Successful surgical repair of acute type A aortic dissection without the use of blood products

We report successful surgical treatment of type A aortic dissection in a Jehovah’s Witness without the use of any blood products. An interposition graft replacement of the ascending aorta was carried out. This was under right axillo-atrial cardiopulmonary bypass with antegrade cerebral perfusion via right a subclavian and left carotid cannula for 24 minutes at 28ºC. Body temperature was kept at 32ºC throughout. Autologous transfusion was deployed using cell salvage and a preoperative haemodilution technique. The patient was given tranexamic acid, desmopressin, recombinant factor VIIa, folic acid and epoetin alfa. Patients who object to transfusion represent a significant challenge, especially those who are at a high risk of coagulopathy associated with inherent aortic dissection leading to perturbed haemodynamics, cardiopulmonary bypass and hypothermic circulatory arrest. Type A aortic dissection repair is possible in patients refusing the use of blood products with blood salvage techniques and synthetic products that can limit the risk of bleeding. Minimal hypothermia is vital to preserve platelet


Successful surgical repair of acute type A aortic dissection without the use of blood products N Papalexopoulou, RQ Attia, VN Bapat
Guy's and St Thomas' NHS Foundation Trust, UK aBstract We report successful surgical treatment of type A aortic dissection in a Jehovah's Witness without the use of any blood products. An interposition graft replacement of the ascending aorta was carried out. This was under right axillo-atrial cardiopulmonary bypass with antegrade cerebral perfusion via right a subclavian and left carotid cannula for 24 minutes at 28ºC. Body temperature was kept at 32ºC throughout. Autologous transfusion was deployed using cell salvage and a preoperative haemodilution technique. The patient was given tranexamic acid, desmopressin, recombinant factor VIIa, folic acid and epoetin alfa.
Patients who object to transfusion represent a significant challenge, especially those who are at a high risk of coagulopathy associated with inherent aortic dissection leading to perturbed haemodynamics, cardiopulmonary bypass and hypothermic circulatory arrest. Type A aortic dissection repair is possible in patients refusing the use of blood products with blood salvage techniques and synthetic products that can limit the risk of bleeding. Minimal hypothermia is vital to preserve platelet function and avoid coagulopathy. Thus, a combination of normothermic/minimal hypothermia and antegrade cerebral protection with a blood conservation strategy can be deployed for a successful surgical outcome in aortic dissection without transfusion.
Surgical repair of acute type A aortic dissection has a high risk of postoperative bleeding and coagulopathy, requiring the routine use of blood products. 1 Ascending aorta repair can, however, be completed without the use of blood products if transfusion is not available. This is extremely rare, with a few successful cases reported in the literature. [1][2][3] We report a case of type A aortic dissection repair carried out successfully without the use of blood products.

case history
A 55-year-old man presented with acute, tearing chest pain radiating to the back. Computed tomography (CT) confirmed the diagnosis of type A aortic dissection. This extended from the aortic root and involved the entire aorta distally (Figs 1 and 2). Transoesophageal echocardiography demonstrated aortic root dilatation (4.4cm) and moderate aortic regurgitation. The patient was a Jehovah's Witness who refused all blood products apart from recombinant proteins. Two cardiothoracic centres deemed bloodless ascending aorta repair to have a prohibitive high risk and he was therefore referred to us.
On arrival, the patient was severely hypertensive and drowsy although easily rousable. On examination, he had a holodiastolic murmur in the aortic area and all pulses were present. Significant past medical history included hypertension. His preoperative haemoglobin level was 17.1g/dl, his international normalised ratio was 1.0 and his activated partial thromboplastin time was 25 seconds. His predicted mortality according to the logistic EuroSCORE was 36.3%.
The patient underwent replacement of the ascending aorta with an interposition graft. He was placed on right subclavian-atrial cardiopulmonary bypass (CBP). The ascending aorta was found to be dissected although the site of the intimal tear was not identified. It was then clamped and transacted, and his aortic valve was resuspended in a 28mm dacron interposition tube graft. Suture lines were reinforced with polytetrafluoroethylene (PTFE) pledgets, PTFE felt and BioGlue ® (CryoLife, Guildford, UK). CBP and crossclamp times were 115 minutes and 78 minutes respectively. Antegrade cerebral perfusion lasted 24 minutes at 28ºC. Body temperature was kept at 32ºC throughout. Autologous transfusion was deployed using cell salvage and a preoperative haemodilution technique. The patient was given tranexamic acid, desmopressin and recombinant factor VIIa. His postoperative haemoglobin level was 13.0g/dl.
Following discharge from the critical care unit, the patient was put on antihypertensives, folate and epoetin alfa.
PAPALEXoPoULoU ATTIA BAPAT successful surgical repair of acute type a aortic dissection without the use of Blood products He was discharged on day 10 and remained well at the 12-month follow-up visit.

