Amid Sparse Data on Infection After ASD Closure, Experts Urge Focus on Dental Health

While rare, infective endocarditis is a devastating complication after device closure of atrial septal defects (ASDs), and much remains unknown about when infections begin and how clinicians can best prevent them, according to a case report and literature review.

Improvements in medical technology have increased not only the number of patients undergoing certain types of congenital repair procedures but also the range of patients potentially exposed to infective endocarditis. The current incidence of the complication in patients with congenital heart disease is estimated to be between 15 and 140 times that of the general adult population, according to Pascal Amedro, MD, PhD (University Hospital, Montpellier, France), Camille Soulatges, MD (INSERM, Montpelier, France), and Alain Fraisee, MD, PhD (Royal Brompton and Harefield Hospital Trust, London, England).

Their paper, published online September 19, 2016, ahead of print in Catheterization and Cardiovascular Interventions, additionally highlights that recent guidelines have “restrained antibiotic prophylaxis and reinforced nonspecific hygiene measures.” Yet, ASDs remain the second most common form of congenital heart disease, and “catheter closure is usually performed on carefully selected patients, as we need more data from randomized clinical trials comparing oral anticoagulants, antiplatelet therapy, and catheter occlusion,” they write.

A Pediatric Case

In the case report, the authors describe a situation where an 8-year-old boy was diagnosed with infective endocarditis 3 years after undergoing transcatheter ASD closure with the Amplatzer device (AGA Medical) and subsequently being treated with antiplatelet therapy for 6 months. Following diagnosis, he received IV antibiotics as well as treatment for several dental cavities.

Eventually, thee prosthesis was successfully removed via surgery after no immune deficiency was found and blood tests remained negative. The patient’s status is “favorable” 2 years later, according to the report.

In an email, Amedro told TCTMD that it is hard to come to any conclusions on how to treat infective endocarditis in this patient group or how the complication will manifest in the future because there have only been 22 cases reported in the literature.

Dental Care at the Forefront

To best prevent cases going forward, Amedro advised physicians to postpone ASD closure if the patient presents with any recent clinical symptoms of infection “even if preanesthetic blood tests are negative.”

This is primarily due to the fact that “mechanisms of infection after ASD closure remain unclear,” the authors write. “In many of these reported cases, it is difficult to know whether the introduction of bacteria occurred before, during, or after the catheter procedure.”

Amedro also advised, especially for children, paying close attention to dental hygiene and educating patients and parents as much as possible as to the importance of dental health and regular check-ups “to reduce the risk of infection in their patients.”

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• Infective Endocarditis After TAVR Linked to Diabetes, Residual Aortic Regurgitation in Large Registry
• High Mortality Following Infective Endocarditis After TAVR Warrants Better Prevention, Treatment
• Percutaneous Closure of Atrial Septal Defect Beneficial at Any Age