Thorac Cardiovasc Surg 2016; 64(01): 002-005
DOI: 10.1055/s-0035-1551682
Original Cardiovascular
Georg Thieme Verlag KG Stuttgart · New York

High-Risk Cardiac Surgery in Patients with Intravenous Drug Abuse and/or Active Hepatitis C or HIV Infection: An Ethical Discussion of Six Cases

Laura Sophie Gansera
1   Department of Cardiology, Klinikum Augsburg, Augsburg, Bavaria, Germany
,
Edgar Eszlari
2   Department of Cardiovascular Surgery, Klinikum Bogenhausen, Munich, Bavaria, Germany
,
Oliver Deutsch
2   Department of Cardiovascular Surgery, Klinikum Bogenhausen, Munich, Bavaria, Germany
,
Walter Benno Eichinger
2   Department of Cardiovascular Surgery, Klinikum Bogenhausen, Munich, Bavaria, Germany
,
Brigitte Gansera
2   Department of Cardiovascular Surgery, Klinikum Bogenhausen, Munich, Bavaria, Germany
› Author Affiliations
Further Information

Publication History

20 September 2014

28 February 2015

Publication Date:
01 June 2015 (online)

Abstract

Objectives To discuss the dilemma of adequate decision making in patients with intravenous drug abuse and recurrent valve prosthesis infections or in patients with positive HIV or hepatitis C status. Ethical, social, and economic considerations, not only in terms of technical feasibility but also in terms of unpromising results and aspects of resources, are discussed. Thoughts are presented about the legitimation of cardiac surgery centers refusing to perform surgery in high-risk patients with HIV or hepatitis C infections.

Methods Presentation of six cases for discussion. Three patients were addicted to intravenous drugs and had recurrent prosthetic valve endocarditis, and the other three patients had either paravalvular leakage of a mitral valve prosthesis or acute aortic dissection or coronary artery disease. Five of these patients suffered from HIV/AIDS and infective hepatitis C. Four of these patients were refused by other centers due to high risk or a lack of capacity.

Results All six patients were operated during 2013. Mortality was 17%.

Conclusion Decision making in noncompliant drug addicts with recurrent prosthesis infection and in HIV-positive patients leads beyond surgical challenges to ethical and economic considerations.

 
  • References

  • 1 Sade RM. The primary obligation of physicians should be to their patients, not to society. J S C Med Assoc 2006; 102 (3) 81-83
  • 2 Council on Ethical and Judicial Affairs, American Medical Association. E-2.03: Allocation of limited medical resources. In: Code of Medical Ethics: Current Opinions with Annotations, 2008–2009 ed. Chicago, IL: American Medical Association; 2008: 9-10
  • 3 Perucci CA, Forastiere F, Rapiti E, Davoli M, Abeni DD. The impact of intravenous drug use on mortality of young adults in Rome, Italy. Br J Addict 1992; 87 (12) 1637-1641
  • 4 Kelleher MJ, Keown PJ, O'Gara C, Keaney F, Farrell M, Strang J. Dying for heroin: the increasing opioid-related mortality in the Republic of Ireland, 1980–1999. Eur J Public Health 2005; 15 (6) 589-592
  • 5 Yamaguchi H, Eishi K. Surgical treatment of active infective mitral valve endocarditis. Ann Thorac Cardiovasc Surg 2007; 13 (3) 150-155
  • 6 Wallace SM, Walton BI, Kharbanda RK, Hardy R, Wilson AP, Swanton RH. Mortality from infective endocarditis: clinical predictors of outcome. Heart 2002; 88 (1) 53-60
  • 7 Delay D, Pellerin M, Carrier M , et al. Immediate and long-term results of valve replacement for native and prosthetic valve endocarditis. Ann Thorac Surg 2000; 70 (4) 1219-1223
  • 8 United Kingdom Heart Valve Registry. The United Kingdom heart valve registry report 2000. London: United Kingdom Heart Valve Registry, Imperial College School of Medicine; 2002
  • 9 Frater RW. Surgical management of endocarditis in drug addicts and long-term results. J Card Surg 1990; 5 (1) 63-67
  • 10 Smyth B, Hoffman V, Fan J, Hser YI. Years of potential life lost among heroin addicts 33 years after treatment. Prev Med 2007; 44 (4) 369-374
  • 11 Smyth B, Fan J, Hser YI. Life expectancy and productivity loss among narcotics addicts thirty-three years after index treatment. J Addict Dis 2006; 25 (4) 37-47
  • 12 DiMaio JM, Salerno TA, Bernstein R, Araujo K, Ricci M, Sade RM. 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?. Ann Thorac Surg 2009; 88 (1) 1-8