Surgical Outcomes of Infective Endocarditis among Intravenous Drug

Abusers: Results from Two Large Academic

CentersJoon Bum Kim1,3, Julius I. Ejiofor2, Maroun Yammine2, Sandra B.

Nelson1, Arthur Y. Kim1, Serguei I. Melnitchouk1, James D. Rawn2,

Marzia Leacche2, John G. Byrne2, Thoralf M. Sundt1

1Massachusetts General Hospital and 2Brigham and Women’s Hospital, Harvard Medical School, Boston, MA

3Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea

Disclosure

• Joon Bum Kim: 62nd AATS Graham Traveling Fellow

• Thoralf M. Sundt: Consultant for Thrasos Therapeutics

IV Heroin Use in the United States

314,000

681,000

Heroin-Related Deaths

Richard et al. N Eng J Med 2015Major Public Heath Issue

6,000 deaths

Background

• Infective endocarditis among IVDUs:

- 100 to 400 per 100,000 person-years (50-100 fold ↑)

• Risks of Recidivism and Reinfection

• Shorter life expectancy of IVDUs:

Drug intoxication, violence and suicide

56% of initiators become chronic continuous users

Mortality rate 6.9 times greater

IVDAs lost an average 18.3 years of life….

Smith B, et al. J Addict Dis 2006

Joe GW, et al. Am J Public Health 1987

Background

• Questions about futility of aggressive, resource-intensive

surgical procedures for active IVDUs

Study Aim

• To evaluate

- Trends in IVDUs among surgical patients with IE

- Outcomes of surgery in IVDUs

in the interest of informing decisions on optimal

management strategy for these patients

Methods

• Data were pooled from the prospective cardiac surgery

databases of two Harvard Medical School affiliated

Hospitals: MGH and BWH

• Queried to identify adult patients (age ≥ 17 years)

undergoing heart valve operations due to active infective

endocarditis from January 2002 through August 2014

Methods

• Follow-up information:

Data from Partners Health Care system

( centralized clinical data registry of all patients encountered)

• Social Security Death Index search if necessary

• IRB approval: waived informed consent

Subject Patients

• There were 436 patients who met the enrollment criteria

from the two centers (MGH, n=192; BWH, n=244).

• Overall, 78 patients (17.9%) were current IVDUs

IV Drugs of Abuse

Heroinn=33

Heroin+Cocainen=19

Heroin+Cocaine+othersn=5

Cocainen=18

Amphetaminen=2

Other polysubstancesn=1

IV Drugs of Abuse

Heroinn=57 (73.1%)

IV Drugs of Abuse

Cocainen=42 (53.8%)

