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The Annals of Thoracic Surgery CME Program is located online at http://cme.ctsnetjournals.org. To take the CME activity related to this article, you must have either an STS member or an individual non-member subscription to the journal. Cardiac Surgery in Jehovah’s Witness Patients: Ten-Year Experience Arminder Singh Jassar, MBBS, Patricia A. Ford, MD, Howard L. Haber, MD, FACC, Alice Isidro, PA, Jabaris D. Swain, MD, Joseph E. Bavaria, MD, and Charles R. Bridges, MD, ScD Division of Cardiovascular Surgery, University of Pennsylvania Medical Center; Divisions of Hematology and Oncology, and Cardiovascular Medicine, Pennsylvania Hospital, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania; and Department of Thoracic and Cardiovascular Surgery, Sanger Heart and Vascular Institute, Carolinas Healthcare System, Charlotte, North Carolina Background. Cardiac surgery in Jehovah’s Witnesses poses unique challenges. We have developed a comprehensive multimodality program for these patients and have obtained excellent results. Methods. Ninety-one Jehovah’s Witness patients underwent cardiac surgery between 2000 and 2010. Preoperative, intraoperative, and postoperative considerations in the conduct of bloodless surgery in the Jehovah’s Witness population are discussed. Mortality for isolated coronary artery bypass graft surgery and isolated aortic valve replacement was compared with predicted mortality from The Society of Thoracic Surgeons (STS) risk models. Perioperative outcomes were stratified by urgent and elective status of operations. Results. Mean age was 65 ⴞ 12.4 years. Comorbid conditions included hypertension (84.6%), diabetes mellitus (48.4%), previous myocardial infarction (23.1%), chronic lung disease (38.5%), peripheral vascular disease (20.9%), and renal failure (11%). In-hospital mortality was 5.5% (n ⴝ 5). Mortality for isolated coronary artery bypass graft surgery and isolated aortic valve replacement was 2.2% (observed to expected ratio ⴝ 1.05, 95% confidence interval: 0 to 3.02) and 5.6% (observed to expected ⴝ 1.46, 95% confidence interval: 0 to 3.76), respectively. Other complications included reoperation (all ⴝ 8.8%, cardiac ⴝ 2.2%), sepsis (2.2%), sternal wound infection (1.1%), transient ischemic attack (1.1%), renal failure requiring dialysis (1.1%), and prolonged ventilation (18.7%). Major complication rates were not significantly different between the elective group and the urgent group. Conclusions. Bloodless cardiac surgery in Jehovah’s Witness patients can be performed with excellent outcomes in both elective and urgent situations. Mortality rates for isolated coronary artery bypass graft surgery and isolated aortic valve replacement are within the expected 95% confidence intervals of STS predicted mortality. (Ann Thorac Surg 2012;93:19 –25) © 2012 by The Society of Thoracic Surgeons S At the Pennsylvania Hospital (PAH) of the University of Pennsylvania Medical Center, we have developed a multidisciplinary bloodless medicine program that provides holistic care to these patients. This report comprises one of the largest series of cardiac surgery results in the JW population. ince its inception in 1869, the Jehovah’s Witness (JW) faith has grown to more than 7 million followers in 236 countries [1]. In 1945, the governing body of the Jehovah’s Witnesses—the Watchtower Society—introduced a ban on accepting blood transfusions, even in life-threatening situations [2]. Autologous blood must also be refused if it is predeposited—thus excluding preoperative autodonation. However, autologous blood is acceptable if it is not separated from the patients’ circulation at any time [2]. Also, while acceptance of the “primary components” of blood, defined as red blood cells, white blood cells, platelets, and plasma, is forbidden, the acceptance of the fractions of the primary components (ie, cryoprecipitate, albumin) has been left to the individual patient [3]. It is important for a surgeon to understand these tenets of the JW faith to allow for a knowledgeable discussion of these options with the patients preoperatively. Material and Methods Patients From May 2000 to April 2010, 