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 underg oing first-time coronary artery bypass grafting at our institution to define these risks and develop a multimodality blood conservation prog ram based on the results. This program was subsequently applied on a p rospective basis to a select group of patients who refuse blood transf usion on religious grounds (Jehovah's Witnesses [JW]) (n = 15). Encour aging initial results with coronary artery bypass grafting in this gro up (n = 8) led to the application of the program to more complex opera tions (n = 7), including repeat bypass grafting with use of the intern al mammary artery, repeat mitral valve replacement, aortic and mitral valve replacement with coronary artery bypass grafting, mitral valve r eplacement with bypass grafting, chronic type 1 dissection repair, aor tic valve replacement, and atrial septal defect repair in 1 patient ea ch. The blood conservation program employed in these patients included the use of (1) aprotinin (full Hammersmith regimen), (2) high-dose er ythropoietin, (3) ''maximal''-volume intraoperative autologous blood d onation, (4) low-prime cardiopulmonary bypass, (5) exclusive use of in traoperative cell salvage, and (6) continuous reinfusion of shed media stinal blood. There were no deaths in the JW group. Thromboembolic com plications consisted of a transient posterior circulation stroke in on ly 1 patient (dissection repair). No blood or blood products were tran sfused compared with the transfusion of 5.1 +/- 7.8 units (mean +/- st andard deviation) in the 100 primary coronary bypass patients in whom the blood conservation program was not employed. Postoperative hematoc rits in the JW group were equal to or greater than those for the contr ol group despite the absence of red cell transfusion and despite the s ignificantly lower admission hematocrits and red blood cell mass in th at 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 opera tions can be performed without homologous transfusion by optimally app lying currently available blood conservation techniques. More generali zed application of these measures may increasingly allow ''bloodless'' cardiac operations.