6. Social implications

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

valves in the setting of ongoing substance abuse. Until more objective data and experiences are available to guide such decision-making, clearly prior to withholding potentially high-risk, lifesaving, re-operative surgery, a referral to palliative care and ethics team is indicated—not to mention an open and honest (and well-documented) discussion with the patient and family regarding the severity of the issue at hand. Many surgical teams will force the patient to sign a plan of care contract prior to surgery acknowledging that noncompliance and valve reinfection

Figure 1. Echocardiogram of a 28-year-old mother of two with a long-standing history of substance abuse and multiple admissions over several years for tricuspid valve endocarditis. Surgery was not offered on multiple occasions due to concerns of recurrence and noncompliance and her substance abuse. She presented with severe right ventricular (RV) failure, severe right atrial (RA) enlargement, and a nonexistent tricuspid valve, ascites, and hepatic congestion, and was deemed to be inoperable by a multidisciplinary team. A palliative care consult was obtained, and she was referred to

Introductory Chapter: Introduction to Advanced Concepts in Endocarditis

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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

might result in withholding further or future therapies (Figure 1).

hospice. She died of right-sided heart failure several months later.

7. Conclusions

Introductory Chapter: Introduction to Advanced Concepts in Endocarditis http://dx.doi.org/10.5772/intechopen.79883 9

Figure 1. Echocardiogram of a 28-year-old mother of two with a long-standing history of substance abuse and multiple admissions over several years for tricuspid valve endocarditis. Surgery was not offered on multiple occasions due to concerns of recurrence and noncompliance and her substance abuse. She presented with severe right ventricular (RV) failure, severe right atrial (RA) enlargement, and a nonexistent tricuspid valve, ascites, and hepatic congestion, and was deemed to be inoperable by a multidisciplinary team. A palliative care consult was obtained, and she was referred to hospice. She died of right-sided heart failure several months later.

valves in the setting of ongoing substance abuse. Until more objective data and experiences are available to guide such decision-making, clearly prior to withholding potentially high-risk, lifesaving, re-operative surgery, a referral to palliative care and ethics team is indicated—not to mention an open and honest (and well-documented) discussion with the patient and family regarding the severity of the issue at hand. Many surgical teams will force the patient to sign a plan of care contract prior to surgery acknowledging that noncompliance and valve reinfection might result in withholding further or future therapies (Figure 1).
