A 29-year-old Jehovah’s Witness (JW) patient, who underwent an orthotopic heart transplant (OHT) at 9 years of age for idiopathic cardiomyopathy, presented for repeat OHT after exacerbation of heart failure.
On hospital day (HD) 2, an intra-aortic balloon pump (SC-IABP) was placed via the right subclavian artery and was anticipated to be removed postoperatively, once the patient was in stable condition. The closed-chest subclavian access was favored because it is a less invasive approach than intraoperative subclavian insertion, and it allows the patient to ambulate sooner than minimally invasive insertion through the femoral artery.1
Erythropoietin use was commenced preoperatively and continued until discharge. Inotropes were not administered preoperatively. On HD 8, the patient underwent the repeat OHT using a bicaval technique. The patient’s hemoglobin was 13.9 mg/dl preoperatively (Table 1). The patient refused all blood product transfusions; his blood type was A-POS. However, he did agree to allow the reinfusion of his blood using the cell saver. The intraoperative strategy was the use of the cell saver and retrograde autologous priming before putting the patient on cardiopulmonary bypass (CPB) to reduce hemodilution.2 Using the cell saver, 500 ml of the patient’s blood were retransfused and 1,500 ml of crystalloid fluid and 500 ml of albumin were administered. The patient was transferred to the intensive care unit (ICU) in a stable condition, with hemoglobin of 11.2 mg/dl.
After his extubation on postoperative day (POD) 1, the patient experienced a cardiac arrest with pulseless electrical activity (PEA) but, after intubation, regained spontaneous circulation and a stable pulse. A chest x-ray suggested the presence of right pleural bleeding, leading to the emergent exploration of the patient’s chest. Minimal blood was found, but the patient experienced another PEA arrest and was resuscitated again. Given his instability and high pressor requirement, extracorporeal membrane oxygenation (ECMO) was initiated.
Our standard ECMO circuit consists of a Quadrox D membrane oxygenator (Maquet, Inc., Wayne, NJ) and a CentriMag centrifugal pump (Thoratec Corporation, Pleasanton, CA). Access was obtained percutaneously. Inflow came from the left femoral artery and the outflow returned to the right femoral vein. A distal perfusion catheter was also placed directly by cut down from a Y taken from the arterial cannula. The SC-IABP remained.
Extracorporeal membrane oxygenation therapy successfully increased the oxygen saturation and normalized blood pressure. However, the patient’s hemoglobin decreased to 8.4 mg/dl and the white blood cell (WBC) count increased to 12.3 K/μl. The elevation in WBC count was attributed to aspiration at the time of emesis likely due to the patient’s history of delayed gastric emptying. While on ECMO support, the patient’s course was further complicated by anuric renal failure, requiring continuous venovenous (V-V) hemodialysis and a decreased hemoglobin level of 4.7 mg/dl.
Extracorporeal membrane oxygenation support was continued for 2 days beyond the needed window for cardiopulmonary support to allow for an increase in the hemoglobin level. On POD 8, with hemoglobin of 5.4 mg/dl, the patient returned to the operating room for decannulation.
On restoration of blood flow, the foot appeared perfused, and positive monophasic Doppler signals in his posterior tibial and dorsalis pedis arteries were observed. Because blood conservation strategies were the highest priority, the perfusion team drained blood from the ECMO pump to the cell saver and readministered it to the patient. The patient was transferred to the ICU, and no additional complete blood counts were drawn until POD 12, at which point the hemoglobin was 7.0 mg/dl.
The patient was discharged to home on POD 52/HD 60 with a feeding tube. At discharge, the hemoglobin was 10.3 mg/dl. The tracheostomy was removed and the renal function recovered, forgoing the need for further hemodialysis. Since his discharge, the patient continues to do well and multiple biopsies of the transplanted heart have shown no evidence of rejection.
