Open heart surgery for acquired heart disease in Jehovah's Witnesses

Open Heart Surgery for Acquired Heart Disease in Jehovah’s Witnesses A Report of 42 Operations

JOHN R. ZAORSKI, MD GRADY L. HALLMAN, MD, DENTON A. COOLEY, MD, Houston,

FACC FACC

Texas

Patients belonging to the Jehovah’s Witness faith may present a special problem when undergoing open heart surgery since they steadfastly refuse blood transfusion. Using a bloodless prime technique of extracorporeal circulation, we performed during an 8-year period 42 open heart operations for acquired heart disease in a consecutive series of 40 patients who were Jehovah’s Witnesses. Three patients (7 percent) died, and only 1 death was caused by anemia. The*_favorable results we attribute in part to the brief periods of cardropulmonary bypass used. In more than 70 percent of cases pump time was less than 40 minutes. We believe that our experience demonstrates the feasibility of open heart surgery in Jehovah’s Witnesses and, moreover, indicates that blood transfusion can and should be used sparingly to reduce morbidity and mortality in all patients.

“Every moving thing with the life thereof, (Genesis 9 : 3,4)

that liveth shall be meat for you . . . but flesh which is the blood thereof, shall ye not eat.”

Literal interpretation of this and other similar Biblical passages has caused many patients belonging to the Jehovah’s Witness faith to refuse blood transfusion in the belief that it is a sin against God, and thus deny themselves the benefits of open heart surgery. This religious sect originated in 1870 in a small Bible study class in Allegheny, Pa. All members are preachers, and their evangelistic work has resulted in phenomenal growth. The faith is now represented in 193 countries, has a worldwide membership of more than 1,250,OOO and numbers more than 343,000 members in the United States alone.’ Fundamentalists by nature, the Jehovah’s Witnesses derive all matters of policy from scriptural sources-even their name, which was conceived from the Bible passage: “Ye are my witnesses, saith the Lord . . .” (Isaiah 43 : 10). Their steadfast refusal of blood transfusion, which they regard as an actual “eating of blood” (in the same manner that an infusion of glucose solution provides nourishment), is based on a literal interpretation of Biblical references such as the followFrom the Texas Heart Institute of St. Luke’sTexas Children’s Hospitals, Houston, Texas. Manuscript receiv,ed January

27, 1971, accepted March 25, 1971. Address for reprints: Denton A. Cooley, MD, Texas Heart institute, PO Box 20345, Houston, Texas 77025.

186

ing : “And whatsoever even set my face off from among and I have given your souls; for

man . . . that eateth any manner of blood ; I will against that soul that eateth blood, and will cut him his people. For the life of the flesh is in the blood ; it to you upon the altar to make an atonement for it is the blood that maketh an atonement for the

The

American

Journal

of CARDIOLOGY

OPEN HEART SURGERY

soul. Therefore I said unto the children of Israel, no soul of you shall eat blood.” (Leviticus 17: lo14)

Jehovah’s Witnesses rarely depart from their religious beliefs by accepting blood transfusion, even when the alternative is death. The surgeon unwilling to treat these persons on the terms of their faith should not accept them as patients. To administer a transfusion to such patients against their wishes could imply bodily assault and constitute a violation of their rights.2-” The advent of hemodilution techniques for cardiopulmonary bypass using a bloodless prime has allowed these patients safe repair of cardiac defects without blood transfusion. Since 1962 bloodless prime has been routinely utilized in more than 5,000 operations at this institution with excellent results; and several hundred of these operations were performed electively without blood transfusion in patients most of whom were not Jehovah’s Witnesses.Br7 In this report we detail our experience with 42 open heart operations for acquired heart disease performed on 40 Jehovah’s Witnesses without using blood.

