Strategies and outcomes of cardiac surgery in Jehovah's Witnesses

Open Heart Dual Valve Surgery Without Blood Transfusion: A Case Report

In Nepal, rheumatic heart disease (RHD) is alarmingly prevalent, marked by presentations like migratory joint arthritis, carditis, subcutaneous nodules, erythema marginatum, and Sydenham chorea. This condition can progress to instigate valvular defects. Although these patients are first approached medically, they may require surgery for severe cases. Refusal for blood transfusion might not be a major issue for other general surgeries; however, in cardiac surgery, where there is massive blood loss, it's quite a challenge. This challenge becomes even more pronounced in a developing country that lacks advanced facilities like a cell saver for autotransfusion. Herein, we report a case of a 22-year-old female, a Jehovah's Witness, suffering from RHD, severe mitral regurgitation, severe tricuspid regurgitation, and severe pulmonary artery hypertension. She underwent mitral valve replacement and tricuspid repair surgery (modified DeVega) by avoiding any form of blood product transfusion.

Bloodless Cardiac Surgery in Jehovah's Witness: A Comprehensive Review

This article explores the major challenges and specialized strategies involved in managing cardiovascular surgery patients who are Jehovah's Witnesses and refuse blood transfusions due to their religious beliefs. It delves into preoperative, intraoperative, and postoperative approaches aimed at minimizing blood loss and optimizing patient outcomes while respecting their autonomy. Preoperative measures focus on correcting anemia and coagulopathy through targeted interventions, such as iron supplementation and erythropoietin therapy, and meticulous screening for bleeding disorders. Intraoperative techniques include the use of vasoconstrictors, hemostatic agents, and innovative blood conservation methods like acute normovolemic hemodilution and cell salvage. Postoperative care emphasizes infection control, hemostasis, and judicious monitoring to prevent anemia and facilitate recovery. Through a multidisciplinary approach and adherence to evidence-based practices, healthcare providers can effectively meet the needs of Jehovah's Witness patients, ensuring safe and successful cardiovascular surgery outcomes without the use of blood transfusions.

Everyday Cardiac Surgery in Jehovah's Witnesses of Typically Advanced Age: Clinical Outcome and Matched Comparison

BACKGROUND AND OBJECTIVES

Jehovah's Witnesses (JW) reject the transfusion of blood components based on their religious beliefs, even if they are in danger of harm or death. In cardiac surgery, this significantly reduces the margin of safety and leads to ethical conflicts. Informed consent should be carefully documented and the patient's family should be involved. This study aims to compare the postoperative course of JW who underwent major cardiac surgery with a similar population of non-Witnesses (NW).

PATIENTS AND METHODS

Demographic, procedural, and postoperative data of all consecutive JW who underwent cardiac surgery at our institution were obtained from the records. They were compared with a propensity-score-matched group of NW. Anemic JW were treated with erythropoietin and/or iron as needed. Cardiac surgery was performed by experienced surgeons using median sternotomy and cardiopulmonary bypass. Common blood-sparing techniques were routinely used. Periprocedural morbidity and mortality were statistically evaluated for both groups.

RESULTS

A total of 32 JW and 64 NW were part of the matched dataset, showing no demographic or procedural differences. EPO was used preoperatively in 34.4% and postoperatively in 15.6% of JW but not in NW. Preoperative hemoglobin levels were similar (JW, 8.09 ± 0.99 mmol/L; NW, 8.18 ± 1.06; p = 0.683). JW did not receive any transfusions except for one who revoked, while NW transfusion rates were 2.5 ± 3.1 units for red cells (p < 0.001) and 0.3 ± 0.8 for platelets (p = 0.018). Postoperative levels differed significantly for hemoglobin (JW, 6.05 ± 1.00 mmol/L; NW, 6.88 ± 0.87; p < 0.001), and hematocrit (JW, 0.29 ± 0.04; NW, 0.33 ± 0.04; p < 0.001) but not for creatinine. Early mortality was similar (JW, 6.3%; NW, 4.7%; p = 0.745). There were more pacemakers and pneumonias in JW, while all other postoperative conditions were not different.

