A Successful Repair of Left Ventricular-right Atrial Shunt due to Postoperative Infective Endocarditis in an Infant with a Double Outlet Right Ventricle

Abstract

A 9-month-old female infant underwent complete repair for double outlet right ventricle (Fallot type). She made a good recovery until 6 days after repair when she developed a high fever. Blood cultures indicated a methicillin-resistant Staphylococcus aureus (MRSA) infection. Although the fever subsided with the use of antibiotics, an echocardiogram disclosed vegetation on the surface of the ventricular septal defect (VSD) patch on postoperative day (POD) 15. She was diagnosed as postoperative infective endocarditis. As recurrent VSD shunt was not detected, antibiotic therapy was continued. On POD 20, acute right heart failure and acute hepatic failure rapidly developed, and an echocardiogram disclosed the left ventricular-right atrial shunt. As the reoperation under the hypocoagulable state carries considerable risk of bleeding, continuous hemodiafiltration (CHDF) and slow plasma exchange was induced, and the reoperation was undertaken after the recovery of coagulability. The VSD patch and the outflow patch was replaced by new ePTFE patches, and the tricuspid valvuloplasty was undertaken. She had a relapse of infection after the reoperation, but she recovered from circulatory instability and was discharged from the hospital 75 days after the reoperation. We report this case with particular emphasis on the rapid progress of acute hepatic failure in postoperative left ventricular-right atrial shunt due to postoperative infective endocarditis.