Cardiovascular surgery in Jehovah's Witness patients: The role of preoperative optimization

Abstract

Objective: We aimed to identify factors associated with adverse outcomes in Jehovah's Witness patients undergoing complex cardiovascular surgery and to validate our preoperative optimization protocol.

Methods: We retrospectively reviewed 144 Jehovah's Witnesses who underwent cardiovascular surgery between 1999 and 2014. We excluded 7 salvage cases. The operative procedures included 56 coronary artery bypass graft surgeries, 43 valve procedures, 13 ventricular assist device implantations, 11 heart transplantations, 9 aortic surgeries, and 5 congenital defect repairs. Our preoperative optimization protocol for Jehovah's Witnesses includes discontinuing antiplatelets and adding iron/vitamin or erythropoietin to achieve a target hemoglobin greater than 12 g/dL. We evaluated the risk factors for postoperative mortality and composite outcomes (mortality, myocardial infarction, stroke, acute kidney injury, heart failure, sternal wound infection), and compared the outcomes of optimized patients with a preoperative hemoglobin level greater than 12 g/dL (n = 93) versus unoptimized patients with a preoperative hemoglobin level less than 12 g/dL (n = 44).

Results: Preoperative and intraoperative demographics in the optimized and unoptimized groups were similar except for preoperative hemoglobin levels, renal dysfunction (optimized = 25/93 [26.9%], unoptimized = 26/44 [59.1%], P < .001), and emergency/urgent cases (optimized = 20/93 [21.5%], unoptimized = 17/44 [38.6%], P = .035). The mean preoperative, intraoperative nadir, and discharge hemoglobin levels of the entire cohort were 12.7 ± 1.7 g/dL, 9.5 ± 2.6 g/dL, and 9.7 ± 1.8 g/dL, respectively. Hospital mortality was 9 of 137 patients (6.6%) (optimized = 2/93 [2.2%], unoptimized = 7/44 [15.9%], P = .002), and composite outcomes were observed in 44 of 137 patients (32.1%) (optimized = 21/93 [22.6%], unoptimized = 22/44 [50.0%], P = .001). The Youden index identified a cutoff value of the preoperative hemoglobin of 11.7 g/dL for mortality (area under curve, 0.719; sensitivity, 77.8%; specificity, 76.0%). Multivariate analysis identified a suboptimal preoperative hemoglobin (<12 g/dL) as the only important independent factor associated with mortality (odds ratio, 5.64; 95% confidence interval, 1.14-42.18) and composite outcomes (odds ratio, 2.49; 95% confidence interval, 1.06-5.88).

Conclusions: Complex cardiovascular surgery in Jehovah's Witnesses was associated with acceptable surgical outcomes, especially if they electively completed optimization. Our Jehovah's Witnesses' optimization protocol targeting a hemoglobin level greater than 12 g/dL seemed to be effective in reducing adverse events at The University of Chicago Medicine.

Keywords: Jehovah's Witness; blood conservation; cardiopulmonary bypass; cardiovascular surgery.