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Abstract
Emerging evidence suggests surgical outcomes of patients undergoing cardiovascular surgery that refuse autologous transfusion is comparable to those who accept whole blood product transfusions. There are several methods that can be used to minimize blood loss during cardiovascular surgery. These methods can be categorised into pharmacological measures, including the use of erythropoietin, iron and tranexamic acid, surgical techniques, like the use of polysaccharide haemostat, and devices such as those used in acute normovolaemic haemodilution. More prospective studies with stricter protocols are required to assess surgical outcomes in bloodless cardiac surgery as well as further research into the long-term outcomes of bloodless cardiovascular surgery patients. This review summarizes current evidence on the use of pre-, intra-, and post-operative strategies aimed at the subset of patients who refuse blood transfusion, for example Jehovah's Witnesses.
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Chambault AL, Brown LJ, Mellor S, Harky A. Outcomes of cardiac surgery in Jehovah's Witness patients: A review. Perfusion 2020; 36:661-671. [PMID: 33325336 PMCID: PMC8446884 DOI: 10.1177/0267659120980375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Objective: To review current literature evidence on outcomes of cardiac surgery in
Jehovah’s Witness patients. Methods: A comprehensive electronic literature search was done from 2010 to 20th
August 2020 identifying articles that discussed optimisation/outcomes of
cardiac surgery in Jehovah’s Witness either as a solo cohort or as
comparative to non-Jehovah’s Witnesses. No limit was placed on place of
publication and the evidence has been summarised in a narrative manner
within the manuscript. Results: The outcomes of cardiac surgery in Jehovah’s Witness patients has been
described, and also compared, to non-Witness patients within a number of
case reports, case series and comparative cohort studies. Many of these
studies note no significant differences between outcomes of the two groups
for a number of variables, including mortality. Pre-, intra and
post-operative optimisation of the patients by a multidisciplinary team is
important to achieve good outcomes. Conclusion: The use of a bloodless protocol for Jehovah’s Witnesses does not appear to
significantly impact upon clinical outcomes when compared to non-Witness
patients, and it has even been suggested that a bloodless approach could
provide advantages to all patients undergoing cardiac surgery. Larger
cohorts and research across multiple centres into the long term outcomes of
these patients is required.
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Affiliation(s)
- Aimee-Louise Chambault
- Medical School, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Louise J Brown
- Medical School, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Sophie Mellor
- Medical School, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest, Liverpool, UK.,Department of Integrative Biology, Faculty of Life Sciences, University of Liverpool, Liverpool, UK.,Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, UK.,Department of Cardiac Surgery, Alder Hey Children Hospital, Liverpool, UK
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3
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Harris JE, Varnado S, Herrera E, Salazar E, Colavecchia AC. Evaluation of postoperative clinical outcomes in Jehovah's Witness patients who receive prothrombin complex concentrate during cardiac surgery. J Card Surg 2020; 35:801-809. [PMID: 32048355 DOI: 10.1111/jocs.14463] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Patients who refuse allogeneic blood transfusions (alloBT) on the basis of religious doctrine, such as Jehovah's Witnesses (JWs), can pose a challenge when undergoing surgical procedures. During cardiac surgery, special considerations regarding surgical techniques and blood loss minimization strategies can lead to improved outcomes. Limited literature exists to guide the use of four-factor prothrombin complex concentrate (4PCC) in this patient population undergoing cardiac surgery. STUDY DESIGN AND METHODS This retrospective, single-center study evaluated the impact of 4PCC on hemoglobin (Hgb) change from baseline to postoperative nadir within a 7-day period among patients who refused alloBT during cardiac surgery. This study identified patients who refused alloBT from January 2011 to June 2017. Multivariable linear regression was used to control for confounding variables to evaluate the effectiveness of 4PCC. RESULTS During the study timeframe, 79 patients met inclusion criteria, all of whom identified as JWs, and underwent cardiac surgery. Of these, 19 received intraoperative 4PCC. Multivariable linear regression found no difference in Hgb change in patients who received 4PCC vs those who did not. No significant differences were found in mortality, thromboembolic complications, or in-hospital postoperative events. CONCLUSIONS In JWs undergoing cardiac surgery who refuse alloBT, intraoperative use of 4PCC was not associated with a difference in Hgb change within 7 days postoperatively when adjusting for confounding variables. In the event of excessive blood loss, the utilization of 4PCC may provide a viable option in JW patients who undergo cardiac surgery where few options exist to mitigate blood loss.
