Cardiac surgery in Jehovah’s Witness children: Clinical characteristics and outcomes from a limited single-center cohort

Abstract

Background:

Jehovah’s Witnesses (JWs), a religious group with over 9 million members globally, refuse allogeneic blood transfusions on religious grounds. Awareness of this population and their unique medical needs remains limited in India, particularly within the pediatric cardiac surgical context. Managing such patients poses legal, ethical, and clinical challenges. This study aims to describe the clinical profile, perioperative management, and outcomes of JW children undergoing cardiac surgery at a tertiary center.

Methodology:

A retrospective cohort study was conducted at a tertiary care hospital in Bangalore, India, including all pediatric JW patients who underwent cardiac surgery between 2019 and 2024. Data were collected on demographics, diagnoses, perioperative hemoglobin levels, blood-conservation strategies, postoperative complications, and outcomes.

Results:

Ten JW pediatric patients underwent cardiac surgery during the study period, including six infants. Seven had acyanotic congenital heart disease, whereas three had cyanotic defects. The mean preoperative hemoglobin and hematocrit were 13.1 ± 2.3 g/dL and 36.7% ± 5.2%, respectively; postoperative values were 10.3 ± 1.2 g/dL and 28.6% ± 3.9%. Blood conservation measures included postoperative recombinant erythropoietin in five patients and tranexamic acid in seven. There were no mortalities, and most patients had an uneventful recovery.

Conclusions:

Pediatric cardiac surgery in JW patients can be performed safely and effectively when a structured, multimodal blood conservation strategy is meticulously applied. Increased awareness and preparedness among clinicians are essential for optimizing outcomes in this unique population.

INTRODUCTION

The Jehovah’s Witness (JW) religion, with over 9 million followers worldwide, was founded in the US in the 1870s, with minimal to complete absence of awareness about the existence of this community in India.[1] JWs refuse the transfusion of blood products, based on Biblical passages citing to “abstain from food polluted by idols, from sexual immorality, from the meat of strangled animals and from blood” (Acts 15:19-20), which is an integral part of their faith.[2,3,4] The lack of awareness within the medical community about this unique patient population is truly remarkable. Beyond the legal and ethical complexities involved in treating these individuals, the most significant challenges arise when they require cardiac surgery, particularly in childhood. The intricacies of these cases, coupled with the vulnerability of young patients, make the situation even more daunting. Due to the limited number of surgical teams willing to perform complex cardiovascular procedures on children from JW families, there is a significant lack of literature addressing their perioperative care and outcomes.[5,6]

Blood transfusions are often necessary during open-heart surgery in pediatric patients, with reported rates ranging from 27% to 95%. In addition to the risk of bleeding, hemodilution is a significant concern in children because the relatively large, fixed volume of crystalloid solution used to prime the heart-lung machine is substantial compared to a child’s total blood volume. As a result, performing “bloodless” open-heart surgery in JW patients poses a considerable challenge.[7]

JWs refuse transfusions of whole blood, packed red blood cells, plasma, white blood cells, and platelets. However, many adherents do accept the use of heart-lung machines or similar extracorporeal circulation equipment – provided the circuit is continuous and not primed with blood. The ethical framework surrounding the treatment of JW patients, particularly minors, has been the subject of extensive legal and bioethical discourse. Judicial rulings in many jurisdictions have generally upheld the right to individual medical autonomy, including the right to refuse blood products. The United Nations Convention on the Rights of the Child (1989) implemented in 1990, further emphasizes the necessity for special protections and considerations in pediatric care, underscoring both the child’s vulnerability and the importance of respecting evolving capacities and individual rights.[8,9]

METHODOLOGY

Study design and setting

This was a retrospective observational study conducted at the cardiac intensive care unit (ICU) of a tertiary care hospital in Bangalore, India. The study was designed to describe the perioperative outcomes of pediatric JW patients undergoing cardiac surgery between January 2015 and December 2024.

