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130 Advanced Concepts in Endocarditis

logy. 2002;**39**:1489-1495

**Chapter 9**

**Provisional chapter**

**The Ethics in Repeat Heart Valve Replacement Surgery**

The treatment of patients with intravenous drug use (IVDU) has evolved to include a wide range of medications, psychiatric rehabilitation, and surgical interventions, especially for life-threatening complications such as infective endocarditis (IE). These interventions remain at the discretion of physicians, particularly surgeons, whose treatment decisions are influenced by several medical factors, unfortunately not without bias. The stigma associated with substance use disorder is prevalent, which leads to significant biases, even in the healthcare system. This bias is heightened when IVDU patients require repeat valve replacement surgeries for IE due to continued drug use. Patients who receive a valve replacement and continue to use illicit drugs intravenously often return to their medical providers, months to a few years later, with a reinfection of their bioprosthetic valve; such patients require additional surgeries which are at the center of many ethical discussions due to high mortality rates, for many complex medical and social reasons, associated with continuous chemical dependency after surgical interventions. This chapter examines the ethics of repeat heart valve replacement surgery for patients who are struggling with addiction. Considerations of justice, the fiduciary therapeutic relationship, and guiding ethical principles justify medically beneficial repeat heart valve replacement surgeries for IVDU patient

**Keywords:** replacement valve surgery, ethics, justice, addiction, intravenous drug use

The treatment of patients with intravenous drug use (IVDU) has evolved to include a wide range of medications, psychiatric rehabilitation, and surgical interventions, especially for

**The Ethics in Repeat Heart Valve Replacement Surgery**

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

distribution, and reproduction in any medium, provided the original work is properly cited.

DOI: 10.5772/intechopen.76844

Julie M. Aultman, Emanuela Peshel,

and Michael S. Firstenberg

**Abstract**

populations.

**1. Introduction**

http://dx.doi.org/10.5772/intechopen.76844

Cyril Harfouche and Michael S. Firstenberg

Julie M. Aultman, Emanuela Peshel, Cyril Harfouche

Additional information is available at the end of the chapter

Additional information is available at the end of the chapter

#### **The Ethics in Repeat Heart Valve Replacement Surgery The Ethics in Repeat Heart Valve Replacement Surgery**

DOI: 10.5772/intechopen.76844

Julie M. Aultman, Emanuela Peshel, Cyril Harfouche and Michael S. Firstenberg Julie M. Aultman, Emanuela Peshel, Cyril Harfouche and Michael S. Firstenberg

Additional information is available at the end of the chapter Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.76844

#### **Abstract**

The treatment of patients with intravenous drug use (IVDU) has evolved to include a wide range of medications, psychiatric rehabilitation, and surgical interventions, especially for life-threatening complications such as infective endocarditis (IE). These interventions remain at the discretion of physicians, particularly surgeons, whose treatment decisions are influenced by several medical factors, unfortunately not without bias. The stigma associated with substance use disorder is prevalent, which leads to significant biases, even in the healthcare system. This bias is heightened when IVDU patients require repeat valve replacement surgeries for IE due to continued drug use. Patients who receive a valve replacement and continue to use illicit drugs intravenously often return to their medical providers, months to a few years later, with a reinfection of their bioprosthetic valve; such patients require additional surgeries which are at the center of many ethical discussions due to high mortality rates, for many complex medical and social reasons, associated with continuous chemical dependency after surgical interventions. This chapter examines the ethics of repeat heart valve replacement surgery for patients who are struggling with addiction. Considerations of justice, the fiduciary therapeutic relationship, and guiding ethical principles justify medically beneficial repeat heart valve replacement surgeries for IVDU patient populations.

**Keywords:** replacement valve surgery, ethics, justice, addiction, intravenous drug use

#### **1. Introduction**

The treatment of patients with intravenous drug use (IVDU) has evolved to include a wide range of medications, psychiatric rehabilitation, and surgical interventions, especially for

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

life-threatening complications such as infective endocarditis (IE). These interventions, however, remain at the discretion of surgeons, and the healthcare team, whose treatment decisions are influenced by several medical factors, unfortunately not without bias. The stigma associated with substance use disorder is prevalent, especially toward IVDU, which leads to significant biases, even in the healthcare system [1]. This bias is heightened when IVDU patients require multiple or repeat valve replacement surgeries for IE due to continued drug use, which can be quite costly for healthcare institutions.

