Severe blood conservation in conjunction with cardiac surgery is not associated with long-term adverse consequences, according to a new study published in Archives of Internal Medicine. ￼
Investigators from the Cleveland Clinic and the NHLBI compared 322 patients who were Jehovan's Witnesses with an equal number of matched controls. Due to their religious beliefs Witnesses do not receive blood transfusions, and therefore "provide a unique natural experiment in severe blood conservation," according to the authors.
Compared to patients who had transfusions, Witnesses had better short term and long term outcomes. They had fewer complications in the hospital and better survival out to 15 years.
Perioperative MI: 0.31% for Witnesses versus vs 2.8% for controls (p = .01)
Operation for bleeding: 3.7% vs 7.1% (p = .03)
Prolonged ventilation: 6% vs 16% (p < .001)
Hours in the ICU (15th, 50th, and 85th percentiles): 24 versus 24, 25 versus 48, and 72 versus 162 (p < .001)
Survival at 5 years: 86% versus 74%
Survival at 10 years: 69% versus 53%
Survival at 15 years: 51% versus 35%
The investigators concluded that although they "found differences in complications among Witnesses and control groups that received transfusions, current extreme blood management strategies do not appear to place patients at heightened risk for reduced long-term survival."
In an accompanying editorial, Victor Ferraris points out that "Witnesses who undergo cardiac surgery are likely a healthier subgroup of Witnesses because those who are believed by their surgeons to require blood transfusion to survive cardiac surgery presumably never go to the operating room." Nevertheless, "the finding that the Witnesses who did not receive transfusions did at least as well as, if not better than, those who received a transfusion raises questions about whether more patients might benefit from surgical strategies that minimize transfusion of blood products."
Here is the press release from Archives:
Study Examines Outcomes of Patients Who Refuse Transfusion Following Cardiac Surgery
CHICAGO– Jehovah's Witness patients who undergo cardiac surgery do not appear to be at increased risk for surgical complications or death when compared to patients who undergo cardiac surgery and receive blood transfusions, according to a report published Online First by Archives of Internal Medicine, a JAMA Network publication.
Jehovah's Witness patients (Witnesses) hold beliefs that disallow blood product transfusion and encourage the use of a number of blood conservation practices, according to background information in the article.
Gregory Pattakos, M.D., M.S., of the Cleveland Clinic, Ohio, and colleagues, sought to compare morbidity and long-term survival rates of Witnesses undergoing cardiac surgery with a similarly matched group of patients who received blood transfusions.
The authors found that after propensity matching, Witnesses (322 patients) and non-Witnesses (322 patients) had similar risks for hospital mortality, but Witnesses had significantly lower occurrence of additional operation for bleeding, renal failure and sepsis compared with non-Witnesses who received transfusions.
Witnesses had fewer acute complications, including myocardial infarction (heart attack), additional operations for bleeding and prolonged ventilation. Witnesses also had shorter hospital lengths of stay compared with matched patients who received transfusions, as well as shorter intensive care unit lengths of stay.
Additionally, Witnesses had higher survival rates compared with non-Witnesses at one-year (95 percent vs. 89 percent) but both groups had similar 20-year survival rates (34 percent vs. 32 percent).
The authors conclude that the Jehovah's Witness patients undergoing cardiac surgery at the Cleveland Clinic experienced similar or better short- and long-term survival than non-Witnesses. "Although we found differences in complications among Witnesses and control groups that received transfusions, current extreme blood management strategies do not appear to place patients at heightened risk for reduced long-term survival," they conclude.
Editor's Note: This study was supported in part by the Kenneth Gee and Paula Shaw, Ph.D., Chair in Heart Research, held by one of the study authors. Another author is a National Heart, Lung and Blood Institute Clinical Research Scholar of the Cardiothoracic Surgical Trials Network, and was supported by a grant from the National Institutes of Health. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.
Invited Commentary: Severe Blood Conservation
In an invited commentary, Victor A. Ferraris, M.D., Ph.D., of the University of Kentucky Chandler Medical Center,Lexington, notes that Jehovah's Witnesses, "believe that the Bible prohibits ingesting blood and that Christians should therefore not accept blood transfusions or donate or store their own blood for transfusion."
Ferraris continues saying, "the finding that the Witnesses, who did not receive transfusions did at least as well as, if not better than, those who received a transfusion raises questions about whether more patients might benefit from surgical strategies that minimize transfusion of blood products."
"The findings of this analysis by Pattakos and colleagues add to the increasing data that suggest that more conservative use of blood transfusions would be in our patients' interest, in both Witnesses and non-Witnesses," he concludes.
(Arch Intern Med. Published online July 2, 2012. doi:10.1001/archinternmed.2012.2458)