Perfusion without donor blood

Leukocyte filtration and miniature perfusion during arrested heart CABG on a Jehovah’s Witness patient

Bloodless surgery and a reduction in the use of allogeneic blood products has long been the standard of care in medicine. Many individuals in our communities have demanded this form of surgical treatment for personal and religious reasons. On 6 December 2002, a 72-year-old male patient was admitted to our institution as a critical air flight transfer. The patient’s height was 190.5 cm and weight was 59.3 kg (body surface area 1.83 m2). His preliminary diagnosis was chest pain with myocardial infarction as evidenced by elevated blood cardiac isoenzymes. His principle diagnosis was subendocardial infarction with paroxysmal ventricular tachycardia. Cardiac catheterization was performed and demonstrated severe triple vessel disease with an ejection fraction of 30%. He was evaluated and accepted as a candidate for coronary artery bypass grafting. Multidisciplinary consultation concluded that a safe and effective method of perioperative treatment would involve the use of arrested heart support with cold blood cardioplegia using a low prime miniature perfusion circuit as no blood products would be considered for use. Additionally, the combined modalities of perfusion interventions to minimize hemodilution consisted of intraoperative autologous blood collection totaling 500 mL and rapid autologous priming of the miniature perfusion circuit. The miniature perfusion system was a low prime Cardiovention (Santa Clara, CA) CORx device which includes a hollow-fiber oxygenator and integral centrifugal pump with a surface area of 1.2 m2. This system also incorporates an air sensing solenoid which triggers rapid air evacuation in a bolus range of 1 mL or greater. Kinetic venous drainage is another feature of this device as the centrifugal pump is integrated into the oxygenator. We believed that a miniature extracorporeal circuit would enhance the desired clinical outcome as opposed to the risk of: (1) off-pump coronary artery bypass (OPCAB) approach and the concern of emergent transition to an on-pump procedure and (2) use of larger surface area with conventional systems that impose a greater hemodilutional effect. Leukocyte filtration was employed as the patient had a significant past medical history of chronic obstructive pulmonary disease. We herein report our clinical experience with this method of treatment on a patient who refused the use of blood products in his surgical treatment. It is our belief that the multiple modalities utilized in combination during this procedure resulted in positive clinical outcomes as demonstrated by an intubation time of 8 hours 35 min with a discharge on the fifth postoperative day.

Reoperation, emergency and urgent open cardiac surgery in Jehovah's Witnesses

Progressive advances in perfusion technology and perioperative supportive management have made it possible for members of the Jehovah's Witnesses religious group to undergo open cardiac operations with remarkable safety. However, hospital mortality remains high in (1) patients requiring reoperation (in whom both technical and bleeding problems tend to be more frequent) and (2) patients with significantly compromised cardiac performance requiring urgent or emergency operation. Employing a number of perioperative measures designed to minimize blood loss and maintain hematocrit levels (including use of the recently available recombinant human erythropoietin in two patients whose cases are reported herein), 13 reoperations and five urgent or emergency operations were performed. The one death in the entire series occurred in a patient (reoperation group) who died of a cerebrovascular accident of presumed embolic etiology, having undergone combined debridement of a stenotic heavily calcified aortic valve and a second coronary artery revascularization procedure. None of the patients required surgical exploration for bleeding. We suggest that currently available methodology permits Jehovah's Witnesses to undergo reoperation, emergency surgery, or urgent open cardiac operation at a level of risk not dissimilar to that seen in patients who permit use of homologous blood and products in their treatment.

An Automatically Regulated Low Prime Heart-Lung Machine for Infants: A Rabbit Model

A new compact heart-lung machine for paediatric use was designed. The total volume of this system of only 90ml allows for priming without the use of donor blood. The priming volume could be kept small mainly by replacing gravity drainage with drainage by a negative pressure in the venous reservoir. To avoid volume shifts between the extracorporeal circuit and the infant's circulation and to safely operate this minimal volume circuit, the heart-lung machine was automatically controlled. In this study we show that the miniaturized system functioned reliably under various conditions during cardiopulmonary bypass in rabbits.

