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A 33-year-old man presented with a seizure of recent onset. He was a known case of a ventricular septal defect (VSD) from childhood. Physical examination showed a harsh systolic murmur at the lower sternal border and apex.

Fig. 56.1
figure 1

There is a turbulent flow across the ventricular septum toward the right ventricle, in favor of a VSD. LA left atrium, LV left ventricle, RA right atrium, RV right ventricle

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Fig. 56.2
figure 2

The VSD is not evident in the parasternal long-axis (a) and short-axis (b) views. LA left atrium, LV left ventricle, AO aorta, RV right ventricle, AOV aortic valve

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Fig. 56.3
figure 3

The VSD is partially closed by the aneurysm formation of the interventricular septum and the septal leaflet of the tricuspid valve (arrow). LA left atrium, LV left ventricle, RA right atrium, RV right ventricle

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Fig. 56.4
figure 4

The tricuspid regurgitation gradient is about 18 mmHg in the apical four-chamber view

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Fig. 56.5
figure 5

The VSD cannot be visualized on transesophageal echocardiography (TEE) short-axis (a) and long-axis (b) views. LA left atrium, LV left ventricle, AO aorta, RV right ventricle, AOV aortic valve

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Fig. 56.6
figure 6

A small turbulent flow can be seen on TEE (long-axis view) (arrow) (a). The defect can be visualized by two-dimensional echocardiography (b). There is a small mobile mass on the right ventricular side of this defect (curved arrow), which is highly suggestive of vegetation. The mass is 3 mm in size (c). LA left atrium, LV left ventricle, AO aorta, RV right ventricle

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FormalPara Diagnosis

The patient was diagnosed with a perimembranous VSD, which was partially closed by the septal leaflet of the tricuspid valve and the aneurysm formation of the interventricular septum. Only a small defect remained poorly visualized, but a small mobile mass was present on the right ventricular side of this defect, highly suggestive of vegetation.

FormalPara Comment

Work-up for infective endocarditis was recommended for the patient.

FormalPara Lesson
  1. 1.

    Even when the VSD is partially closed, the risk of infective endocarditis persists.

  2. 2.

    Vegetation is found on the right ventricular side of the VSD [84, 85].