An alternative surgical approach for isolated pulmonary valve infective endocarditis secondary to restrictive ventricular septal defect: a case report

Abstract
Background
Native pulmonary valve (PV) infective endocarditis (IE) is a rare condition with an incidence of 1.5–2%. Although medical therapy is the mainstay of treatment, surgical intervention is still indicated in cases that fail to respond to antibiotics. To date, there is lack of consensus about the best surgical approach for isolated native PV IE. While valve repair is sometimes feasible, most of the cases require valve replacement depending on the extent of tissue damage. A stented bioprosthesis can be used when infection is confined to the valve leaflets. However, extension of damage to the pulmonary root or right ventricular outflow tract usually requires debridement and root replacement.

Case presentation
A 30-year-old lady with a long history of restrictive ventricular septal defect (VSD) presented with fever and shortness of breath shortly after vaginal delivery that was diagnosed as isolated PV IE with pulmonary septic emboli. After 1 week of antibiotic therapy, there was no response with persistent infection and complete valve destruction. Heart team discussion recommended PV replacement using a Freestyle valve along with VSD repair. On follow-up after 1 year, she was doing fine with well-functioning Freestyle valve.

Conclusion
Unrepaired restrictive VSD can be a predisposing factor for native PV IE. A Freestyle valve in the pulmonary position is a valid option for such cases, with good early outcomes and reasonable durability, particularly when there is extensive tissue infection and homograft is not available. More evidence is still required to evaluate the long-term outcomes of PV Freestyle in cases of IE.