Should Jehovah's Witness patients be listed for heart transplantation?

Abstract

This best evidence topic in Cardiac Surgery was written according to a structured protocol. The question addressed was: for [Jehovah's Witness patients with end-stage heart failure] can these patients undergo a [heart transplantation] without an increased rate of mortality. Altogether, 133 papers were found using the reported search strategy. Of those, 29 papers represented the best evidence to answer the clinical question. Five papers focusing on patients of the Jehovah's Witness (JW) faith who had end-stage heart failure were published. Successful heart transplantation was performed in a total of seven patients without mortality, re-exploration or blood transfusion. One patient had left ventricular reduction surgery twice and another patient had bypass surgery several years after transplantation. Other successful organ transplantations were also reported, including lung, liver, kidney and pancreas in both adult and paediatric patients of the JW faith, with comparable mortality and morbidity to non-JW patients. A publication bias is likely; nevertheless, we conclude that although there are no large studies directly focused on heart transplantation in JW patients, a multidisciplinary team approach to such surgery can make it technically feasible and without an increased mortality risk in suitable candidates. Therefore, such patients may be considered for heart transplantation under selected and favourable circumstances.

INTRODUCTION

A best evidence topic was constructed according to a structured protocol. This is fully described in the ICVTS [1].

THREE-PART QUESTION

For [Jehovah's Witness patients with end-stage heart failure] can these patients undergo a [heart transplantation] without [an increased mortality]?

CLINICAL SCENARIO

At Heart Transplant Committee Meeting a transplant cardiologist presented a 28-year old male patient who is a known Jehovah's Witness (JW) and had dilated cardiomyopathy with an ejection fraction of 18%. There was a debate regarding whether a heart transplant should be offered to him, knowing that blood products are not acceptable to him. A fellow in cardiac surgery decided to perform a search on the feasibility and safety of a heart transplant in JW patients to shed light on this controversy.

SEARCH STRATEGY

The literature searches were performed in Pubmed and Medline on Ovid-Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations and Ovid MEDLINE(R) from 1948 to date. The results were limited to English language publications, using the following as search words: heart transplantation in JW patients, cardiac surgery in JW patients, bloodless heart transplant surgery, complex cardiac surgery in JW patients, redo cardiac surgery in JW patients and organ transplantation in JW patients.

SEARCH OUTCOME AND RESULTS

One hundred and thirty-three articles were retrieved that discussed cardiac surgery and organ transplantation in JW patients. Of those, 29 represented articles that were relevant for the subject of this study. Thirteen articles were large studies discussing general cardiac surgery in JW patients, 11 articles discussed other organ transplants in JW patients and only five articles directly addressed the issues related to heart transplant in JW patients Tables 1 and 2.

Table 1:

Examples of published articles on cardiac surgery in JW patients

Author (year), country Study type	Patient population	Main results and conclusion
Ott and Cooley (1977) [16], USA Retrospective	Five hundred and forty-two patients (age range from 1 day to 89 years) with mixed cardiovascular procedures; of those, 362 patients required cardiopulmonary bypass	The mortality rate was 9.4% Preoperative or postoperative Anaemia was a contributing factor in 12 deaths (2.2%) and loss of blood was the direct cause of three deaths
Podesta et al. (2002) [17], Italy Prospective randomized	Forty-five patients underwent a mixed cardiac procedure (CABG, valve surgery). Randomized to receive epoetin alpha and ferrous sulphate or placebo	The mortality rate was not reported No patient in the study required blood transfusion
Moraca et al. (2011) [18], USA Retrospective	Forty patients underwent mixed cardiac procedures, reoperative valve replacement (n = 4), reoperative CABG (n = 2), valve/ascending aorta replacement (n = 1) Patients were classified as high risk (45%, n = 18) and low risk (55%, n = 22)	The overall mortality was 5% (n = 2) all of whom were in the high-risk group. Six patients underwent a delayed sternal closure due to postoperative coagulopathy No statistically significant differences in the outcomes between the high- and low-risk surgical groups
Jassar et al. (2012) [19], USA Retrospective	Ninety-one patients underwent mixed cardiac procedures and 10 patients had redo procedures	The in-hospital mortality rate was 5.5% The mortality rate for isolated coronary artery bypass graft surgery and isolated aortic valve replacement was 2.2% Reoperation (all = 8.8%, cardiac = 2.2%) and sepsis (2.2%) Major complication rates were not significantly different between the elective group and the urgent group