Method Hemodilution perfusion has been used since 1962 at this institution and was employed in all cases in this study.“*7 The priming volume of a Travenol bag or Bentley Temptrol oxygenator consisted of 20 to 30 ml of 5 percent dextrose solution per kilogram of body weight, with 25 mg of heparin added per 1,000 ml of priming solution. Normothermia was maintained during perfusion. Upon completion of bypass, all the blood in the extracorporeal unit was slowly returned to the patient. The Jehovah’s Witness patients in this series received the same treatment as all other patients except that all Witness patients received injectable iron before and after operation, and no blood was held in reserve for them at the blood bank. The only fluid they received was the priming solution and intravenously administered dextrose in dilute saline or Ringer’s lactate solution. Dextran was used in only 1 patient, who had prolonged excessive bleeding after surgery and subsequently died.

Case Material From May 16, 1962 to May 15, 1970, 42 open heart operations for acquired heart disease were performed without blood transfusion on 40 Jehovah’s Witnesses. The patients ranged in age from 29 to 69 years (average 42 years). Most patients underwent mitral valve replacement (13 cases) or aortic valve replacement (12 cases). Other operations included double and triple valve surgery, mitral annuloplasty, bilateral aortocoronary bypass, and left ventricular aneurysmectomy (Table I). In more than ‘70 percent of cases less than 40 minutes of perfusion time was required for surgical correction.

VOLUME

29, FEBRUARY

1972

IN JEHOVAH’S

WITNESSES

TABLE I Results of 42 Open Heart Operations Disease in 40 Jehovah’s Witnesses

for Acquired

Patients

Deaths (Mortality)

Procedure

(no.)

(no.)

Mitral valve replacement Aortic valve replacement Double valve surgery Mitral annuloplasty Triple valve surgery Bilateral aortocoronary bypass Repair left ventricular aneurysm Total

13 12 9 5 1

1(8%> 0

1 1 42

Heart

Duration of Total Cardiopulmonary Pump Time (range in min)

2 (22%) 0 0 0 0

18-39 30-43 37-60 11-21 60 72 19

3 (7%)

Results Mortality for the entire series was 7 percent or 3 deaths, and it was greatest (22 percent) in the 9 patients who had double valve surgery (Table I). One of these, a 29 year old man, died from myocardial insufficiency, a few days after operation. His hematocrit at the time of death was 39 percent. Another patient, a 4’7 year old woman with embolism to the right cerebral artery causing left hemiplegia, died of pneumonia 18 days after aortic and mitral valve replacement. A thrombus was discovered in the left atrium at operation. The third death was the only one attributed to anemia. It occurred in a 52 year old man who had a cardiac arrest 3 days after mitral valve replacement. His hematocrit was 23 percent at the time of death. The average hematocrit 1 week after surgery for all 40 patients was 34 percent.

Discussion Since 1962 we have routinely employed hemodilution techniques with bloodless prime for open heart surgery.? The bloodless prime technique has the practical advantage of conserving the limited amouhts of blood in banks and hospitals, reducing the cost of operation to the patient and making open heart surgery more readily available in emergencies. Complications that may occur as a direct result of blood transfusion are well known. Homologous

blood syndrome :

Bloodless

prime

is beneficial to renal function of the patient since it creates a profound diuresis after return of prime volume, favoring improved renal function during the early postoperative period. Obviously, renal failure secondary to mismatched blood groups or other factors is eliminated by avoiding blood transfusion. Many complications of early

187

ZAORSKI ET AL.

