Ann Thorac Surg 2003;78:695-697
© 2003 The Society of Thoracic Surgeons
Case report
Jehovah's witnesses requiring complex urgent cardiothoracic surgery
Richard L. Holta,
Tomas D. Martin, MDa,
Philip J. Hess, MDa,
Thomas M. Beaver, MDa,
Charles T. Klodell, MDa*
a Division of Thoracic and Cardiovascular Surgery, University of Florida College of Medicine Health Science Center, Gainesville, Florida, USA
Accepted for publication July 30, 2003.
* Address reprint requests to Dr Klodell, Division of Thoracic and Cardiovascular Surgery, University of Florida College of Medicine, Health Science Center, PO Box 100286, Gainesville, FL 32610-0286, USA
e-mail: klodell{at}surgery.ufl.edu
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Abstract
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Blood-sparing surgical technique and perioperative medical management allows complex surgery in Jehovah's Witnesses. The authors review four cases of urgent cardiothoracic surgery performed on Jehovah's Witnesses. No lasting sequelae associated with either bleeding or end-organ ischemia were noted. Cardiopulmonary bypass management, meticulous hemostatic operative technique, and pharmacologic support of hemostasis and erythropoiesis permit this complex surgery.
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Introduction
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The Jehovah's Witnesses, numbering greater than 5 million in the United States, refuse blood component transfusion as part of their religion. This stems from interpretation of biblical passages, not from antipathy toward medicine. The following cases are presented to demonstrate the various strategies used to permit complex cardiothoracic surgery in Jehovah's Witnesses. Perioperative pharmacologic management of erythrocyte mass and coagulation is of paramount importance. Aprotinin (Trasylol; Bayer Corp, West Haven, CT) has proven effective not only in reducing transfusion requirement, but also may counteract bypass-related inflammatory response [1]. The full Hammersmith regimen of 6 million total KIU may be considered acceptable, if not standard, in Jehovah's Witness patients [2]. Technically, fastidious hemostatic operative technique, the limited use of laparotomy pads and discard suction, and reduced blood sampling for laboratory tests minimizes "lost" blood. The use of small-volume oxygenators and small-diameter tubing, retrograde autologous priming, and intraoperative autologous donation has become fairly standard [3]. Reclamation of autologous blood loss and infusion by means of continuous circuit of salvaged cells also aid in maintaining intraoperative hematocrit [4]. The liberal use of ultrafiltration limits hypervolemic dilutional anemia, and aids in the preservation of hemostatic blood components.
The patients in the following cases all agreed to intraoperative hemodilution as well as the reinfusion of blood from a cell-saving device.
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Case reports
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Patient 1
A 38-year-old female Jehovah's Witness with a 6-week history of shortness of breath was noted to have evolving heart failure secondary to left-sided Streptococcus viridans endocarditis. Antibiotic therapy had been initiated 3 weeks before referral, to which regimen erythropoietin and iron were added. Echocardiogram revealed a markedly regurgitant aortic valve and a flail anterior mitral leaflet. Medical management was continued to permit optimization of red blood cell mass before surgery. The patient's hematocrit increased from 25% on admission to 39% during 2 weeks of high-dose erythropoietin (200 U/kg daily) and iron supplementation. Intraoperative blood conservation consisted of retrograde autologous priming, intraoperative autologous transfusion, and ultrafiltration. A total bypass time of 155 minutes with a cardiac ischemic time of 110 minutes was required. After closing, her hematocrit had fallen to 18%, and there was some suspicion of continued mediastinal bleeding; therefore the surgical site was reexplored to exclude the possibility of even minimal bleeding. No bleeding was identified, and complete hemostasis was verified before reclosure. The patient experienced no postoperative complications other than edema and shortness of breath that resolved with aggressive diuresis. No neurologic or renal sequelae were noted. She was discharged on postoperative day 12 on erythropoietin.
Patient 2
A 70-year-old female Jehovah's Witness with known aortic and mitral insufficiency was admitted for progressive dyspnea. Her past cardiac surgical history included coronary artery bypass grafting 4 years prior, mitral valve repair 3 years prior, and pacemaker implantation with AV nodal ablation for poorly controlled chronic atrial fibrillation 9 months before the current admission. She also had experienced at least five cerebrovascular accidents during the past several years. Other medical comorbidities included hypertension, diabetes, hypercholesterolemia, and peptic ulcer disease. The patient had been deemed a prohibitive surgical risk at multiple institutions. Unfortunately, the rapidly progressive nature of her heart failure necessitated surgical intervention, and it was decided to proceed with aortic valve replacement, mitral valve replacement, and tricuspid annuloplasty.
The standard pharmacologic and technical measures were applied. The operation proceeded uneventfully until protamine administration, at which point severe distention of the right atrium with concomitant right heart failure consistent with protamine reaction developed in the patient. After reheparinization, cardiopulmonary bypass was reinitiated, and after the administration of multiple inotropic agents the patient was ultimately weaned from bypass with near baseline ventricular function. Reversal of systemic heparinization was accomplished by slowly administering protamine through the left atrial catheter. The preoperative hematocrit of 45% had fallen to 34% on postoperative evaluation. The patient was transferred from the cardiac intensive care unit 8 days later with stable hematocrit, intact renal function, and no new clinically evident neurologic deficits. On postoperative day 12 she was discharged to a subacute care facility.
