Outcome of Patients Who Refuse Transfusion After Cardiac Surgery: A Natural Experiment With Severe Blood Conservation

Study Questions:

What is the morbidity and long-term survival of Jehovah’s Witness patients undergoing cardiac surgery compared with a similarly matched group of patients who received transfusions?

Methods:

A total of 322 Witnesses and 87,453 non-Witnesses underwent cardiac surgery at the author’s center from January 1, 1983, to January 1, 2011. All Witnesses prospectively refused blood transfusions. Among non-Witnesses, 38,467 did not receive blood transfusions and 48,986 did. The investigators used propensity methods to match patient groups and parametric multiphase hazard methods to assess long-term survival. Their main outcome measures were postoperative morbidity complications, in-hospital mortality, and long-term survival.

Results:

Witnesses had fewer acute complications and shorter length of stay than matched patients who received transfusions: myocardial infarction, 0.31% versus 2.8% (p = 0.01); additional operation for bleeding, 3.7% versus 7.1% (p = 0.03); prolonged ventilation, 6% versus 16% (p < 0.001); intensive care unit length of stay (15th, 50th, and 85th percentiles), 24, 25, and 72 versus 24, 48, and 162 hours (p < 0.001); and hospital length of stay (15th, 50th, and 85th percentiles), 5, 7, and 11 versus 6, 8, and 16 days (p < 0.001). Witnesses had better 1-year survival (95%; 95% confidence interval [CI], 93%-96%; vs. 89%; 95% CI, 87%-90%; p = 0.007), but similar 20-year survival (34%; 95% CI, 31%-38%; vs. 32%; 95% CI, 28%-35%; p = 0.90).

Conclusions:

The authors concluded that Jehovah’s Witnesses do not appear to be at increased risk for surgical complications or long-term mortality when comparisons are properly made by transfusion status.

Perspective:

This study reports that Jehovah’s Witnesses were at lower risk for adverse postoperative outcomes after cardiac surgery. Witnesses had fewer postoperative myocardial infarctions, fewer episodes of postoperative ventilator support beyond 24 hours, fewer additional operations for bleeding, shorter intensive care unit and postoperative lengths of stay, and a lower hazard for in-hospital death. Overall, the data suggest that current extreme blood management strategies do not appear to place patients at heightened risk for reduced long-term survival. Additional studies are indicated to further assess these blood management strategies that may benefit other patient groups.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention

Keywords: Outcome Assessment (Health Care), Postoperative Complications, Myocardial Infarction, Religion and Medicine, Hospital Mortality, Morbidity, Postoperative Period, Length of Stay, Blood Transfusion, Cardiovascular Diseases, Confidence Intervals, Cardiac Surgical Procedures, Christianity


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