open heart operations were actually due to using large volumes of pooled blood. Gadboys et al.* reported a “homologous blood syndrome” associated with significant morbidity observed in cases in which pooled homologous blood was used for priming the extracorporeal system. This was further studied by Hegarty and Stahl,g who found that a specific sensitivity reaction at the capillary level and increased capillary permeability cause loss of fluid and protein into the extracellular space. The resultant increase in pulmonary vascular resistance may lead to reduced pulmonary perfusion and systemic circulatory collapse. One of the factors in homologous blood syndrome may be transmission of antigens from previous blood transfusions. Perkins et al.l” reported the massive hemolysis of donor red cells occurring because of isoimmunization even though isoantibodies were not detected before operation. The antibody subtype must be identified before further blood is administered in such cases. In addition to problems in matching and isoimmunization, other factors may cause complications in patients receiving large volumes of pooled homologous blood during open heart surgery. For instance, McNamara and co-workers,ll while caring for combat casualties, found a significant amount of fibrin, red cell aggregates and platelet debris in stored blood, but not in fresh whole blood. This debris can easily pass the filters of most blood transfusion sets and result in pulmonary microembolism. Post-transfusion hepatitis and clotting abnormalities : The use of a bloodless prime has reduced the incidence of post-transfusion hepatitis, currently reported as 6 percent per unit of commercial bank blood.12 At some medical centers where large volumes of blood are used to prime the bypass units, the incidence of hepatitis has been as high as 51 percent.13 In 1 series of patients who underwent open heart operations requiring blood transfusion, mortality from serum hepatitis alone was 11.2 percent-more than the overall mortality for those with acquired heart disease reported on herein. l4 Blood-borne diseases such as malaria and syphilis have also occurred, although rarely, as a result of transfusion. Recently, fresh heparinized blood has been incriminated in transferring a cytomegalovirus, the virus causing cytomegalic inclusion disease which has serious and often fatal results in infants and chi1dren.l” The post-perfusion syndrome characterized by the delayed onset of fever, lymphocytosis and splenomegaly is another complication for which the use of blood may be responsib1e.l” Abnormalities of coagulation may cause hemorrhage and should be avoided especially in the Jehovah’s Witness. Patients previously receiving anticoagulant agents must be carefully prepared with vitamin K. Clotting abnormalities are decreased

188

when less blood is used for cardiopulmonary bypass. In a study by Cue110et a1.l’ of the total serosanguineous output through chest catheters during the first 24 hours after operation, patients who received dextrose and water prime had a lower overall amount of chest drainage than those who received blood and dextran prime. Bypass time: According to Porter et al.ls clotting abnormalities increase with bypass time. After 1 hour of cardiopulmonary bypass the platelet count, prothrombin and factor V are considerably decreased. Fibrinogen decreases more slowly, and fibrinolytic activator activity increases in linear fashion with bypass time. Since every possible safeguard should be taken to avoid excessive blood loss in the Jehovah’s Witness, we believe that the duration of cardiopulmonary bypass should be kept as short as reasonably possible. In 39 of our 42 cases bypass time was less than 1 hour. This shortened bypass time together with exacting hemostasis and total correction of the cardiac lesion contributed significantly toward the successful results obtained in these patients. Dextran: We did not use dextran in the priming solution because it remains longer in the vascular compartment than does 5 percent dextrose and water. Low molecular weight dextran has an intravascular half life of about 14 hours and could cause prolonged hemodilution and hypervolemia when the patient’s blood is returned at completion of operation. Hypervolemia taxes cardiac function and may contribute to failure in patients with a compromised myocardium. In addition, low molecular weight dextran increases the bleeding time and decreases the fibrinogen content, which does not return to normal for 24 hours. It may also cause allergy and anaphylactic reactions. All of our patients were given iron therapy before and after surgery to enhance erythropoiesis. Epsilon-amino-caproic-acid (EACA) has been advocated as a prophylaxis for reducing postoperative bleeding, and it is effective in inhibiting plasminogen activator substance and, to a lesser degree, plasmin activity, I9 Several patients in this series received EACA. Vascular surgery : Recently we reported our experience with 20 Jehovah’s Witnesses who underwent central or peripheral vascular surgery for congenital or acquired disease.20 Only 2 of these patients died, 1 of whom was 74 years old. In the other patient death occurred after a subsequent open heart operation. Results in this series compared favorably with results in other patients, not Jehovah’s Witnesses, undergoing similar operations, indicating that a good outcome can be obtained in vascular surgery without using blood transfusion. Clinical implications : Successful accomplishment of open heart operations without blood transfusion is not unusual. From December 3, 1969 to

The American

Journal

of CARDIOLOGY

OPEN HEART SURGERY

January 30, 1970, 100 consecutive cases of open heart surgery in other patients at this institution required a total of only 141 units of blood (including blood used during the entire hospital stay of each patient). In 35 cases no blood was used ; and in 31, only 1 unit was administered. The average transfusion requirement was less than 2 units of blood, even though 2 patients received 10 units each. Thus, the Jehovah’s Witness patient under-

IN JEHOVAH’S

WITNESSES

going open heart surgery does not necessarily present a special problem at this institution, since we are routinely cautious in administering blood. Admittedly, the Jehovah’s Witness patient foregoes the added safeguard of having blood on standby in case it is needed. Generally, however, such a patient can face an open heart operation without blood transfusion with the assurance of favorable results.

