Leukocyte filtration and miniature perfusion during arrested heart CABG on a Jehovah's Witness patient

Bloodless surgery and a reduction in the use of allogeneic blood products has long been the standard of care in medicine. Many individuals in our communities have demanded this form of surgical treatment for personal and religious reasons. On 6 December 2002, a 72-year-old male patient was admitted to our institution as a critical air flight transfer. The patient's height was 190.5 cm and weight was 59.3 kg (body surface area 1.83 m2). His preliminary diagnosis was chest pain with myocardial infarction as evidenced by elevated blood cardiac isoenzymes. His principle diagnosis was subendocardial infarction with paroxysmal ventricular tachycardia. Cardiac catheterization was performed and demonstrated severe triple vessel disease with an ejection fraction of 30%. He was evaluated and accepted as a candidate for coronary artery bypass grafting. Multidisciplinary consultation concluded that a safe and effective method of perioperative treatment would involve the use of arrested heart support with cold blood cardioplegia using a low prime miniature perfusion circuit as no blood products would be considered for use. Additionally, the combined modalities of perfusion interventions to minimize hemodilution consisted of intraoperative autologous blood collection totaling 500 mL and rapid autologous priming of the miniature perfusion circuit. The miniature perfusion system was a low prime Cardiovention (Santa Clara, CA) CORx device which includes a hollow-fiber oxygenator and integral centrifugal pump with a surface area of 1.2 m2. This system also incorporates an air sensing solenoid which triggers rapid air evacuation in a bolus range of 1 mL or greater. Kinetic venous drainage is another feature of this device as the centrifugal pump is integrated into the oxygenator. We believed that a miniature extracorporeal circuit would enhance the desired clinical outcome as opposed to the risk of: (1) off-pump coronary artery bypass (OPCAB) approach and the concern of emergent transition to an on-pump procedure and (2) use of larger surface area with conventional systems that impose a greater hemodilutional effect. Leukocyte filtration was employed as the patient had a significant past medical history of chronic obstructive pulmonary disease. We herein report our clinical experience with this method of treatment on a patient who refused the use of blood products in his surgical treatment. It is our belief that the multiple modalities utilized in combination during this procedure resulted in positive clinical outcomes as demonstrated by an intubation time of 8 hours 35 min with a discharge on the fifth postoperative day.