sensitivities, but the organism was still present on follow-up urine culture a month later. Since a “test of cure” urine culture was not obtained after initial antibiotic therapy, the repeat positive culture may have represented incomplete treatment, or perhaps a second infection. Subsequently, \u003cem\u003eEnterococcus faecalis\u003c/em\u003e was found on blood culture when he presented three months post-procedure with subacute IE complicated by severe aortic insufficiency. We suspect that despite inserting the Foley using topical sterile technique, \u003cem\u003eEnterococcus faecalis\u003c/em\u003e colonizing the distal urethra were mechanically translocated to the bladder, where delayed emptying from abnormal urodynamics predisposed to enhanced replication and long-standing UTI that was incompletely treated with antimicrobials to which \u003cem\u003eEnterococcus\u003c/em\u003e seemed sensitive, culminating in hematogenous spread that reached the heart. After reviewing the post-operative pathology, it remained unclear if IE originated at the aortic non-coronary cusp where catheter ABL eliminated his VT, or elsewhere nearby.\u003c/p\u003e\u003cp\u003eThe first reported case of \u003cem\u003eEnterococcus faecalis\u003c/em\u003e infective endocarditis after a catheter ablation procedure was in a 73-year-old immunosuppressed male receiving steroids for colonic tubular adenomas\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e, circumstances quite dissimilar to our 15-year-old patient. Contemporary pediatric EP procedures have a low incidence of complications, with IE being exceedingly rare\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. While antimicrobial prophylaxis is not usually recommended for patients with neurogenic bladders, recent urologic guidelines recommend a short course of antibiotics in the peri-interventional period for invasive urological procedures to help prevent bacteremia\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. Available guidelines for pediatric cardiac catheterization procedures do not recommend routine antimicrobial prophylaxis for circumstances similar to those of our patient\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003ch3\u003eLessons for the Clinician:\u003c/h3\u003e\u003cul\u003e \u003cli\u003e \u003cp\u003eIn patients with or without pre-existing structural heart disease who present with fatigue and a new murmur after recent invasive cardiac procedures, infective endocarditis should be included on the initial differential diagnosis.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eClinicians should have a low threshold for consulting infectious disease experts when treating infections with potentially aggressive pathogens such as \u003cem\u003eEnterococcus faecalis\u003c/em\u003e, especially in patients who have undergone invasive cardiac procedures.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eRoutine use of a Foley catheter in pediatric patients undergoing catheter-based cardiac interventions should be carefully weighed if there is any known pre-existing risk of urinary tract infection prior to or soon after the procedure.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eIf a Foley is considered to be indicated for such patients, routine pre-procedure urinalysis, urine culture and/or empiric peri-procedure antimicrobial prophylaxis might also be considered.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cem\u003eEP - electrophysiology\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eABL - radiofrequency ablation\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eUTI - urinary tract infection\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eED - emergency department\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEKG - electrocardiogram\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePCR - polymerase chain reaction\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePO - per oral\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eICU - intensive care unit\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eID - infectious disease\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIE - infective endocarditis\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIV - intravenous\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eVT - ventricular tachycardia\u003c/em\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor Disclosure:\u003c/strong\u003e None of the authors have any financial disclosures relevant to this article. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.\u003c/p\u003e\n\u003cp\u003e● Ethics approval and consent to participate:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNon-applicable\u003c/p\u003e\n\u003cp\u003e● Consent for publication\u003c/p\u003e\n\u003cp\u003eWritten informed consent for publication from patient's parents has been obtained. Consent was obtained for submission and publication from parent of child since he was 15 years old when case occurred and is still under the age of 18 at the time of submission. A signed copy is available upon request from the journal editors\u003c/p\u003e\n\u003cp\u003e● Availability of data and materials\u003c/p\u003e\n\u003cp\u003eThere is no research data to declare. Still images representing the 3D mapping during the electrophysiology study as well as the transthoracic echocardiogram confirming diagnosis of infective endocarditis are included in supplementary materials. A twelve-lead electrocardiogram is also available in supplementary materials demonstrating ventricular tachycardia with an outflow tract origin. Complete echocardiographic imaging is available for upload upon request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e● Competing Interests\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;There are no competing interests with this submission.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e● Funding\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Non-applicable\u003c/p\u003e\n\u003cp\u003e● Authors' contributions\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;HK prepared the manuscript for submission to this journal. CJ and SD were the physicians who initially performed this patient’s electrophysiology study as well as ablation prior to his subsequent presentation. SD was responsible for choosing the images demonstrating the valvular damage from subacute bacterial endocarditis for inclusion in this report. \u0026nbsp;LT was the primary physician caring for patient after initial surgical repair as well as oversaw formulation of manuscript with CJ, SD, and HK. BA was responsible for the surgical intervention after initial diagnosis and as part of evidence-based care for patient after ablation procedure. All authors have reviewed the final manuscript prior to submission.