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Department of Cardiothoracic Surgery, Erasmus Medical Center, Room 575, PO Box 2040, 3000 CA Rotterdam, The Netherlands
(Email: m.mokhles{at}erasmusmc.nl).
Although infective endocarditis (IE) is the second major acute complication of intravenous drug use [1], few studies are available on clinical outcome and the role of surgical intervention in patients with this condition.
Rabkin and colleagues [2] performed a retrospective review of 197 consecutive operations for IE at a single institution over an 11 year time period. The article nicely compares the differences in outcome between intravenous drug users (IVDUs; n = 64) and non-IVDUs (n = 133). Survival rate after 5 years of follow-up was 47% for IVDUs and 71% for non-IVDUs. It is remarkable that the survival rate for non-IVDUs after 10 years of follow-up is significantly lower than in a recent study from our institution (52% versus 71%) [3], while the patient characteristics seems to be comparable.
The authors indicate that bioprostheses are reasonable for IVDUs undergoing valve-replacement for IE regardless of age; however, the follow-up duration is simply too short to draw such a definite conclusion. With a median follow-up duration of less than 4 years, it is impossible to make any sensible statement about the durability of bioprostheses in IVDUs. In addition, it can be hypothesized that bioprostheses that show degeneration are more susceptible to infection, whereas the risk of bacteremia is already increased in IVDUs. This can ultimately lead to higher reoperative hazard for IVDUs with bioprosthetic valves compared to non-IVDUs with bioprosthetic valves. Long-term follow-up studies are needed to confirm the results of this study and to assess whether bioprostheses are indeed the desirable choice in IVDUs undergoing valvular surgery.
The present study also confirms that right-sided valvular infections are no longer the hallmark of IE in IVDUs, as some other recent clinical series have shown [4]. Almost 74% of the patients in the IVDU cohort had exclusively left-sided lesions. The reason for this changing pattern is not exactly clear, but the authors speculate that referral bias with right-sided infections managed more often medically might explain this shift. Other studies have shown that certain microorganisms are more often associated with left-sided endocarditis in IVDUs (eg, Enterococcus and Streptococcus species) [5, 6] and that female IVDUs are more prone to mitral valve endocarditis because of increased prevalence of subclinical mitral valve prolapse [7].
Despite the limitations (eg, retrospective nature of the study, sample size, and follow-up duration of IVDUs), the authors made an excellent effort to analyze the challenging problem of infective endocarditis in IVDUs. The issue of IE in IVDUs can create a major challenge to heart surgeons. The main reason for this challenge is the potential recurrence of drug use, which in turn increases the risk of recurrent IE. Unfortunately, operations are often expensive stop-gap measures. Future studies with longer follow-up duration are desirable to assess long-term prognosis of IVDUs with IE and to confirm the results of this study.
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