References 1. Yearbook of Jehovah’s Witnesses 1970. Pittsburgh, Pa., Watchtower Bible and Tract Society, 1970 2. Schechter DC: Problems relevant to major surgical op erations in Jehovah’s Witnesses. Amer J Surg 116:7380,1968 3. McDonald RTr Blood, the Jehovah’s Witnesses and the physician. Ariz ‘Med 24:969-973, 1967 Some issues in4. Thomas IG, Edmark RW, Jones m: volved with major surgery on Jehovah’s Witnesses. Amer Surg 34:538-544, 1968. 5. Fit& WT Jr, Orloss MJ: Blood transfusion and Jehovah’s Witnesses. Surr! Gvnec Obstet 108:502-507. 1959 6. Cooley DA, Beill AC Jr, Grondin P: Open’heart operations with disposable oxygenators, 5 percent dextrose prime and normothermia. Surgery 52:713-719,1962 7. Cooley DA, Beall AC Jr, Hallman GL: Open heart surgery using disposable plastic oxygenators, 5 percent dextrose for priming and maintenance of normothermia: experience with 1162 operations. Ann Chir Thorac Cardiovasc 4:423-430, 1965 8. Gadboys HL, Slonim R, Litwak RS: Homologous blood syndrome. 1. Preliminary observations on its relationship to clinical cardiopulmonary bypass. Ann Surg 156:793804, 1962 9. Hegarty JC, Stahl WM: Homologous blood syndrome pressure relationships and lymphatic studies. J Thorac Cardiovasc Surg 53:415-424, 1967 10. Perkins HA, Day D, Hill E: Immunologic basis for massive loss of red blood cells after open heart surgery. Proceedings of the Ninth Congress of the International

VOLUME

29, FEBRUARY

1972

Society of Blood Transfusion, 1962, p 97-102 11. McNamara JJ, Molet MD, Stremple JF: Screen filtration pressure of blood in combat casualties. Ann Surg 172: 334-341, 1970 12. Allen JG: Some factors regulating duration of incubation for serum hepatitis. Arch Surg (Chicago) 100:2-5, 1970 13. Walsh JH, Purcell RH, Morrow AG, et al: Post transfusion hepatitis after open heart operations, JAMA 211: 261-265, 1970 14. Mosley JW: Surveillance of transfusion associated with viral hepatitis. JAMA 193:1007-1010, 1965 15. Kaariainen L, Paloheimo J, Kleomola E, et al: Cytomegalovirus mononucleosis: isolation of virus and demonstration of subcli,nical infections after fresh blood transfusion in connection with open heart surgery. Ann Med Exp Biol Fenn 44:297-301,1966 16. Kirsh M, McIntosh K, Kahn D, et al: Postpericardiectomy syndromes. Ann Thorac Surg 9:158-179, 1970 17. Cuello L. Bhannanada K. Mack J. et al: Hemodilution in extra&pore2 circulation. Surgery 56:34+354, 1964 18. Porter JM, Silver D, Sabiston DC Jr: Alteration in fibrinolysis and coagulation associated with cardiopulmonary bypass. J Thorac Cardiovasc Surg 56:869-878. 1968 19. Sterns LP, Lillehei CW Effect of epsilon amino caproic acid on blood loss following open heart surgery. Canad J Surg l&304-307,1967 20. Simmons CW Jr, Messmer BJ, Hallman GL, et al: Vascular surgery in Jehovah’s Witnesses. JAMA 213:10321034,197o

189