Episode 2: Broken Hearts

Intravenous drug use is breaking hearts. Patients return for recurrent valve replacements because of continued drug use. Is the surgeon obligated to offer multiple valves to patients?

Infective endocarditis is an infection of the inner lining of the heart and the heart valves. The infection is introduced by a variety of conditions. Some causes like hemodialysis and long term indwelling catheters can’t be attributed to the patient’s actions, whereas others like IV drug use can.

As promised on the podcast, here's the modified Duke Criteria:

Diagnostic: 2 Major criteria and 0 Minor criteria

1 Major criteria and 3 Minor criteria

0 Major criteria and 5 Minor criteria

Major Diagnostic Criteria:

- Positive blood culture for typical infective endocarditis organisms from 2 cultures drawn >12 hours apart.

- Echo showing vegetations, abscesses, partial dehiscence of prosthetic valve or a new valvular regurgitation.

- Single positive blood culture for Coxiella burnetii or IgG antibodies for the same.

Minor Diagnostic Criteria:

- Predisposing heart condition or IV drug use

- Temp >100.4F

- Vascular phenomena: subconjunctival hemorrhage, Janeway lesions etc.

- Immunological phenomena: glomerulonephritis, Osler nodes, Roth spots, etc.

- Microbiological evidence: Positive blood culture that do not meet the major criteria.

You can check out this link that has the questionnaire that rules the diagnosis in or out based on the Duke criteria: https://www.merckmanuals.com/medical-calculators/EndocarditisMod.htm

Here's the ethical framework:

This could be used for any ethical question you're trying to answer.

1. What is the ethical dilemma? Should surgeons perform repeat valve replacements in patients with IE who go back to using IV drugs?

2. What knowledge is available of the outcomes of the surgery vs the alternatives (medical therapy or otherwise)?

3. Are the decisions regulated by laws or guidelines?

4. Who are the parties involved?

5. What are the potential burdens and benefits for the parties involved?

6. Whose interests are in the conflict?

7. Which principles and values are in conflict?

Please feel free to share your thoughts in the forum. I hope to see you next time on Learn With Me.

If you would like to read some of the great articles I used for this episode, check out the references below:

1. Firstenberg MS. The Ethics in Repeat Heart Valve Replacement Surgery. Advanced Concepts in Endocarditis, 2018.

2. Bates MC, Annie F, Jha A, Kerns F. Increasing incidence of IV‐drug use associated endocarditis in southern West Virginia and potential economic impact. Clinical Cardiology; 42(4), p 432-437/

3. DiMaio J et. al. Ethical Obligation of Surgeons to Noncompliant Patients: Can a Surgeon Refuse to Operate on an Intravenous Drug-Abusing Patient With Recurrent Aortic Valve Prosthesis Infection? The Annals of Thoracic Surgery; 88(1), p 1-8.

4. Hayden M, Phil M. Repeat Valve Surgery in Recurrent Injection Drug Use Associated Infective Endocarditis: A Qualitative Study of Provider Attitudes and Approaches and a Normative Analysis of Relevant Bioethical Concepts.

5. McDonald JR. Acute Infective Endocarditis. Infect Dis Clin North Am. 2009 September ; 23(3): 643–664. doi:10.1016/j.idc.2009.04.013.

6. Guerin R, et. al. Considerations in Multiple Valve Replacement for Infective Endocarditis Secondary to IV Drug Use.Innovations in Clinical Ethics: A working Un-conference. https://clevelandclinic.org/unconference

7. Miljeteig I, et.al. Should patients who use illicit drugs be offered a second heart-valve replacement? Medical Ethics. Tidsskr Nor Legeforen nr. 9, 2013; 133: 977–80