Bloodless cardiac surgery was first described by Cooley et al.,3 and few large case reports have been reported since.4–6 They suggest that, with careful patient selection, outcomes in JW patients are comparable with patients who are willing to accept blood transfusions. Data on complex cardiac surgery on JW patients are extremely scarce.7 To our knowledge, this case report presents the first description of a cardiac retransplantation in a JW patient with a complicated postoperative course requiring ECMO. Due to the lack of data, there is no consensus on OHTs in JWs. Elmistekawy et al. 8 report seven successful OHTs in JW patients and conclude that these patients may be considered for heart transplantation under favorable circumstances, specifically in experienced centers.
Our institution’s selection criteria for JW patients include few comorbidities, hemoglobin >12 mg/dl, and hypervolemia. Relative contraindications for surgery include recent cardiac surgery (<12 months), significant complications during previous cardiac surgery, congenital heart disease, high pulmonary artery pressures, renal failure, and significant potential for anatomic injury.
Due to the scarcity of available organs for transplantation, the decision to offer this patient a second heart transplantation was very challenging and based on several factors. First, the patient demonstrated extremely favorable outcomes following his first transplant, with the graft lasting 20 years. Second, the patient exhibited strict medical compliance. Third, the patient was 29 years old. Fourth, there had been a long interval since his previous operation. These factors prompted us to offer this patient retransplantation.
The use of meticulous surgical technique, preferential use of pump suckers, and maximization of the cell saver helped to conserve blood intraoperatively. Effective blood loss was minimized by removing plasma using ultrafiltration during CPB, hemoconcentration of remaining volume at the end of the CPB, and the use of retrograde autologous priming.
At the time of the cardiac arrests, the patient required high-dose vasoactive medications and already had an IABP. Venovenous ECMO was considered because the underlying issue was due to hypoxia and aspiration. However, venoarterial (V-A) ECMO was initiated because the patient experienced two cardiac arrests and a later conversion from V-V to V-A support would have resulted in more blood loss and potential for further clinical instability.
This patient experienced multiple, severe, complications, which were a reminder of the high risk involved in performing complex cardiac surgery on patients who refuse to accept blood products. Nonetheless, despite these setbacks, the patient is now thriving. The management of ECMO was crucial in his survival. The early utilization, continuation beyond the recommended window, along with a clear plan developed in advance, meticulous attention to hemostasis, and blood conservation during ECMO decannulation, allowed for the hemoglobin to increase. Although these techniques are developed out of necessity for managing patients who refuse blood products, they are widely applicable to other, more traditional patient populations.
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2. Murphy GS, Szokol JW, Nitsun M, et al. Retrograde autologous priming of the cardiopulmonary bypass circuit: Safety and impact on postoperative outcomes. J Cardiothorac Vasc Anesth. 2006;20:156–161
3. Cooley DA, Crawford ES, Howell JF, Beall AC Jr. Open heart surgery in Jehovah’s Witnesses. Am J Cardiol. 1964;13:779–781
4. Ott DA, Cooley DA. Cardiovascular surgery in Jehovah’s Witnesses. Report of 542 operations without blood transfusion. JAMA. 1977;238:1256–1258
5. Moraca RJ, Wanamaker KM, Bailey SH, et al. Strategies and outcomes of cardiac surgery in Jehovah’s Witnesses. J Card Surg. 2011;26:135–143
6. Vaislic CD, Dalibon N, Ponzio O, et al. Outcomes in cardiac surgery in 500 consecutive Jehovah’s Witness patients: 21 year experience. J Cardiothorac Surg. 2012;7:95
7. Frazier OH, Myers TJ, Westaby S, Gregoric ID. Use of the Jarvik 2000 left ventricular assist system as a bridge to heart transplantation or as destination therapy for patients with chronic heart failure. Ann Surg.;237:631–636 discussion 636–637, 2003.
8. Elmistekawy E, Mesana TG, Ruel M. Should Jehovah’s Witness patients be listed for heart transplantation? Interact Cardiovasc Thorac Surg. 2012;15:716–719