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Seeing the entire forest in endocarditis

Open ArchivePublished:June 03, 2016DOI:https://doi.org/10.1016/j.jtcvs.2016.05.050
      Figure thumbnail fx1
      Viewing the US forest organic biomass from NASA's earth observatory. Sometimes we need to step back to see the entire problem.
      Viewing the US forest organic biomass from NASA's earth observatory. Sometimes we need to step back to see the entire problem.
      See Articles page 677 and 832.
      See Editorial Commentary page 842.
      In the current issue of the Journal,
      • Ferraris V.A.
      • Sekela M.E.
      Missing the forest for the trees: the world around us and surgical treatment of endocarditis.
      Drs Ferraris and Sekela present a timely and impassioned overview of the current epidemic of endocarditis secondary to intravenous drug abuse (IVDA). This story is a sad one, not only for the Appalachian middle class highlighted in this review, but for thousands of patients and their families afflicted at an accelerated rate across the United States. The recent influx of inexpensive options for those tormented by IVDA provides both motive and opportunity for an insidious penetration across the geographic and socioeconomic spectrum.
      For the last several years, many of us practicing in urban environments have seen a substantial increase in volume of IVDA-related endocarditis. Once rare, these cases have become so common that they occur several times a week in certain centers. Frequent socioeconomic associations lead to a perception of presumptive regional phenomenon. Although many of us have acknowledged the gravity and depth of the problem, we commonly and naturally revert to addressing this at a patient-level or center-level. Many experienced surgeons realize that it is much more than an inability to “see the forest for the trees” but one of an inability to address the root cause—the epidemic of IVDA.
      As the authors
      • Ferraris V.A.
      • Sekela M.E.
      Missing the forest for the trees: the world around us and surgical treatment of endocarditis.
      eloquently point out, this problem has become pervasive across all regions and economic strata. The documented up-tick in US death rates is evidence enough for a more aggressive national policy on hard drugs. As physician leaders in our communities, we have an opportunity to address our regional “forest” populations by becoming more active in state and national political discourses. As a consequence of this epidemic, IVDA has now achieved the status of a national crisis. National economic development, more effective local intervention, and legislative efforts to limit narcotic prescriptions are essential.
      Perhaps the most direct contribution that we as cardiothoracic surgeons can make is in the form of improved management of valvular endocarditis. It is clear that timely mitral and tricuspid valve repair for endocarditis achieves better early and late outcomes,
      • Ruttmann E.
      • Legit C.
      • Poelzl G.
      • Mueller S.
      • Chevchitch O.
      • Cottogni M.
      • et al.
      Mitral valve repair provides improved outcome over replacement in active infective endocarditis.
      • Shang E.
      • Forrest G.N.
      • Chizmar T.
      • Chim J.
      • Brown J.M.
      • Zhan M.
      • et al.
      Mitral valve infective endocarditis: benefit of early operation and aggressive use of repair.
      and techniques for reconstruction of destroyed aortic valves are maturing.

      Mazzitelli D, Rankin JS, Schreiber C, Lange R. Aortic valve reconstruction for endocarditis using tissue-engineered bovine pericardium. Available at: http://www.ctsnet.org/article/aortic-valve-reconstruction-endocarditis-using-tissue-engineered-bovine-pericardium. Accessed March 15, 2016.

      Converting predominantly to valve repair instead of replacement whenever possible may have substantive impact.
      • Gammie J.S.
      • O'Brien S.M.
      • Griffith B.P.
      Surgical treatment of mitral valve endocarditis in North America.
      In the final analysis, the dominant issue is prevention of recidivism,
      • Kim J.B.
      • Ejiofor J.I.
      • Yammine M.
      • Ando M.
      • Camuso J.M.
      • Youngster I.
      • et al.
      Surgical outcomes of infective endocarditis in intravenous drug users.
      which produces a major resource strain across several aspects of health care: ethical, social, and financial. In many US hospitals, IVDA-related endocarditis heart teams are being developed. This structure involves surgeons, cardiologists, infectious disease specialists, drug addiction psychiatrists, social workers, medical ethicists, and palliative care specialists. Together, they cultivate pathways of evidence-based management for first-time IVDA-related endocarditis facilitating early diagnosis, and aggressive antimicrobial and surgical therapy. This is followed by engaging regional systems of outpatient drug rehabilitation and social worker home follow-up in an attempt to mitigate medical noncompliance and recidivism.
      When a relapse occurs, and patients present with recurrent IVDA-related endocarditis after recent valve operation, it is often the surgeon who is placed in the difficult position to decide when and whether to reoperate, despite a foreknowledge of poor long-term prognosis regardless of a technically excellent result.
      • Kim J.B.
      • Ejiofor J.I.
      • Yammine M.
      • Ando M.
      • Camuso J.M.
      • Youngster I.
      • et al.
      Surgical outcomes of infective endocarditis in intravenous drug users.
      Heart teams can provide surgeons much-needed assistance, in the form of standardized protocols and hospital support. Palliative care definitely has a role in many of these patients, but it is difficult to tell a 30-year-old habitual IV drug abuser and his or her family, when he or she presents for a third or fourth valve reoperation for IVDA-related endocarditis, that nonsurgical palliation is recommended. All stakeholders need to develop agreed-on algorithms and a system that does not leave the surgeon isolated in these decisions. In-depth discussions of long-term plans and approaches should be completed with the patients before his or her first operation. Despite these efforts, rates of recidivism remain high. If an active national program is not provided to minimize IVDA long-term, the impact to health care will only magnify, and we will miss this opportunity to step back and see the entire forest and not just the trees.

