Invited Commentary: High Risk Cardiac Surgery in Intravenous Drug-Addicted Patients: Are There Any Limits for Repetitive Surgical Treatment?

Infective endocarditis remains a common cause of hospitalization in drug-addicted patients, with high morbidity and substantial mortality rates, independent from the HIV status.

In 1993, my colleagues and I published an article on 22 patients presenting with addiction-associated endocarditis.[1] This was a time when Zürich was unfortunately world-known for its “needle park”; today, this area is the beautifully restored Platzspitz behind the central train station and close to the river Limmat.

Staphylococcus aureus was the most frequent infective organism. Ten patients (three of them HIV-positive) were treated surgically with a 30-day mortality of 20% (2/10). One patient died from cerebral hemorrhage and another from multiorgan failure. Three patients died after a mean follow-up of 10 months. Survival in this small group was 50% at 1 year. In 12 patients, surgery was not attempted because of persisting intravenous drug abuse and renal and/or liver failure. Five of these patients died after a mean follow-up of 13 months, 2 from septicemia, 2 from AIDS-related complications, and 1 from drug overdose (survival at 1 year was 58%).

Due to this deleterious outcome, the policy at that time was one operation and no second one. Stabilization of the HIV-infected patients was not possible, and their prognosis was poor, independent of the endocarditis. Fortunately, times have changed. The incidence of infective endocarditis in intravenous drug-addicted patients has currently decreased in several geographical areas, probably due to liberal distribution programs but also to changes in drug administration habits to avoid HIV transmission. Advances allow treatment of more people more effectively; therefore, doctors may be faced with rising pressure on cost containment and the most judicious allocation of resources. A recent study from Heidelberg University Hospital shows that results have considerably improved over time, with 5-year survival higher than 80% and freedom from reoperation of 100%.[2]

Gansera and associates have to be thanked for bringing this delicate problem to the readership of this journal. However, one of the major problems of this small series of patients is the broad mix of cases, even though all patients had HIV and/or hepatitis infection.

Before commenting on the questions summarized at the end of the article, I strongly believe that cases 2, 4, and 5 should be excluded from the present discussion. Why? Because the infection in case 2 was most probably the consequence of unqualified medical handling, case 4 was an elective redo coronary artery bypass grafting surgery in a completely stable patient without any additional risk, and case 5 was an emergency situation in which surgery represented the only therapeutic option, as for every patient, except those with severe and established neurologic deficit prior to surgery. In all three cases, there was no direct “responsibility” of the patient due to a faulty prior or actual behavior. Therefore, only cases 1, 3, and 6 may be considered as critical in term of decision making, especially if the authors would like to emphasize the consequences of refusing a medical treatment and the reasons to decide so.

Of several publications dealing with this topic, my favorites are those by Di Maio et al and by Hull and Jadbabaie.[3] [4] Accordingly, we are increasingly confronted with the challenge of identifying the limits of providing care. Even if a discussion concerning limits of medical treatment may appear to be against the Hippocratic oath, it might be questionable to provide escalating care to patients whose illness continues to ravage them despite maximal efforts, especially when self-destructive behavior lies at the origin of their disease.[4]

Personally, I do not expect too much support from the ethics committee. This forum deliberates mainly on clinical research projects and innovations to be introduced in daily practice but lacks from experience with rare and complex medical conditions. And the ethicists will never decide—they will only moderate a discussion “pro versus against,” which might be helpful of course.

Returning to Hull and Jadbabaie, I would like to emphasize that medical doctors must treat all patients carefully and fairly, regardless of the patients' societal transgressions, and at the same time, doctors must know when to say, “Enough is enough.”[4] The most recent American College of Cardiology/American Heart Association guidelines do not give any specific recommendation, except that “surgery is not indicated if complications (severe embolic cerebral damage) or comorbid conditions make the prospect of recovery remote.”[5] Instead of studying why other institutions did not want to treat the patients, it might be wiser to think about policies on how to make the patient more responsible—for instance, to encourage the addicted patient to sign a contract for accompanied drug delivery and to make a substantial effort to abstain from drug abuse in the future.[4]

When discussing how many procedures a patient may undergo, doctors will have to increasingly balance the obligations to individual patients versus the expectations of the society. More precise guidelines would allow to provide better care to these patients.

I do not think that surgeons can be forced to perform a complex operative procedure, and in some instances, it seems acceptable to transfer the patient to a more experienced institution or to send the patient to a surgeon who is convinced that a straightforward procedure is the only reasonable option. However, more than one redo may be considered as an overtreatment in those patients with persisting drug abuse. Finally, I do not consider economic aspects a significant issue. Compared with the high number of patients receiving an unnecessary, much more expensive transcatheter aortic valve implantation instead of a simple surgical aortic valve replacement in Germany, the problem of treating drug-addicted patients may be a peanut issue.

• References

• 1 Carrel T, Schaffner A, Vogt P , et al. Endocarditis in intravenous drug addicts and HIV infected patients: possibilities and limitations of surgical treatment. J Heart Valve Dis 1993; 2 (2) 140-147
• 2 Weymann A, Borst T, Popov AF , et al. Surgical treatment of infective endocarditis in active intravenous drug users: a justified procedure?. J Cardiothorac Surg 2014; 9: 58
• 3 DiMaio JM, Salerno TA, Bernstein R, Araujo K, Ricci M, Sade RM. Ethical obligation of surgeons to noncompliant patients: can a surgeon refuse to operate on an intravenous drug-abusing patient with recurrent aortic valve prosthesis infection?. Ann Thorac Surg 2009; 88 (1) 1-8
• 4 Hull SC, Jadbabaie F. When is enough enough? The dilemma of valve replacement in a recidivist intravenous drug user. Ann Thorac Surg 2014; 97 (5) 1486-1487
• 5 Nishimura RA, Otto CM, Bonow RO , et al; American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014; 63 (22) 2438-2488