Abstract Introduction Aortic root abscesses (ARAs) are a complication of infectious endocarditis (IE) and represent a destructive extension of infection and inflammation involving the aortic root and aortomitral intervalvular fibrosa. Surgical intervention and long-term antibiotics are mainstays of treatment; however, an early multidisciplinary effort focused on drug cessation and social determinants of health (SDH) is critical to prevent reinfection and death in people who inject drugs (PWID). Case Presentation A 35-year-old male with polysubstance use and recent E faecalis endocarditis presented with encephalopathy. A left frontotemporal stroke was found on initial head imaging and later was found to have an aortic valve vegetation that required surgical replacement. Palliative care was recommended but was not coordinated in the inpatient or outpatient setting at that time despite concerns related to a poor prognosis given the patient’s reported drug use history. He was readmitted 2 months later for septic shock, an inoperable aortic root abscess due to persistent drug use, and hypoxemia requiring intubation. Once extubated, palliative care was consulted and the topic of prognosis was addressed, but he was deemed to lack capacity due to encephalopathy. Discussions related to hospice and a do-not-resuscitate (DNR) status were continued, however, the patient suffered a cardiac arrest and passed despite extensive resuscitative efforts. Discussion This case emphasizes the importance of an early multidisciplinary approach in PWID and prosthetic valves due to the high risk of reinfection, valvular complication, and higher mortality (1). Established guidelines for endocarditis management encourage a formal multidisciplinary team to individualize care, expedite risk-stratification, and address SDH (2). Difficult ethical considerations regarding surgical intervention for management of IE in PWID includes risk of reinfection and poor long-term life expectancy with continued substance use (3). For this case, discharge to a rehabilitation center on initial admission may have encouraged substance cessation and improved outpatient care coordination. Additionally, given the inoperable ARA, an earlier exploration of goals of care, spiritual values, and symptomatic burden may have provided an opportunity to reduce harm and psychological trauma to the patient and family. Conclusion ARAs are a life-threatening complication of IE that requires a multi-disciplinary approach to address addiction, social support structures, and other SDHs to reduce substance use and reinfection risk. Additionally, in the critically ill patient with poor functional status and health complications, earlier engagement of the patient and family to explore goals of care and resuscitation status can prevent unintended patient harm. This abstract is funded by: None
Phan et al. (Fri,) studied this question.