Nguemeni Tiako Max Jordan, Mori Makoto, Bin Mahmood Syed Usman, Shioda Kayoko, Mangi Abeel, Yun James, Geirsson Arnar
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.
Semin Thorac Cardiovasc Surg. 2019 Spring;31(1):40-45. doi: 10.1053/j.semtcvs.2018.07.016. Epub 2018 Aug 27.
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.
因静脉注射毒品（IVDU）导致的感染性心内膜炎（IE）而需要手术治疗的病例比例显著增加，这与全国范围的阿片类药物危机相呼应。复发很常见，但其对术后结果的影响尚不清楚。我们旨在评估该人群中与复发相关的短期和中期术后结果。我们回顾性分析了2011年至2016年期间连续接受手术治疗的180例IE患者（54例IVDU患者和126例非IVDU患者）。机构数据库与康涅狄格州公共卫生部死亡指数相关联，以获取全州范围内的长期死亡率和死亡原因。采用回归模型评估IVDU状态与围手术期不良事件、中期生存率和死亡原因之间的关联。IVDU患者更年轻，合并症更少。与非IVDU患者相比，IVDU患者中糖尿病、高血压、外周血管疾病和既往冠状动脉旁路移植术的发生率更低（所有P值均<0.05）。IVDU患者的胸外科医师协会IE死亡率预测评分更低（22.9对33.6，P<0.001）。IVDU与围手术期不良事件风险显著增加（比值比2.88，95%置信区间1.02 - 8.12）以及中期死亡风险增加（风险比2.2，95%置信区间1.04 - 4.78，P = 0.04）相关。IVDU患者的主要死亡原因与复发有关，而非IVDU患者的主要死亡原因与慢性疾病有关。尽管IVDU患者更年轻且合并症更少，但与非IVDU患者相比，因IE接受心脏手术的IVDU患者围手术期不良事件风险更高，中期生存率更低。IVDU队列中的死亡主要归因于复发。改善IVDU IE患者长期预后的努力应包括药物成瘾干预和其他减少复发的策略。
