Case Presentation: A 44-year-old male with a medical history of active injection drug use (IDU) and three prior admissions for native mitral valve endocarditis was admitted to the hospital for sepsis. On physical examination, the patient had JVP elevated to 10cm, bibasilar crackles and 2+ pitting peripheral edema. Transesophageal echocardiogram (TEE) revealed a large vegetation on the mitral valve, severe mitral regurgitation, perforation of leaflet P1 and a perivalvular abscess. The patient underwent valvular replacement with a bioprosthetic valve and IV vancomycin was given for six weeks. He was discharged with cardiothoracic surgery and infectious disease follow up. Six months later, the patient was readmitted to the hospital for confusion and left-sided weakness. He reported IDU after the previous discharge. CT head revealed a focal hypodensity of right basal ganglia. A TEE showed vegetations on the bioprosthetic mitral valve with leaflet destruction and a large perivalvular abscess. The patient was started on IV vancomycin. Cardiothoracic surgery felt that he would not be a good surgical candidate due to the extensive involvement of the abscess which would place the patient at increased risk of death with the surgery. The patient was transferred to another facility for further surgical evaluation and care.

Discussion: Indications for surgery for infective endocarditis include valve dysfunction causing heart failure; development of abscess, fistula or heart block; difficult-to-treat pathogen; persistent bacteremia; and recurrent embolization with persistent vegetation despite appropriate antibiotic therapy. The decision for surgical intervention in a patient with IDU infective endocarditis (IDU-IE) can be challenging, and there is limited literature to support clinical decision making in this circumstance. Our patient met criteria for surgery due to development of abscess and heart failure though had actively used injection drugs after the initial valve replacement surgery leading to bioprosthetic valve degeneration and perivalvular abscess. This led to a challenge in management on whether to repeat a valvular surgery.As medical providers, we have an ethical obligation to treat all the patients in need. Often, however, patient actions can negatively impact their health, jeopardizing their outcomes. Such outcomes can have a significant economic burden on the healthcare system. In the situation of recurrent complications from ongoing substance abuse, providers are frequently faced with ethical dilemmas surrounding justice and resource allocation.  These may be coupled with valid concerns about medical futility should substance abuse continue. In these situations, however, the principle of beneficence should guide decision making and necessary treatments should not be withheld.  This applies also to cases of IDU-IE. Valve replacement coupled with intensive substance abuse treatment should be offered to patients who have accepted indications for valvular surgery.

Conclusions: Ethical dilemmas arise routinely in the hospital practice and medical providers are required to avoid medical futility, but following the principle of beneficence is vital in such circumstances.