Are all ventricular septal defects created equal?

The authors report the occurrence of infective endocarditis in a 32-year-old man with a ventricular septal defect and a left ventricular-to-right-atrial shunt who adhered to the revised 2007 American Heart Association guidelines for infective endocarditis. The patient had received antibiotic prophylaxis prior to multiple previous dental procedures. At a recent dental evaluation for fillings, he was informed that he no longer needed prophylaxis. Fatigue and fevers developed 1 week later, and he was treated with an oral course of ciprofloxacin. The symptoms recurred, and blood cultures grew Streptococcus viridans. A 7-mm vegetative mass was seen on the septal leaflet of the tricuspid valve during transesophageal echocardiography. This report raises the concern that patients with ventricular septal defects and left ventricular-to-right-atrial shunts are at higher risk for endocarditis and may require antibiotic prophylaxis.