Proportions of IVDUs among All Surgical Patients with IE

Baseline Characteristics

IVDU

N=78

Non-IVDU

N=358

P value

Age, yr 35.9±9.9 59.3±14.1 <0.001

Female gender 38.5% 31.0% 0.20

Body mass index, kg/m2 26.7±7.9 27.8±7.0 0.24

Ethnicity 0.83

White 87.2% 89.1%

Black 6.4% 3.9%

Hispanic 1.3% 2.5%

Asian 1.3% 1.4%

Others 3.8% 3.1%

Age, yr 35.9±9.9 59.3±14.1 <0.001

Baseline Characteristics

IVDU

N=78

Non-IVDU

N=358

P value

Diabetes mellitus 7.6% 20.7% 0.027

Hypertension 20.5% 62.8% <0.001

NYHA functional class III or IV 44.9% 49.4% 0.46

On dialysis 3.8% 8.7% 0.24

Creatinine clearance, mL/min/1.73m2 103.5±53.6 73.1±44.1 <0.001

Cigarette smoking history 67.9% 39.7% <0.001

Current smoking 35.9% 8.1% <0.001

Baseline Characteristics

IVDU

N=78

Non-IVDU

N=358

P value

Embolic events 46.2% 29.9% 0.006

Causative pathogens 0.14

Viridans Streptococci 20.5% 24.9%

Other streptococci 2.6% 9.2%

Staphylococcus, methicillin-susceptible 25.6% 20.7%

Staphylococcus, methicillin-resistant 12.8% 18.2%

Entercococcus 15.4% 13.4%

Other 11.5% 6.7%

Negative culture 11.5% 7.0%

Baseline Characteristics

IVDU

N=78

Non-IVDU

N=358

P value

Single valve affected 73.1% 82.1% 0.068

Aortic valve 41.0% 55.9%

Mitral valve 16.7% 24.0%

Tricuspid valve 15.4% 2.2%

Multiple valves affected, 26.9% 17.9% 0.068

Aortic + Mitral 16.7% 15.1%

Aortic + Tricuspid 3.8% 1.7%

Mitral + Tricuspid 6.4% 0.6%

Aortic +Mitral + Tricuspid 0 0.6%

Baseline Characteristics

IVDU

N=78

Non-IVDU

N=358

P value

Right-side valve involvement 25.6% 5.0% <0.001

Vegetation diameter ≥10mm 70.5% 49.7% <0.001

Abscess formation 23.1% 33.8% 0.066

Prosthetic endocarditis 21.8% 30.7% 0.12

Severe valve dysfunction valves 75.6% 68.4% 0.21

Left ventricular ejection fraction, % 59.5±10.4 60.1±10.9 0.64

Emergent surgery 20.5% 23.2% 0.61

On IABP 3.8% 5.0% >0.99

Surgical Procedures

IVDU

N=78

Non-IVDU

N=358

P value

Primary procedure 0.87

Valve repair 12.8% 9.8%

Valve replacement, mechanical 23.1% 22.6%

Valve replacement, bioprostheses 44.9% 47.8%

Valve replacement, allograft 19.2% 19.8%

Associated procedures

Aorta replacement 6.4% 18.4% 0.007

CABG 12.8% 15.6% 0.60

Aortic root replacement 24.4% 26.8% 0.78

Follow-up

• Data on mortality: 100% complete

- Median, 52.3 months (IQR, 14.0-100.0 months)

- 2165.4 patient-years

• Data on valve-related complications: 76.4% complete

- Median, 29.4 mo (IQR, 4.7-72.6 mo)

- 570 patient-years

Survival

3.8%

13.7%

Early mortality

P=0.012 P=0.39

Freedom from Reinfection and Reoperation

Freedom from EventEvent-free Survival

< 10%

Age-Adjusted OutcomesIVDUs vs. Non-IVDUs

Adjusted

HR 95% CI P value

Early mortality 0.53 0.11-1.78 0.34

Late mortality 2.77 1.09-6.72 0.031

Valve related complications 3.07 1.66-5.68 <0.001

Valve re-infection 5.36 2.37-12.13 <0.001

Valve reoperation 2.99 1.31-6.79 0.009

Thromboembolism 2.03 0.58-7.02 0.27

Hemorrhage 2.46 0.57-10.61 0.23

IVDU Subgroup: Reinfection

N=78

Surgical: n=14 Medical: n=14

N=28 (35.9%)

Reinfection

Early death: n=0

Late death: n=1

Early death: n=3

Late death: n=3

ICH in 3Profound sepsis in 2Cardiac arrest in 1In-hospital IVDU in 3Resolution in 5

Limitations

• Retrospective analyses

• Selection bias in the decision to undertake surgery

• Experiences confined to urban tertiary academic centers

• Significant follow-up loss

Conclusions

• IVDUs among surgical patients with IE is increasing

• Although IVDUs are young, with lower cardiovascular risk

burdens, long-term clinical outcomes are discouraging:

> 5-fold increase in reinfection risk

> 2-fold increase in late death

• This information should be considered when making

decisions regarding operative intervention on IE among IVDU

Thank you