COMBINED APROTININ AND ERYTHROPOIETIN USE FOR BLOOD CONSERVATION - RESULTS WITH JEHOVAH-WITNESSES

Despite recent advances in blood conservation techniques, major risks persist for excessive bleeding and blood transfusion after open heart operations. We reviewed the records of 100 consecutive patients undergoing first-time coronary artery bypass grafting at our institution to define these risks and develop a multimodality blood conservation program based on the results. This program was subsequently applied on a prospective basis to a select group of patients who refuse blood transfusion on religious grounds (Jehovah's Witnesses [JW]) (n = 15). Encouraging initial results with coronary artery bypass grafting in this group (n = 8) led to the application of the program to more complex operations (n = 7), including repeat bypass grafting with use of the internal mammary artery, repeat mitral valve replacement, aortic and mitral valve replacement with coronary artery bypass grafting, mitral valve replacement with bypass grafting, chronic type 1 dissection repair, aortic valve replacement, and atrial septal defect repair in 1 patient each. The blood conservation program employed in these patients included the use of (1) aprotinin (full Hammersmith regimen), (2) high-dose erythropoietin, (3) ''maximal''-volume intraoperative autologous blood donation, (4) low-prime cardiopulmonary bypass, (5) exclusive use of intraoperative cell salvage, and (6) continuous reinfusion of shed mediastinal blood. There were no deaths in the JW group. Thromboembolic complications consisted of a transient posterior circulation stroke in only 1 patient (dissection repair). No blood or blood products were transfused compared with the transfusion of 5.1 +/- 7.8 units (mean +/- standard deviation) in the 100 primary coronary bypass patients in whom the blood conservation program was not employed. Postoperative hematocrits in the JW group were equal to or greater than those for the control group despite the absence of red cell transfusion and despite the significantly lower admission hematocrits and red blood cell mass in that group. Total chest tube output 24 hours after operation was 340 +/- 140 mL and 880 +/- 320 mL for the JW and control groups, respectively (p < 0.001). These results suggest that even complex open heart operations can be performed without homologous transfusion by optimally applying currently available blood conservation techniques. More generalized application of these measures may increasingly allow ''bloodless'' cardiac operations.