Participants

The study population included all patients aged 0–18 years who were identified as JW and underwent any form of cardiac surgery during the study period. Patients were identified through the hospital’s electronic medical record system using religious affiliation and surgical procedure codes. Inclusion criteria were: (1) age ≤18 years, (2) confirmed JW status, and (3) having undergone open or closed cardiac surgical intervention requiring cardiac ICU admission. No exclusion criteria were applied.

Ethical considerations

The study was approved by the Institutional Ethics Committee. Given the study’s retrospective nature and the use of de-identified data from existing medical records, the requirement for informed consent was waived. All measures to ensure the confidentiality and privacy of patient information were rigorously followed, in accordance with institutional and national ethical guidelines.

Data sources and variables

Data were extracted from patient medical records and hospital databases. Collected variables included: Demographic data: age, sex, and weight, Clinical information: primary cardiac diagnosis and preoperative preparation, Surgical details: type of procedure performed, and Outcomes: length of hospital stay (days), intraoperative and postoperative complications, and inhospital mortality.

All data were anonymized before analysis, and a standardized data collection form was used to ensure consistency across records.

Perioperative management protocol

JW pediatric patients underwent preoperative screening for serology, hemoglobinopathies, and renal function. Laboratory testing was minimized using microtainers to reduce iatrogenic blood loss. In elective cases, hemoglobin optimization was achieved with erythropoietin and oral or intravenous iron supplementation. During cardiopulmonary bypass, a shortened circuit with a centrifugal pump and albumin-primed solution was used to limit hemodilution. A closed-loop cell salvage system was employed. Normothermia was maintained throughout. Nonblood hemostatic agents, including cryoprecipitate, prothrombin complex concentrate, fibrinogen concentrate, recombinant clotting factors, and antifibrinolytics (aprotinin, tranexamic acid), were administered as needed. Postoperative care included humidified ventilation and hemodynamic support with inotropes to prevent hypertension.

Statistical methods

The study details were recorded in a proforma, and the data were generated in an Microsoft Excel sheet (Microsoft® Corp., Redmond, WA). Descriptive analysis was done using the Statistical Package for the Social Sciences (SPSS) for Windows Version 26 (IBM corporation, Chicago, United states).

RESULTS

Participants and baseline characteristics

The study cohort included 10 pediatric JW patients who underwent cardiac surgery for various indications [Tables 1 and 2]. According to demographic data [Table 3], 60% (n = 6) of the patients were under 1 year of age, with the youngest undergoing surgery at 2 months. The mean body weight was 15.6 kg (range: 3.2–44 kg). Six of the ten patients were male.

Table 1.

Clinical profile of Jehovah’s Witness children requiring cardiac surgery

Sex	Age	Weight (kg)	Diagnosis	Operative procedure	Preoperative Hb (g/dL)	Postoperative Hb (g/dL)	Duration of ventilation (days)	Complication	Outcome	Specific blood salvage technique used
Male	5 months	3.2	Large VSD, ASD with PAH	VSD patch closure, TV annuloplasty	11.4	10	20	Ventilator-associated pneumonia, septic shock	Required tracheostomy and decantation done on day 40, discharged	EPO Albumin TA
Male	10 months	7.2	TOF	VSD right ventricle outflow tract muscle excision, pulmonary valvotomy	16.9	11.9	1	None	Discharged	None
Male	5 months	6.4	Large ASD, PAH	Pericardial patch closure of ASD	12	9.5	1	None	Discharged	Iron Albumin TA
Female	2 months	3.7	Truncus arteriosus	Truncus arteriosus repair	16.8	10.3	15	Sepsis	Discharged	EPO Iron TA Albumin
Male	6 months	4.2	Dows with AV canal defect, mitral and tricuspid regurgitation, PAH	Av canal repair PDA ligation	10.3	9.3	7	None	Discharged	EPO Albumin TA
Male	4 years	20.6	Large VSD	VSD patch closure	13.3	12.9	1	None	Discharged	Albumin, TA
Female	3 years	12.5	Large inlet VSD with subaortic extension with PAH	VSD patch closure	12	9.3	1	None	Discharged	Albumin TA
Female	14 years	44	Subaortic VSD, severe infundibular pulmonary stenosis, right ventricular hypertrophy	VSD repair and RVOT muscle bundle excision	11.8	9.7	1	None	Discharged	EPO Albumin TA
Male	8 months	7	AV canal defect	AV canal Repair	13.5	11.8	5	None	Discharged	Albumin, TA, Hexamethyl starch
Female	11 years	44	Atrial septal defect	ASD closure	13.1	11.1	1	None	Discharged	Albumin, TA

