title: High-Risk Cardiac Surgery in Patients with Intravenous Drug Abuse and/or Active Hepatitis C or HIV Infection: An Ethical Discussion of Six Cases.
abstract: OBJECTIVE
  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%.
  
  
  CONCLUSIONS
  Decision making in noncompliant drug addicts with recurrent prosthesis infection and in HIV-positive patients leads beyond surgical challenges to ethical and economic considerations.
authors.affiliation: Department of Cardiology, Klinikum Augsburg, Augsburg, Bavaria, Germany.
authors.forename: Laura Sophie
authors.initials: LS
authors.lastname: Gansera
authors.affiliation: Department of Cardiovascular Surgery, Klinikum Bogenhausen, Munich, Bavaria, Germany.
authors.forename: Edgar
authors.initials: E
authors.lastname: Eszlari
authors.affiliation: Department of Cardiovascular Surgery, Klinikum Bogenhausen, Munich, Bavaria, Germany.
authors.forename: Oliver
authors.initials: O
authors.lastname: Deutsch
authors.affiliation: Department of Cardiovascular Surgery, Klinikum Bogenhausen, Munich, Bavaria, Germany.
authors.forename: Walter Benno
authors.initials: WB
authors.lastname: Eichinger
authors.affiliation: Department of Cardiovascular Surgery, Klinikum Bogenhausen, Munich, Bavaria, Germany.
authors.forename: Brigitte
authors.initials: B
authors.lastname: Gansera
mesh_terms: D000328:Adult; D001291:Attitude of Health Personnel; D006348:Cardiac Surgical Procedures / Q000009:adverse effects / Q000191:economics / Q000941:ethics*; D002318:Cardiovascular Diseases / Q000175:diagnosis / Q000191:economics / Q000601:surgery* / Q000821:virology; D060085:Coinfection; D003362:Cost-Benefit Analysis; D055030:Drug Users; D005260:Female; D015658:HIV Infections / Q000150:complications* / Q000175:diagnosis / Q000191:economics / Q000821:virology; D007722:Health Knowledge, Attitudes, Practice; D006526:Hepatitis C / Q000150:complications* / Q000175:diagnosis / Q000191:economics / Q000821:virology; D017721:Hospital Costs / Q000941:ethics; D006801:Humans; D008297:Male; D008875:Middle Aged; D010349:Patient Compliance; D018579:Patient Selection / Q000941:ethics*; D012008:Recurrence; D016079:Refusal to Treat / Q000941:ethics; D012086:Reoperation; D018570:Risk Assessment; D012307:Risk Factors; D015819:Substance Abuse, Intravenous / Q000150:complications* / Q000175:diagnosis / Q000191:economics / Q000534:rehabilitation; D055815:Young Adult