Jehovah’s Witnesses are members of a religious movement known for their view of rejecting blood transfusions, even in life or death situations. There are reportedly 8.3 million Jehovah’s Witnesses around the world and nearly 120,000 congregations.
Before major surgery, these patients are confronted with the stress of both the operation and the potential need for transfusion. The role of the health care provider is to assure the physical and psychological welfare of patients while respecting their philosophical and religious beliefs. However, despite the important evolution of blood preservation techniques, there is still a great risk for transfusion in cardiac surgery. Transfusion rates during hospitalization for a cardiac surgery procedure vary from 25 to 95 %. In this context, cardiac surgery in Jehovah’s Witnesses represents a real challenge, necessitating a close collaboration between the surgical, anesthesiological, and medical teams.
Cardiac surgery is a specialty that often requires the use of blood products. For this reason, cardiac surgery in patients who refuse to use these products, such as Jehovah´s Witnesses (JW), can be a huge challenge for health personnel.
Cardiac surgery in Jehovah’s Witnesses may be challenging during the operation and postoperative period given their refusal of blood products. Highly complex cardiovascular procedures are not offered to patients at most centers because of the high risk of mortality and morbidity if massive blood loss occurs and transfusions are refused. There are few surgical teams willing to perform complex cardiovascular procedures on Jehovah’s Witness patients all over the world.
The invasive nature of a cardiac procedure, the associated decrease of body temperature and especially the use of cardio-pulmonary bypass (CPB) are major reasons for an increased blood loss and the high incidence for blood transfusions during and after cardiac surgery. Allogenic blood transfusions are often necessary in cardiac surgery; they do however increase mortality, morbidity and major adverse outcomes. The evolution of less invasive cardiac approaches, such as off-pump procedures for myocardial revascularization or minimally-invasive valve repair may contribute to a further reduction of blood transfusion. Furthermore, off-pump surgery even allows coronary artery bypass grafting (CABG) while avoiding CPB. Various data are available reporting decrease of postoperative complications and blood transfusions in patients undergoing the off-pump approach
In addition to meticulous operative techniques, we developed a perioperative management protocol of optimization of Jehovah’s Witness patients. Antiplatelet agents are discontinued at least 5 days preoperatively. Any supplement, food, or medication that may increase the risk of bleeding (ie, vitamin E, fish oil, turmeric, and ginger) is also withheld. In addition, procedures such as cardiac catheterization are scheduled several weeks before surgery to allow the patient to recover from the renal toxicity of the contrast and any blood loss.
Patient blood management comprises three main elements: 1) correction of perioperative anemia, 2) minimizing perioperative blood-loss and 3) using low hemoglobin-based transfusion triggers.
A 39-year-old, 60-kg male patient of the Jehovah’s Witness faith, with no other co-morbidities who was admitted with NSTEMI. His Cardiac catheterization done outside revealed severe multivessel coronary artery disease and was advised CABG. His operation was refused in some centres because of refusal of blood transfusion by the patient and in some centres patient was not confident in getting it done. When he came to our centre, we offered him Off-pump CABG and the patient was willing to getting it done in our centre with confidence. He was admitted on 8/11/18. His pre-op haemoglobin was 13.5gm% and his ECHO revealed left ventricular ejection fraction of 60% with Regional Wall Motion Abnormality of basal inferior wall. His anti-platlelets were stopped 5 days prior to surgery and underwent CABG on 14/11/18 under General Anaesthesia. Perioperatively 250 ml of autologous blood was collected in a blood bag. Bone wax was used after sternotomy to minimize bleeding. Bilateral Internal mammary artery was harvested and Off-pump total arterial revascularization was done after. heparinization. Meticulous hemostasis was achieved and 2 drains placed. Postoperative bleeding was minimal and course in the hospital was uneventful. He was discharged on 20/11/18 with haemoglobin of 12.6gm%.
Dr Isaac Christian Moses Medical Director of Sri Ramakrishna Hospital confirms that our case is unique in two aspects. Firstly patient underwent coronary bypass surgery successfully without undergoing any blood transfusion. Second, he underwent total arterial revascularisation without use of leg veins. This procedure is not offered in many centres. Total arterial revascularisation is done using both internal mammary arteries, the use of this ensures that the bypass surgery grafts work for more than 20 years. This patient was below 50 yrs of age hence this was done. Surgical team was headed by Dr.Thiagarajamurthy along with Dr Sujith and Dr Renus Demel. Anesthesia was managed by Dr Ashok Hariharan and Dr.Narendra Menon. Sri Ramakrishna hospital has all facilities for adult and pediatric cardiac surgery and can undertake any complex heart surgeries.