2. Surgery for tricuspid valve infective endocarditis

#### 2.1. Epidemiology

The key predisposing factors for tricuspid valve infective endocarditis include intravenous drug use, cardiac implantable electronic devices, long-term central venous access catheters, and congenital heart disease [4].

In the study of Murdoch et al. [1], current intravenous drug use was found in 16% of the cohort of North America, chronic intravenous access accounted was found in 25%, implantable cardiac devices accounted was found in 12%, and congenital heart disease accounted was found in 25%.

Moss et al. reported that 41% of injection drug users with bacteremia had the evidence of endocarditis [5].

Athan et al. performed a prospective cohort study which described a 6.4% incidence of cardiac device-related infective endocarditis among 2760 patients [6]. There was coexisting valve involvement in 37.3% patients and predominantly tricuspid valve infection (24.3%). Concomitant valve infection was associated with higher mortality than no valve infection (odds ratio, 3.31; 95% confidence interval, 1.71–6.39).

#### 2.2. Indications for surgery

The most recent guidelines from the American Heart Association stated that the surgical intervention is reasonable for patients with certain complications with class IIa recommendations, and they also stated that it is reasonable to avoid surgery when possible in patients who are intravenous drug users [7]. The 2015 European Society of Cardiology guidelines for the management of infective endocarditis stated that surgery should be considered in the following situations with class IIa recommendations: [1] right heart failure secondary to severe tricuspid regurgitation with poor response to diuretic therapy, [2] infective endocarditis caused by organisms that are difficult to eradicate (e.g. persistent fungi) or bacteremia for at least 7 days despite adequate antimicrobial therapy, and [3] tricuspid valve vegetations >20 mm that persist after recurrent pulmonary emboli with or without concomitant right heart failure [8].

Hecht et al. followed the clinical course of 121 patients with right-sided infective endocarditis caused by intravenous drug use, and reported that vegetations greater than 20 mm were associated with increased mortality [9].

Kiefer et al. performed a prospective, multicenter study enrolling over 4000 patients with infective endocarditis and known heart failure status [10]. In-hospital mortality was lower in the patients undergoing valvular surgery compared with medical therapy alone (20.6 vs. 44.8%, p < 0.001), and 1-year mortality was also lower in patients undergoing surgery compared with medical therapy alone (29.1 vs. 58.4%, p < 0.001).

#### 2.3. Timing of surgery

Tricuspid valve infective endocarditis was relatively rare and accounted for 5 to 10% of all infective endocarditis [2]. In the study of Murdoch et al. which was reported in 2009 [1], tricuspid valve infective endocarditis was found in 12% of the entire cohort. However, the frequency of tricuspid valve infective endocarditis is rapidly increasing along with the epidemic of intravenous drug use. Seratnahaei et al. reported that the incidence of tricuspid valve infective endocarditis was 6% between 1999 and 2000, and it markedly increased to 36% between 2009 and 2010

The key predisposing factors for tricuspid valve infective endocarditis include intravenous drug use, cardiac implantable electronic devices, long-term central venous access catheters,

In the study of Murdoch et al. [1], current intravenous drug use was found in 16% of the cohort of North America, chronic intravenous access accounted was found in 25%, implantable cardiac devices accounted was found in 12%, and congenital heart disease accounted was

Moss et al. reported that 41% of injection drug users with bacteremia had the evidence of

Athan et al. performed a prospective cohort study which described a 6.4% incidence of cardiac device-related infective endocarditis among 2760 patients [6]. There was coexisting valve involvement in 37.3% patients and predominantly tricuspid valve infection (24.3%). Concomitant valve infection was associated with higher mortality than no valve infection (odds ratio,

