Surgical treatment of infective endocarditis in active intravenous drug users: a justified procedure?

Abstract

Background: Infective endocarditis is a life threatening complication of intravenous drug abuse, which continues to be a major burden with inadequately characterised long-term outcomes. We reviewed our institutional experience of surgical treatment of infective endocarditis in active intravenous drug abusers with the aim of identifying the determinants long-term outcome of this distinct subgroup of infective endocarditis patients.

Methods: A total of 451 patients underwent surgery for infective endocarditis between January 1993 and July 2013 at the University Hospital of Heidelberg. Of these patients, 20 (7 female, mean age 35 ± 7.7 years) underwent surgery for infective endocarditis with a history of active intravenous drug abuse. Mean follow-up was 2504 ± 1842 days.

Results: Staphylococcus aureus was the most common pathogen detected in preoperative blood cultures. Two patients (10%) died before postoperative day 30. Survival at 1, 5 and 10 years was 90%, 85% and 85%, respectively. Freedom from reoperation was 100%. Higher NYHA functional class, higher EuroSCORE II, HIV infection, longer operating time, postoperative fever and higher requirement for red blood cell transfusion were associated with 90-day mortality.

Conclusions: In active intravenous drug abusers, surgical treatment for infective endocarditis should be performed as extensively as possible and be followed by an aggressive postoperative antibiotic therapy to avoid high mortality. Early surgical intervention is advisable in patients with precipitous cardiac deterioration and under conditions of staphylococcal endocarditis. However, larger studies are necessary to confirm our preliminary results.

Figure 1

Kaplan-Meier survival estimate for IVDU patients with IE who underwent surgical treatment between January 1993 and July 2013.

Figure 2

Postoperative white cell count (WCC) course in 90-day survivors vs. 90-day non-survivors. There are no statistically significant differences between the two groups (p = 1.000).

Figure 3

Postoperative CRP course in 90-day survivors vs. 90-day non-survivors. There are no statistically significant differences between the two groups (p = 0.275).

Figure 4

Postoperative body temperature course in 90-day survivors vs. 90-day non-survivors. Postoperative body temperature was significantly higher in the non-survivor group (p = 0.026) at all time points.