Perimembranous ventricular septal defect vegetation in a patient with right- and left-sided infective endocarditis

A 27-year-old-man was admitted with fever and elevated inflammatory parameters, attributed to multiple small lung abscesses. At admission a continuous systolic--diastolic murmur was heard from the left sternal edge to the apex. Workup included transthoracic echocardiography, which revealed a restrictive perimembranous ventricular septal defect (VSD) (velocity 4.89 m/s) partly covered by a previously unknown typically aneurysmal tricuspid valve (TV) (Figure 1A and B). A vegetation was present on the atrial side of the TV (Figure 1C), but there was also an image suggestive of vegetation attached to the VSD (white arrow). Aortic valve involvement with two vegetations and severe regurgitation was also demonstrated (Figure 1D). The unusual presence of vegetation at the VSD and the characteristic prolapse of the right aortic cusp with the attached vegetation (Figure 2) were confirmed by transesophageal echocardiography.