94 JW patients underwent cardiac surgery at PAH. Of these, data were unavailable for 2 patients. One patient consented to and received blood products, and was excluded from this study. Data for the remaining 91 patients were collected from the hospital cardiac surgery database. Accepted for publication June 14, 2011. Address correspondence to Dr Bridges, Department of Thoracic and Cardiovascular Surgery, Sanger Heart and Vascular Institute, Carolinas Healthcare System, 1001 Blythe Blvd, Ste 300, Charlotte, NC 28203; e-mail: [email protected]. © 2012 by The Society of Thoracic Surgeons Published by Elsevier Inc Dr Bridges discloses that he has financial relationships with Baxter Healthcare, Baxter Biosurgery, and Zymogenetics. 0003-4975/$36.00 doi:10.1016/j.athoracsur.2011.06.029 ADULT CARDIAC CARDIOTHORACIC ANESTHESIOLOGY: 20 ADULT CARDIAC JASSAR ET AL CARDIAC SURGERY IN JEHOVAH’S WITNESSES Bloodless Medicine Program at PAH The Center of Bloodless Medicine and Surgery at PAH receives approximately 1,000 outpatient visits per year. The JW patients comprise approximately 95% of these visits. The “bloodless medicine team,” which consists of a patient coordinator, nurse, and a hematologist, assesses every JW patient. Special provisions are made for JW patients during all phases of their care, as follows. PREOPERATIVE. All JW patients are treated with intravenous iron supplement and subcutaneous erythropoietin (40,000 to 60,000 units per week) as indicated, toward goal hemoglobin (Hb) of 14 to 16 g/dL (or highest plateau attainable). It is our observation that red cell volume (RCV [Hb ⫻ body weight in kilograms]) of more than 1,200 typically provides a safe reserve for these patients, whereas RCV less than 800 indicates an increased chance of requiring a transfusion. Thus, a patient with a larger body weight can be operated upon with lower Hb level. A lower threshold for Hb level may have to be accepted for patients with renal failure or cancer. Elective cardiac catheterization should be performed a few weeks before surgery to avoid an unpredictable Hb drop. If patients need surgery within 48 hours after catheterization, use of a vascular closure device is preferred. Patients presenting with acute coronary syndromes (n ⫽ 2) were initially managed medically and underwent coronary artery stent (bare metal only) placement to stabilize them. Three patients with unstable angina stayed in the hospital for a duration of 4 to 12 weeks before they could attain an optimal Hb level. Risk factors for bleeding such as renal or hepatic dysfunction or bleeding diathesis (eg, hemophilia, Von Willebrand disease, acquired or hereditary coagulation factor deficiency) are identified. Patients are advised to discontinue intake of alcohol and medications or supplements that may increase bleeding risk (eg, celecoxib [Celebrex], vitamin E, ginkgo supplements, garlic, saw palmetto). Before operation, aspirin (3 to 5 days) and clopidogrel (Plavix [7 days]) are withheld. Patients receiv- Fig 1. Although Jehovah’s Witness (JW) patients refuse transfusion of primary blood components (above dotted line) as directed by the Watch Tower Society, acceptance of other components or blood substitutes (below dotted line) has been left to the individual patient. Ann Thorac Surg 2012;93:19 –25 ing coumadin have their international normalized ratio normalized and may need to be converted to low molecular weight heparin (outpatient) or unfractionated heparin (inpatient). Last administered dose of enoxaparin (Lovenox) should ideally be 48 hours before surgery. In addition to the standard surgical consent, a detailed “itemized” blood product consent form allows the patients to select specific blood fractions that they will or will not accept (Fig 1). After the patient is anesthetized, based on their RCV, 1 to 3 units of blood (RCV ⬎900, 1 unit; RCV ⬎1,100, 2 units; RCV ⬎1,400, 3 units) are removed using gravity drainage, and this volume is replaced with 5% albumin (acute normovolumic hemodilution). The blood is kept in a continuous loop and reconnected to the patient using an in-continuity circuit. Since 2006, a low prime circuit (Cobe CV; Sorin GroupUSA Inc, Arvada, CO) was used to conduct