Acquired left ventricular outflow tract to right atrial fistula due to tricuspid valve endocarditis.
Nadeem O, Motwani A, Parikh S, Borgi J, and Hudson M. Acquired left ventricular outflow tract to right atrial fistula due to tricuspid valve endocarditis. Am J Respir Crit Care Med 2017; 195.
Am J Respir Crit Care Med
A 56-year-old African American male with end stage renal disease/ home hemodialysis, presented with fever, rigors, and malaise for 2 days. Four months prior, the patient was admitted for methicillin sensitive Staphylococcus aureus (MSSA) bacteremia, 1st degree Atrioventricular block, and tricuspid valve endocarditis with transesophageal echocardiography (TEE) showing 1.5 cm vegetation on septal tricuspid valve leaflet plus moderate-severe TR. The patient completed 6 weeks intravenous cefazolin antibiotic therapy with no heart failure symptoms. Blood cultures collected during hospital readmission were again positive for MSSA. Repeat TEE showed moderate tricuspid insufficiency, resolution of the tricuspid valve vegetation, and new high-velocity color flow between left ventricular outflow tract (LVOT) and right atrium, confirmed by CT imaging. Discussion: This case demonstrates a rare structural complication of staphylococcal aureus bacteremia and tricuspid valve endocarditis. A similar congenital LOVT-right atrium communication is called a Gerbode Defect with rare previous case reports describing this acquired defect following cardiac surgery, myocardial infarction, thoracic trauma and more commonly aortic valve endocarditis. The patient presently has no ongoing infection or right heart failure symptoms and is being managed without plans for surgical debridement/valve replacement. Conclusion: We present a case of tricuspid valve endocarditis with LVOT-right atrial fistula (Gerbode Defect), in order to raise awareness of this rare endocarditis sequelae and to highlight diagnostic utility of repeat TEE and CT imaging in endocarditis patients. Optimal management of this complication without recurrent bacteremia, severe TR or RV volume/pressure overload is uncertain.