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Affiliation(s)
- Jesse E Harris
- Department of Pharmacy, Houston Methodist Hospital, Houston, Texas
| | - Sara Varnado
- Department of Pharmacy, Houston Methodist Hospital, Houston, Texas
| | - Elizabeth Herrera
- Department of Anesthesiology, Houston Methodist Hospital, Houston, Texas
| | - Eric Salazar
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas
| | - Anthony C Colavecchia
- Department of Pharmacy, Houston Methodist Hospital, Houston, Texas.,Pfizer Inc., New York, New York
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Wauthy P, Pierrakos C, Chebli L, Tortora R. Long-term survival and quality of life in Jehovah's witnesses after cardiac surgery: a case control study. BMC Cardiovasc Disord 2019; 19:73. [PMID: 30922241 PMCID: PMC6440098 DOI: 10.1186/s12872-019-1061-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 03/22/2019] [Indexed: 11/24/2022] Open
Abstract
Background We previously analyzed morbidity and mortality in Jehovah’s Witnesses patients after cardiac surgery compared to control population patients. Patients who were Jehovah’s Witnesses were operated in accordance with their philosophical convictions and in respect of their refusal of transfusions. We propose to assess long-term survival and quality of life in the patients of this preliminary study. Methods We contacted 31 adult Jehovah’s Witnesses patients who underwent heart surgery at the Brugmann hospital between 1991 and 2012 and compared them to a control population of 62 patients that had no transfusion restriction, and matched them for sex, age at the time of intervention and the type of surgery performed. We compared long-term quality of life in both populations through the MacNew software, a validated instrument to assess quality of life of patients with cardiovascular disease. The long-term survival of patients was analyzed by Kaplan Meier curves. Results Long-term quality of life and survival do not appear different between the two groups. Patient evaluation by MacNew software shows comparable physical (p = 0.54), emotional (p = 0.12), social (p = 0.21) and global (p = 0.25) scores between the two populations. The analysis of the actuarial survival curves shows no differences in terms of long-term survival of these patients (p = 0.37). Conclusions Cardiac surgery in Jehovah’s Witnesses can be performed with identical long-term quality of life and survival compared to surgery without blood transfusion restriction, if one follows rigorous blood conserving strategies. Trial registration NCT03348072. Retrospectively registered 16 November 2017.
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Affiliation(s)
- Pierre Wauthy
- Department of Cardiac Surgery, CHU Brugmann, Place A van Gehuchten, 1020, Brussels, Belgium.
| | | | - Louis Chebli
- Department of Cardiac Surgery, CHU Brugmann, Place A van Gehuchten, 1020, Brussels, Belgium
| | - Redente Tortora
- Department of Cardiac Surgery, CHU Brugmann, Place A van Gehuchten, 1020, Brussels, Belgium
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Valle FH, Pivatto Júnior F, Gomes BS, Freitas TMD, Giaretta V, Gus M. Cardiac Surgery in Jehovah's Witness Patients: Experience of a Brazilian Tertiary Hospital. Braz J Cardiovasc Surg 2018; 32:372-377. [PMID: 29211216 PMCID: PMC5701095 DOI: 10.21470/1678-9741-2017-0012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 05/07/2017] [Indexed: 11/30/2022] Open
Abstract
Introduction The outcomes of Jehovah's Witness (JW) patients submitted to open heart
surgery may vary across countries and communities. The aim of this study was
to describe the morbidity and mortality of JW patients undergoing cardiac
surgery in a tertiary hospital center in Southern Brazil. Methods A case-control study was conducted including all JW patients submitted to
cardiac surgery from 2008 to 2016. Three consecutive surgical non-JW
controls were matched to each selected JW patient. The preoperative risk of
death was estimated through the mean EuroSCORE II. Results We studied 16 JW patients with a mean age of 60.6±12.1 years. The
non-JW group included 48 patients with a mean age of 63.3±11.1 years
(P=0.416). Isolated coronary artery bypass graft
surgery was the most frequent surgery performed in both groups. Median
EuroSCORE II was 1.29 (IQR: 0.66-3.08) and 1.43 (IQR: 0.72-2.63),
respectively (P=0.988). The mortality tended to be higher
in JW patients (18.8% vs. 4.2%, P=0.095),
and there was a higher difference between the predicted and observed
mortality in JW patients compared with controls (4.1 and 18.8%
vs. 2.1 and 4.2%). More JW patients needed hemodialysis
in the postoperative period (20.0 vs. 2.1%,
P=0.039). Conclusion We showed a high rate of in-hospital mortality in JW patients submitted to
cardiac surgery. The EuroSCORE II may underestimate the surgical risk in
these patients.
