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Semin Thorac Cardiovasc Surg. 2018 Aug 27. pii: S1043-0679(18)30162-X. doi: 10.1053/j.semtcvs.2018.07.016. [Epub ahead of print]

Recidivism Is the Leading Cause of Death Among Intravenous Drug Users Who Underwent Cardiac Surgery for Infective Endocarditis.

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Section of Cardiac Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut.
Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut.
Section of Cardiac Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut. Electronic address:


The proportional incidence of intravenous drug use (IVDU)-associated infective endocarditis (IE) cases requiring surgery has increased significantly, mirroring the national opioid crisis. Recidivism is common but its impact on postoperative outcomes is unclear. We aimed to evaluate short- and mid-term postoperative outcomes associated with recidivism in this population. We retrospectively reviewed 180 consecutive patients (54 IVDU and 126 non-IVDU) surgically treated for IE from 2011 to 2016. The institutional database was linked to the Connecticut Department of Public Health Death Index to capture statewide long-term mortality and causes of death. Regression models were fitted to evaluate the association between IVDU status and perioperative adverse events, mid-term survival, and causes of death. IVDU patients were younger and had fewer comorbidities. Diabetes, hypertension, peripheral vascular disease, and previous coronary artery bypass graft were less frequently present in IVDU patients compared to non-IVDU patients (P < 0.05 for all). The Society of Thoracic Surgeons mortality prediction score for IE was lower in IVDU patients (22.9 vs 33.6, P < 0.001). IVDU was associated with a significantly increased risk of perioperative adverse events (odds ratio 2.88, 95% confidence interval 1.02-8.12) and increased risk of mid-term mortality (hazard ratio 2.2, 95% confidence interval 1.04-4.78, P = 0.04). The leading cause of death in IVDU patients was related to recidivism whereas that of non-IVDU patients was related to chronic conditions. IVDU patients who underwent cardiac surgery for IE experienced higher risks of perioperative adverse events and inferior mid-term survival compared to non-IVDU, despite being younger and having less comorbidities. Deaths in IVDU cohort were predominantly due to recidivism. Efforts to improve long-term outcome of patients presenting with IVDU IE should include drug addiction intervention and other strategies to reduce recidivism.


cardiac surgery; endocarditis; opioid epidemic; recidivism

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