The most recent guidelines from the American Heart Association stated that the surgical intervention is reasonable for patients with certain complications with class IIa recommendations, and they also stated that it is reasonable to avoid surgery when possible in patients who are intravenous drug users [7]. The 2015 European Society of Cardiology guidelines for the management of infective endocarditis stated that surgery should be considered in the following situations with class IIa recommendations: [1] right heart failure secondary to severe tricuspid regurgitation with poor response to diuretic therapy, [2] infective endocarditis caused by organisms that are difficult to eradicate (e.g. persistent fungi) or bacteremia for at least 7 days despite adequate antimicrobial therapy, and [3] tricuspid valve vegetations >20 mm that persist after

Hecht et al. followed the clinical course of 121 patients with right-sided infective endocarditis caused by intravenous drug use, and reported that vegetations greater than 20 mm were

recurrent pulmonary emboli with or without concomitant right heart failure [8].

[3]. Also reported history of intravenous drug use increased from 15 to 40%.

2. Surgery for tricuspid valve infective endocarditis

2.1. Epidemiology

104 Advanced Concepts in Endocarditis

found in 25%.

endocarditis [5].

and congenital heart disease [4].

3.31; 95% confidence interval, 1.71–6.39).

associated with increased mortality [9].

2.2. Indications for surgery

The early surgical intervention for left-sided infective endocarditis has been well suggested [7, 11, 12]; however, the surgical indications for right-sided infective endocarditis are not well defined.

Akinosoglou et al. suggested that the timing of surgical management depends on the following factors: [1] cause of endocarditis (e.g. urgent in pacemaker and prosthetic infective endocarditis), [2] causative infective factors (e.g. fungal and Staphylococcus aureus), [3] coexistent left-sided infection, [4] response to antibiotic therapy, [5] toxicity of medical treatment, and [6] complications of disease (e.g. abscess and increased vegetation size) [13].

Early surgery should be considered if the causative organism is Staphylococcus aureus, which often results in large vegetations, massive valve destruction, and embolic manifestations [14]. Remadi et al. reported that early surgery was associated with reduced mortality in Staphylococcus aureus infective endocarditis [15].

Taghavi et al. compared the outcomes between surgical management and medical treatment for tricuspid valve endocarditis [16]. They found that patients treated surgically had clear blood cultures sooner, defervesced earlier, and demonstrated a complete resolution of vegetations. They concluded that the early surgery is warranted for patients with tricuspid valve endocarditis when they are bacteremia and/or systemically infected despite optimal medical treatment.

In contrast, Gaca et al. reviewed the surgical outcomes for isolated tricuspid valve endocarditis using the Society of Thoracic Surgeons Database, and reported that patients in the healed tricuspid valve endocarditis had lower complications rates, shorter overall length of stay, and a trend toward lower operative mortality compared with active endocarditis [17].

#### 2.4. Tricuspid valve reconstruction

Akinosoglou et al. suggested that, in intravenous drug users who run a high risk of complications, vegetectomy and valve repair, avoiding artificial materials should be considered as that can improve late survival rate [13].

Successful surgical intervention requires radical debridement of infected tissue first [4]. In case of leaflet perforation or small defects localized to one or two leaflets can be repaired by either direct closure or patch plasty using an autologous pericardial patch [18] (Figure 1).

In case of limited infection on the posterior leaflet, bicuspid valve formation of the tricuspid valve can be performed by excising the posterior leaflet and mobilizing the anterior and septal leaflets [18] (Figure 2). Ghanta et al. reported good mid-term outcomes of suture bicuspidization of the tricuspid valve [19].

showed that the ring annuloplasty is superior to suture annuloplasty in terms of recurrent

In case of severe valve destruction, valve replacement is performed using either a mechanical

Cho et al. compared surgical outcomes of mechanical tricuspid valve replacement (n = 59) and tissue tricuspid valve replacement (n = 45), and found that there was no difference in long-term

Hwang et al. also reported that there was no difference in long-term survival, cardiac death rates, and thromboembolic and bleeding complication rates between mechanical and tissue