Table 2:

Solid organ and heart transplants in JW patients

Author (year), country Study type	Patient population and main results
Experience with other solid organ transplantation
Kaufman et al. (1988) [9], USA Retrospective	From 1979 to 1987, renal transplant was performed in 13 JWs; six patients received kidneys from mismatched living-related donors; two patients received human leucocyte antigen-identical sibling grafts; and five patients received cadaveric renal allografts. The outcomes after renal transplantation in JWs were compared with those of a paired control group (n = 25) matched for age, date of transplant, donor source and diabetic status. The overall results suggest that renal transplantation can be safely and efficaciously performed on most JWs, but those with anaemia who undergo early rejection episodes are a high-risk group relative to other transplant patients
Conte and Orens (1999) [14], USA Case report	A successful left single-lung transplantation in a 48-year old Hispanic female with idiopathic pulmonary fibrosis and secondary pulmonary hypertension
Grande et al. (2003) [15], Italy Case report	A successful procedure in a JW. The patient, a 38-year old female with type I diabetes and affected by idiopathic pulmonary fibrosis, underwent left lung transplantation. From the same pulmonary bloc, a twinning procedure was obtained by means of right lung transplantation in a 58-year old man affected by the same pathology. Both patients tolerated the surgery well and were doing well 1 year after the transplantation. The JW patient died 14 months after transplantation from acute rejection
Figueiro et al. (2003) [10], USA Retrospective	Five JW recipients of simultaneous pancreas–kidney transplants. None of the patients received transfusion of blood or blood products, either before or after the transplant. Patient and graft survival were similar to those of the non-JW group
Jabbour et al. (2004) [11], USA Retrospective	Liver transplantation was performed in 38 patients: eight in JW patients (transfusion-free group) and 30 in non-JW patients (transfusion-eligible group). The operative time, blood loss and postoperative haematocrits were similar in both groups. No blood products were used in transfusion-free patients while 80% of transfusion-eligible patients received a median of 4.5 ± 3.5 units of packed red cells. The length of the ICU and hospital stay were similar in both groups. The survival rate was 100% in transfusion-free patients and 90% in transfusion-eligible patients
Boggi et al. (2004) [20], USA Retrospective	Six JWs received a kidney and/or a pancreas transplant without blood transfusions at the time of surgery. No recipient sustained a significant blood loss at the time of surgery or thereafter. However, there occurred a life-saving rescue transfusion in one patient post-transplant
Jabbour et al. (2005) [21], USA Retrospective	Twenty-seven liver transplantations were performed in JW patients (24 adults and 3 children). Nineteen of these were living donor and eight were deceased donor liver transplants. The preoperative liver disease severity score was higher in the deceased donor group. We had 100% graft and patient survivals in the living donor group and 75% in the deceased donor recipients
Jabbour et al. (2005) [22], USA Retrospective	From June 1999 to April 2004, 13 consecutive adult JW donor hepatectomies. The mean length of hospital stay was 6.2 days. All donors were alive and well at a median follow-up time of 3 years and 4 months. Live liver donation can be safely performed in the JW population
Detry et al. (2005) [23], USA Retrospective	Between September 1998 and November 2004, 9 of 29 JWs evaluated for liver transplantation were transplanted after medical preparation (six adult patients and a 6-year old child underwent cadaveric whole liver transplantation and two patients, living-related liver transplantation using a right lobe). None of these patients received any blood product during the surgical procedure
Jabbour et al. (2005) [12], USA Case report	This report describes two paediatric patients undergoing liver transplantation. Despite the small size and low total blood volume of these patients, acute normovolemic haemodilution and cell saver were used without complications
Detry et al. (2005) [13], Belgium Retrospective	Nine Jehovah's Witness patients were listed for liver transplantation. No patient received any blood product during the surgical procedure. One patient who suffered from deep anaemia after a living-related liver transplantation, was transfused as required by his family, but died from aspergillus infection
Experience with heart transplant
Corno et al. (1986) [6], USA Case report	Heart transplantation has been successfully performed without blood products in a 45-year old JW
Lammermeier et al. (1988) [24], USA Case report	Heart transplantation has been successfully performed without blood products in a 46-year old JW
Burnett et al. (1990) [25], USA Retrospective case series	Successful cardiac transplantations without administering blood products were performed in five patients (mean age, 44.4 ± 8.3 years) of this faith. No patients required re-exploration for haemorrhage, and there was a 0% mortality
McMullan et al. (2000) [8], USA Case report	A left ventricular reduction in a JW was redone a few months later with mitral valve replacement
Gregory et al. (2005) [7], USA Case report	Post-transplant off-pump (utilizing a left thoracotomy incision) coronary bypass and laser revascularization were performed in a Jehovah's Witness, in a 57-year old man, who had received a heart transplant 14 years earlier. No blood or blood products were transfused

