Uncommon acquired Gerbode defect following extensive bicuspid aortic valve endocarditis

The uncommon intercavitary shunt between the left ventricle (LV) to right atrium (RA), known as Gerbode defect (GD) has been mainly described as congenital in origin, representing less than 1% of all congenital heart defects. However there are also few cases reported as acquired, namely after complicated infective endocarditis (IE) [1]. Its clinical spectrum depends on the underlying etiology and the size of the defect. In small ones, it may be well tolerated without symptoms or clinical signs, except for an associated murmur. Larger communications lead to volume overload, chamber enlargement and eventually heart failure.Despite being a rare intercavitary shunt, its nature, with an abnormal flow towards an anterior cardiac chamber, shall be revealed by a comprehensive detailed transthoracic echocardiography (TTE), obviating the need for other imaging modalities.We report an unusual acquired GD developing in the clinical workup of a complicated case of aortic valve IE. TTE was sufficient both to establish the diagnosis and to decide its management.We describe a clinical case of a 50-year-old man admitted to the emergency department due to recurrent fever, tiredness and poliarthralgia with one month of evolution. He was previously followed at our institution for a bicuspid aortic valve with moderate aortic regurgitation, mild LV dilatation and preserved LV ejection fraction. Physical examination was positive for fever (38.4°C), high pulse pressure, a 3/6 holosystolic murmur over the precordium and bilateral pulmonary rales. Laboratorial profile showed a normocytic normochromic anaemia (Hb: 10.8 g/L) and increased inflammatory markers (C-reactive protein: 15.2 mg/dl, sedimentation velocity: 69 mm/h, leucocytes: 11500/L). The 12-lead electrocardiogram revealed a first-degree atrioventricular block, prolonged at 260 ms, not previously known.For the clinical suspicion of an infective IE a TTE was performed, revealing an echogenic, pediculated and mobile mass attached to t