CONCLUSIONS

Real-world data indicate that Jehovah's Witnesses can safely undergo cardiac surgery provided that patients are preconditioned and treated by experienced surgeons who use blood-saving strategies. Postoperative anemia is observed but does not translate into a worse clinical outcome. This is consistent with other studies. Finally, the results of this study suggest that all patients should benefit from optimal pretreatment and blood-sparing strategies in cardiac surgery, not just Jehovah's Witnesses.

Outcomes of cardiac surgery in Jehovah's Witness patients: A review

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.

Optimising bloodless cardiovascular surgery for Jehovah's Witnesses and beyond

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.

Evaluation of postoperative clinical outcomes in Jehovah's Witness patients who receive prothrombin complex concentrate during cardiac surgery

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.

When Transfusion Is Not an Option-the Challenges and Rewards

The decision to develop a formal Bloodless Medicine Program to attract and effectively care for patients who decline blood transfusion was made in 1998 by clinical and administrative leaders at our flagship hospital, Allegheny General Hospital, part of the Allegheny Health Network. The Bloodless Medicine Program has more than 20 years of experience in caring for this sometimes challenging patient population and with this experience has provided extensive insight into best practices related to effective, safe, patient blood management. Patient blood management is a patient-centered, evidence-based approach to transfusion that seeks to provide the right care, in the right setting, in the right way, every time. It includes honoring the wishes of patients who decline blood products in their care, that is, "bloodless" medicine. Encouraging patients to participate in their own health care decisions is a vital part of safe, compassionate care. When called upon to provide care to a patient who declines a common therapy such as blood transfusion, clinicians must often develop alternative strategies to achieve the desired results. Their willingness to think creatively and push boundaries has resulted in significant advancement of clinical knowledge and practice related to the use of blood products for all patients. Nurses who advocate for the best care for their patients are a vital component of any successful patient blood management program.

Life-Threatening Pancreatitis in Jehovah's Witness Patients With Severe Anemia Treated Without Transfusions and by Interventional Radiology Techniques

Blood transfusions in anemic patients frequently are used for critically ill patients as a life-saving therapeutic maneuver. Jehovah's Witness (JW) patients typically refuse blood transfusions due to religious beliefs. Numerous clinical reports, in a wide spectrum of medical specialties, have shown no greater morbidity or mortality in JW patients or others who refused transfusions compared to those patients who accept transfusions. We report our experience with two JW patients who presented with severe anemia and life-threatening pancreatitis. Despite undergoing percutaneous drainages by interventional radiology (IR) for complex pancreatic collections (and other IR drainages), neither patient suffered any adverse effect from the IR procedures, even though they refused blood transfusions. Our experience suggests that IR procedures also may be successful with this more limited blood product protocol.

Outcomes from cardiac surgery in Jehovah's witness patients: experience over twenty-one years

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.

Hybrid operation for combined aortic arch aneurysm and aortic root dilation in a Jehovah's witness patient

Aortic surgery for Jehovah's Witness patients with extended aneurysms is challenging. The present report describes a case of a 65-year-old male Jehovah's Witness with aortic aneurysm that extended from the ascending to the transverse aortic arch. Two-stage hybrid operation was performed as follows: ascending aortic replacement with debranching of brachiocephalic artery, followed by extra-anatomic bypass of cervical arteries, and thoracic aortic stent-grafting. The patient fully recovered without complication, and the lowest hemoglobin concentration during the hospital admission was 9.5 g/dL. We conclude that the hybrid procedure was effective in securing a margin of safety for bloodless aortic surgery.

Outcomes in cardiac surgery in 500 consecutive Jehovah's Witness patients: 21 year experience

BACKGROUND

Refusal of heterogenic blood products can be for religious reasons as in Jehovah's Witnesses or otherwise or as requested by an increasing number of patients. Furthermore blood reserves are under continuous demand with increasing costs. Therefore, transfusion avoidance strategies are desirable. We describe a historic comparison and current results of blood saving protocols in Jehovah's Witnesses patients.