all cardiopulmonary bypass cases. For routine cardiopulmonary bypass cases, we typically cool to 32°C. Both antegrade and retrograde priming of the bypass circuit reduces the circuit prime volume to 250 mL. Small doses of neosynephrine are utilized to maintain hemodynamic stability in most patients. Vacuum-assisted venous drainage is used routinely. At the end of the case, blood is retrieved from the reservoir using follow through. Two cell-saving devices— one each for chest and leg areas—with an in-continuity circuit are used. We routinely employ a single sponge throughout the procedure to minimize sponge-related loss of red cells— the “one sponge technique.” Adequate hemostasis of the sternum and all cardiotomy sites is essential before closure. Hemostatic adjuncts, most recently, Floseal (Baxter Healthcare, Deerfield, IL), is used routinely to control bleeding, usually in combination with Gelfoam (Baxter Healthcare). Tisseel (Baxter Healthcare, topical thrombin, and Surgicel (Ethicon, Cornelia, GA) are used in selected cases. In rare cases, bone wax is applied to sternum if it appears to be osteoporotic. Full rewarming to 36°C is INTRAOPERATIVE. achieved before weaning off bypass. For the majority of the first 55 patients, aprotinin was used as per the Hammersmith (full-dose) protocol. Since its withdrawal in 2007, aminocaproic acid is used in all cases. Protamine is administered in established doses to reverse heparininduced coagulopathy. POSTOPERATIVE. In case of bleeding, non-blood product measures are aggressively instituted. The patient is warmed to normothermia, and hypertension is avoided. Positive end-expiratory pressure is increased to 7 cm to 10 cm of H2O if hemodynamically tolerated. Crystalloids and acceptable colloids (Fig 1) are judiciously infused to maintain euvolemia. Hydroxyethyl starch is avoided if there is suspicion of platelet dysfunction or if the patient’s chest tubes are draining more than 100 mL per hour of blood. Desmopressin (0.3 k/kg) is considered for patients receiving aspirin therapy or for those with renal failure. Cryoprecipitate (for patients who will accept) and factor VII can be used as indicated based on bleeding. We avoid the use of factor VII for coronary artery bypass patients, and restrict its use to valve or aortic surgery patients. Factor VII was used in 2 patients in our series (aortic root replacement, aortic dissection repair). A low threshold is maintained to reexplore early if surgical bleeding is suspected. Blood loss during testing is minimized by judicious laboratory ordering and use of low-volume “serum plus” tubes that require only 1 mL for blood counts and 3 mL for chemistry. Coagulation profile (which consumes the most amount of blood) is avoided in patients who are not thought to be bleeding. Point of care testing (eg, finger sticks for glucose level) and in-line blood draw systems that prevent waste during arterial sampling are routinely employed. Blood draws from central venous lines are avoided to minimize wastage. The bloodless medicine team follows each patient on a daily basis, and other measures such as erythropoietin administration are employed as appropriate. Data Analysis Continuous variables are reported as mean ⫾ SD. Discreet data are reported as percentage. Expected mortality rate and 95% confidence intervals for risk-adjusted patients who underwent isolated aortic valve replacement (AVR) or isolated coronary artery bypass graft surgery (CABG) were obtained from The Society of Thoracic Surgeons (STS) risk models. Given the infrequent incidence of other procedures, subgroup analysis and comparison with STS risk models were performed only for these two groups. Survival data were collected from online Social Security Death Index database (available at: http://ssdi.rootsweb. ancestry.com). Kaplan-Meier survival analysis was performed and is presented as mean ⫾ SE. Results Preoperative Risk Factors Preoperative demographics and comorbidities are depicted in Table 1. Fifty-five patients (60.4%) were able to JASSAR ET AL CARDIAC SURGERY IN JEHOVAH’S WITNESSES 21 Table 1. Preoperative Characteristics Characteristic Total n ⫽ 91 (%) Isolated Isolated CABG AVR n ⫽ 45 (%) n ⫽ 18 (%) Male 45 (49.5) 29 (64.4) 6 (33.3) Age at surgery, 65 ⫾ 12.4 63.5 ⫾ 9.2 65.8 ⫾ 16.9 mean ⫾ SD CVD/CVA 11/8 (12.1/8.8) 4/3 (8.9/6.7) 1/0 (5.6/0) Diabetes mellitus 44 (48.4) 28 (62.2) 9 (50) Hypertension 77 (84.6) 39 (86.7) 14 (77.8) Peripheral vascular 19 (20.9) 9 (20.0) 5 (27.8) disease Renal failure 10 (11) 6 (13.3) 1 (5.6) Renal failure on 5 (5.5) 4 (8.9) 1 (5.6) dialysis Chronic lung disease 35 (38.5) 15 (33.3) 7 (38.9) Elective 78 (85.7) 34 (75.6) 17 (94.4) Urgent 13 (14.3) 11 (24.4) 1 (5.6) Redo cardiac surgery 10 (11) 4 (8.9) 3 (16.7) Angina at presentation 39 (42.9) 29 (64.4) 3 (16.7) NYHA classification Class I 4 (4.4) 2 (4.4) 0 (0) Class II 41 (45.1) 19 (42.2) 11 (61.1) Class III 22 (24.2) 11 (24.4) 5 (27.8) Class IV 12 (13.2) 6 (13.3) 1 (5.6) Previous MI 21 (23.1) 15 (33.3) 2 (11.1) Ejection fraction (%) ⱕ30 9 (10.6) 3 (7) 0 (0) 31–40 11 (12.9) 6 (14) 1 (5.6) 41–50 23 (27.1) 13 (30.2) 5 (27.8) ⬎50 42 (49.4) 21 (48.8) 12 (66.7) AVR ⫽ aortic valve replacement; CABG ⫽ coronary artery bypass graft surgery; CVA ⫽ cerebrovascular accident; CVD ⫽ cerebrovascular disease; MI ⫽ Myocardial infarction; NYHA ⫽ New York Heart Association. be optimized as outpatients, and 36 were admitted to the hospital preoperatively (mean preoperative length of stay 14.6 ⫾ 18.3 days, median 6.5). The goal of preadmission of these patients was optimization of Hb level in the presence of additional factors that deemed it unsafe to discharge them while waiting for Hb to increase. For example, 1 patient was admitted for 42 days for treatment of endocarditis, renal dysfunction, and heart failure. Another patient with severe aortic stenosis was admitted for 59 days for monitoring episodes of chest pain; a groin yeast infection caused further delay in surgery. Another patient was maintained as an inpatient for 63 days owing to unstable left main coronary artery disease. Operative Procedures Surgical procedures and operative times are listed in Table 2. Ten patients (11%) had undergone prior cardiac surgery (Previous CABG ⫽ 6, previous valve replacement ⫽ 3, previous CABG plus valve replacement ⫽ 1) and required redo operation. Thirty-two prosthetic valves were implanted (22 AVR, 9 mitral valve replacement, 1 aortic root), of which 25 were bioprosthetic (patient age, ADULT CARDIAC Ann Thorac Surg 2012;93:19 –25 22 ADULT CARDIAC JASSAR ET AL CARDIAC SURGERY IN JEHOVAH’S WITNESSES Ann Thorac Surg 2012;93:19 –25 Table 2. Operative Procedures and Times n ⫽ 91 Procedure a CABG AVR MVRb MV repairc CABG ⫹ AVR CABG ⫹ MVRd CABG ⫹ MV repair Aortic root replacement Left atrial mass resection Right atrial mass resection ⫹ ASD closure PFO closure Aortic dissection repair CPB time, minutes, n ⫽ 86e Aortic cross-clamp, minutes, n ⫽ 85e 45 18 7 5 4 2 5 1 1 1 1 1 106.98 ⫾ 47.91 82.62 ⫾ 31.67 a Five off-pump coronary artery bypass graft surgery (CABG), 40 with b cardiopulmonary bypass (CPB). One combined mitral valve replacec One combined mitral valve (MV) ment (MVR) plus Maze surgery. repair plus tricuspid valve repair plus radiofrequency ablation plus left d atrial appendage excision. One combined CABG plus MVR plus e Maze. Eighty-six cases were performed on CPB; aorta was not clamped for 1 of these cases (CABG). ASD ⫽ atrial septal defect; patent foramen ovale. AVR ⫽ aortic valve replacement; PFO ⫽ 74.3 ⫾ 7.3 years; 9 males) and 7 were mechanical (patient age, 51.3 ⫾ 19.3 years; 1 male). Outcomes Perioperative complications are presented in Table 3. Of the 5 patients (5.5%) who died in the hospital, 2 died intraoperatively. The first patient had bleeding from the atrioventricular groove after a combined CABG/mitral valve replacement/Maze procedure. Given that the patient weighed only 100 lb, and had Hb of 8 g/dL at the time, we decided not to go back on bypass for fear of dropping the Hb too low. Bleeding was controlled, and the sternum was closed. The patient subsequently arrested and could not be resuscitated and died while still in the operating room. For the second patient, with a preoperative Hb of approximately 16 g/dL, the technical portion of a redo CABG/AVR was successfully completed, but the patient had endobronchial bleeding during cardiopulmonary bypass wean. Cardiopulmonary