Open Heart Surgery in Jehovah’s Witnesses: A Propensity Score Analysis

Abstract

Background. Jehovah's Witnesses (JW) refuse allogeneic blood transfusions and therefore pose a unique challenge in case of major surgery. This retrospective study reviewed an experience with JW patients who were undergoing open heart surgery.Methods. By using patient blood management strategies, 35 adult JW patients underwent cardiac surgery at Kepler University Hospital in Linz, Austria between 2008 and 2017. Outcomes were compared with patients who accepted blood transfusions (non-JW patients) by using propensity score matching.Results. There were no significant differences in clinical and operative data between the groups. Twelve JW patients (34.3%) were pretreated with erythropoietin and iron, with a preoperative increase in mean hemoglobin of 2.0 g/dL. On admission, hemoglobin was 14.1 ± 1.1 g/dL in JW patients, compared with 13.2 ± 2.0 g/dL in non-JW patients (P [ .022). The hematocrit in JW patients was higher throughout the hospital stay, even though 51.4% of non-JW patients received allogeneic red blood cell transfusions. The perioperative red blood cell loss was significantly lower in JW patients than in non-JW patients (619 ± 420 mL vs 929 ± 520 mL; P [ .010). Major complication rates were not different between the groups. The hemoglobin at discharge was 11.5 ± 1.5 g/dL in JW patients compared with 10.3 ± 1.3 g/dL in non-JW patients (P < .001). In-hospital mortality was 2.9% in each group, and long-term survival was comparable.Conclusions. By implementing patient blood management, open heart surgery in JW patients can be performed with low morbidity and mortality. Preoperative optimization of hemoglobin and minimization of perioperative blood loss are cornerstones in the prevention of blood loss, anemia, and transfusions.

Mortality and morbidity in non‐transfusable and transfusable patients: A systematic review and meta‐analysis

“…Data on short‐term mortality were provided in 35 of the 41 studies included in our review., 14,15,17–34,37–42,44,46–53 with 32 reporting in‐hospital mortality, and three 30‐day mortality. Of these, 12 reported zero deaths in both groups, 17,19,20,25–28,30,33,40,49,53 and the remaining 23 reported no significant differences between groups 14,15,18,21–24,29,31,32,34,37–39,41,42,44,46–48,50–52 . Eleven moderate risk of bias studies were included in the meta‐analysis of short‐term mortality (Figure 2).…”

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

“…The predominant technique evident within the literature is intraoperative cell salvage due to its general acceptability with Witness patients. 11,12,52,57 This is in addition to the use of intraoperative normovolaemic haemodilution, which was utilised in 37 of the 45 Witness patients undergoing cardiac surgery in a study by McCartney et al 3 The utilisation of antifibrinolytics, heparinisation and carefully considered surgical techniques are also discussed within the clinical literature. 3,11,58 An example of this is the use of sternum bone wax as standard for Witness patients in a study by Emmert et al 59 Other operative aspects such as CPB and cross clamp times were not significantly different between Witness and non-Witness groups in various comparative studies (Table 2).…”

“…Additionally, a large proportion of the study designs are single-centre and nonrandomised. 3,8,57 There is an increased likelihood that surgeons will be more cautious when operating on Witnesses, this in turn could result in reduced blood loss, which is impossible to measure and thus cannot be accounted for. 56 However, it is important to note that these research limitations were taken into account and propensity matching employed in some studies, to define the control group and minimise such limitations.…”

“…56 However, it is important to note that these research limitations were taken into account and propensity matching employed in some studies, to define the control group and minimise such limitations. 15,57 Nonetheless, this only accounts for variables that were recorded, when in reality there will have been a greater number of confounding variables that could not be included in the propensity matching.…”

Outcomes of Cardiac Surgery in Jehovah’s Witness Patients: A Review

“…The predominant technique evident within the literature is intraoperative cell salvage due to its general acceptability with Witness patients. 11,12,52,57 This is in addition to the use of intraoperative normovolaemic haemodilution, which was utilised in 37 of the 45 Witness patients undergoing cardiac surgery in a study by McCartney et al 3 The utilisation of antifibrinolytics, heparinisation and carefully considered surgical techniques are also discussed within the clinical literature. 3,11,58 An example of this is the use of sternum bone wax as standard for Witness patients in a study by Emmert et al 59 Other operative aspects such as CPB and cross clamp times were not significantly different between Witness and non-Witness groups in various comparative studies (Table 2).…”