7. Conclusions

(including this author) that this approach is completely against surgical and medical wisdom, inappropriate ethically, and predisposes patients to unreasonable postoperative complications and that operative intervention must involve appropriate debridement of all infected tissues but, as importantly, not predispose the patient to the catastrophic sequelae of "wide-open" tricuspid regurgitation. The technical and ethical aspects of right-sided disease and the management of patients with substance abuse are discussed in this text. Rarely is right-side infections managed with procedures that result in severe regurgitation—a pathophysiology that is often the initial

The growing population of patients who abuse intravenous drugs, as discussed, has resulted in a significant increase in those patients presenting with endocarditis. There has been a reported twofold increase in the number of active heroin users between 2006 and 2013 [32]. The implications of this cannot be ignored. While it is unclear if it is infected needles, skin contamination, or infected drugs being injected—or a combination of events—the consequences are the same. In addition, as a function of their substance abuse, often these patients present with underlying, and often untreated, hepatitis B, hepatitis C, and the human immunodeficiency virus (HIV) [33]. These patients often have chronic pain syndromes and high levels of tolerance to narcotics associated with their drug addictions, not to mention associated personality and psychological disorders, all of which challenge the short- and long-term care and management options for this population. Long-term compliance with medical therapies, such as anticoagulation for mechanical valves, might predispose these patients to early tissue valve failure and the need for reintervention. Such decision-making must also consider existing comorbidities, such as liver dysfunction from untreated hepatitis or recent embolic strokes. As such, it is easy to appreciate that even a single episode of endocarditis can have tremendous lifelong ramifications [34]. As such, having a good understanding of the long-term outcomes of these patients is important in decision-making at the time of their index event. For example, one study reported that between 2002 and 2014, there was a two times increase in the number of patients requiring surgery for infected endocarditis at their institution space (14.8% in 2002 to 26% in 2012). Of the 436 patients studied over a mean follow-up of 29 months, adverse events occurred in 20%, including 10% developing reinfections—often as a function of continued substance abuse. Even though there was a lower operative mortality in patients with drug abuse mainly due to their age, a propensity score analysis demonstrated that IV drug abuse was associated with an almost fourfold increase in valve-related complications and a 6.2-fold increase in the risk for reinfection. Unfortunately, because of the biased beliefs (some of which might be valid) of relapse of drug abuse, noncompliance, limited access to chronic healthcare, and poor socioeconomic status of many of these patients, surgery in the setting of long-standing drug abuse is often viewed as intervening on an end-stage disease that is often imminently fatal. Some clinicians view attempts at curing these patients of their infections and substance abuse as being futile. The consequence of this, as discussed in the chapter on the ethics of surgery, is the issue of what to do with patients who reinfected their prosthetic heart

indication for intervention.

8 Advanced Concepts in Endocarditis

6. Social implications

Improvements in technology and a greater awareness of the problem have resulted in a substantial increase in the diagnosis of infectious endocarditis. Furthermore, as patients present with

Author details

Colorado, USA

References

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\*Address all correspondence to: msfirst@gmail.com

1 Cardiothoracic Surgery, The Medical Center of Aurora and Rose Hospital, Aurora,

Introductory Chapter: Introduction to Advanced Concepts in Endocarditis

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11

2 Surgery and Integrative Medicine–College of Medicine, Adjunct Faculty–College of

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Cardiology. Published online June 20, 2018. DOI: 10.1001/jamacardio.2018.1602

Graduate Studies, Northeast Ohio Medical Universities, Ohio, USA

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Figure 2. Structure of an "Endocarditis Heart Team" (adopted from Firstenberg [25]).

more complex and high-risk comorbidities, difficult social problems—such as intravenous substance abuse—and a wider utilization of invasive cardiac therapies, the risk for developing infectious complications has also increased. Without a doubt, the management of endocarditis —regardless of the presentation—continues to be an evolving and difficult problem. As such, much like many other complex medical and surgical problems, there is growing evidence that a team approach to both short- and long-term management is a foundation to success (Figure 2) [35, 36].

The goal of this text is to provide some valuable insights into some of the ever-evolving topics and controversies and by no means is it intendent to be the definitive reference—the area is too complex and the science is moving too quickly. Nevertheless, hopefully with a greater awareness and understanding, there can be ongoing improvements in the prevention, diagnosis, and treatment of this devastating problem.