Liu et al. performed a meta-analysis to review the results of mechanical and bioprosthetic valves in the tricuspid valve position [27]. They did not find difference in survival, reoperation,

The surgical outcomes for tricuspid valve infective endocarditis are listed in Table 1. Overall good surgical outcomes were reported, and the durability of tricuspid valve reconstruction

Surgical technique Mortality (%) Recurrence

11.3% for reconstruction, 12.5% for TVR

7.6% for reconstruction, 12.1% for valvectomy, 6.3% for TVR

of

0 3 patients

9 2 patients

regurgitation

Surgical Treatment for Tricuspid Valve Infective Endocarditis

http://dx.doi.org/10.5772/intechopen.74951

107

had grade 1–2 TR

had grade > 2 TR

— —

— 2 patients had

Recurrence of infection

reoperation due to reinfection after the tricuspid reconstruction.

2 patients had recurrent endocarditis, which were treated conservatively.

3 patients underwent reoperation for recurrent

endocarditis

valve-related complications such as thromboembolic or bleeding events [25].

tricuspid regurgitation or reoperation [21–24].

2.5. Tricuspid valve replacement

tricuspid valve replacements [26].

or prosthetic valve failure between two valve types.

2007 51 31 reconstructions, 17 tissue

2007 22 18 reconstructions, 3 tissue

2013 33 15 reconstructions,14 tissue

2013 910 354 reconstructions,

TVR, tricuspid valve replacement; TR, tricuspid regurgitation.

Table 1. Surgical outcomes for tricuspid valve endocarditis.

TVR, 3 mechanical TVR

TVR, 1 mechanical TVR

TVR, 4 mechanical TVR

66 valvectomies, 490 TVR

2.6. Surgical outcomes for tricuspid valve infective endocarditis

valve or tissue valve.

was good.

Musci et al. [28]

Gottardi et al. [18]

Baraki et al. [29]

Gaca et al. [17]

Study Year Number

of pts

Artificial chordae using expanded polytetrafluoroethylene sutures can be applied after the resection of infected chordae [20].

Tricuspid annuloplasty is performed either with prosthetic rings or with non-prosthetic suture annuloplasty such as Kay's or De Vega's annuloplasty [13]. Although suture annuloplasty has an advantage of avoiding prosthetic materials in the setting of infection, several studies

Figure 1. Endocarditic lesion on the anterior leaflet (A), the posterior leaflet (B), or on both (C), anterior and septal leaflet (D–F) after the excision of the endocarditic lesion, patch plasty, and stabilization of the valve with a tricuspid annuloplasty ring.

Figure 2. (A) Endocarditic lesion on the posterior leaflet. (B) Excision of the posterior leaflet. (C) Partial mobilization of the anterior and septal leaflet and preparation of plication sutures. (D) Bicuspid leaflet formation of the valve. (E) Stabilization of the valve with a tricuspid annuloplasty ring.

showed that the ring annuloplasty is superior to suture annuloplasty in terms of recurrent tricuspid regurgitation or reoperation [21–24].

## 2.5. Tricuspid valve replacement

leaflets [18] (Figure 2). Ghanta et al. reported good mid-term outcomes of suture bicuspidization

Artificial chordae using expanded polytetrafluoroethylene sutures can be applied after the

Tricuspid annuloplasty is performed either with prosthetic rings or with non-prosthetic suture annuloplasty such as Kay's or De Vega's annuloplasty [13]. Although suture annuloplasty has an advantage of avoiding prosthetic materials in the setting of infection, several studies

Figure 1. Endocarditic lesion on the anterior leaflet (A), the posterior leaflet (B), or on both (C), anterior and septal leaflet (D–F) after the excision of the endocarditic lesion, patch plasty, and stabilization of the valve with a tricuspid

Figure 2. (A) Endocarditic lesion on the posterior leaflet. (B) Excision of the posterior leaflet. (C) Partial mobilization of the anterior and septal leaflet and preparation of plication sutures. (D) Bicuspid leaflet formation of the valve.

