Original article
Adult cardiac
Long-Term Outcome for the Surgical Treatment of Infective Endocarditis With a Focus on Intravenous Drug Users

https://doi.org/10.1016/j.athoracsur.2011.08.016Get rights and content

Background

We reviewed our experience with surgical procedures for infective endocarditis (IE) in order to evaluate modern outcomes and objectively examine our institutional preferences, including the use of bioprostheses in intravenous drug users (IVDUs) regardless of age and prompt surgical intervention in patients with either septic cerebral emboli or active infection.

Methods

Review of medical records was conducted from February 1999 to November 2010. The Social Security Death Index was used to determine death from any cause in the postoperative period. Hospital records were used to identify infectious complications, recurrent endocarditis, and reoperation.

Results

Sixty-four patients were identified as IVDUs and 133 patients as non-IVDUs. Survival at 30 days, 1 year, 5 years, and 10 years for IVDUs and non-IVDUs was 91.2% versus 93.6%, 77.5% versus 83.0%, 46.7% versus 71.1%, and 41.1% versus 52.0%, respectively. Cox regression analysis identified intravenous drug use as an independent risk factor for diminished survival (p = 0.03), although not for reoperation (p = 0.95) despite 95.3% of IVDUs receiving bioprostheses versus 73.7% of non-IVDUs (p = 0.0002, Fisher's exact test). Forty-three patients were identified as having preoperative septic cerebral emboli; none had a perioperative hemorrhagic event. Active infection approached significance as an independent risk factor for the composite end point of recurrent IE and perioperative infection (odds ratio 2.8; 95% confidence interval, 0.777 to 10.9; p = 0.12, Fisher's exact test).

Conclusions

Bioprostheses are reasonable for IVDUs undergoing valve replacement for IE regardless of age. Prompt surgical intervention in the setting of septic cerebral emboli is justified; in the setting of active infection it is less clear.

Section snippets

Material and Methods

After obtaining institutional review board approval, the adult cardiac surgery database of the University of Washington Medical Center was reviewed from February 1999 to November 2010 for patients undergoing operation who were identified with a diagnosis of endocarditis. Patients were considered to be IVDUs only if there was documented acknowledgement by the patient of intravenous drug use at any time in their past. In the non-IVDU group, mechanical valves were used for patients younger than 65

Results

Two hundred eighty-two patients were identified as having undergone cardiac surgery between February 1999 and November 2010 with a diagnosis of endocarditis. Of these patients, 85 were excluded based on examination of the medical record; the most common reason for exclusion (46 patients) was a distant history of endocarditis unrelated to the current presentation. The second most common reason (37 patients) was failure to confirm the diagnosis of endocarditis using the modified Duke criteria [13

Comment

An overall 30-day survival of 92.8% is similar to previously reported modern results [14] and considerably improved when compared with conventional results [2]. Similar perioperative mortality and the large difference in median survival between the IVDU and non-IVDU population likely reflects, at least in part, the hazards of recidivist illicit drug use and accompanying comorbid medical and socioeconomic challenges. Survival among our non-IVDU population at 1, 2, and 4 years (83.0%, 78.1%, and

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