      References

        • Ferraris V.A.
        • Sekela M.E.
        Missing the forest for the trees: the world around us and surgical treatment of endocarditis.
        J Thorac Cardiovasc Surg. 2016; 152: 677-680
        • Ruttmann E.
        • Legit C.
        • Poelzl G.
        • Mueller S.
        • Chevchitch O.
        • Cottogni M.
        • et al.
        Mitral valve repair provides improved outcome over replacement in active infective endocarditis.
        J Thorac Cardiovasc Surg. 2005; 130: 765-771
        • Shang E.
        • Forrest G.N.
        • Chizmar T.
        • Chim J.
        • Brown J.M.
        • Zhan M.
        • et al.
        Mitral valve infective endocarditis: benefit of early operation and aggressive use of repair.
        Ann Thorac Surg. 2009; 87: 1728-1734
      1. Mazzitelli D, Rankin JS, Schreiber C, Lange R. Aortic valve reconstruction for endocarditis using tissue-engineered bovine pericardium. Available at: http://www.ctsnet.org/article/aortic-valve-reconstruction-endocarditis-using-tissue-engineered-bovine-pericardium. Accessed March 15, 2016.

        • Gammie J.S.
        • O'Brien S.M.
        • Griffith B.P.
        Surgical treatment of mitral valve endocarditis in North America.
        Ann Thorac Surg. 2005; 80: 2199-2204
        • Kim J.B.
        • Ejiofor J.I.
        • Yammine M.
        • Ando M.
        • Camuso J.M.
        • Youngster I.
        • et al.
        Surgical outcomes of infective endocarditis in intravenous drug users.
        J Thorac Cardiovasc Surg. 2016; 152: 832-841.e1

      Linked Article

      • Missing the forest for the trees: The world around us and surgical treatment of endocarditis
        The Journal of Thoracic and Cardiovascular SurgeryVol. 152Issue 3
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          There has been a dramatic increase in intravenous drug abuse (IVDA)–related deaths in midlife Americans. Nowhere is this more profound than in rural Appalachia, with Kentucky in the midst of the epidemic. The causes of this finding are multifactorial and likely related to social, economic, legal, and population factors. Evidence suggests that the economic middle class is shrinking. The traditionally white midlife demographic that used to comprise more than 80% of the US middle class now accounts for less than 60%.
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      • The vagaries of patient selection in cardiovascular surgery
        The Journal of Thoracic and Cardiovascular SurgeryVol. 152Issue 3
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          People who inject drugs face increased risk of dying from both acute and chronic illnesses—in a pooled analysis they were more than 14 times more likely to die per year than similar persons who did not inject drugs.1 The most common causes of death are drug-related, unintentional injuries, and suicide (accounting for more than 85% of deaths).2 Infections (predominantly bloodborne viral illnesses, but including endocarditis and other bacterial infections) account for <10% of deaths. If injection of drugs confers such negative prognosis why, as Kim and colleagues report,3 is the 10-year survival after surgery for endocarditis in patients who inject drugs similar to that of patients with endocarditis who did not inject drugs (70% vs 69%)? This occurred despite a high incidence of valve reinfection in the drug-injecting group (60% by 8 years).
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      • Surgical outcomes of infective endocarditis among intravenous drug users
        The Journal of Thoracic and Cardiovascular SurgeryVol. 152Issue 3
        • Preview
          With increasing prevalence of injected drug use in the United States, a growing number of intravenous drug users (IVDUs) are at risk for infective endocarditis (IE) that may require surgical intervention; however, few data exist about clinical outcomes of these individuals.
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