Recurrent substance use and reoperative valve surgery for acute infective endocarditis

Reoperative valve surgery in the setting of infective endocarditis (REDO) conveys a high risk of morbidity and mortality. Recurrent substance use in patients with substance use disorder (SUD) may complicate decision making in valve reinfection. We sought to evaluate the relative impact of recurrent substance use in REDO.

An institutional multidisciplinary endocarditis database, including Society of Thoracic Surgeons (STS) data, was analyzed for all patients undergoing isolated or concomitant valve surgery for acute infective endocarditis between July 2016 and June 2024. Patients were stratified by REDO and recurrent substance use. Multivariable regression modeling assessed the interaction between REDO and SUD on risk-adjusted outcomes.

A total of 741 consecutive patients undergoing valve surgery for endocarditis were analyzed, including 475 with SUD (64.1%) and 210 undergoing REDO (28.3%). The incidence of second or further REDO was higher among SUD patients compared to non-SUD patients (23.1% vs 16.1%; P = .003). Compared to first-time valve surgery, REDO was associated with higher rates of mortality (7.6% vs 2.6%; P = .002) and major morbidity (31.9% vs 23.0%; P = .012). After risk adjustment, REDO was associated with increased STS composite mortality or major morbidity in non-SUD patients (odds ratio [OR], 4.6; P = .005) but not in SUD patients (OR, 1.4; P = .271). However, >2 reoperations in the setting of recurrent substance use was associated with higher risk-adjusted major morbidity or mortality (OR, 6.23; P < .0001).

Reoperation for infective endocarditis is associated with increased morbidity and mortality. For patients with recurrent substance use, initial reoperative surgery did not independently impact outcomes, but multiple reoperations did. These data can inform surgical decision making when approaching recurrent endocarditis due to recurrent substance use.