Patient 3
A 45-year-old church elder in the Jehovah's Witnesses was transferred emergently with acute ascending aortic dissection, aortic insufficiency, and an expanding pericardial effusion with early tamponade. The patient arrived in extremis but was sufficiently capacitated to confirm both his consent to surgical treatment and his refusal of any transfusion of blood products. Before sternotomy the right femoral artery was expeditiously cannulated. Once the mediastinum was exposed, an adventitial tear at the root of the aorta was identified as the origin of the tamponade. The defect was controlled with digital pressure while the ascending aorta was dissected free.
In this circumstance, we elected to proceed with aortic root replacement rather than a more protracted valve salvage procedure as described by David [5]. After the valve and ascending aorta were resected and sized, the patient was placed in deep Trendelenburg position and anterograde cerebral perfusion was initiated with balloon-tip perfusion catheters. During a 12-minute antegrade cerebral perfusion period the ascending aorta and proximal arch were resected back until normal tissue was revealed at the origin of the innominate artery, and a polyethylene terephthalate fiber (Dacron; Intervascular, Montvale, NJ) graft was placed. Total body perfusion was then reestablished. The remaining anastomoses were performed and reinforced with BioGlue (Cryolife Inc, Kennesaw, GA), air was removed from the heart, and the aortic cross-clamp was removed.
The patient was extubated 43 hours postoperatively and spent 4 days in the cardiac intensive care unit. The preoperative hematocrit of 42% had fallen to 34%. Although the patient experienced minor elevations in serum creatinine, wavering hematocrit, and transient fever while hospitalized, all resolved without further complication, and the patient was discharged on postoperative day 20.
Patient 4
A 48-year-old male Jehovah's Witness with chronic anemia, renal insufficiency, and hypertension had been receiving erythropoietin in preparation for elective repair of a 7-cm descending thoracic aneurysm. He presented to an outside hospital with severe chest and back pain and was transferred emergently to our institution. On arrival to the operating room, a standard left posterolateral thoracotomy incision revealed no rupture, but rather what appeared to be an acute expansion of the aneurysm that had led to the patient's symptoms. Although plaque was noted at the proximal extent of the aneurysm between the subclavian and carotid arteries, adequate control between these vessels was achieved. The subclavian artery was clamped separately, as was the thoracic aorta at the distal extent of what was discovered intraoperatively to be a type III dissection. The remainder of the operation was uncomplicated. The patient's preoperative hematocrit of 39% had fallen to 28%. During postsurgical hospitalization the only complication encountered was significant hypertension that was difficult to control. No deterioration in renal function was encountered, nor were any obvious neurologic defects noted. The patient was discharged home on postoperative day number 7.
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Comment
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There is considerable experience with elective coronary surgery with blood conservation [6–8]; however, more complex surgeries are less common. These cases demonstrate that even complex problems such as protamine reaction, acute dissection of the aorta, multiple redo sternotomy, or emergent aneurysm repair, do not pose insurmountable problems in Jehovah's Witnesses. Appropriate preoperative planning and subsequent management make it possible to offer these patients complex operations.
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References
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- Murkin J.M. Attenuation of neurologic injury during cardiac surgery. Ann Thorac Surg 2001;72(Suppl):S1838-1844.[Abstract/Free Full Text]
- Rosengart T.K., Helm R.E., Klemperer J., Krieger K.H., Isom O.W. Combined aprotinin and erythropoietin use for blood conservation: results with Jehovah's Witnesses. Ann Thorac Surg 1994;58:1397-1403.[Abstract]
- Rosengart T.K. Cardiac surgery in Jehovah's Witnesses. In: Krieger K.H., Isom O.W., eds. Blood conservation in cardiac surgery. New York: Springer, 1998:159-168.
- Malan T.P., Jr, Whitmore J., Maddi R. Reoperative cardiac surgery in a Jehovah's Witness: role of continuous cell salvage and in line reinfusion. J Cardiothorac Anesth 1989;3:211-214.[Medline]
- David TE. Aortic valve-sparing operations for aortic root aneurysms. Semin Thorac Cardiovasc Surg. 2001 Jul;13:291–6
- Ott D.A., Cooley D.A. Cardiovascular surgery in Jehovah's Witnesses: report of 542 operations without blood transfusion. JAMA 1977;238:1256-1258.[Abstract/Free Full Text]
- Helm R.E., Rosengart T.K., Gomez M., et al. Comprehensive multimodality blood conservation: 100 consecutive CABG operations without transfusion. Ann Thorac Surg 1998;65:125-136.[Abstract/Free Full Text]
- Aldea G.S., Shapira O.M., Treanor P.R., Lazar H.L., Shemin R.J. Effective use of heparin-bonded circuits and lower anticoagulation for coronary artery bypass grafting in Jehovah's Witnesses. J Card Surg 1996;11:12-17.[Medline]
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Abstract
Introduction