METHODS

Data on 250 Jehovah's Witness patients operated upon between 1991 and 2003 (group A) were reviewed and compared with a second population of 250 patients treated from 2003 to 2012 (group B).

RESULTS

In group A, mean age was 51 years of age compared to 68 years in group B. An iterative procedure was performed in 13% of patients in group B. Thirty days mortality was 3% in group A and 1% in group B despite greater operative risk factors, with more redo, and lower ejection fraction in group B. Several factors contributed to the low morbidity-mortality in group B, namely: preoperative erythropoietin to attain a minimal hemoglobin value of 14 g/dl, warm blood cardioplegia, the implementation of the Cornell University protocol and fast track extubation.

CONCLUSIONS

Cardiac surgery without transfusion in high-risk patients such as Jehovah Witnesses can be carried out with results equivalent to those of low risk patients. Recent advances in surgical techniques and blood conservation protocols are main contributing factors.

Minimized perfusion circuits: an alternative in the surgical treatment of Jehovah’s Witnesses

Objectives:

Jehovah’s Witnesses present a challenge to cardiac surgeons, as quality of care is not only defined by mortality and morbidity, but also by the avoidance of blood transfusions. Over the last years, minimized perfusion circuits (MPC) have contributed substantially to the achievement of this goal in our clinic. Presented is a retrospective analysis of our experience.

Methods:

Twenty-nine Jehovah’s Witnesses, aged 69 ± 10 years, have undergone cardiac surgery with a MPC in our institution since 2005. The ROCsafe (Reservoir Optional Circuit) MPC was used in most of these patients (n=27) as it offers the unique possibility of a speedy integration of a reservoir in the event of a major air leak, thereby, negligating any safety concerns.

Results:

There was no in-hospital or 30-day postoperative mortality. Mean ICU stay was 1.6 ± 2 days with a mean intubation time of 11.3 ± 9.1 hrs. Postoperative complications included one myocardial infarction with accompanying low cardiac output, one stroke, one transient delirium, one idiopathic thrombocytopenia and three re-operations (one sternal infection, one postoperative bleeding and one delayed tamponade). The mean postoperative hospital stay was 9.9 ± 2.3 days. Mean decrease in hemoglobin was 2.1 ± 1.3 g/dl during cardiopulmonary bypass and 3.4 ±1.4 g/dl at discharge. The lowest postoperative hemoglobin level was 9.3 ±1.8 (Range 6-12.9).

Conclusions:

These encouraging results emphasize the role MPCs can play in optimizing the quality of patient care. We hope that this report can serve as a stimulus for similar experiences.

Should Jehovah's Witness patients be listed for heart transplantation?

This best evidence topic in Cardiac Surgery was written according to a structured protocol. The question addressed was: for [Jehovah's Witness patients with end-stage heart failure] can these patients undergo a [heart transplantation] without an increased rate of mortality. Altogether, 133 papers were found using the reported search strategy. Of those, 29 papers represented the best evidence to answer the clinical question. Five papers focusing on patients of the Jehovah's Witness (JW) faith who had end-stage heart failure were published. Successful heart transplantation was performed in a total of seven patients without mortality, re-exploration or blood transfusion. One patient had left ventricular reduction surgery twice and another patient had bypass surgery several years after transplantation. Other successful organ transplantations were also reported, including lung, liver, kidney and pancreas in both adult and paediatric patients of the JW faith, with comparable mortality and morbidity to non-JW patients. A publication bias is likely; nevertheless, we conclude that although there are no large studies directly focused on heart transplantation in JW patients, a multidisciplinary team approach to such surgery can make it technically feasible and without an increased mortality risk in suitable candidates. Therefore, such patients may be considered for heart transplantation under selected and favourable circumstances.