Should Addicts Get Repeat Valve Surgeries for Endocarditis?

NEW ORLEANS -- Whether patients with opioid addiction should receive repeat valve replacements for infective endocarditis was debated here at the Society of Thoracic Surgeons (STS) meeting, with both sides agreeing that not enough is being done to treat the underlying addiction disease of these patients.

A woman with a known drug addiction is placed in a well-reputed drug rehabilitation program after receiving a surgical valve for endocarditis. She does not keep her appointments at the rehab center nor does she show up for surgical follow-up visits after discharge. Months later, she goes to the emergency department with high fever, chills, and needle marks indicating IV drug use. She admits to using heroin within a month after leaving the hospital.

Robert Sade, MD, of Medical University of South Carolina in Charleston, posed the question during an ethics forum: What would operators do in this hypothetical situation? Should the patient get a second valve replacement?

Arguing that the ethics favor giving the patient a second operation was Eric Roselli, MD, of Cleveland Clinic.

"We have to look at the patient as a person and respect that they have other comorbid conditions," he said. "For this patient in particular, we have to respect the fact that she has addiction disease."

"She has a life-threatening problem, so we have an obligation to treat that now," he said.

Roselli noted that at his institution, the proportion of patients who inject drugs has more than tripled in just a decade since the start of the opioid epidemic. Cleveland Clinic has responded with a team approach that utilizes a psychiatry/addiction nurse practitioner (NP) inpatient service.

"We do okay with saving these people's lives," he told the audience. "But 3 to 6 months post is a very high risk period for death or relapse. Beyond this high-risk period, outcomes are comparable to other patients."

"What we don't do okay with is the treatment of addiction," according to Roselli. "It's a problem that we have not begun to solve as well as we should. Only 10% of patients with addictions, other than nicotine, receive treatment."

On "the dark side," in his own words, was G. Michael Deeb, MD, of University of Michigan Medical Center in Ann Arbor, who questioned whether treating the result of a disease without treating the actual cause is good medicine.

He asked STS session participants what to make of a similar dilemma: a patient with an acute exacerbation of her Crohn's disease who refuses to comply with the recommendation to undergo a bowel resection with ileostomy and mucus fistula formation. Six months later, she comes to the hospital with endocarditis.

The surgeon may feel "medically justified" in not offering surgery for the patient with Crohn's disease, but not so for the patient with opioid use disorder -- even though "opioid use disorder and endocarditis are separate individual diagnoses that are irrevocably linked and cannot be treated as separate and independent entities," Deeb suggested.

It may be that the surgeon suffers from the social stigma of being perceived as withholding surgery secondary to moral disapproval of the patient's lifestyle and actions, indicating possible personal bias, he said.

"If a patient refuses definitive therapy for their primary medical problem, then it is hopeless to continually treat complications with high-risk, high-trauma, and minimal-yield surgeries," he argued.

Even so, "we need to allow the patient to consent not only to have surgery but to refuse surgery," Roselli said, stressing the "informed" part of "informed consent."

He added that medication-assisted treatment (MAT) works well for opioid addiction.

Deeb emphasized the importance of MAT, arguing that surgery and antibiotics together do not comprise complete treatment for infective endocarditis associated with drug injection.

It is really when a person has maximal therapy with MAT and fails this that Deeb wouldn't reoperate on them, he said. He noted the literature showing that medical therapy matches surgery for high-risk candidates for valve replacement, and said he would operate if there weren't any existing medical therapies.

During the Q&A part of the session, audience member Andrea Carpenter, MD, PhD, of UT Health San Antonio, commented that the finite resources available to healthcare mean that giving a patient with a drug addiction another valve replacement would mean withholding the procedure from another person.

"A lot of countries having gone to rationing healthcare, and the U.S. is moving that way," Roselli acknowledged. "We have an obligation to the whole community ... and I think we do have to be careful not to be providing futile care."

"I'm just a simple country heart surgeon," he quipped. "I don't make decisions about whether addiction disease has come to an end. That's why we have a psychiatric team."

"I don't want to make the decision, but eventually we should. Because I don't want another [person] making it for us," Carpenter responded, noting that insurance companies are the ones today who ultimately make the decision.