which includes high-risk surgeries, detoxification programs, and extensive mental health care for chemical dependency among other related mental health disorders. Helping the addict is discussed less frequently as an important step to fight this epidemic [3], which is relevant to our ethical and social examination as to why we need to re-think the standards of medical care and treat patients holistically by incorporating mental health care into every aspect of their overall care. This is especially pertinent to the treatment of IE

The Ethics in Repeat Heart Valve Replacement Surgery http://dx.doi.org/10.5772/intechopen.76844 135

With the rise of the opioid epidemic in the past few years, high-risk valve replacement surgeries have become a growing medical, financial, and ethical burden. Historically, IVDU represented a small percentage of patients with IE. In one study, the proportion increased from 14.8% in 2002–2004 to 26% in 2012–2014 during which time, heroin use doubled [4, 5]. Today, approximately 11% of IVDU are at risk for developing IE [6], which is characterized by infection of the inner lining of the heart, leading to the growth of vegetation on heart valves that disrupt the ability to pump blood. Overall, IE is an extremely morbid disease: in-hospital mortality rates range from 11 to 26% with an estimated 5-year mortality of up to 50% [7]. Complications include heart failure, valve insufficiency, embolic strokes, and intracerebral hemorrhage. IE secondary to IVDU is most commonly caused by bacteremia from *Staphylococcus aureus* and *Enterococcus faecalis* that are abundantly found on the skin and gastrointestinal tract, or by particulates in illicit drugs that cause micro-damage to tissues as they circulate [8, 9] following injection. Treatment is often sufficient using high-dose antibiotics,

Studies have shown that patients with IE secondary to IVDU are younger than patients with no IVDU and more likely to be young Caucasian males, with some regional variability among populations [4]. The average age of patients who suffer from IE secondary to IVDU is 30 years old, and 90% of them are heroin addicts [7, 8]. Approximately 75% of individuals admitted to treatment for heroin abuse or dependency reported using injection as the primary method of

Despite IVDU representing a significantly younger patient population with less cardiovascular and comorbid risk factors, long-term outcomes are compromised by reinfection [4] and continued drug abuse. A patient who receives a valve replacement yet continues to use intravenous drugs is likely to re-infect their bioprosthetic or homograft valves, requiring additional valve replacement surgeries. However, such treatment opportunities may not be offered to this patient population due to high mortality rates. For example, studies have found that patients who resume IVDU after their initial valve replacement have high mortality compared to patients who abstain from drug use after their surgery [11]. A patient who resumes IVDU may get an extra 1–5 years of life out of their new valve rather than the 10–15 years of life that a new valve (mechanical or biological) can give without IVDU. Such decision-making must also be done in the setting of the overall poor and limited (but somewhat incompletely

**2.1. Relationship of intravenous drug use and infective endocarditis**

but 60 to 70% of severe cases require surgical intervention [4].

defined) life-expectancy of the habitual use of IV drugs.

secondary to IVDU.

drug use [10].

We explore various barriers when considering repeat heart valve surgeries, especially the implicit bias that can negatively influence the duty of physicians and their decision to provide comprehensive patient care. Patients who receive a valve replacement and continue to use illicit drugs intravenously, often return to their medical providers months to years later with a re-infection of their prosthetic valve; many of these patients have several medical comorbidities and require extensive care. The topic of multiple or repeat heart valve surgeries are the center of many ethical discussions due to the high mortality rates associated with both the inherent mortality from ongoing drug abuse and the risks of often complex and technically challenging high-risk re-operative cardiac surgery.

This chapter examines the ethics of repeat heart valve replacement surgery for patients who are struggling with addiction, and the important factors that ought to guide health care professionals in making future treatment decisions. Considerations of justice, the fiduciary therapeutic relationship, and guiding ethical principles justify medically beneficial repeat heart valve replacement surgeries for IVDU patient populations. We will present and analyze two cases, which were presented to a hospital ethics committee, and provide justification for a narrative-based ethical approach to identify those factors for when patients ought to receive multiple heart valves and the conditions for pursuing this surgical intervention despite chemical dependency challenges.

To better examine the ethical and social issues significant to discussions about heart valve replacement surgery among IVDU populations, particularly those seeking repeat surgeries due to chemical dependency relapse, it is important to understand the current climate in the United States with respect to IVDU and IE, as well as the need for comprehensive surgical and mental health care for patients who are committed to their recovery.