ASD: Atrial septal defect, VSD: Ventricular septal defect, PAH: Pulmonary arterial hypertension, EPO: Erythropoietin, RVOT: Right ventricular outflow tract, TV: Tricuspid valve, AV: Atrioventricular, TA: Tranexamic acid, Hb: Hemoglobin, TOF: Tetralogy of Fallot

Table 2.

Etiological profile of the cohort

Diagnosis	n
TOF physiology	2
Truncus arteriosus	1
VSD	2
ASD	2
Both atrial and VSD	1
AV canal defect	2

ASD: Atrial septal defect, VSD: Ventricular septal defect, AV: Atrioventricular, TOF: Tetralogy of Fallot

Table 3.

Demographic profile of pediatric Jehovah’s Witnesses patients who underwent cardiac surgery

Parameter	Value
Age
<1 year	6
>1 year	4
Sex
Male	6
Female	4
Weight (kg)	15.6 (3.2–44)
Average CPB time (min)	89 (32–218)
Average cross clamp time (min)	68 (14–157)
Average systemic cooling temperature (°C)	31 (28–34)

CPB: Cardiopulmonary bypass

Seven children had acyanotic congenital heart disease [Table 2]: this group included two cases each of isolated ventricular septal defect (VSD) and large atrial septal defect (ASD), and one case with both VSD and ASD. Two patients were diagnosed with a complete atrioventricular canal defect; one of these had Down syndrome with associated bilateral pelvi-ureteric junction obstruction, whereas the other had glucose-6-phosphate dehydrogenase (G6PD) deficiency. No additional dysmorphic features requiring genetic evaluation were identified in any of the patients. Among the three patients with cyanotic congenital heart disease, one had classical tetralogy of Fallot (TOF), another had TOF physiology without overriding of the great vessels, and one had truncus arteriosus type II. Pulmonary arterial hypertension was present in five patients.

Perioperative hematological parameters and blood conservation measures

The mean preoperative hemoglobin level was 13.1 ± 2.3 g/dL, and the mean hematocrit was 36.7 ± 5.2%. Postoperatively, the mean hemoglobin decreased to 10.3 ± 1.2 g/dL and the hematocrit to 28.6 ± 3.9% [Table 4]. There was no significant difference observed between preoperative and postoperative hemoglobin levels.

Table 4.

Pre- and post-operative hemoglobin of children who underwent surgery

Parameters	Values (mean±SD)
Hb (g/dL)
Preoperative	13.1±2.3
Postoperative	10.3±1.2
Hematocrit (%)
Preoperative	36.7±5.2
Postoperative	28.6±3.9

SD: Standard deviation, Hb: Hemoglobin

Preoperative optimization of hemoglobin was achieved using erythropoietin and iron supplementation (oral or intravenous), as clinically indicated. Postoperatively, five patients received recombinant erythropoietin and seven received tranexamic acid as part of a multimodal blood-conservation strategy. Immediate postoperative iron therapy was administered in one case. All patients were discharged on oral iron supplementation.

Postoperative complications and outcomes

Postoperative complications occurred in two patients, both of whom developed septic shock. One of these patients subsequently developed ventilator-associated pneumonia, necessitating prolonged mechanical ventilation, tracheostomy, and eventual decannulation 40 days after surgery.

In the remaining patients, the median duration of mechanical ventilation was 1–2 days, with successful weaning achieved in all cases – specifically, 5 of 10 patients required only 1 day of ventilation. The two patients with complete atrioventricular canal defects required prolonged ventilatory support for 5–7 days. No inhospital or 30-day mortalities were reported in this cohort.

