2025 FSA Podium and Poster Abstracts

Introduction: Bloodless cardiac surgery is recognized as an important alternative for patients who refuse blood transfusions for medical or personal reasons. To preserve patient autonomy, individuals are asked to elect which interventions they are willing to accept preoperatively. Common approaches include erythropoietin (EPO) administration, iron supplementation, acute normovolemic hemodilution (ANH), cell salvage, antifibrinolytics, and volume expanders. Here we describe challenges in perioperative management of a Jehovah’s Witness patient undergoing aortic and mitral valve replacement.

Case Presentation: A 62-year-old male Jehovah’s Witness male with infective streptococcus endocarditis developed acute CHF (NYHA Class III, EF 51%) due to severe aortic and mitral regurgitation. He was admitted to an outside facility, where he was stabilized and discharged on a six-week course of IV antibiotics as well as a prescription for erythropoietin (EPO) injections to increase his hemoglobin (baseline 13.5 g/dL) prior to surgical repair. However, due to his comorbidities and challenges with insurance coverage, he was repeatedly hospitalized with CHF exacerbations and was unable to obtain EPO.

Three months later, further attempts at optimization were aborted and he was scheduled for AVR MVR.  His baseline hemoglobin level was 12.4 g/dL (based on ABG), and he consented to receiving albumin, cryoprecipitate (CPP), factor VII, prothrombin complex concentrate (PCC), cell salvage, and acute normovolemic hemodilution (ANH). His surgical procedure proceeded smoothly. Intraoperatively he received DDAVP,  490 units PCC, 1182 mg of tranexamic acid, 750 cc autologous blood via cell salvage, with 450 cc autologous blood via ANH.

Postoperatively, transesophageal echocardiography demonstrated significant improvement in aortic and mitral regurgitation, along with a mild increase in ejection fraction from 47% to 53%. His hemoglobin was 11.3 g/dL, PT/INR was 12.9/1.2, APTT was 37.6, and fibrinogen was 309. He was transferred to the CVICU intubated, mechanically ventilated, and sedated. Overnight, he developed bleeding and was found to have a large right-sided hemothorax. Chest tube placement drained 3.3 L of old blood, with subsequent labs revealing a hemoglobin level of 5.1 g/dL. His hemodynamics continued to deteriorate throughout the day, and despite maximum vasopressor support, methylene blue administration, and epicardial pacing, he passed away approximately one day after the procedure.

Discussion/Conclusion: Studies show that bloodless surgery does not significantly impact clinical outcomes compared to standard care. In fact, research suggests that all patients undergoing cardiac surgery could benefit from preoperative optimization and blood-sparing strategies. These techniques represent a cost-effective alternative to traditional approaches and potentially benefit patients who are willing to receive blood products.