Abstract
In primary or first time cardiac surgery, it takes just several minutes for the surgeon to open the chest by median sternotomy (cutting the breast bone). The anatomic landmarks are intact, which allows the surgeon to perform the heart operation without a lot of difficulty. In fact, many operations have been performed without blood transfusion. Some patients later require a repeat operation—redo-surgery, for example redo-valve replacement or redo-coronary artery bypass graft (CABG). Redo-surgery presents added challenges. Adhesions or scars develop as a natural consequence of the body healing, and the heart is often encased by scars and attached intimately to surrounding vital structures. Repeat median sternotomy is the usual access to the heart. This procedure has to be done very carefully because the heart is just underneath the sternum. Opening the chest may take 30 minutes to an hour or more, depending on the severity of adhesions. Careful dissection is continued to free the heart before proceeding with the planned operation, which adds to the operative time. Therefore, redo-operation is a much more involved operation, with higher risk of potential bleeding and complications.
Is it possible to do redo-cardiac surgery without blood transfusion? This report of a single-surgeon experience is important, since there are no large-series reports on this subject specifically involving Jehovah’s Witness patients, who for religious reasons absolutely do not accept blood transfusion.
Clinical Report
Forty-two (42) adult Jehovah’s Witness patients were reoperated. All the previous heart surgeries were by median sternotomy. There were twenty-eight (28) male and fifteen (15) female patients. The age range was thirty-three (33) to seventy-six (76) years. Thirty-one (31) of the cases were valve operations: twenty-three (23) single valve replacements and eight multiple valves. Of the multiple valves, five (5) were double valves—mitral valve replacements (MVR) and aortic valve replacements (AVR) and three were triple valves—MVR and AVR and tricuspid valve repairs (TVr). There were ten (10) redo-CABG. Six (6) patients had third-time operations. One of these had resection of the ascending aorta and Dacron graft repair for increasing size aneurysm, six cm in transverse diameter. This patient had the first aortic valve repair as a youngster because of a stenotic valve, followed years later with AVR. These operations are summarized in the following table:
Redo-Cardiac Surgery
(n = 42)
| Redo Cardiac Surgery (n=42) | |
| Valve replacements | 23 |
| Mitral=11
Aortic=11 Tricuspid= 1 |
|
| Double Valve | 5 |
|
Triple valve (MVR, AVR, TVr) |
3 |
| Redo CABG | 10 |
| Asc. aorta aneurysm repair | 1 |
Results:
All the redo-surgery patients survived their operations except one. The 30-day mortality rate is 2.3%. The patient who did not make it expired 22 days after surgery because of complication of CVA (cerebro-vascular accident) unrelated to blood loss or anemia. There was no significant bleeding encountered in the entire series.
About the Author
Manuel R. Estioko, MD is a Cardiac Surgeon from Los Angeles, California. He first developed an interest and involvement in Bloodless Surgery because of the very high incidence of Hepatitis C in open heart patients (18 % in New York City). At that time (late 1960’s & 1970):
- Almost all patients received blood transfusion, the early heart/lung machines required high volume prime with use of blood.
- Blood was obtained from donors with questionable health through commercial blood banking, (the change to all volunteer donors came years later).
- There was no blood test for Hepatitis.
In 1996, Dr. Estioko coined and popularized the term “Transfusion Free Surgery” which is the other widely used designation for Bloodless Surgery.