(E) Stabilization of the valve with a tricuspid annuloplasty ring.

of the tricuspid valve [19].

106 Advanced Concepts in Endocarditis

annuloplasty ring.

resection of infected chordae [20].

In case of severe valve destruction, valve replacement is performed using either a mechanical valve or tissue valve.

Cho et al. compared surgical outcomes of mechanical tricuspid valve replacement (n = 59) and tissue tricuspid valve replacement (n = 45), and found that there was no difference in long-term valve-related complications such as thromboembolic or bleeding events [25].

Hwang et al. also reported that there was no difference in long-term survival, cardiac death rates, and thromboembolic and bleeding complication rates between mechanical and tissue tricuspid valve replacements [26].

Liu et al. performed a meta-analysis to review the results of mechanical and bioprosthetic valves in the tricuspid valve position [27]. They did not find difference in survival, reoperation, or prosthetic valve failure between two valve types.

#### 2.6. Surgical outcomes for tricuspid valve infective endocarditis

The surgical outcomes for tricuspid valve infective endocarditis are listed in Table 1. Overall good surgical outcomes were reported, and the durability of tricuspid valve reconstruction was good.


Table 1. Surgical outcomes for tricuspid valve endocarditis.

Musci et al. reported a 20-year single institution surgical experience for right-sided infective endocarditis [28]. They performed 31 tricuspid valve reconstructions and 20 valve replacements. The 30-day, 1-, 5-, 10- and 20-year survival rate after the operation was 96.2, 88.4, 73.5, 70.4 and 70.4%, respectively, for isolated right-sided infective endocarditis. The survival rate was significantly better than the patients with combined right- and left-sided infective endocarditis. Survival was not different between valve reconstruction and replacement.

Gottardi et al. performed 18 tricuspid valve repair and 4 tricuspid valve replacements for active infective endocarditis, and there was no mortality [18]. During the follow-up, three patients presented with grade 1–2 tricuspid valve regurgitation after the valve reconstruction.

Baraki et al. reviewed 33 tricuspid valve surgeries for endocarditis, which included 14 tissue valve replacements, 4 mechanical valve replacements, and 15 tricuspid valve repairs [29]. Thirty-day mortality was 9%, and advanced age, EuroSCORE, and Staphylococcus aureus were associated with a less long-term survival rate. Residual tricuspid valve regurgitation grade ≥2 was found in two patients.

#### 2.7. Intravenous drug user

Intravenous drug abuse is increasing dramatically in the United States [30]. Of many medical complications caused by drug use, infective endocarditis is one of the most challenging issues given the significant risk of acute mortality as well as late recidivism, reinfection, and poor social situations.

The infection caused by the drug use can be found both on right- and left-sided heart or even on both sides. Even though the prognosis of right-sided infective endocarditis is better than left-sided, surgery may be required in at least 25% of patients [31].

The surgical outcomes for drug-induced endocarditis are summarized in Table 2. Overall, the short-term and long-term survival was not different between drug users and non-drug users; however, the rates of late reinfection and reoperation are higher in drug users.

Jeganathan et al. reviewed 68 patients who had previous history of tricuspid valve surgery and underwent reoperations on the tricuspid valve, and in-hospital mortality was 13.2% [38]. They also reported high incidence of postoperative bleeding, low cardiac output syndrome, stroke,

Second University of

Naples

Musci et al. reported that 6 out of 79 patients underwent reoperation due to reinfection after the correction of right-sided active infective endocarditis, and only 1 of them (16.7%) survived

The prognosis of prosthetic valve infection without surgical intervention is dismal. Ivert et al. reported that 64% of the patients with prosthetic valve endocarditis died, and most deaths occurred within 3 months of the first evidence of infection [40]. Nevertheless, the surgical

Luciani et al. performed multicentre study for surgical outcomes for prosthetic valve endocarditis [42]. Among 209 patients who underwent surgery for prosthetic valve endocarditis, the in-hospital mortality was high (21.5%). Grubitzsch et al. reviewed 149 patients who underwent

redo surgery for prosthetic valve endocarditis [43]. The operative mortality was 12.8%.

treatment for prosthetic valve endocarditis is also challenging [41].