discussion
Type A aortic dissection repair is possible in patients refusing blood products. The intraoperative surgical strategy requires precise surgical technique with meticulous attention to haemostasis and efforts to minimise CPB, cross-clamp and operative time. Haemodynamic status was optimised by fluid resuscitation, inotropic support and Trendelenburg positioning. Transoesophageal echocardiography and pulmonary artery catheter measurements were used to assess haemodynamic compromise. Body temperature was monitored centrally and peripherally, and was kept close to normothermia to preserve platelet function and avoid coagulopathy. 1,2 An indirect retransfusion system was used with continuous autotransfusion for effective blood salvage. A continuous connection was maintained using a line from the cell saver washed blood bag, which had been primed and connected to the patient's intravenous line to maintain an intact circuit. No blood was cross-matched prior to or during the operation and no blood derivatives (fresh frozen plasma, platelets or cryoprecipitate) were used. The only fluid given to the patient was Hartmann's solution and plasma volume expanders, as deemed necessary.
Permissive hypotension was employed with the mean arterial pressure kept at 50-55mmHg. Bone wax minimised bleeding from the sternum. Other synthetic haemostatic agents such as fibrin glue, BioGlue ® and Coseal ® (Baxter, Hayward, CA, US) were used. Postoperatively, red blood cell synthesis was promoted with erythropoietic agents while recombinant factor VIIa and desmopressin were used to improve thrombocyte function and stimulate endothelial release of tissue factors. 2,3 Additionally, there was minimal blood sampling postoperatively.
Extensive dissection involving all the branches of the aortic arch necessitates aortic arch replacement requiring longer CPB, cross-clamp and operative times, ideally at a lower temperature for cerebral protection. The aim of the surgery in this case was to perform a life-saving operation. Endovascular treatment of the remaining dissection can be performed in the future, once the patient has recovered and if deemed necessary. The possibility of an extra-anatomical bypass would allow aortic arch and descending stent grafting to mitigate the continuing morbidity and mortality associated with a persistent aortic dissection flap. 4 Beneficence and non-malevolence guide clinical practice. In high risk cases, the conflict between benefit and risk may be mitigated by evidence-based published data, expert consensus guidelines and discussions with colleagues. The true risk-benefit ratio, however, remains unknown for each individual case. It would not be appropriate to turn down a patient even at extreme high risk. This is because the patient's long-term survival is unlikely without immediate surgery. If a unit does not feel comfortable undertaking high risk bloodless operations, the staff should refer the patient to a tertiary centre that has the necessary experience. Patients need to be informed of the potential bleeding complications and, following their consent, surgery should be performed to optimise their treatment and survival rate. PAPALEXoPoULoU ATTIA BAPAT successful surgical repair of acute type a aortic dissection without the use of Blood products conclusions This case highlights the conflict between the desire of the patient (and the patient's family) to live within the confines of their religious belief and the surgical team's decision to operate on the patient knowing that they would not be able to offer potentially life-saving treatment with blood products. It is nevertheless possible to achieve a satisfactory outcome in high risk cases with a combination of blood conserving surgical techniques and optimised medical management. references