bypass was reinitiated, and the situation discussed with patient’s family. Given the dismal likelihood of survival without blood transfusion, the patient was weaned from cardiopulmonary bypass in accordance with the patient’s and family’s wishes, and died thereafter. The cause for the endobronchial bleed could not be identified. Two other deaths occurred within the first 48 hours postoperatively. The first patient became acidotic, anemic (Hb 6 g/dL), and coagulopathic (international normalized ratio 7), and could not be resuscitated despite pressor and intraaortic balloon pump support. The second patient had significant bleeding (preoperative Hb 13.2 g/dL that fell to 5.9 g/dL), and several episodes of ventricular arrhythmias that became refractory to cardio- version. The patient became progressively acidotic, and care was withdrawn after discussion with the family. The remaining mortality was not related to blood loss (Hb 8 g/dL); the patient died of overwhelming sepsis and multisystem failure on postoperative day 11. Two patients (2.2%) were taken back to the operating room for bleeding. The first patient underwent CABG, and was noted to have chest tube drainage of about 750 mL upon arrival to the intensive care unit and was expeditiously returned to the operating room. Reexploration revealed bleeding from the internal mammary artery bed. The patient’s platelet count was 33,000/L, and initial postoperative Hb was approximately 14 g/dL, which stabilized at approximately 12 g/dL after return to the operating room. The other patient was taken back for reexploration during the first postoperative night after bioprosthetic mitral valve replacement for increased chest tube drainage, and a drop in Hb from 13 g/dL to 11 g/dL. At reexploration, a moderate amount of blood was seen in the pericardial space, tracking from the left atrial suture line; however, no active bleeding was identified. Bioglue was applied to the left atrial suture line, and the chest was washed out and closed. Hemoglobin level had fallen to 6.3 g/dL by the time reexploration was completed. Both patients subsequently recovered to be discharged from the hospital. Other reoperations included 1 patient who had drainage from the sternal incision and required debridement and omental flap placement. Another patient went into coma after cardiac arrest, and needed tracheostomy tube placement and discharge to a ventilation management Table 3. Perioperative Outcomes After Cardiac Surgery Among All Patients, of Patients Who Underwent Isolated Coronary Artery Bypass Graft Surgery (CABG) and Isolated Aortic Valve Replacement (AVR) Perioperative Outcome Total n ⫽ 91 (%) Isolated CABG n ⫽ 45 (%) Isolated AVR n ⫽ 18 (%) Postoperative length 9.83 ⫾ 7.92/7 8.27 ⫾ 4.63/7 10 ⫾ 6.45/9 of stay, mean ⫾ SD/ median Freedom from major 51 (56) 26 (57.8) 11 (61.1) complications In-hospital mortality 5 (5.5) 1 (2.2) 1 (5.6) reoperation Bleeding/tamponade 2 (2.2) 1 (2.2) 0 (0) Other, cardiac 2 (2.2) 1 (2.2) 0 (0) Other, noncardiac 4 (4.4) 1 (2.2) 0 (0) Sepsis 2 (2.2) 0 (0) 0 (0) Deep sternal wound 1 (1.1) 0 (0) 0 (0) infection Transient ischemic 1 (1.1) 1 (2.2) 0 (0) attack Stroke 0 (0) 0 (0) 0 (0) Prolonged ventilation 17 (18.7) 7 (15.6) 1 (5.6) Renal failure 6 (6.6) 3 (6.7) 0 (0) Renal failure requiring 1 (1.1) 0 (0) 0 (0) dialysis JASSAR ET AL CARDIAC SURGERY IN JEHOVAH’S WITNESSES 23 facility. A third patient required a decompressive craniotomy for intracranial hemorrhage on postoperative day 14 after a mechanical composite root prosthesis that necessitated postoperative anticoagulation therapy. 