Ethical Dilemma: Should Continuous Intravenous Drug Use Affect Appropriate Management in Prosthetic Valve Endocarditis?

Abstract

Drug use is a major challenge that negatively impacts many aspects of health. The issue of drug use is growing with every passing day. Efforts to mitigate its use are countered by even more people succumbing to the intravenous drug use due to their relatively easy availability and patients' poor insight into their medical condition. Infective endocarditis (IE) is a condition with high mortality and morbidity. It requires prolonged treatment with antibiotics, and, under some special circumstances, surgical management is also necessitated. Intravenous drug users who get valve replacement after index IE episode may continue to use drugs despite our utmost efforts to prevent it. They can subsequently develop prosthetic valve endocarditis (PVE), which is one of the indications for surgical valve replacement, hence requiring a redo surgery. However, their irregular behavior can create reservations while considering a repeat valvular surgery and delay the appropriate treatment. This can increase morbidity and mortality from PVE in intravenous drug users with otherwise no or few comorbidities.

A 34-Year-Old Male Intravenous Drug User with a Third Episode of Tricuspid Valve Endocarditis Treated with Repeat Valve Surgery

“…This discussion stage is where many institutions reside today regarding the approach to redo valve replacement [ 12 , 13 ]. Numerous clinical guidelines and systematic reviews regarding infective endocarditis in the setting of IVDU address the medical and surgical needs of these patients [ 9 , 10 , 18 – 20 ]. However, the ethics behind these decisions are often not addressed.…”

“…The ethics underlying the decision to operate is not well defined in the literature. While some research has focused on the short- and long-term outcomes of IVDU patients who underwent 1 or more cardiac valve surgeries, there is a relative dearth of guidelines on benefits and risks of repeated cardiac operations from both a biological and ethical perspective in this patient population [ 6 – 10 ].…”

The opioid epidemic and endocarditis: Frontiers in the management of injection drug use–related endocarditis

“…In resource-rich countries such as the United States, surgeons might have the luxury of offering the operation for IDU-IE without immediate resource constraints. Such is often not the case for resource-poor countries 23 and as the extreme situations in the COVID pandemic taught us, even extremely wealthy countries like the United States are vulnerable to situations that call for triaging immediate life support such as a mechanical ventilator. 24 On a daily basis, cardiac surgeons engage themselves in the allocation of the donor heart, a scarce resource, even though the visceral weight of the decision is blunted by the nonhuman, algorithmic working of the organ allocation system.…”