What is the clinical evidence from this study?

Study design: Observational. Population: Infective endocarditis in intravenous drug users (n=29). Intervention: Cardiac surgery (valve surgery). Primary outcome: 30-day mortality after first time surgery.

January 29, 2016Open Access

Cardiac surgery for infective endocarditis in patients with intravenous drug use

Key Result

Cardiac surgery for infective endocarditis in intravenous drug users resulted in a 30-day mortality of 7% and a 5-year survival of 59%, with a 52% reinfection rate during follow-up.

Study Design

Type

Observational (n=29)

Multicenter

Structured PICO

Population

29 injecting drug users treated with valve surgery for infective endocarditis, median age 36, 93% male.

Intervention

Valve surgery for infective endocarditis (aortic valve replacement in 83%, biological valve prostheses in all but 3 patients)

Outcome

Survival (assessed by Kaplan-Meier analysis)hard clinical

Valve surgery for infective endocarditis in intravenous drug users has acceptable early mortality but is associated with high rates of reinfection and moderate long-term survival due to continued drug use.

Abstract

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.