3.7% and 90.3% ⫾ 4.7%, respectively. One-year and 5-year cumulative survival for the isolated AVR group was 88.9% ⫾ 7.4% and 62.2% ⫾ 14.7%, respectively (Fig 2). Fifty-six patients underwent CABG in our series: 9 were single vessel, 5 were double vessel, 22 were triple vessel, 17 were quadruple vessel, and 2 patients had 5-vessel bypass. Five of these procedures were done off cardiopulmonary bypass. Complications for CABG patients are presented in Table 3. Compared with the STS risk models, the observed to expected mortality for isolated CABG was 1.05 (0, 3.02). Comment OUTCOMES FOR ISOLATED CABG. OUTCOMES AFTER ISOLATED AVR. Fourteen bioprosthetic valves (patient mean age, 74.2 ⫾ 7.4 years; 10 males), and four mechanical valves (patient mean age, 40.3 ⫾ 16.7 years; 1 male) were implanted. Complications for isolated AVR are presented in Table 3. Compared with the STS risk models, the observed to expected mortality for isolated AVR was 1.46 (0, 3.76). ELECTIVE VERSUS URGENT PROCEDURES. Reasons for urgent intervention (n ⫽ 13) included acute presentation with angina (n ⫽ 7), or non–ST-segment elevation myocardial infarction/acute coronary syndrome (n ⫽ 3), type A dissection (n ⫽ 1), congestive heart failure with pulmonary edema (n ⫽ 1), and adverse coronary anatomy with left main disease (n ⫽ 1). Complications are presented in Table 4. LONG-TERM SURVIVAL. Overall cumulative survival for all patients at 1 year and 5 years was 87.9% ⫾ 3.4% and 76.1% ⫾ 5.4%, respectively. One-year and 5-year cumulative survival for the isolated CABG group was 93.3% ⫾ Table 4. Outcomes After Cardiac Surgery in Jehovah’s Witness Patients, Elective Versus Urgent Perioperative Outcome Postoperative length of stay, mean ⫾ SD/median Freedom from complications Mortality Reoperation Bleeding/tamponade Other, cardiac Other, noncardiac Sepsis Deep sternal wound infection Transient ischemic attack Stroke Prolonged ventilation Renal failure Renal failure requiring dialysis Elective n ⫽ 78 (%) Urgent n ⫽ 13 (%) p Value 9.90 ⫾ 8.17/7 9.38 ⫾ 6.65/6 0.83 42 (53.8) 9 (69.2) 0.37 5 (6.4) 8 (10.3) 2 (2.6) 2 (2.6) 3 (3.8) 2 (2.6) 1 (1.3) 0 (0) 1 (7.7) 0 (0) 0 (0) 1 (7.7) 0 (0) 0 (0) 1.00 1.00 1.00 1.00 0.46 1.00 1.00 1 (1.3) 0 (0) 15 (19.2) 5 (6.4) 1 (2.6) 0 (0) 0 (0) 2 (15.4) 1 (7.7) 0 (0) 1.00 1.00 1.00 1.00 1.00 Jehovah’s Witness patients present a unique challenge to cardiac surgeons owing to their religious beliefs. Some surgeons may hesitate in providing requisite care to these patients because of these considerations, and because of the legal and ethical questions that may arise. In this study, we examine our outcomes for, often complex, cardiac surgical interventions in JW patients. We performed a variety of cardiac surgical procedures in this population. Ten patient (11.1%) required a redo sternotomy, and 13 (14.3%) had more than one procedure performed. Despite the complexity of cases, we had a low incidence of major complications postoperatively (Table 3). Of the 5 deaths, 3 were related to blood loss, whereas the other 2 may have not been preventable even with blood transfusion (atrioventricular dissociation, sepsis). Our mortality rates for CABG and AVR are well within the 95% confidence interval for expected mortality derived from the STS risk models. Although preoperative optimization of Hb levels is desirable, it is not always possible in nonelective cases. However, our data show that, even for urgent operations, the risk of mortality or major complications is fairly low and not significantly different than that for elective operations. Although we generally use the accepted criteria [4] for deciding when to use tissue versus mechanical valves, we may be somewhat more biased toward tissue valves to avoid the need for long-term anticoagulation therapy. Risks and benefits of either prosthetic type are discussed with each patient during the consent process. Long-term KaplanMeier curves, although limited in providing information regarding cause-specific mortality, show excellent (90.3%) survival for the isolated CABG group, and 76.1% survival at 5 years for the entire cohort. We believe that our data provide incremental information to the existing data. Only one larger series of cardiac surgery in JW patients exists in the English literature [5]. The study by Ott and colleagues [5] presents outcomes of cardiac surgery in 437 JW patients. Those investigators report a 30-day mortality rate of 10.5% (10.7% for cases on cardiopulmonary bypass and 9.3% for cases without cardiopulmonary support). These rates are higher than our reported mortality. Possible explanations are that children are included in their study and that, during this study, patients did not receive any blood derivatives, including fibrinogen, albumin, or cryoprecipitate. Also, newer aids to promote erythropoiesis