O. Ozeke · E. Celik · E. Grbovic · A. Colak · P. Dogan · O. Tufekcioglu · Z. Golbasi · H.L. KisacikDepartment of Cardiology, Turkiye Yuksek Ihtisas Hospital, Kardiyoloji Klinigi, Ankara

Delayed left ventricular-to-right atrial communication (acquired Gerbode defect) after aortic valve replacement

Left ventricular (LV)-to-right atrial (RA) communications, collectively known as Gerbode defects [1], are mostly congeni-tal defects, but acquired cases are also de-scribed mainly following infective endo-carditis, mitral and aortic valve replace-ment (AVR), thoracic trauma, or acute myocardial infarction [2, 3, 4, 5, 6, 7, 8]. Its clinical spectrum depends on the un-derlying etiology and the size of the de-fect. Symptoms of LV–RA shunts vary from none to severe heart failure and ul-timately to death [8]. Whereas small com-munications may be well tolerated with-out symptoms or clinical signs, the larg-er ones lead to volume overload, chamber enlargement, and eventually heart failure [2]. We present an uncommon acquired LV-RA communication (acquired Ger-bode-type defect) following an AVR in an asymptomatic patient.

Case report

A 43-year-old asymptomatic man who had undergone AVR 9 years earlier was referred for echocardiography as part of a routine postoperative evaluation. He had taken no medications other than warfarin, and he had no clinical signs

and symptoms of infective endocardi-tis or intravascular hemolysis. Cardio-vascular auscultation revealed a grade 3 holosystolic murmur at the left paraster-nal border. Two-dimensional transtho-racic echocardiography revealed normal chamber sizes, a LV ejection fraction of 0.65, and a high-velocity systolic jet en-tering the RA (Videos 1 and 2). A subcos-tal view also correctly demonstrated a jet taking a serpiginous course from the LV into the RA, consistent with a Gerbode defect (Video 3). Moderate periprosthetic leaks were also detected (Video 4). Con-trast echocardiography from the left ante-cubital vein showed no significant right-to-left shunt at the interatrial or interven-tricular level (Video 5). This defect, which was likely a delayed postoperative com-plication, was managed with observation because the patient was asymptomatic, the defect was associated with a small re-strictive shunt, and there was absence of right heart dilatation or dysfunction.

Discussion

Acquired LV–RA communication (Ger-bode-type defect) is a rare complication of valve surgery. It is anatomically possi-ble because the normal tricuspid valve is more apically displaced than the mitral valve. Whereas a previous cardiac oper-ation is its most common cause, infec-tive endocarditis is the second most im-portant cause of acquired LV–RA shunt [8]. Therefore, it can be related with an underlying infective endocarditis and/or

the erosion of the membranous septum by the rigid prosthetic ring in postopera-tive patients [8, 9]. From a technical point of view, excessive debridement of a heav-ily calcified annulus or an abscess cavity may cause weakening of the membranous septum and lead to LV–RA shunt [8].

One of the hallmarks of Gerbode de-fect is the high Doppler gradient be-tween the LV and RA on echocardio-grams; however, it can be difficult to dis-tinguish ventricular septal defect (VSD), aorto-RA fistula, and tricuspid leaks from LV–RA defect [8]. A murmur of the LV–RA shunt is also typical for VSD. Because aortic diastolic pressure is higher than RA pressure, left-to-right shunting across the aorto–RA communication is seen during both systole and diastole [10]; a shunting across a Gerbode defect occurs mainly in systole (as shown in Videos 1, 2, and 3) be-cause LV systolic pressure is much high-er than RA pressure; in diastole, LV pres-sure is only slightly higher [2]. Therefore, this might be a useful echocardiographic criterion for the differentiation of aorto–RA communications from LV–RA com-munications, both of which could be seen after valve surgery.

Since re-operation is always a risk, and after previous excessive debridement of calcification the correction of a shunt may be very demanding [8], percuta-neous closure by an occluder technique should be considered as the first option. In our case, however, in keeping with the current ACC/AHA guidelines for VSD closure [11], and given the patient’s nor-

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Additional material online

This article includes five additional videos. You will find this supplemental at dx.doi.org/10.1007/s00059-013-3971-3.

Herz 2013 DOI 10.1007/s00059-013-3971-3Received: 1 August 2013Revised: 25 August 2013Accepted: 26 August 2013© Urban & Vogel 2013

1Herz 2013  | 

mal right and left ventricular size and function as well as the lack of pulmonary hypertension or history of infective endo-carditis, it was elected to manage her con-servatively (with a plan for future mon-itoring with serial noninvasive imaging) instead of any operative repair or percu-taneous closure.

Corresponding address

O. OzekeDepartment of Cardiology, Turkiye Yuksek Ihtisas Hospital, Kardiyoloji Klinigi06100 AnkaraTurkeyozcanozeke@gmail.com

Compliance with ethical guidelines

Conflict of interest. O. Ozeke, E. Celik, E. Grbovic, A. Colak, P. Dogan, O. Tufekcioglu, Z. Golbasi, H.L. Kisacik state that there are no conflicts of interest.

The accompanying manuscript does not include stud-ies on humans or animals.

References

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