The Ethics in Repeat Heart Valve Replacement Surgery

Abstract

The treatment of patients with intravenous drug use (IVDU) has evolved to include a wide range of medications, psychiatric rehabilitation, and surgical interventions, especially for life-threatening complications such as infective endocarditis (IE). These interventions remain at the discretion of physicians, particularly surgeons, whose treatment decisions are influenced by several medical factors, unfortunately not without bias. The stigma associated with substance use disorder is prevalent, which leads to significant biases, even in the healthcare system. This bias is heightened when IVDU patients require repeat valve replacement surgeries for IE due to continued drug use. Patients who receive a valve replacement and continue to use illicit drugs intravenously often return to their medical providers, months to a few years later, with a reinfection of their bioprosthetic valve; such patients require additional surgeries which are at the center of many ethical discussions due to high mortality rates, for many complex medical and social reasons, associated with continuous chemical dependency after surgical interventions. This chapter examines the ethics of repeat heart valve replacement surgery for patients who are struggling with addiction. Considerations of justice, the fiduciary therapeutic relationship, and guiding ethical principles justify medically beneficial repeat heart valve replacement surgeries for IVDU patient populations.

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

“…First-time isolated TV infective endocarditis patients have operative mortality rates of 0–15% [ 8 ]. The 2- and 5-year survival rates following cardiac surgery for IVDU infective endocarditis are 79% and 59%, respectively [ 9 ]. With regard to morbidity, IVDU patients with TV infective endocarditis who undergo cardiac surgery are at risk for reinfection [ 8 ].…”

“…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.…”

Principlist approach to multiple heart valve replacements for patients with intravenous drug use-induced endocarditis

“…Along these lines, Sarah Hull and Farid Jadbabaie argue that medical institutions should not offer a patient a third replacement valve to ‘establish a futility threshold in an effort to balance our obligations to individual patients versus society’ 11. Aultman et al maintain that if ‘the patient is unwilling to commit to a comprehensive treatment programme after thorough guidance by the healthcare team, then it is ethically justifiable to refuse surgery’ 12…”

Surgeons' re-operative valve replacement practices in patients with endocarditis due to drug use

“…Recommendations for early surgery in patients with IE-IVDU, along with integrated, comprehensive addiction treatment, have been made in addition to the use of existing general United States (U.S.) and European surgical intervention guidelines for IE. [ 6 7 8 9 ]…”