and enhance coagulation have been employed since the study was published in 1977 (eg, erythropoietin routinely and factor VII in highly selected aortic and valve cases). Other series have reported mortality rates from 4% to 14.3% [2, 6-12]. Henderson and colleagues [13] reported a mortality of 25% in procedures done on cardiopulmonary bypass versus 8.3% in cases done off cardiopulmonary bypass. Most (94.5%) of our cases were done on cardiopulmonary ADULT CARDIAC Ann Thorac Surg 2012;93:19 –25 24 ADULT CARDIAC JASSAR ET AL CARDIAC SURGERY IN JEHOVAH’S WITNESSES Ann Thorac Surg 2012;93:19 –25 Fig 2. Kaplan-Meier analysis of long-term survival of Jehovah’s Witness patients after cardiac surgery. (AVR ⫽ aortic valve replacement; CABG ⫽ coronary artery bypass graft surgery.) bypass, with much lower mortality. Two series report zero in-hospital mortality after cardiac surgery for JW patients [14, 15]. Most of these studies are small, with only two reporting data for 50 or more patients. In our study, we demonstrate that a variety of combined and complex procedures can be safely performed in JW patients, in both the elective and urgent setting. Institutional commitment is paramount to optimize the care for these patients— establishing bloodless teams and protocols, whereby the special needs of such patients are prospectively recognized and addressed. Surgeons who feel uncomfortable providing care for JW patients should refer them to specialized centers with experience in bloodless surgery. Nonetheless, a small, but finite risk of an occasional adverse outcome related to a bleeding event has to be recognized and accepted. It is important to address these issues with the patient and the family before surgery. Rarely, as in the case of 1 patient excluded from our series, the patient may consent to receive blood transfusion when presented with the options and consequences in a frank and open manner. Establishment of advance directives or power of attorney will ensure that if the patient were incapacitated, their wishes would still be fulfilled. There are numerous studies [16-18] that establish blood transfusion as an independent predictor of poor outcome after cardiac surgery. Institute-specific, evidence-based blood transfusion protocols should be established and strictly adhered to for all patients, especially for those at high risk of transfusion-associated complications [19]. Jehovah’s Witness patients represent a salient subset of a large cohort of patients who undergo surgery without receiving blood products; however, for JW patients, this decision is prospective, mandatory, and for almost all, irreversible— even in the face of certain death. Our data demonstrate that with meticulous preparation and expertise, excellent results are achievable in a consecutive series of JW patients undergoing complex cardiac surgery. The authors acknowledge the help and support provided by Mary E. Mckenna, BSN, toward data collection for this study. Dr Jassar is supported by a postdoctoral fellowship from the American Heart Association. References 1. 2010 World Statistics on Jehovah’s Witnesses. Available at: http://www.watchtower.org/e/statistics/worldwide_report. htm. Accessed February 19, 2011. 2. Hughes DB, Ullery BW, Barie PS. The contemporary approach to the care of Jehovah’s witnesses. J Trauma Jul 2008;65(1):237–247. 3. Sniecinski R, Levy JH. What is blood and what is not? Caring for the Jehovah’s Witness patient undergoing cardiac surgery. Anesth Analg 2007;104:753– 4. 4. Bonow RO, Carabello BA, Chatterjee K, et al. 2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease). Circulation 2008;118:e523– 661. 5. Ott DA, Cooley DA. Cardiovascular surgery in Jehovah’s Witnesses. Report of 542 operations without blood transfusion. JAMA 1977;238:1256 – 8. 6. Chikada M, Furuse A, Kotsuka Y, Yagyu K. Open-heart surgery in Jehovah’s Witness patients. Cardiovasc Surg 1996;4:311– 4. 7. Herczeg, L, Szokol J, Horvath G, Vaszily M, Peterffy A. Open-heart surgery and Jehovah’s Witnesses. Med Law 2006;25:233–9. 8. Juraszek A, Dziodzio T, Roedler S, et al. Results of open heart surgery in Jehovah’s Witnesses patients. J Cardiovasc Surg (Torino) 2009;50:247–50. 