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Ann Thorac Surg 2005;80:1507-1510
© 2005 The Society of Thoracic Surgeons

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Case report

Bloodless Surgery of Acute Type A Aortic Dissection in a Jehovah's Witness Patient

Deutsches Herzzentrum Berlin, Berlin, Germany

Accepted for publication March 16, 2004.

^_* Address reprint requests to Dr Pasic, Deutsches Herzzentrum Berlin, Augustenburger Platz 1, Berlin D-13353, Germany (Email: pasic{at}dhzb.de).

	Abstract

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We report successful surgery for acute type A aortic dissection in a Jehovah's Witness patient without the use of any transfusion of allogeneic blood or blood products. We combined the normothermic cross-clamping technique with a blood conservation strategy.

	Introduction

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Surgery of acute aortic dissection almost always requires transfusion of relatively large amounts of allogeneic blood products. An increased postoperative blood loss is caused by the technically demanding procedure in the presence of a poor quality aortic wall and disturbed coagulation. Recently we were faced with a very rare problem of acute aortic dissection in a patient who refused the transfusion of any type of allogeneic blood or blood products. As a Jehovah's Witness, the patient's refusal of allogeneic blood products was based on his religion. We successfully operated on the patient without the use of allogeneic blood or blood products using the normothermic cross-clamping technique combined with a blood conservation strategy.

A 55-year-old man (height, 194 cm; weight, 85 kg) with a body surface area of 2.16 m² experienced acute severe chest pain. The patient had been healthy before this event. He also had no Marfan characteristics. Acute coronary syndrome was excluded. A computed tomographic scan of the chest was performed, which showed dissection of the entire aorta (Stanford type A, DeBakey type I) (Fig 1) and a pericardial effusion. The patient refused transfusion of allogeneic blood and blood products. The operative risk was assessed as extremely high with these conditions; therefore he was not accepted for surgery at three cardiovascular centers. The patient was then transferred to our institution.

View larger version (109K): [in this window] [in a new window]   Fig 1. Preoperative computed tomographic scan showing the typical finding of the aortic dissection including the dissecting membrane in the aortic arch. The diameter of the arch is slightly increased.

This emergency situation was first evaluated by our staff and then we discussed it with the patient. We discussed extensively the natural course of the disease, the standard and the modified surgical strategies, the possible risks of surgery, the need for blood and blood products during the surgery and postoperatively, and the postoperative course. The patient accepted surgical therapy, but again he refused transfusion of allogeneic blood and blood products. We decided to operate on the patient. We evaluated computed tomographic scans and then compared the computed tomographic findings with the findings of the preoperative transthoracic and transesophageal echocardiography. We did not see any intimal tear in the aortic arch. Accordingly, we planned our surgical strategy. We discussed it with the patient. The written informed consent was obtained (a standard, obligatory procedure in Germany).

Anesthesia was performed using a total intravenous technique (etomidate, propofol, sufentanil, and pancuronium bromide). A right and a left radial artery catheter and a right femoral artery catheter, as well as a pulmonary artery catheter were used for hemodynamic monitoring. A high-dose regimen of aprotinin was administered instead of our institutional standard of a half-dose regimen. After a test dose, 2 million kallikrein inhibiting units of aprotinin were slowly administered intravenously and another 2 million kallikrein inhibiting units of aprotinin were added to the priming solution of the heart-lung machine. In addition, aprotinin was given intravenously (dosage, 500,000 kallikrein inhibiting units per hour) during surgery and for the first 6 postoperative hours. Heparin-level based anticoagulation management was performed according to the results of the Hepcon HMS (Medtronic, Minneapolis, MN) [1].