COMMENT

The Jehovah’s Witness (JW) faith was founded by Charles Taze under the name of the Watchtower Bible and Tract Society in 1884 in the USA. This society was re-incorporated by the International Bible Students under the name of the JW faith. The JW has remarkably grown worldwide and now reportedly includes >7 million followers (http://www.watchtower.org/e/statstics/worldwide_report).

JW patients refuse blood products, including their own blood once their blood has been disconnected from their body's circulation, based on their interpretation of the biblical passages that forbid them to do so [2]. Fractions of blood such as albumin and clotting factors as well as techniques such as cardiopulmonary bypass, dialysis, the intraoperative use of blood salvage and autologous blood transfusion devices (as long as the blood stays in continuity with the patient's circulation) are accepted by some individuals [3].

With the concept of bloodless cardiac surgery, different kinds of primary and repeat cardiac surgery have been successfully performed in JW patients, with comparable results to non-JW patients (Table 1).

Complex repeat cardiac surgery has been reported in many case reports, including in JW patients who are more prone to bleeding, such as those with thrombocytopenia or requiring circulatory arrest [4, 5].

As such, heart transplantation has been described in only seven JW patients, with the first transplant in a JW taking place as early as 1986 [6], by the University of California Los Angeles heart transplant team. Subsequent interventions in the form of an off-pump Coronary artery bypass grafting surgery and transmyocardial laser were described in a JW patient who had cardiac transplantation [7], and left ventricular reduction therapy was performed as a repeat surgery in one patient [8] (Table 2).

Experience with other organ transplantation

Organ transplantation especially heart transplantation represents a challenging situation in JW patients for several reasons: first, heart transplantation usually requires blood and blood product utilization. A life-threatening haemorrhage due to a technical problem or to a coagulopathy associated with cardiopulmonary bypass is always a risk in transplant surgery and cannot always be predicted. Secondly, there is a possibility of the need for retranslate or redo surgery, especially in younger recipients and, thirdly, the anti-rejection medications post-surgery impose upon those patients with a risk of bone marrow suppression.

For organ transplantation, each Witness is called on to decide personally whether to accept, or not, the condition that no part of the transplantation process may include the use of blood or its main fractions [2]. In this regard, the first report of a safe and efficacious kidney transplant was reported by Kaufman et al. [9], who demonstrated the safety and similar survival of a renal transplant in JW patients compared with non-JW patients. Kidney and pancreas transplantations were successfully performed in six patients [10]. Finally, although it is known that liver transplantation is a major surgical procedure usually requiring a large amount of blood products, non-transfusion liver transplantation has been reported by several groups in adult and paediatric patients [11–13]. The first lung transplantation in a JW patient was also described in 1999 [14] and another successful lung transplantation was reported in 2003 [15] (Table 2).

CLINICAL BOTTOM LINE

Although heart transplantation is rare in JW patients, a multidisciplinary team, which involves a cardiac surgeon, anaesthesiologist, cardiologist, haematologist, perfusionist and intensivist, can facilitate the safe performance of bloodless heart transplantation surgery in such patients. Therefore, heart transplantation appears to be a technically feasible option in select and suitable JW candidates, with outcomes that may reflect a mortality rate similar to that for non-JW candidates.

Conflict of interest: none declared.