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Cardiac surgery for infective endocarditis in patients with intravenous drug use
Oda Bratland Østerdal1, Pirjo-Riitta Salminen2, Stina Jordal3
1Department of Clinical Science, Faculty of Medicine and Dentistry, University of Bergen, Bergen, Norway.
Insights
Cardiac surgery for infective endocarditis in intravenous drug users shows acceptable early outcomes. However, high reinfection rates and continued drug use pose significant long-term challenges for this patient group.
Area of Science:
- Cardiology
- Infectious Diseases
- Cardiac Surgery
Background:
- Intravenous drug users (IDUs) face elevated risks of infective endocarditis (IE) and diminished survival rates.
- Cardiac surgery is sometimes indicated for IE in IDUs, but the efficacy of repeat surgeries remains debated.
Purpose of the Study:
- To evaluate the characteristics and outcomes of intravenous drug users who underwent cardiac surgery for infective endocarditis.
- To assess the survival rates and complication incidence, including reinfection, in this specific patient population.
Main Methods:
- A retrospective analysis of 29 injecting drug users treated with valve surgery for endocarditis between 2001 and 2013.
- Kaplan-Meier analysis was employed to determine patient survival rates.
Main Results:
- The majority of patients were male (93%), with Staphylococcus aureus and Enterococcus faecalis as common pathogens. Opioids and amphetamines were frequently abused. High rates of Hepatitis C virus antibody positivity (86%) and homelessness (41%) were noted.
- Indications for surgery included regurgitation, heart failure, embolization, and infection. Aortic valve replacement was the most common procedure. Thirty-day mortality was 7% for initial surgeries and 10% for redo surgeries.
- Reinfection occurred in 52% of patients within the follow-up period, with continued drug use reported in 70% after the first operation and 44% after the second.
Conclusions:
- Cardiac surgery for infective endocarditis in intravenous drug users yields acceptable early postoperative results.
- Long-term survival rates at 2 and 5 years were 79% and 59%, respectively, but high reinfection rates underscore the challenge of continued drug use.
Objectives:
Intravenous drug users have a high risk of infective endocarditis and reduced survival. Cardiac surgery may be recommended for these patients, but redo surgery is controversial. This study describes the characteristics and outcomes of intravenous drug users accepted for surgery during a 12-year period.
Methods:
This retrospective study included 29 injecting drug users treated with valve surgery for endocarditis between January 2001 and December 2013 at a tertiary academic centre. Survival was assessed by Kaplan-Meier analysis.
Results:
The median patient age was 36 (24-63) years and 27 patients (93%) were male. Staphylococcus aureus (52%) and Enterococcus faecalis (17%) were the most common microorganisms. Common illicit drugs were opioids (69%), amphetamines (52%) and benzodiazepines (24%). Mixed abuse was reported in 66% of patients. Seven patients (24%) had prior intracardial implants or native valve pathology. Twenty-five patients (86%) were positive for hepatitis C virus antibody, but none carried the human immunodeficiency virus. Twelve (41%) were homeless and 15 (52%) had poor dental hygiene. Three patients (10%) received medication-assisted rehabilitation before surgery. The main indications for surgery were regurgitation and secondary heart failure (86%), embolization (41%) and uncontrolled infection (24%). Aortic valve replacement was performed in 24 patients (83%), either as part of univalvular or multiple valve surgery. Seven patients (24%) had multivalvular endocarditis. All but 3 patients received biological valve prostheses. The 30-day mortality was 7% after first time surgery. During follow-up, 15 patients (52%) presented with reinfection: 10 (35%) were offered a second and 2 (7%) a third operation. Thirty-day mortality was 10% after redo surgery. Thirteen patients (45%) died within a median of 22 (0-84) months. Continued intravenous drug use was reported in 70 and 44% of patients after the first and second operation, respectively.
Conclusions:
Cardiac surgery for infective endocarditis has acceptable early postoperative results among intravenous drug users. The 2- and 5-year survival were 79 and 59%, respectively. The number of reinfections was high within 2 years, as continued drug use seems to be a major challenge for this group.