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Editorial Comment

Bloodless Orthotopic Heart Transplantation in a Jehovah’s Witness

Frazier, O. H. MD

doi: 10.1213/XAA.0000000000000111
Case Reports: Case Report
Free

Center for Cardiac Support, Texas Heart Institute, Houston, Texas, lschwenke@texasheart.org

I read with interest the case report by Dallas et al.1 They used a fibrinogen concentrate (RiaSTAP) and other time-honored approaches as part of a protocol that allowed them to perform a “bloodless” heart transplant in a patient of the Jehovah’s Witness faith. At the Texas Heart Institute, we have extensive experience in performing cardiac surgery on Jehovah’s Witnesses. In May 1962, Dr. Denton Cooley2 performed the world’s first open heart operation on a Jehovah’s Witness. In 1977, Ott and Cooley3 described a series of 542 Jehovah’s Witness patients who had undergone cardiac surgery with an early mortality rate of 9%. In 1986, Corno et al.4 reported the first successful cardiac transplant operation involving a Jehovah’s Witness.

Our first successful heart transplant in a Jehovah’s Witness was reported in 1988.5,6 As of July 2014, we had performed heart transplants in 16 Jehovah’s Witnesses (unpublished data). Two of these patients died early, but only 1 of those deaths was related to bleeding complications. Only 1 of the 16 patients required treatment for acute cellular rejection, and none of the patients was diagnosed with humoral rejection. Thus, our results have been good, although we excluded most patients who had previous median sternotomies. Also, only 1 of our patients was having a redo operation, and only 1 was being supported by an intraaortic balloon pump, so ours is a select group. The mean postoperative survival time of our 15 long-term survivors is 8 years (range, 73 days to 25.7 years). Six of these patients have survived for >20 years.

The Jehovah’s Witness faith now allows some leeway for patients to receive procoagulant factors, but this was not the case when most of our heart transplants in Jehovah’s Witnesses were performed. As noted by Dallas et al.,1 the use of concentrated fibrinogen may be of significant benefit in selected patients. Like these surgeons,1 we have also given procoagulant factors, but we have not used concentrated fibrinogen, because it was not approved for Jehovah’s Witnesses when most of our cases occurred. For postoperative bleeding, we generally use cryoprecipitate rather than concentrated fibrinogen, not only because cryoprecipitate contains a similar quantity of fibrinogen in addition to other procoagulant factors but primarily because it is more cost-effective than fibrinogen.

With regard to the overall current state of organ transplantation in Jehovah’s Witnesses, these patients have undergone transplantation not only of hearts and kidneys but also (more rarely) of livers and lungs. In fact, Partovi et al.7 have performed both single- and double-lung transplants in Jehovah’s Witnesses. Unfortunately, however, many transplant centers will not consider treating members of this faith. The number of transplants performed in these patients varies from country to country, being greatest in the United States and other developed countries. The United Network for Organ Sharing does not have a particular policy regarding Jehovah’s Witnesses. The Jehovah’s Witness headquarters, based in Brooklyn, New York, keeps excellent records, and its office of Hospital Information Services has the most reliable and up-to-date information about organ transplantation in members of this faith (www.jw.org).

In summary, Dallas et al.1 are to be commended for performing this life-saving, successful procedure on a high-risk Jehovah’s Witness patient who was undergoing intraaortic balloon pump support. This operation required courage in addition to skill. We have noted that our Jehovah’s Witnesses appear to do as well as, or even better than, the typical transplant patient, although they are a selected subgroup. The minimal rejection seen in our patients may be a reflection of their not having had blood products both pre- and postoperatively. We have also found Jehovah’s Witnesses, who have a strong social network, to be entirely compliant in following preoperative and postoperative orders, including drug regimens. Despite these and others good results, constant oversight from medical organizations, United Network for Organ Sharing, insurance companies, the Centers for Medicare and Medicaid Services, hospital administrators, and others remains an impediment for surgeons treating many patients deemed high risk, such as Jehovah’s Witnesses.

O. H. Frazier, MD

Center for Cardiac Support

Texas Heart Institute

Houston, Texas

lschwenke@texasheart.org

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REFERENCES

1. Dallas T, Welsby I, Bottiger B, Milano C, Daneshmand M, Guinn N. Bloodless orthotopic heart transplantation in a Jehovah’s Witness. A & A Case Reports. 2015;4:140–2
2. Cooley DA, Crawford ES, Howell JF, Beall AC Jr.. Open heart surgery in Jehovah’s Witnesses. Am J Cardiol. 1964;13:779–81
3. Ott DA, Cooley DA. Cardiovascular surgery in Jehovah’s Witnesses. Report of 542 operations without blood transfusion. JAMA. 1977;238:1256–8
4. Corno AF, Laks H, Stevenson LW, Clark S, Drinkwater DC. Heart transplantation in a Jehovah’s Witness. J Heart Transplant. 1986;5:175–7
5. Lammermeier DE, Duncan JM, Kuykendall RC, Macris MP, Frazier OH. Cardiac transplantation in a Jehovah’s Witness. Tex Heart Inst J. 1988;15:189–91
6. Burnett CM, Duncan JM, Vega JD, Lonquist JL, Sweeney MS, Frazier OH. Heart transplantation in Jehovah’s Witnesses. An initial experience and follow-up. Arch Surg. 1990;125:1430–3
7. Partovi S, Bruckner BA, Staub D, Ortiz G, Scheinin SA, Seethamraju H, Loebe M. Bloodless lung transplantation in Jehovah’s Witnesses: impact on perioperative parameters and outcome compared with a matched control group. Transplant Proc. 2013;45:335–41
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