Cardiac surgery in Jehovah's witnesses. A review of 36 cases

Between January 1971 and January 1985, 31 Jehovah's witnesses underwent 24 bypass and 12 non-bypass cardiothoracic operations at the National Heart Hospital. Fifty-eight% of the group were under 16 years of age. There was one death in the non-bypass group unrelated to blood loss. Six deaths occurred in the bypass group. In one of these, blood loss contributed to the cause of death and in two patients, blood loss was directly related to the cause of death. The anaesthetic management of Jehovah's witnesses undergoing cardiac surgery is discussed.

Reduction of postoperative donor blood requirement by use of the cell separator

In a prospective, randomized study of 20 patients undergoing elective open-heart surgery, up to c. one-third of the total intraoperative and postoperative transfusion requirement could be provided by autologous centrifuged blood. Retransfusion of washed, packed red blood cells freed from cellular debris, heparin and activated clotting factors significantly reduced blood loss during and after surgery. The cell separator is a valuable aid in autotransfusion technique.

Blood loss and bank blood requirement in coronary bypass surgery

With the use of nonblood prime and refinement in perfusion and surgical techniques, blood requirement for coronary bypass operations has been reduced to a minimum. Of 240 patients (average number of bypasses, 3.07; average pump time, two hours and 22 minutes), no blood was used in pump prime or before perfusion. During perfusion, 29 patients (12%) received 34 units of blood in the pump-oxygenator, and after bypass 64 patients (27%) received 65 units of blood in the operating room (average intraoperative use, 203 ml per patient). For the total hospital stay, the blood requirement was 728 ml per patient. For the last 60 patients operated on, the figure was 328 ml. There were no surgical deaths, and only 1 reexploration for postoperative hemorrhage (0.4%). Discharge hemoglobin level averaged 11.8 gm, whereas the admission hemoglobin level had averaged 13.8 gm. Autotransfusion, avoidance of entry into the pleural space, shorter perfusion time, postoperative platelet count of more than 150,000, and normal partial thromboplastin time tend to reduce blood requirement, but not to a striking degree. Bank blood requirement for the coronary bypass program accounted for 3.7% of the hospital need and 2% of the community need.

Myocardial protection during aortic valve replacement

The results following aortic valve replacement (AVR) were compared in 40 patients in whom the myocardium was protected by topical hypothermic arrest or continuous coronary perfusion with sustained electrical fibrillation (Group A) and 40 similar patients in whom the hearts were also continuously perfused but were kept in the beating state (Group B). The operative mortality was not greatly different between the two groups, being 10 and 5%, respectively. The postperfusion cardiac performance was strikingly different, however. Seventeen patients (43%) in Group A required inotropic support, while this was necessary in only 1 patient (3%) in Group B. In this instance, recurrent ventricular fibrillation persisted despite attempts at reversion. These data show that the myocardium is preserved best during AVR when continuous coronary perfusion is used and the heart is maintained in the beating state.

Banked and fresh autologous blood in cardiopulmonary bypass surgery

When 50 patients having autologous transfusions of two units of blood collected intraoperatively during coronary bypass surgery were compared with 50 patients receiving only homologous donor blood, it was found that a two-unit (20%) decrease in homologous blood usage per case occurred in the group receiving the autologous blood. No decrease occurred in total units of blood used per case. In 15 patients undergoing coronary bypass surgery, in addition to the two units of autolobous blood collected during surgery, two or four units of autologous blood were obtained preoperatively and administered intraoperatively. When four units were collected, the red blood cells were frozen until just prior to surgery. Total blood usage per case remained unchanged but a 4.6 unit (41%) decrease in homologous donor blood usage was noted. Patients phlebotomized preoperatively took 325 mgm of oral iron t.i.d. through the postoperative recovery period. These patients had an average decrease in hematocrit of 4.25 to 4.3 per cent following the final phlebotomy and just prior to surgery.