DISCUSSION

JW patients undergoing cardiac surgery present a distinct clinical challenge due to their refusal of allogeneic blood transfusions. Declined products typically include whole blood, erythrocytes, platelets, fresh frozen plasma, cryoprecipitate, granulocytes, and predeposited autologous blood.[10] Acceptable alternatives often include acute normovolemic hemodilution, intraoperative red blood cell salvage, erythropoietin, hemodialysis, cardiopulmonary bypass, and venovenous bypass. The Watch Tower Society does not prohibit albumin, immunoglobulins, or hemophilic preparations, although acceptance remains subject to individual beliefs.[11]

Advances in perioperative care, including refined surgical techniques and blood-conservation strategies, have improved outcomes in adult JW patients undergoing cardiac surgery.[12,13] Pediatric cases have shown similar feasibility, as demonstrated by Olshove et al.[14] Our findings are consistent with these results, showing no significant postoperative hemoglobin drop and no perioperative mortality in the studied cohort.

A variety of pharmacological agents are employed to minimize blood loss or improve hemoglobin, including tranexamic acid, desmopressin, erythropoietin, oral and intravenous iron, recombinant clotting factors, thrombopoietin mimetics, aprotinin, and tissue sealants. In our series, intraoperative cell salvage combined with tranexamic acid was used routinely. Although acute normovolemic hemodilution is a known strategy, its application in children remains limited due to risks such as myocardial ischemia and volume overload. Predeposit autologous blood donation remains largely unacceptable among JW patients. Surgical techniques aimed at reducing blood loss included minimally invasive or transcatheter approaches when applicable, the use of vasoconstrictive agents, tourniquets, regional anesthesia, deliberate hypotension, therapeutic hypothermia, and precision tools such as harmonic scalpels and radiofrequency ablation devices.[15]

Postoperative management required standard care with specific modifications, such as avoiding hypertension, maintaining normothermia, and using pediatric or low-volume tubes for blood sampling. Adjuncts such as intravenous iron and desmopressin were administered as needed.[15,16] Tanaka et al. recommended extended mechanical ventilation to optimize oxygen delivery in this group;[15] however, other studies found no significant differences in ventilation duration between JW and non-JW patients.[17,18,19,20] In our cohort, the median ventilation time was 1 day, with successful weaning in all but one case of ventilator-associated pneumonia.

Several studies report lower postoperative blood loss in JW patients compared to controls, likely reflecting more careful intraoperative management (e.g. 466.8 vs. 843 mL, P = 0.0001; 312 ± 141 vs. 721 ± 619 mL, P < 0.05).[17,20] These findings support the idea that, with proactive planning, JW patients can achieve outcomes equal to or better than those of non-JW patients.

Emergency cardiac surgeries in JW patients pose additional risks due to the absence of preoperative hemoglobin optimization and greater potential for intraoperative bleeding. In life-threatening situations where blood refusal cannot be verified, clinicians may legally proceed with transfusion in the patient’s best interest.[21] Mortality risk increases substantially in JW patients with severe anemia (hemoglobin ≤8 g/dL or hematocrit ≤ 24%), with rates reported as high as 37%.[22] Hogervorst et al. also highlighted the association between low hemoglobin levels and adverse outcomes.[23] Conversely, a 10-year study of 91 JW patients reported no significant differences in mortality or complications between emergency and elective surgeries.[16]

Most JW patients carry advance decision cards that explicitly refuse allogeneic blood products and autologous pre-donation. In their absence, clinicians should aim to honor religious beliefs while ensuring patient safety. Ultimately, decision-making falls to the responsible clinician.[9] Familiarity with the ethical and legal frameworks surrounding JW patient care is essential for ensuring informed, respectful, and safe surgical management.

Limitation

The sample size is too small to calculate the significance and comment on complications.

CONCLUSIONS

Cardiac surgery in JW pediatric patients is feasible and safe when meticulous perioperative blood conservation strategies are employed. With proper planning and ethical consideration, outcomes can be comparable to or better than those in non-Witness patients, even in emergency settings.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.