Heart India

: 2019  |  Volume : 7  |  Issue : 2  |  Page : 87--89

Rare case of bacterial endocarditis associated with ostium secundum atrial septal defect

Rahul Singla, Nagesh Waghmare, Vikas Mishra, Anil Kumar, NO Bansal 
 Department of Cardiology, Sir J J Hospital and Grant Government Medical College, Mumbai, Maharashtra, India

Correspondence Address:
Dr. Rahul Singla
Department of Cardiology, 4th Floor ICCU, Main Building, Sir J J Hospital, Byculla, Mumbai - 400 008, Maharashtra


Aortic valve disease and ventricular septal defects are common lesions to be associated with Infective Endocarditis. However atrial septal defect is rarely associated with infective endocarditis, due to shunting taking place between low pressure difference chambers. Though rare there are few case reports of Infective endocarditis in atrial septal defects. We report a case of atrial septal defect with infective endocarditis having vegetation over the warfarin ridge near left atrial appendage. Mitral regurgitation was caused due LV geometrical changes secondary to Ostium secundum ASD producing a turbulent jet that was hitting warfarin ridge of left atrium which may have lead to injury and development of vegetation.

How to cite this article:
Singla R, Waghmare N, Mishra V, Kumar A, Bansal N O. Rare case of bacterial endocarditis associated with ostium secundum atrial septal defect.Heart India 2019;7:87-89

How to cite this URL:
Singla R, Waghmare N, Mishra V, Kumar A, Bansal N O. Rare case of bacterial endocarditis associated with ostium secundum atrial septal defect. Heart India [serial online] 2019 [cited 2019 Dec 11 ];7:87-89
Available from: http://www.heartindia.net/text.asp?2019/7/2/87/261836

Full Text


Endocarditis in the secundum atrial septal defect (ASD) is rare. However, there are reports of endocarditis associated with secundum ASD as an isolated event or after percutaneous device closure of ASDs. Aortic valve disease and ventricular septal defects are more commonly associated with infective endocarditis (IE). We report a case of ASD and mitral regurgitation (MR) and IE having vegetation over the warfarin ridge near left atrial (LA) appendage where MR jet was hitting the endocardium.

 Case Report

A 19-year-old female patient presented to the Cardiology Department of Sir J J Hospital with chief complaints of breathlessness on exertion for the past 2–3 years with fever for the last 1 week with ejection systolic murmur Grade 4 heard over the pulmonary region and systolic murmur Grade 4 over the mitral area with splitting of the second heart sound. On echocardiography a 22 mm Ostium secundum atrial septal defect was seen associated with moderate MR as shown in [Figure 1] and [Figure 2]. There was no rheumatic affection and mitral valve prolapse. A thin oscillatory structure was seen attached to warfarin ridge near LA appendage where MR jet was hitting the LA wall; findings were confirmed with transesophageal echocardiography and later with cardiac magnetic resonance imaging (MRI);further, three sets of blood culture from three different sites were collected and one of them was positive for Enterococcus species. Later, a cardiac MRI [Figure 3] was done to confirm the diagnosis which also showed similar findings. The patient was treated with 4 weeks of intravenous antibiotic and was later on considered for ASD device closure.{Figure 1}{Figure 2}{Figure 3}


Over the past few decades, the incidence of IE has greatly reduced, but IE still remains a life-threatening disease with substantial morbidity and mortality. The highest risk for development of IE involves congenital cardiac lesions with high-velocity jets and/or foreign material. Any lesion associated with turbulence of flow, with or without shunting, can be a substrate for IE. Aortic valve disease and ventricular septal defects are common which can develop IE.[1] However, ASD is rarely associated with IE; this is because shunting does not occur through high-pressure difference chambers. Though there are earlier case reports of infective endocarditis associated with atrial septal defects most of them are associated with vegetations at heart valves, we here report a rare and interesting case of Ostium secundum ASD associated with MR what we believed was due to altered geometry of left ventricle (LV), producing a turbulent jet that that was hitting warfarin ridge of LA which may have led to injury and development of vegetation.[2],[3],[4],[5] Regarding MR, it is not uncommonly associated with secundum ASD; the incidence ranges from 4% to 9.1% in different studies published earlier. Its recognition is important because the clinical course of MR is altered by the presence of an ASD. The causes of MR associated with secundum ASD can be the extrinsic factors such as rheumatic valve disease or IE, especially in the developing countries; there is evidence from the literature that secundum ASD itself could give rise to MR.[6],[7],[8] It can be due to secondary valve changes caused by abnormal cusp movement and resultant valve trauma presumably related to increased flow and altered LV geometry found in secundum ASD. In our patient, what we believed was MR was caused due to either IE or LV geometrical changes secondary to ostium secundum ASD. Although earlier case reports[9],[10] of association of ASD with IE were available, uniqueness of our case lies in the site of vegetation being present on warfarin ridge rather than mitral valve.

Declaration of patient 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. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.


1Awadallah SM, Kavey RE, Byrum CJ, Smith FC, Kveselis DA, Blackman MS, et al. The changing pattern of infective endocarditis in childhood. Am J Cardiol 1991;68:90-4.
2Bush RT. Staphylococcal endocarditis with atrial septal defect. Report of a fatal case with a review of treatment. N Z Med J 1959;58:444-9.
3Cay S, Korkmaz S. Tricuspid valve vegetation in a chronic renal failure patient with an ostium secundum type atrial septal defect after placement of a peripheral catheter. Anadolu Kardiyol Derg 2005;5:261.
4Aliaga L, Santiago FM, Martí J, Sampedro A, Rodríguez-Granger J, Santalla JA. Right-sided endocarditis complicating an atrial septal defect. Am J Med Sci 2003;325:282-4.
5Rahman A, Burma O, Felek S, Yekeler H. Atrial septal defect presenting with brucella endocarditis. Scand J Infect Dis 2001;33:776-7.
6Hynes KM, Frye RL, Brandenburg RO, McGoon DC, Titus JL, Giuliani ER, et al. Atrial septal defect (secundum) associated with mitral regurgitation. Am J Cardiol 1974;34:333-8.
7Murray GF, Wilcox BR. Secundum atrial septal defect and mitral valve incompetence. Ann Thorac Surg 1975;20:136-43.
8Davies RS, Green DC, Brott WH. Secundum atrial septal defect and cleft mitral valve. Ann Thorac Surg 1977;24:28-33.
9Agrawal V, Sihag BK. Mitral Valve endocarditis in a patient with atrial septal defect: JICC 2014;4:230-2.
10Hamadanchi A, Bothe W, Pfeil A, Rad AA, Brehm BR, Figulla HR, et al. Left atrial endocarditis as a rare complication of mitral valve endocarditis: A clinical case. BMC Cardiovasc Disord 2012;12:103.