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Affiliation(s)
- Felipe Homem Valle
- Hospital de Clínicas de Porto Alegre (HCPA), Cardiology Division, Porto Alegre, RS, Brazil
| | - Fernando Pivatto Júnior
- Hospital de Clínicas de Porto Alegre (HCPA), Internal Medicine Division, Porto Alegre, RS, Brazil
| | - Bruna Sessim Gomes
- Hospital de Clínicas de Porto Alegre (HCPA), Cardiology Division, Porto Alegre, RS, Brazil
| | | | - Vanessa Giaretta
- Hospital de Clínicas de Porto Alegre (HCPA), Cardiology Division, Porto Alegre, RS, Brazil
| | - Miguel Gus
- Hospital de Clínicas de Porto Alegre (HCPA), Cardiology Division, Porto Alegre, RS, Brazil
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“Bloodless” Neurosurgery Among Jehovah's Witnesses: A Comparison with Matched Concurrent Controls. World Neurosurg 2017; 97:132-139. [DOI: 10.1016/j.wneu.2016.09.028] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 09/03/2016] [Accepted: 09/06/2016] [Indexed: 11/20/2022]
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Vasques F, Kinnunen EM, Pol M, Mariscalco G, Onorati F, Biancari F. Outcome of Jehovah's Witnesses after adult cardiac surgery: systematic review and meta-analysis of comparative studies. Transfusion 2016; 56:2146-53. [DOI: 10.1111/trf.13657] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Revised: 04/04/2016] [Accepted: 04/04/2016] [Indexed: 02/01/2023]
Affiliation(s)
- Francesco Vasques
- Department of Medicine; Anesthesia and Intensive Care Unit, Padua University Hospital; Padua Italy
| | | | - Marek Pol
- Institute of Anatomy, First Faculty of Medicine, Charles University in Prague; Prague Czech Republic
| | - Giovanni Mariscalco
- Department of Cardiovascular Sciences; University of Leicester, Glenfield Hospital; Leicester UK
| | - Francesco Onorati
- Division of Cardiac Surgery; University of Verona Medical School; Verona Italy
| | - Fausto Biancari
- Department of Surgery; Oulu University Hospital; Oulu Finland
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Marinakis S, Van der Linden P, Tortora R, Massaut J, Pierrakos C, Wauthy P. Outcomes from cardiac surgery in Jehovah's witness patients: experience over twenty-one years. J Cardiothorac Surg 2016; 11:67. [PMID: 27079663 PMCID: PMC4831181 DOI: 10.1186/s13019-016-0455-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 04/05/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cardiac surgery in Jehovah's Witnesses may be challenging during the operation and postoperative period given their refusal of blood products. The aim of this study was to document our center's experience with Jehovah's Witnesses undergoing major cardiac surgery and to compare surgical outcomes with a matched control group. METHODS We retrospectively reviewed the demographic, perioperative, and in-hospital postoperative data for 31 Jehovah's Witness patients undergoing surgery from 1991 to 2012 and compared findings with a control group of 62 patients of the same sex and age, who underwent the same type of operations in the same period. Early mortality, major in-hospital morbidity, laboratory findings, and hospital stays were compared between groups. RESULTS Demographic data were similar between groups, except that more patients in the Jehovah's Witness group had extracardiac arteriopathy compared with controls (p = 0.04). There was no difference in predicted mortality, calculated by the Euroscore II, between groups (2.8 ± 3.3 in study group versus 2.4 ± 2.2 in control group, p = 0.469). For postoperative outcomes, there were no differences between Jehovah's Witnesses versus controls in hospital mortality (3 % versus 2 %, p = 0.548), total drain loss (847 ± 583 mL versus 812 ± 365 mL, p = 0.721), mechanical ventilation time (1.26 ± 2.24 versus 0.89 ± 0.55 days, p = 0.218), intensive care unit stay (4.3 ± 3.9 versus 3 ± 1.4 days, p = 0.080), and hospital stay (12.9 ± 7.6 versus 10.9 ± 6.6 days, p = 0.223). CONCLUSIONS Outcomes after cardiac surgery are similar between Jehovah's Witnesses and general population, in centers applying rigorous blood patient management protocols.
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Affiliation(s)
- Sotirios Marinakis
- Department of Cardiac Surgery, Brugmann University Hospital, Laeken, Belgium
| | | | - Redente Tortora
- Department of Cardiac Surgery, Brugmann University Hospital, Laeken, Belgium
| | - Jacques Massaut
- Department of Intensive Care Unit, Brugmann University Hospital, Laeken, Belgium
| | | | - Pierre Wauthy
- Department of Cardiac Surgery, Brugmann University Hospital, Laeken, Belgium.
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Kim TS, Lee JH, Na CY. Blood Conservation Strategy during Cardiac Valve Surgery in Jehovah's Witnesses: a Comparative Study with Non-Jehovah's Witnesses. Korean J Crit Care Med 2016. [DOI: 10.4266/kjccm.2016.31.2.101] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Tae Sik Kim
- Department of Thoracic and Cardiovascular Surgery, Korea University Medical Center, Seoul, Korea
| | - Jong Hyun Lee
- Department of Anesthesiology and Pain Medicine, Sejong General Hospital, Bucheon, Korea
| | - Chan-Young Na
- Department of Thoracic and Cardiovascular Surgery, Keimyung University Dongsan Medical Center, Daegu, Korea
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