We adapted our standard surgical strategy for acute aortic dissection (the standard technique is graft replacement of the ascending aorta, inspection of the aortic arch with or without concomitant arch surgery, and open distal anastomosis during deep hypothermic circulatory arrest and retrograde cerebral perfusion [2]). It was decided to perform surgery in normothermia. The sequence of the surgical procedure was as follows: the right axillary artery was dissected, a median sternotomy was performed, heparin was given intravenously, and then the right axillary artery was cannulated. The pericardium was opened, and the right atrium was cannulated with a standard 36 French two-stage cannula. Normothermic cardiopulmonary bypass was initiated, and a left-ventricular vent was placed through the right upper pulmonary vein. The ascending aorta was clamped with a soft clamp, the proximal part of the ascending aorta was longitudinally incised, and the cold crystalloid cardioplegic solution was instilled directly into the coronary ostia. Inspection of the local situs revealed acute aortic dissection with aortic regurgitation due to dissection of the wall. The aortic valve leaflets were normal. A circular tear of the aortic intima ("entry") was seen above the ostia of the coronary arteries. The aortic basis was reconstructed with gelatin-resorcinol-formaldehyde glue and the aortic valve was reconstructed using commissural re-suspension. The supracoronary graft replacement of the ascending aorta was performed with a 28-mm diameter Dacron graft. Teflon strips (Boston Scientific, Meadox Medical Inc, Oakland, NJ) were used to support both proximal and distal anastomosis in a "sandwich" technique. Precise surgical technique was applied throughout the procedure and meticulous hemostasis was performed at the end of surgery. Normovolemic autologous hemodilution (to the lowest level of hemoglobin, 5.4 g/dL) was performed at the beginning of cardiopulmonary bypass with 5 L of blood that was slowly transferred into an additional reservoir bag that was connected to the cardiopulmonary bypass system. After cardiopulmonary bypass ceased, modified ultrafiltration (in total 4,000 mL) was started while hemodiluted whole blood was re-transfused. Protamine was administered according to the result of the Hepcon HMS (Medtronic) measurement and desmopressin (Minirin, dose: 36 µg, Ferring AB, Limhamn, Sweden) was given intravenously. An autotransfusion device (CATS, Fresenius, Bad Homburg, Germany) was prepared for use from the beginning of the surgical procedure. Blood was collected in this device, continuously processed, and then re-transfused during surgery, enabling uninterrupted blood flow. Extracorporeal circulation time was 107 minutes, aortic cross-clamp time was 74 minutes, and reperfusion time was 25 minutes. During cardiopulmonary bypass, the hemoglobin ranged from 5.40 g/dL to 11.9 g/dL. At the end of surgery, a transesophageal echocardiography showed no regurgitation of the aortic valve and good right and left ventricular function. The examination revealed the persistent dissecting membrane in the aortic arch and descending aorta, but no intimal tear. The patient was transferred to the intensive care unit where initial laboratory data showed hemoglobin was 9.89 g/dL; hematocrit was 29%; platelet count was 71,700/µL; prothrombin time was 35%; activated partial thromboplastin time was 57.6 seconds; and international normalized ratio was 2.33. The hemodynamic situation was stable without a need for inotropic agents.

The postoperative strategy included drug-controlled hypotension with a mean arterial pressure of 60 mm Hg during the first hours after surgery to minimize bleeding. Furthermore we set a lower threshold than usual for early reexploration of the chest if the amount of postoperative bleeding should be increased. However the total postoperative drainage blood loss was only 620 mL (less than 50 mL blood per hour). Therefore there was no need for postoperative autotransfusion or reopening of the chest. The patient was extubated 12 hours after intensive care unit admission, and he was transferred to the postoperative ward on the first postoperative day. Postoperatively, oral iron, folic acid, and vitamin B complex were added to the therapy. No postoperative cardiac, renal, pulmonary, neurologic, or any other complications occurred. The early postoperative course was uneventful. At discharge, on the 13th postoperative day, the hemoglobin value was 10.7 g/dL; hematocrit was 32.3%; platelet count was 344,000/µL; prothrombin time was 67%; activated partial thromboplastin time was 40.5 seconds; and international normalized ratio was 2.33. Further postoperative course was also completely uneventful. One year postoperatively, computed tomographic scans of the chest demonstrated the aortic arch without dissection and residual dissection of the descending aorta (Fig 2). Echocardiography showed normal right and left ventricular function and no aortic regurgitation.

View larger version (98K): [in this window] [in a new window]   Fig 2. One year postoperative computed tomographic scan of the chest demonstrated the aortic arch without dissection and residual dissection of the descending aorta. There was no increase of the aortic arch diameter during the postoperative course.

	Comment

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The intraoperative surgical strategy includes precise surgical technique with meticulous hemostasis and efforts to minimize aortic cross-clamp time, cardiopulmonary bypass time, and the total operative time. Normothermic cardiopulmonary bypass should be used instead of deep hypothermic circulatory arrest to preserve hemostasis as far as possible. Perioperative normovolemic hemodilution, the use of an autotransfusion device ("cell saver"), and modified ultrafiltration are applied to eliminate the need for red blood cell transfusion and also to preserve coagulation factors and platelets. Modified ultrafiltration enables the re-transfusion of a large volume of hemodiluted blood in a short period of time without any volume overload. These efforts to preserve the hemostatic system are also facilitated by using a high-dose instead of a low-dose aprotinin regimen, heparin-level based anticoagulation, and desmopressin (Minirin). The latter is administered to improve thrombocyte function and enhance endothelial release of tissue factors [1, 4]. We applied all these measures, although some of their hemostatic effects are not clearly proven [5–7].