Study Year Number of pts Hospital Findings

2016 436; 78 (17.9%) were drug

2012 197; 64 (32.5%) were drug

2007 346; 62 (17.9%) were drug

2006 39 drug-induced infective

endocarditis and 85 non-druginduced infective endocarditis

Table 2. Surgical outcomes for drug-induced infective endocarditis.

users

users

users

2015 536; 41 (8%) were drug users Cleveland clinic Short-term mortality was not different

Massachusetts General Hospital and Brigham and Women's Hospital

University of Washington Medical

Center

between drug users and non-drug users; however, a hazard of death or reoperation between 3 and 6 months after the operation was 10 times higher in drug users compared with non-users.

http://dx.doi.org/10.5772/intechopen.74951

109

Surgical Treatment for Tricuspid Valve Infective Endocarditis

Operative mortality was lower among drug users; however, overall mortality was not different. Drug users had higher risk of valve-related complications principally because of higher rates of reinfection.

Survival was lower in drug users than nondrug users (at 30 days, 1 year, 5 years, and 10 years; 91.2 vs. 93.6%, 77.5 vs. 83.0%, 46.7 vs. 71.1%, and 41.1 vs. 52.0%, respectively, p = 0.027). Intravenous drug use was an independent risk factor for diminished survival (p = 0.03). 8 of 64 (12.5%) of drug users experienced recurrent infective

complications were not different between drug users and non-drug users; however, reoperation for recurrent infection was higher in drug users (17 vs. 5%, p = 0.03).

Although hospital and long-term survival did not significantly differ between two groups, the rate of recurrence of infection

was higher in drug users.

endocarditis.

Washington University Long-term survival and perioperative

and renal failure.

Shrestha et al. [35]

Kim et al. [36]

Rabkin et al. [33]

Kaiser et al. [34]

Carozza et al. [37]

the reoperation [28].

The choice of valve prosthesis for intravenous drug users is controversial [32]. Rabkin et al. reported that the median survival of intravenous drug users was only 3 years, and therefore tissue valves are justified even for young patients [33]. Kaiser et al. used tissue valves more frequently in drug users than non-drug users (75 vs. 52%), even though drug users were younger [34].

In the meantime, several previous studies showed that the postoperative survival rate of drug users is similar to non-drug users [34–37]. That may imply that intravenous drug users receiving tissue valves will live long enough to require a reoperation for valve degeneration. Given the fact that the redo surgery for tricuspid valve carries high risk [38], the use of mechanical valve may be justified for selected patients who can be compliant with anticoagulation. Mechanical tricuspid valves have a risk of thrombosis with an incidence of ≤3.3% of patient-years [39].

#### 2.8. Reinfection after surgery

Patients with intravenous drug use are high risk of reinfection. The surgical outcomes for redo tricuspid valve surgery have been reported to be poor.


Table 2. Surgical outcomes for drug-induced infective endocarditis.

Musci et al. reported a 20-year single institution surgical experience for right-sided infective endocarditis [28]. They performed 31 tricuspid valve reconstructions and 20 valve replacements. The 30-day, 1-, 5-, 10- and 20-year survival rate after the operation was 96.2, 88.4, 73.5, 70.4 and 70.4%, respectively, for isolated right-sided infective endocarditis. The survival rate was significantly better than the patients with combined right- and left-sided infective endo-

