Redo Valve Surgery in Patients with Injection Drug Use: A Cross-sectional Study

Background:
As of 2016, the incidence of infective endocarditis in patients with injection drug use (IDU) was 79 per 10,000 and rising in all regions of the United States (Kadri, 2019). Patients with IDU have approximately ten times higher rate of death after valve replacement for infective endocarditis (IE) compared to patients without IDU (Shrestha, 2015). This high mortality rate is generally attributed to a higher rate of reinfection from ongoing drug use (Kim, 2016). Despite the American Association for Thoracic Surgery (AATS) guidelines recommending valve replacement for all patients with prosthetic valve endocarditis (PVE) regardless of etiology (Pettersson, 2016), many cardiac surgeons limit the number of surgeries for patients with recurrent IE from IDU (Tiako, 2020). To date, current practice patterns regarding the surgical management of PVE in patients with IDU have not been studied.


Methods:
An online survey was distributed to all active members of the Society of Thoracic Surgery (STS). A descriptive analysis was used to report the percentages and frequencies of the data. Chi Square tests were used to examine the demographic factors of those who do and do not offer redo surgery. McNemar tests were used to compare the percentage of those who do not offer native valve replacement for IE from IDU to those who do not offer redo surgery for PVE from IDU.

Results:
Seventy-five of the 2,962 STS members (0.03%) responded to the survey. Two out of the 75 respondents (2.7%) never offer native valve replacement for IE from IDU and fourteen of the 75 (18.67%) never offer redo surgery for PVE from IDU (p < 0.001). Six of the surgeons who choose not to offer redo surgeries (42.9%) have been practicing for more than 20 years. Five (35.7%) work at academic health centers and eight (57.2%) have practices in the East coast. The most common reasons for never offering redo surgery are the concern for recurrent drug use (92.9%), medication nonadherence (92.9%), and lack of psychosocial supports (71.4%). To a lesser degree, high preoperative risk (42.9%), high postoperative mortality (42.9%), and time lapsed from initial valve replacement (42.9%) also factor into surgeons’ decisions not to offer redo surgery.

Conclusion:
Despite the AATS guidelines recommending valve replacement for all patients with PVE irrespective of cause, some cardiac surgeons do not offer redo valve surgery for patients with PVE from IDU. The factors associated with not offering redo valve surgery include the concern for recurrent drug use, medication nonadherence, high preoperative risk, and high postoperative mortality. Expanding the treatment team for these complex patients to include addiction specialists may not only aid in the treatment of substance use disorders, but also reduce perioperative risks and improve surgical outcomes.

References:

AATS Surgical Treatment of Infective Endocarditis Consensus Guidelines Writing Committee Chairs, Pettersson GB, Coselli JS, Writing Committee, Hussain ST, Griffin B, et al. 2016 The American Association for Thoracic Surgery (AATS) consensus guidelines: Surgical treatment of infective endocarditis: Executive summary. J. Thorac. Cardiovasc. Surg. 2017;153:1241–1258.e29

Kim JB, Ejiofor JI, Yammine M, et al. Surgical outcomes of infective endocarditis among intravenous drug users. J Thorac Cardiovasc Surg 2016;152:832-41.e1.

Kadri AN, Wilner B, Hernandez AV, et al. Geographic Trends, Patient Characteristics, and Outcomes of Infective Endocarditis Associated With Drug Abuse in the United States From 2002 to 2016. J Am Heart Assoc. 2019;8(19):e012969.

Nguemeni Tiako MJ, Mszar R, Brooks C 2nd, Mahmood SUB, Mori M, Geirsson A, Weimer MB. Cardiac Surgeons' Treatment Approaches for Infective Endocarditis Based on Patients' Substance Use History. Semin Thorac Cardiovasc Surg. 2020 Dec 3:S1043-0679(20)30426-3.

Shrestha NK, Jue J, Hussain ST, Jerry JM, Pettersson GB, Menon V, et al. Injection drug use and outcomes after surgical intervention for infective endocarditis. Ann Thorac Surg. 2015;100:875 –82.