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Early and Late Surgical Outcomes of Infective Endocarditis among Intravenous Drug Abusers: Results from Two Large Academic Centers
Julius I. Ejiofor, MD1; Joon Bum Kim, MD,PhD2; Maroun Yammine, MD1; Sandra B. Nelson, MD3; Arthur Y. Kim, MD3; Serguei I. Melnitchouk, MD2; James D. Rawn, MD1; Lawrence H. Cohn, MD1; Marzia Leacche, MD1; John G. Byrne, MD1; Thoralf M. Sundt, MD2
1Division of Cardiac Surgery, Brigham and Women’s Hospital, Boston, MA, 2Division of Cardiac Surgery, Brigham and Women’s Hospital, Boston, MA, 3Infectious Disease, Massachusetts General Hospital, Boston, MA

Background:
Increasing numbers of intravenous drug users (IVDUs) with infective endocarditis (IE) are presenting for cardiac surgery. Their youth and risk of recidivism raise ethical and economic concerns. We compared early and late outcomes of surgery for IE in IVDU and non-IVDU patients.

Methods:
Using the prospective databases of two urban tertiary academic centers; 436 adult patients undergoing surgery for active IE between 2002-2014 were identified. Primary endpoints were death and valve-related complications.

Results:
Seventy-eight patients(17.9%) were IVDUs, with the proportion of IVDUs increasing after 2012 (14.8% to 26.1%, P=0.006). IVDUs were younger(35.9±9.9vs59.3±14.1yrs, P<0.001) and had fewer cardiovascular risk factors (hypertension, P<0.001; coronary diseases, P=0.087; renal dysfunction, P<0.001). They presented more frequently, however, with embolic events(46.2% vs. 29.9%, P=0.006), large(?10 mm) vegetations(70.5% vs. 49.8%, P<0.001), and multi-valvular involvement(82.1% vs. 73.1%, P<0.001). Early mortality was lower in IVDUs(3.8% vs. 13.7%, P=0.012), but overall survival rates were not different at 5years (83.5±5.0% vs 79.1±2.2%, P=0.21 respectively). Freedom from valve-related complications, however, was lower among IVDUs at 5years,(52.5±8.4% vs. 84.1±3.1%, P<0.001) mainly attributed to higher rates of reinfection(25.6% vs. 3.9%, P<0.001) and reoperation(23.1% vs. 4.7%, P<0.001). Event-free survival at 5years was lower in IVDUs (P=0.047, Figure). Multivariate analysis showed congestive heart failure, prosthetic IE, multi-valve IE and renal dysfunction as independent predictors of the composite of death and valve-related complications.

Conclusions:
The proportion of IVDUs among surgical patients with IE is increasing. Although IVDUs are young, with lower baseline cardiovascular risk burdens, long-term clinical outcomes are discouraging with a significant rate of reinfection.





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