Gottardi et al. performed 18 tricuspid valve repair and 4 tricuspid valve replacements for active infective endocarditis, and there was no mortality [18]. During the follow-up, three patients presented with grade 1–2 tricuspid valve regurgitation after the valve reconstruction. Baraki et al. reviewed 33 tricuspid valve surgeries for endocarditis, which included 14 tissue valve replacements, 4 mechanical valve replacements, and 15 tricuspid valve repairs [29]. Thirty-day mortality was 9%, and advanced age, EuroSCORE, and Staphylococcus aureus were associated with a less long-term survival rate. Residual tricuspid valve regurgitation grade ≥2

Intravenous drug abuse is increasing dramatically in the United States [30]. Of many medical complications caused by drug use, infective endocarditis is one of the most challenging issues given the significant risk of acute mortality as well as late recidivism, reinfection, and poor

The infection caused by the drug use can be found both on right- and left-sided heart or even on both sides. Even though the prognosis of right-sided infective endocarditis is better than

The surgical outcomes for drug-induced endocarditis are summarized in Table 2. Overall, the short-term and long-term survival was not different between drug users and non-drug users;

The choice of valve prosthesis for intravenous drug users is controversial [32]. Rabkin et al. reported that the median survival of intravenous drug users was only 3 years, and therefore tissue valves are justified even for young patients [33]. Kaiser et al. used tissue valves more frequently in

In the meantime, several previous studies showed that the postoperative survival rate of drug users is similar to non-drug users [34–37]. That may imply that intravenous drug users receiving tissue valves will live long enough to require a reoperation for valve degeneration. Given the fact that the redo surgery for tricuspid valve carries high risk [38], the use of mechanical valve may be justified for selected patients who can be compliant with anticoagulation. Mechanical tricuspid

Patients with intravenous drug use are high risk of reinfection. The surgical outcomes for redo

drug users than non-drug users (75 vs. 52%), even though drug users were younger [34].

left-sided, surgery may be required in at least 25% of patients [31].

however, the rates of late reinfection and reoperation are higher in drug users.

valves have a risk of thrombosis with an incidence of ≤3.3% of patient-years [39].

carditis. Survival was not different between valve reconstruction and replacement.

was found in two patients.

108 Advanced Concepts in Endocarditis

2.7. Intravenous drug user

2.8. Reinfection after surgery

tricuspid valve surgery have been reported to be poor.

social situations.

Jeganathan et al. reviewed 68 patients who had previous history of tricuspid valve surgery and underwent reoperations on the tricuspid valve, and in-hospital mortality was 13.2% [38]. They also reported high incidence of postoperative bleeding, low cardiac output syndrome, stroke, and renal failure.

Musci et al. reported that 6 out of 79 patients underwent reoperation due to reinfection after the correction of right-sided active infective endocarditis, and only 1 of them (16.7%) survived the reoperation [28].

The prognosis of prosthetic valve infection without surgical intervention is dismal. Ivert et al. reported that 64% of the patients with prosthetic valve endocarditis died, and most deaths occurred within 3 months of the first evidence of infection [40]. Nevertheless, the surgical treatment for prosthetic valve endocarditis is also challenging [41].

Luciani et al. performed multicentre study for surgical outcomes for prosthetic valve endocarditis [42]. Among 209 patients who underwent surgery for prosthetic valve endocarditis, the in-hospital mortality was high (21.5%). Grubitzsch et al. reviewed 149 patients who underwent redo surgery for prosthetic valve endocarditis [43]. The operative mortality was 12.8%.

In the setting of high risk of surgical treatment for reinfection, a dilemma exists regarding the surgical indication for patients who are non-compliant to medical treatment, and develop reinfection due to relapsing of drug use [44]. There is a controversy as how many chances surgeons should give to non-compliant patients.

