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Patient Centered Care: Case Studies

Case Study 1:

Revision Surgery for Thoracic and Abdominal Aortic Aneurysm Using a Minimally Invasive Endovascular Fenestrated Stent Graft

An 81-year old female patient (Jehovah’s Witness) presented with an expanding aortic aneurysm in the thoraco-abdominal (chest and abdomen) region that had enlarged from 5 to 7 centimeters. 

The patient’s prior endovascular aortic aneurysm stent graft repair in the infra-renal portion of the abdominal aorta made the current aneurysm repair substantially more challenging. Since she is a Jehovah’s Witness and does not accept blood transfusions, it was decided that an open surgical approach was not an option due to the high risk of bleeding. A minimally invasive, endovascular repair was chosen as the ideal treatment method since the expected blood loss is decreased dramatically compared to traditional open aortic surgery.

The surgery was performed by one of our most experienced vascular surgeons, Dr. James Black, and took place over the course of 7 hours. The anesthesia care was provided by Dr. Steven Frank, the Director of the Center for Bloodless Medicine and Surgery at Johns Hopkins. The spinal drain performed nicely and the patient’s blood pressure was maintained above the threshold necessary to ensure blood flow to the kidneys and the spinal cord. Total blood loss was 300 ml (about 6% of total blood volume). The majority of the blood lost was returned to the patient using autologous blood salvage (Cell Saver). This option had been discussed with the patient, and she agreed to its use.  She awoke from the surgery with normal movement in both arms and both legs. 

illustration of a Fenestrated endovascular aortic stent graft
Fenestrated endovascular aortic stent graft
Illustration permission for use by Cook Medical Incorporated, Bloomington, Indiana

The patient’s preoperative hemoglobin was 11.3 and the postoperative hemoglobin was 9.6, well within the margin of safety. Her postoperative course included 5 days of erythropoietin, intravenous iron, B12, and folate, a regimen recommended by our Bloodless team Hematology consultant, Dr. Linda Resar, in order to stimulate the bone marrow to produce red blood cells. After a few days of physical therapy, she was able to walk on her own and she was discharged from the hospital after an 8-day stay. Since discharge, she has not experienced any further problems, and has not needed to return. 

Case Study 2:

Radial Artery Approach for Cardiac Catheterization followed by an "Off-Pump" Coronary Artery Bypass Surgery

illustration of a off-pump coronary artery bypass
"Beating Heart", off-pump coronary artery bypass
Illustration permission for use granted by Medtronic, Inc.

A 66-year old male Jehovah’s Witness patient was brought to the hospital with chest pain, and referred for a cardiac catheterization. He had a positive nuclear stress test that showed reduced blood flow to the left ventricle with a high suspicion for coronary artery disease.

Dr. John Resar, the director of the cardiac catheterization lab at Johns Hopkins performed the procedure. In order to reduce blood loss from the cardiac catheterization, the approach was planned through the radial artery (in the arm) rather than the femoral artery (in the groin). This approach is associated with reduced bleeding during and after the procedure. The total blood loss during the cardiac catheterization procedure was 50 mls (1% of total blood volume). As expected, the procedure revealed high-grade triple vessel disease (narrowing) that was not treatable with coronary stents. Coronary artery bypass surgery was recommended.

Dr. John Conte performed the coronary bypass surgery. Of interest is the fact that in 1999, Dr. Conte published a case report of the first ever successful bloodless lung transplant in a Jehovah’s Witness patient. In this case presented here, he decided the patient would be best served by performing an "off-pump" cardiac surgery where the heart lung bypass machine is not used. This technique reduces the blood loss that is commonly associated with the bypass machine, since with traditional bypass a substantial amount of the patient’s blood is left behind in the circuit of the machine and is unrecoverable.

The 4-hour surgery went very well. The saphenous vein from his right leg was harvested using an endoscopic approach. Compared to the traditional technique, this method uses a smaller incision to harvest the vein. The internal mammary artery and the saphenous vein were both used to provide blood flow to the narrowed coronary arteries. A special “octopus retractor” was used to stabilize the heart because during off-pump surgery the heart continues to beat (thus the term “beating heart surgery”), unlike the traditional on-pump method where the heart is arrested and completely still. The hemoglobin level was 13.8 before surgery and 13.0 three days later when the patient was discharged from the hospital.  Two weeks after the surgery, the patient attended the open house for our Bloodless Medicine and Surgery Program and looked and felt "as good as ever". 

Case Study 3:

Illustration of before and after heart surgery

Aortic Valve/Aortic Root Replacement with Cardiopulmonary Bypass
Using Retrograde Autologous Prime (RAP) and Intraoperative
Autologous Normovolemic Hemodilution (IANH) 

Aortic Valve and Aortic Root Replacement without Blood Transfusion

A 46-year old female Jehovah’s Witness patient had severe aortic valve regurgitation along with an ascending aortic aneurysm. She had been seen at two other major academic centers in hopes of having a valve replacement along with repair of her “aortic root” (the section of aorta that joins the heart above the aortic valve), but was unable to find a team of physicians that would perform the surgery without blood transfusion. 

Dr. Duke Cameron, the Chief of Cardiac Surgery saw her along with Dr. Steven Frank, Director of the Johns Hopkins Bloodless Medicine and Surgery Program. With the patient and her family present, they reviewed the echocardiogram and cardiac catheterization report from another hospital.  At the time, a discussion took place about the various methods of blood conservation and the various alternatives to transfusion. The patient and her family agreed that blood salvage (Cell Saver) and intraoperative autologous normovolemic hemodilution (IANH) were acceptable options. The patient was sent to the lab for routine blood tests and her hemoglobin level was suboptimal (13.0 g/dL) for this type of surgery. One complicating factor was the patient’s body weight of 95 lbs, which means that her total blood volume and red cell mass was about ½ that of a normal sized adult. 

The patient was scheduled for a 3-week course of erythropoietin and intravenous iron at the infusion clinic at Johns Hopkins. The patient responded nicely to the treatments and her hemoglobin level increased to 15.1 g/dL, at which time the surgery was scheduled. 

Operating room, with surgeons operating

After the patient was under general anesthesia, 2 units of her own blood were removed as part of the IANH technique. These 2 units would be given back to her near the end of the surgery. During surgery, the Perfusionist, who operates the heart lung machine, was able to use a method called retrograde autologous prime (RAP), whereby the patient’s own blood is used to prime the circuit in an effort to conserve the patient’s blood volume. 

After the surgical procedure, the patient was noted to have some cardiac ischemia (deficient blood flow to the left coronary artery).  She was taken to the cardiac cath lab where a coronary stent was placed by an interventional cardiologist into her left main coronary artery. The next day she was weaned of the ventilator and she recovered nicely. Our Bloodless team Hematology consultant, Dr. Linda Resar guided her postoperative therapy which included IV iron and erythropoietin. She was discharged from the hospital with a hemoglobin of 8.0 g/dL, and she and her family had a Baltimore crab dinner before returning home to Roanoke, VA.


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