9. Peterffy A, Horvath G, Tamas C, Bodnar F, Szokol M, Vaszily M. [Open-heart surgery in Jehovah’s witnesses]. Orv Hetil 2000;141:959 – 61. 10. Reyes G, Nuche JM, Sarraj A, et al. [Bloodless cardiac surgery in Jehovah’s witnesses: outcomes compared with a control group]. Rev Esp Cardiol 2007;60:727–31. 11. Rosengart TK, Helm RE, DeBois WJ, Garcia N, Krieger KH, Isom OW. Open heart operations without transfusion using a multimodality blood conservation strategy in 50 Jehovah’s 12. 13. 14. 15. Witness patients: implications for a ”bloodless” surgical technique. J Am Coll Surg 1997;184:618 –29. Stamou SC, White T, Barnett S, Boyce SW, Corso PJ, Lefrak EA. Comparisons of cardiac surgery outcomes in Jehovah’s versus non-Jehovah’s Witnesses. Am J Cardiol 2006;98: 1223–5. Henderson AM, Maryniak JK, Simpson JC. Cardiac surgery in Jehovah’s witnesses. A review of 36 cases. Anaesthesia 1986;41:748 –53. Holt RL, Martin TD, Hess PJ, Beaver TM, Klodell CT. Jehovah’s Witnesses requiring complex urgent cardiothoracic surgery. Ann Thorac Surg 2004;78:695–7. Pompei E, Tursi V, Guzzi G, et al. Mid-term clinical outcomes in cardiac surgery of Jehovah’s witnesses. J Cardiovasc Med (Hagerstown) 2010;11:170 – 4. JASSAR ET AL CARDIAC SURGERY IN JEHOVAH’S WITNESSES 25 16. Koch CG, Khandwala F, Li L, Estafanous FG, Loop FD, Blackstone EH. Persistent effect of red cell transfusion on health-related quality of life after cardiac surgery. Ann Thorac Surg 2006;82:13–20. 17. Koch CG, Li L, Duncan AI, et al. Transfusion in coronary artery bypass grafting is associated with reduced long-term survival. Ann Thorac Surg 2006;81:1650 –7. 18. Whitson BA, Huddleston SJ, Savik K, Shumway SJ. Bloodless cardiac surgery is associated with decreased morbidity and mortality. J Card Surg 2007;22:373– 8. 19. Ferraris VA, Ferraris SP, Saha SP, et al. Perioperative blood transfusion and blood conservation in cardiac surgery: The Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists clinical practice guideline. Ann Thorac Surg 2007;83(Suppl):27– 86. INVITED COMMENTARY The authors [1] present and excellent review of a large and varied series of adult cardiac surgical cases performed without blood transfusion. Patients in this series included primary, reoperations, and elective and emergent operations. It happens that the motivation in this case is driven by religious prohibition against blood transfusions. However, there are valuable lessons in this manuscript that can and should be implemented for all adult cardiac surgical cases. Four years ago, The Society of Thoracic Surgeons and Society of Cardiovascular Anesthesiologists published a joint clinical practice guideline on blood conservation in cardiac surgery [2]. Although there are no reports of transfusion rates available, there have been very few reports of directed efforts to limit blood transfusion. Blood transfusion during cardiac surgery is associated with poorer short-term and long-term outcomes [3]. It would be valuable to reduction of morbidity and to cost containment to examine practices outlined in this manuscript. Adapting such practices to each institution’s systems of care could reduce substantially the utilization © 2012 by The Society of Thoracic Surgeons Published by Elsevier Inc of blood products, lower cost of cardiac surgery, and ultimately improve outcomes. Andrea J. Carpenter, MD, PhD Department of Cardiothoracic Surgery University of Texas Health Science Center- San Antonio 7703 Floyd Curl Dr, MC 7841 San Antonio, TX 78229 e-mail: [email protected] References 1. Jassar AS, Ford PA, Haber HL, et al. Cardiac surgery in Jehovah’s Witness patients: ten-year experience. Ann Thorac Surg 2012;93:19 –25. 2. Ferraris VA, Ferraris SP, Saha SP, et al. Perioperative blood transfusion and blood conservation in cardiac surgery: the Society of Thoracic Surgeons and The Society of Cardiovascular Anesthesiologists clinical practice guideline. Ann Thorac Surg 2007;83(5 Suppl):S27– 86. 3. Koch CG, Li L, Duncan AI, et al. Transfusion in coronary artery bypass grafting is associated with reduced long-term survival. Ann Thorac Surg 2006;81:1650 –7. 0003-4975/$36.00 doi:10.1016/j.athoracsur.2011.08.006 ADULT CARDIAC Ann Thorac Surg 2012;93:19 –25