Because the beliefs of Jehovah's Witnesses preclude blood product transfusion, treatment of Witnesses undergoing cardiac surgery provides a natural experiment in severe blood conservation. Various practices are used to conserve blood in such cases, including preoperative administration of erythropoietin, iron, and B-complex vitamins; intraoperative use of antifibrinolytics; and additional surgery for postoperative bleeding. Some of these methods may be beneficial for all cardiac surgery patients, whereas others may be risky, and their effect on long-term survival is unknown.

Figure. Cardiac patient Henry Song, a Jehovah's Witness, rests comfortably following his triple bypass surgery using a new low-blood-loss technique. Photo by George F. Lee / Star-Bulletin.

Results of a study of Witnesses undergoing cardiac surgery and a matched group of patients who received transfusions indicate that extreme blood conservation doesn't reduce patients' long-term survival. In fact, Witnesses had fewer acute complications and better early survival than other patients.

Between January 1, 1983, and January 1, 2011, 322 Witnesses and 87,453 non-Witnesses underwent cardiac surgery at a major medical center. All Witnesses had refused blood transfusion; of the non-Witnesses, 48,986 received red blood cell transfusions and 38,467 didn't. Mean follow-up among Witnesses was 9.6 years, and 10% of survivors were followed for more than 20 years. Among non-Witnesses who received transfusions, mean follow-up was 8.6 years, and 10% of survivors were followed for more than 19 years.

Risks of in-hospital death, stroke, atrial fibrillation, and renal failure were similar in both groups. Witnesses, however, had lower rates of postoperative myocardial infarction, prolonged ventilation, and additional surgery for bleeding. Also, Witnesses had shorter ICU and postoperative hospital stays. One-year survival was better among Witnesses, but 20-year survival was similar in the two groups.

The authors note that the unusual management strategies used in the care of Witnesses carry certain risks, but red blood cell transfusion carries risks of its own. Examining the care of a patient population that is managed differently could lead to the adoption of management strategies that benefit other groups of patients, they write.-Karen Rosenberg

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