Late Bacterial Endocarditis and Abscess Formation After Implantation of an Amplatzer Septal Occluder Device.

A 37-year-old man was referred to our emergency department after 4 days of a spiking fever of up to 40°C, myalgia, and new development of multiple, small, nontender erythematous macular lesions on his palms and soles compatible with Janeway lesions (Figure 1). He had a history of a large secundum atrial septal defect for which he underwent transcatheter closure with a 24-mm Amplatzer septal occluder (ASO; AGA Medical Corporation, Goden Valley, Minnesota) 4 years prior. The procedure was successful without any residual shunts. One month before his febrile episode, he had received periodontal scaling without antibiotic prophylaxis based on the current guidelines. He adamantly denied a history of intravenous drug abuse, and there was no evidence of immunodeficiency disorders. His blood cultures grew methicillin-sensitive Staphylococcus aureus within 24 hours. Transesophageal echocardiography revealed a 2.1 × 1.4 cm nonmobile hyperechogenic mass attached to the right atrial side of his ASO, which encompassed the aortic rim and extended into the intervalvular fibrosa, compatible with aortic root abscess (Figure 2A and Movie I in the online-only Data Supplement). Bicaval views revealed that the 2 discs of his ASO were heaving with hyperechogenic materials (Figure 2B and Movie II in the online-only Data Supplement). Additionally, there was a large (1.6 cm in maximal length) elongated hypermobile echogenic material attached to the left atrial side of the device (Figure 2C and 2D and Movies III and IV in the online-only Data Supplement). Three-dimensional transesophageal echocar-diography and cardiac-gated computed tomography clearly visualized the hyperechogenic materials and surrounding abscesses (Figure 3A and 3B and Movies V and VI in the online-only Data Supplement). Subsequently, he underwent surgery to remove the seriously infected ASO through a right atrial approach. Abscess pockets and necrotic debris were found around the device rims (Figure 4A). The noncoronary sinus was severely inflamed and a partial rupture was suspected. Therefore, the defect and noncoronary sinus were repaired with bovine pericardium. The removed ASO exhibited incomplete endothelialization on the left atrial surface of the metallic mesh (Figure 4B). There were infected materials on either surface and between the two discs (Figure 4C). Postoperatively, the patient received 6 weeks of antibiotics with nafcillin in combination with rifampin, including synergistic therapy with gentamicin initially. He recovered without further complication, and was discharged to his home. Over the past few decades, the development of several occluding devices has made percutaneous device closure a less invasive alternative to …