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e● Acknowledgements\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;No additional acknowledgements\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eMcDonald EG, Aggrey G, Tarık Aslan A, et al. Guidelines for Diagnosis and Management of Infective Endocarditis in Adults: A WikiGuidelines Group Consensus Statement. JAMA Netw Open. 2023;6(7):e2326366. doi:10.1001/jamanetworkopen.2023.26366\u003c/li\u003e\n \u003cli\u003eCox DA, Tani LY. Pediatric infective endocarditis: A clinical update. Pediatr Clin North Am. 2020;67:875-888.\u003c/li\u003e\n \u003cli\u003eVilcant V, Hai O. Bacterial Endocarditis. [Updated 2023 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470547/\u003c/li\u003e\n \u003cli\u003eAnn Maruncic, Meghan Zimmerman, Jenifer Glatz; Infective Endocarditis. Pediatr Rev October 2023; 44 (10): 601\u0026ndash;603. https://doi.org/10.1542/pir.2022-005561\u003c/li\u003e\n \u003cli\u003eVicent L, Luna R, Mart\u0026iacute;nez-Sell\u0026eacute;s M. Pediatric Infective Endocarditis: A Literature Review. J Clin Med. 2022;11(11):3217. Published 2022 Jun 5. doi:10.3390/jcm11113217\u003c/li\u003e\n \u003cli\u003eGupta S, Sakhuja A, McGrath E, Asmar B. Trends, microbiology, and outcomes of infective endocarditis in children during 2000-2010 in the United States. Congenital Heart Dis. 2017;12:196-201.\u003c/li\u003e\n \u003cli\u003eBaddour LM, Wilson, WR, Bayer AS, Fowler VG, Tleyjeh IM, Rybak ML. Infective Endocarditis in Adults: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Scientific Statement for Healthcare Professionals from the American Heart Association. Circulation. 2015;132(15):1435-1486.\u003c/li\u003e\n \u003cli\u003ePACES/HRS Expert Consensus Statement on the Use of Catheter Ablation in Children and Patients with Congenital Heart Disease. Heart Rhythm Society. Accessed July 17, 2024. https://www.hrsonline.org/guidance/clinical-resources/paceshrs-expert-consensus-statement-use-catheter-ablation-children-and-patients-congenital-heart\u003c/li\u003e\n \u003cli\u003eAhmad S, Cutrone M, Ikram S, Yousaf S, Yousaf A. The First Reported Case of Post-Atrioventricular Node Ablation Enterococcus Faecalis Bacteremia in a Patient With Colonic Tubular Adenomas and Chronic Steroid Use. Cureus. 2021 Dec 20;13(12):e20549\u003c/li\u003e\n \u003cli\u003eGupta A, Perera T, Ganesan A, et al. Complications of catheter ablation of atrial fibrillation. Circulation: Arrhythmia and Electrophysiology. 2013;6(6):1082-1088. doi:10.1161/circep.113.000768\u003c/li\u003e\n \u003cli\u003ePannek J, W\u0026ouml;llner J. Management of urinary tract infections in patients with neurogenic bladder: challenges and solutions. Res Rep Urol. 2017;9:121-127. Published 2017 Jul 11. doi:10.2147/RRU.S113610\u003c/li\u003e\n\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":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"electrophysiology, ablation, infective endocarditis, urinary tract infection, urology","lastPublishedDoi":"10.21203/rs.3.rs-6465826/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6465826/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cem\u003eBackground: \u003c/em\u003eInfective endocarditis is an atypical complication of pediatric cardiac catheterization procedures including electrophysiology study and ablation.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCase Presentation:\u003c/em\u003e A 15-year-old male with neurogenic bladder who had undergone catheter ablation to treat ventricular tachycardia was subsequently diagnosed with endocarditis, likely stemming from post-procedure \u003cem\u003eEnterococcus faecalis\u003c/em\u003eurinary tract infection and requiring extensive cardiac surgery.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConclusion:\u003c/em\u003e\u003cstrong\u003e \u003c/strong\u003eThough infectious endocarditis is a rare complication of invasive cardiac procedures, especially in pediatric patients, there have been several cases where patients have been diagnosed with IE stemming from urinary tract infection. Therefore, specific attention to risk of post-procedure urinary tract infection including systemic involvement should be considered for selected patients in whom urinary catheter placement is anticipated.\u003c/p\u003e","manuscriptTitle":"Fatigue and New Murmur in a 15 year old after a Catheter Ablation Procedure","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-04 08:33:37","doi":"10.21203/rs.3.rs-6465826/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-07-08T09:52:01+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-09T13:56:01+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-09T11:20:06+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-08T10:47:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"253329116590208610346326384323259504890","date":"2025-06-06T15:39:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"87450421218848666975972696931948484874","date":"2025-06-03T10:44:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"322231518369956100234588487065993829274","date":"2025-05-30T15:56:11+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-05-30T14:09:47+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-26T10:20:20+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-05-09T06:59:53+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-08T15:23:43+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pediatrics","date":"2025-05-08T15:22:39+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e134e26a-bc51-467e-8d4a-74668627c8f7","owner":[],"postedDate":"June 4th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-23T05:09:29+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-04 08:33:37","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6465826","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6465826","identity":"rs-6465826","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}