Left Ventricular VSD-Margin Vegetation in Unrepaired Tetralogy of Fallot.

CASE SUMMARY: A 39-year-old woman with unrepaired tetralogy of Fallot had a mobile vegetation on the left ventricular septal surface of a nonrestrictive ventricular septal defect (VSD) on transthoracic echocardiography; transesophageal echocardiography corroborated it in 2 distinct planes. Three blood-culture sets grew a β-hemolytic streptococcus (presumptive Streptococcus pseudoporcinus); imaging plus positive cultures established definite infective endocarditis. Eight weeks of ceftriaxone achieved echocardiographic resolution; she remained asymptomatic at 6 months.

TAKE-HOME MESSAGE: In pressure-equalized nonrestrictive VSDs, vegetation may follow flow geometry rather than the classical jet-lesion pattern; multiplane inspection of both VSD margins is essential.