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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
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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
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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,
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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
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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.
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CARDIAC SURGERY IN JEHOVAH’S WITNESSES
25
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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