The standard treatment of type A dissection is deep hypothermic circulatory arrest to allow open distal anastomosis. Hypothermia, circulatory arrest, and prolonged cardiopulmonary bypass time determine a high probability of allogeneic blood necessary for the patient's survival. Therefore, the adopted bloodless strategy seems strongly related to the choice of normothermia with aortic cross clamping. Moderate hypothermia compared with normothermia may have beneficial effects for organ protection, but our primary aim was not to impair the hemostatic status of the patient. The normothermic cross-clamping technique used for acute type A aortic dissection represents a compromise to find a fine balance between a less safe surgical technique and a blood-sparing protocol. It is an older surgical technique for aortic dissection. Nowadays, it is applied only in selected patients in whom the circulatory arrest and hypothermia are not advisable. The technique can only be used when the intimal tear involves the ascending aorta but not when the tear is extended to the aortic arch. When the ascending aorta is cross clamped, the open distal anastomosis cannot be performed, and the aortic arch cannot be explored for possible distal intimal tears. Furthermore, aortic cross-clamping bears per se are a possible danger of aortic wall damage with iatrogenic intimal tear and can lead to a higher rate of complications after the correction of the aortic lesion. Furthermore, sometimes this technique cannot be applied in case of impending rupture in the distal ascending aorta or in the proximal arch, or if the intimal tear involves both the ascending aorta and the arch. In such a situation, a normothermic modified technique that enables more complex normothermic procedures should be applied. We also considered this possibility when planning our surgical strategy. We made an alternative plan for the situation if closed distal anastomosis had been not possible or even if arch repair had been necessary. This plan was to maintain normothermic cardiopulmonary bypass and, if necessary, to replace the aortic arch under continuous antegrade normothermic perfusion through the right axillary artery, and using endoluminal occlusion of the brachiocephalic trunk with a Fogarty catheter (Edwards Lifesciences, Irvine, CA).

The postoperative strategy included drug-controlled hypotension to maintain a mean arterial pressure of 60 mm Hg during the first postoperative hours to minimize bleeding. Postoperative autotransfusion of shed mediastinal blood may be necessary, and a low threshold for early re-exploration of the chest should be set. Autologous normovolemic hemodilution and the use of a cell saver are acceptable for most patients as long as there is uninterrupted flow from the device to the patient and the blood removed is kept in continuous contact with the circulation [3]. Postoperative therapy may be supported with recombinant human erythropoietin and oral iron administration.

There are several reports on bloodless surgery in high-risk and technically demanding cardiac surgical procedures [3], but we believe this is the first case report of an effective bloodless, surgical treatment of acute type A aortic dissection in a patient refusing blood transfusion. Although the all applied blood-saving measures play an important role in the management of bloodless surgery, avoidance of foreign blood in this patient was also supported by the good hematological condition of the patient at the beginning of surgery. In addition, a large body surface area represented possible help in terms of hemodilution during cardiopulmonary bypass. On the other hand, there are several disease-related factors such as extension and severity of the aortic lesion and poor quality of the aortic wall that may negatively influence the ultimate result of the bloodless strategy. However, we believe that precise surgical technique with meticulous hemostasis is the decisive factor.

	Acknowledgments

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We are grateful to Anne Gale for her editorial assistance.

	References

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1. Koster A, Fischer T, Praus M, et al. Hemostatic activation and inflammatory response during cardiopulmonary bypassimpact of heparin management. Anesthesiology 2002:837-841.
2. Pasic M, Schubel J, Bauer M, et al. Cannulation of the right axillary artery for surgery of acute type A aortic dissection Eur J Cardiothorac Surg 2003:231-235discussion 235–6.
3. Loubser PG, Stoltz SM, Schmoker JD, et al. Blood conservation strategies in Jehovah's Witness patients undergoing complex aortic surgerya report of three cases. J Cardiothorac Vasc Anesth 2003;17:528-535.[Medline]
4. Cattaneo M, Harris AS, Stromberg U, Mannucci PM. The effect of desmopressin on reducing blood loss in cardiac surgery–a meta-analysis of double-blind, placebo-controlled trials Thromb Haemost 1995;74:1064-1070.[Medline]
5. Helm RE, Klemperer JD, Rosengart TK, et al. Intraoperative autologous blood donation preserves red cell mass but does not decrease postoperative bleeding Ann Thorac Surg 1996;62:1431-1441.[Abstract/Free Full Text]
6. Hohn L, Schweizer A, Licker M, Morel DR. Absence of beneficial effect of acute normovolemic hemodilution combined with aprotinin on allogeneic blood transfusion requirements in cardiac surgery Anesthesiology 2002;96:276-278.[Medline]
7. Despotis GJ, Levine V, Saleem R, Spitznagel E, Joist JH. Use of point-of-care test in identification of patients who can benefit from desmopressin during cardiac surgerya randomized controlled trial. Lancet 1999;354:1124-1125.

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Miralem Pasic Roland Hetzer Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Pasic, M. Articles by Hetzer, R. Search for Related Content PubMed PubMed Citation Articles by Pasic, M. Articles by Hetzer, R.