Post-Transcoronary Ethanol Septal Ablation (TESA) Infective Endocarditis Complicated by a Ventricular Septal Defect

ABSTRACT: A 52-year-old man was referred to the cardiology outpatient service with exertional angina and shortness of breath due to hypertrophic obstructive cardiomyopathy. He underwent transcoronary ethanol septal ablation (TESA) with successful procedural outcome. The patient returned to hospital with a 3-week history of intermittent fever and a positive blood culture showing Staphylococcus aureus, sensitive to flucloxacillin. Transoesophageal echocardiography on admission demonstrated vegetation on interventricular septum and a repeated scan 10 days later demonstrated Doppler flow across the interventricular septum, confirming the presence of a small ventricular septal defect. This patient was successfully managed with 6 weeks of intravenous antibiotics and remained well at 1-year follow-up.

J INVASIVE CARDIOL 2011;23:348–350

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Case Report

A 52-year-old man was referred to the cardiology outpatient service with Canadian Cardiovascular Society Functional Class¹ II exertional angina and New York Heart Association² III exertional shortness of breath. No major cardiac risk factors apart from a 10 pack-year smoking history were identified, with normal coronary artery noted on multislice computed tomographic coronary angiography. Subsequently, echocardiography demonstrated 1.6 cm septal hypertrophy with systolic anterior motion of the mitral valve and mild mitral regurgitation. The peak gradient across the left ventricular outflow tract (LVOT) was measured at 108 mmHg.

Due to the presence of significant symptoms and evidence of hypertrophic obstructive cardiomyopathy (HOCM), this patient was brought forward for transcoronary alcohol septal ablation. The third septal branch was identified as the vessel of interest, confirmed by gradient drop after occluding the vessel by a balloon as well as periprocedural echocardiogram with saline contrast injection (Figures 1, 2A, and 2B). This vessel was successfully injected with 2.5 ml of 100% ethanol (Figure 1). The LVOT gradient dropped from 92 to 15 mmHg before and after the ethanol injection; the post-premature ventricular contraction gradient also dropped from 207 to 105 mmHg.

Two weeks after TESA, the patient began to experience episodes of fever, which gradually deteriorated in the following 3 weeks, with high-grade fever, myalgia, and intermittent headache leading to hospital admission. Several sets of blood cultures were positive for Staphylococcus aureus sensitive to flucloxacillin. A tooth abscess was thought to be the source of his infection. An ejection systolic murmur was noted, and Janeway lesions with splinter hemorrhages were seen. A transesophageal echocardiogram (TEE) was performed shortly after admission; it revealed a vegetation in the interventricular septum at the site of ablation (Figure 2C). A repeated TEE 10 days later demonstrated ventricular septal defect (Figures 2D–2F). This patient was commenced on antibiotics (flucloxacillin) on admission. Unfortunately, he developed acute interstitial nephritis due to this antibiotic. The antibiotic was changed to cephazolin and his renal function gradually improved. He received a total of 6 weeks of intravenous antibiotics and recovered well, with a small residual ventricular septal defect. He remained well and relatively free of symptoms at 1 year postprocedure, with LVOT gradient of 4 mmHg.

Discussion

Hypertrophic obstructive cardiomyopathy (HOCM) is a common cardiac genetic disorder associated with dyspnea, angina, syncope, and sudden cardiac death.³ Surgical myectomy was considered the gold-standard management of symptomatic HOCM refractory to medical therapy; however, TESA has emerged as an attractive alternative percutaneous technique since 1995.⁴ Complications of TESA include procedural mortality (1–4%), complete heart block requiring permanent pacemaker implantations (5–15%), and new onset of bundle branch block (60–80%).⁵ Rare complications include ventricular tachycardia during mid-term follow-up and alcohol leakage.⁵ Coronary artery dissection perforation and thrombosis are also reported.⁶ Ventricular septal defect, surprisingly, has been reported just once in the literature and was treated successfully by percutaneous Amplatzer closure device.⁷ The incidence of infective endocarditis in hypertrophic cardiomyopathy is approximately 0.14% per year.⁸ Of note, due to this low incidence, antibiotic prophylaxis for HOCM is not recommended in the recent guidelines.⁹ Zemanek et al reported a case of infective endocarditis in an HOCM patient 11 months post-TESA with a residual gradient of 50 mmHg.¹⁰

In our patient, the Staphylococcus aureus from the tooth abscess infected the septum at the site of ablation due to the combination of the remaining turbulent flow and the raw irregular septum postablation in spite of low residual echo gradient of 20 mmHg. Endocarditis of the mitral valve in HOCM due to the systolic anterior motion and secondary turbulent flow and mitral regurgitation has been described before.¹¹ To our knowledge, this is the second case reported with a vegetation affecting the septum. The ventricular septal defect is likely to have formed secondary to the infection with Staphylococcus eroding into the septum rather than a complication of the TESA procedure. The first TEE did not demonstrate a ventricular septal defect. To the best of our knowledge, post-TESA infective endocarditis resulting in ventricular septal defect has not been previously reported. Postprocedure ventricular septal defect can be a difficult diagnosis, as a residual harsh systolic murmur frequently remains post-TESA. Rapid diagnosis with blood culture and TEE is recommended.

The recommended treatment for infective endocarditis consists of intravenous antibiotics subject to antibiotic sensitivity of the pathogen. However, prompt empiric therapy is recommended based on the previous case report.¹⁰ Closure of the ventricular septal defect is recommended if the patient has a history of infective endocarditis.¹² However, for infective endocarditis causing a ventricular septal defect, the above recommendation may not apply at this stage. Our patient showed minimal left to right shunt with no evidence of left ventricular volume overload or pulmonary hypertension. We have decided to manage him conservatively with regular echocardiography follow-up. Currently, his oral hygiene has improved and antibiotic prophylaxes for future dental procedures have been recommended.

Conclusion

This case demonstrates that infective endocarditis of the interventricular septum could occur post-TESA. Poor oral hygiene can pose a risk to the patient and dental review may be necessary in certain cases. Infective endocarditis with Staphylococcus aureus has the potential to cause ventricular septal defect. Prompt diagnosis can lead to successful management with antibiotics.

References

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From the Department of Cardiology, Waikato Hospital, Hamilton, New Zealand.
The authors report no conflicts of interest regarding the content herein.
Manuscript submitted December 6, 2010, provisional acceptance given January 3, 2011, final version accepted January 26, 2011.
Address for correspondence: Dilesh Jogia, FRACP, PhD, Department of Cardiology, Waikato Hospital, Pembroke Street, Private Bag 3200, Hamilton 3240, New Zealand. Email: Dilesh.jogia@waikatodhb.govt.nz

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Editor’s Note: “This case describes a rare complication of trans-catheter intervention, infective endocarditis after septal ablation causing VSD. It is extremely important to be very vigilant of various differential diagnoses in cases with atypical presentation, like in this patient as evident by a new harsh systolic murmur. Timely diagnosis and appropriate treatment saved the patient."
— Samin K. Sharma, MD,
Mount Sinai Medical Center, New York, New York