[3] Seratnahaei A, Leung SW, Charnigo RJ, Cummings MS, Sorrell VL, Smith MD. The changing 'face' of endocarditis in Kentucky: An increase in tricuspid cases. American

Surgical Treatment for Tricuspid Valve Infective Endocarditis

http://dx.doi.org/10.5772/intechopen.74951

111

[4] Yong MS, Coffey S, Prendergast BD, Marasco SF, Zimmet AD, McGiffin DC, Saxena P. Surgical management of tricuspid valve endocarditis in the current era: A review. Inter-

[5] Moss R, Munt B. Injection drug use and right sided endocarditis. Heart. 2003;89:577-581 [6] Athan E, Chu VH, Tattevin P, Selton-Suty C, Jones P, Naber C, Miró JM, Ninot S, Fernández-Hidalgo N, Durante-Mangoni E, Spelman D, Hoen B, Lejko-Zupanc T, Cecchi E, Thuny F, Hannan MM, Pappas P, Henry M, Fowler VG Jr, Crowley AL, Wang A. ICE-PCS investigators. Clinical characteristics and outcome of infective endocarditis involving implantable cardiac devices. JAMA. 2012;307:1727-1735. DOI: 10.1001/jama.2012.497 [7] Baddour LM, Wilson WR, Bayer AS, Fowler VG Jr, Tleyjeh IM, Rybak MJ, Barsic B, Lockhart PB, Gewitz MH, Levison ME, Bolger AF, Steckelberg JM, Baltimore RS, Fink AM, O'Gara P, Taubert KA. American Heart Association Committee on rheumatic fever, endocarditis, and Kawasaki disease of the council on cardiovascular disease in the young, council on clinical cardiology, council on cardiovascular surgery and anesthesia, and stroke council. Infective endocarditis in adults: Diagnosis, antimicrobial therapy, and Management of Complications: A scientific statement for healthcare professionals from the American Heart Association. Circulation. 2015;132:1435-1486. DOI: 10.1161/CIR.

[8] Habib G, Lancellotti P, Antunes MJ, Bongiorni MG, Casalta JP, Del Zotti F, Dulgheru R, El Khoury G, Erba PA, Iung B, Miro JM, Mulder BJ, Plonska-Gosciniak E, Price S, Roos-Hesselink J, Snygg-Martin U, Thuny F, Tornos Mas P, Vilacosta I, Zamorano JL. ESC guidelines for the management of infective endocarditis: The task force for the management of infective endocarditis of the European Society of Cardiology (ESC). Endorsed by: European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Nuclear Medicine (EANM). European Heart Journal. 2015;36:3075-3128. DOI: 10.1093/eurhe

[9] Hecht SR, Berger M. Right-sided endocarditis in intravenous drug users. Prognostic

[10] Kiefer T, Park L, Tribouilloy C, Cortes C, Casillo R, Chu V, Delahaye F, Durante-Mangoni E, Edathodu J, Falces C, Logar M, Miró JM, Naber C, Tripodi MF, Murdoch DR, Moreillon P, Utili R, Wang A. Association between valvular surgery and mortality among patients with infective endocarditis complicated by heart failure. JAMA. 2011;306:2239-2247. DOI:

[11] Ghoreishi M, Foster N, Pasrija C, Shah A, Watkins AC, Evans CF, Maghami S, Quinn R, Wehman B, Taylor BS, Dawood MY, Griffith BP, Gammie JS. Early operation in patients with mitral valve infective endocarditis and acute stroke is safe. The Annals of Thoracic

features in 102 episodes. Annals of Internal Medicine. 1992;117:560-566

Surgery. 2018;105:69-75. DOI: 10.1016/j.athoracsur.2017.06.069

Journal of Medicine. 2014;127, 04:786.e1, 009-786.e6. DOI: 10.1016/j.amjmed.2014

national Journal of Cardiology. 2016;202:44-48. DOI: 10.1016/j.ijcard.2015.08.211

0000000000000296

artj/ehv319

10.1001/jama.2011.1701

Hull et al. proposed that the patients who have a history of intravenous drug use should be encouraged to sign a contract agreeing to undergo drug rehabilitation and make a good faith effort to abstain from substance abuse in the future [45].
