Keywords
minimally invasive - LVAD - left ventricular assist device - Jehovah's witness
Introduction
Heart Failing Jehovah Witness Patient Successfully Treated by Minimally-Invasive Left
Ventricular Assist Device Implantation without any Blood Transfusions
Minimally invasive left ventricular assist device (LVAD) implantation has proven in
the past years that it is a superior technique to conventional LVAD implantation.[1] The less invasive procedure has several benefits such as reducing right heart failure,
reducing wound infection, and shorter duration of procedure as well shorter intrahospital
stay for the patient. Also, it is associated with a diminished usage of blood products
due to less bleeding complications.[2]
[3]
Surgery on Jehovah's witnesses is always a challenge for surgeons, too. This society
has remarkably grown and counts over 7 million followers worldwide today. According
to Jehovah's witnesses' interpretation of the Bible, it is prohibited to ingest blood
of any kind. It is up to the conscious of each individual to accept transfusions of
fractionations of the primary components.[4]
[5] Especially cardiac surgeries have a higher risk for blood loss with the need of
blood transfusions. This creates a difficult situation for the patient and for the
doctor who is legally bound to provide best medical care to every patient. Therefore,
a minimally invasive LVAD implantation technique was used when a Jehovah's witness
was referred to our clinic with end-stage heart failure.
Results
We present a 48-year-old patient (175 cm, 75 kg, body mass index 24.5 kg/m2) who was admitted to our clinic due to acute decompensation of dilative cardiomyopathy.
The patient presented the signs of hypotonic pressures, dyspnoea, tachycardia, and
acrocyanosis.
Echocardiography was performed and showed a severe decrease of left ventricular ejection
function (13% [Simpson]) and a reduced right ventricular function as well as a second-degree
mitral valve insufficiency. Laboratory parameters showed decreased liver and renal
function. Due to respiratory insufficiency, noninvasive ventilation became necessary.
The history of the patient showed a possible case of viral myocarditis 18 years ago.
Dilated cardiomyopathy was diagnosed 8 years ago. After multiple attempts to medically
stabilize the condition of the patient, the case was presented to the cardiovascular
surgery department ([Fig. 1]). In an interdisciplinary discussion, it was decided to implant a mechanical assist
device. The patient was a Jehovah's witness and approved LVAD implantation but declined
the use of any blood products even in emergency situations.
Fig. 1 Chest X-ray before LVAD implantation.
The procedure was performed with our minimally invasive LVAD implantation technique,
which combines an upper ministernotomy with an anterolateral thoracotomy.[1] Via anterolateral thoracotomy, the sewing ring of the HVAD (HeartWare) was sewed
onto the beating heart. The venous line of the heart–lung machine was placed in the
femoral vein. The arterial line was placed via ministernotomy to the ascending aorta.
After starting of the heart–lung machine, the assist device was placed into the left
ventricle. The outflow graft cannula was tunneled through the pleural cavity and sewed
onto the ascending aorta. The weaning from the heart–lung machine was completely uneventful.
The procedure was performed without any use of blood products including thrombocytes,
fresh frozen plasma, or any other coagulation factors ([Fig. 2]).
Fig. 2 Chest X-ray after LVAD implantation.
Laboratory parameters showed preoperative blood hemoglobin (Hb) and hematocrit (Hct)
just before the operation of 11.3 g/dL and 33.1%, respectively. Mean Hb during the
preoperative hospital stay (16 days) was 9 g/dL with standard deviation (SD) of 0.50
mg/dL and mean Hct was 35% with SD of 1.49%. The first parameters obtained immediately
after the operation were 9.3 g/dL and 27% for Hb and Hct, respectively. Postoperative
data showed mean Hb of 8.53 g/dL with SD of 1.79 g/dL and mean Hct of 25.70% with
SD of 5.21%. The patient was discharged after a completely uneventful intrahospital
stay on postoperative day 17. Hb and Hct on the day of discharge were 13.1 g/dL and
37.5%, respectively. Mean Hb of 9.31 g/dL with SD of 2.11 g/dL and mean Hct of 27.87%
with SD of 6.01% were calculated from data obtained during the total hospital stay
of 35 days ([Fig. 3]).
Fig. 3 Charts showing the hemoglobin and hematocrit values during the hospital stay.
Discussion
The reduction of blood loss is a goal for all surgeries. Especially LVAD implantations
are considered to be prone to high blood loss and high usage of coagulation factors.
Even though tested multiple times before transfusion, blood products still contain
risks for allergic reactions to transfusion of infectious diseases. Furthermore, economic
costs for blood products are one of the major contributors for the high costs of LVAD
implantation. Therefore, the reduction of usage of blood products is one of the keys
to lowering the cost for LVAD programs.
Minimally invasive LVAD implantation, first described by our group, has already proven
itself to be associated with several positive effects. It has been shown that the
total number of blood transfusion was reduced by implanting an LVAD via a minimally
invasive technique.[1]
[2]
[3] Now, it is proven that it is even possible to implant an LVAD minimally invasively
without the use of any blood products. As devices become smaller, incision sites should
reduce in size as well.
Despite the excellent result of this procedure, the surgical approach as well as the
risk and consequences of blood loss must be intensively discussed with the patient.
In our case, the patient accepted blood transfusions only in the case of imminent
death due to blood loss. Although a case of heart transplantation in a Jehovah's witness
has been described,[6] the therapeutic goal of our patient is destination therapy with LVAD support. In
case of reoperation, our strategy is minimally invasive LVAD exchange without the
use of the heart–lung machine.[7]
Conclusion
It has been proven that minimally invasive LVAD implantation without blood transfusion
is possible. This benefits not only Jehovah's witness patients but also all patients
in the need of a ventricular assist device. Yet, the course of the patients has to
be kept in mind, which may require further interventions with the need of blood transfusion.
Therefore, LVAD implantation in Jehovah's witnesses should be a critically evaluated
procedure.
