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Medical First: Bloodless Heart Transplant

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COLUMBUS, Ohio (Ivanhoe Newswire) - From car accidents, to cancer to heart failure. Every two seconds, someone in the U.S. needs donated blood for surgeries. Now, a new technique is catching on across the country that doesn't require any.

It's hard to believe a year ago, Andrew Craver barely had the energy to laugh.

"One of the blood tests came back, and said he had congestive heart failure," Ian Craver, Andrew's dad, told Ivanhoe.

Andrew's heart was so weak it couldn't pump enough blood, or get enough oxygen to his organs.

"He just sort of looked like a small, frail, tired child at the time," Mark Galantowicz, M.D., FACS, a cardiothoracic surgeon at Nationwide Children's Hospital, said.

Andrew's only option was a heart transplant, but the Craver's religion stood in the way.

"We are Jehovah's witnesses. Our goal is to get the best care for our children, but we choose to do it without blood transfusions," Ian said.

"One of the main tenants of the faith is the blood carries the soul so a blood transfusion is sacrilegious." Dr. Galantowicz said.

Dr. Mark Galantowicz and his team performed a heart transplant without using a single drop of donated blood, making Andrew the youngest recipient of a bloodless heart transplant.

"The blood comes out of the body, goes through an artificial lung, an artificial kidney, an artificial heart, a heater, and a cooler," Dr. Galantowicz said.

First, minimal blood tests are taken, while he takes medicine to stimulate red blood cell growth. During surgery, special machines catch any excess blood loss and return it to the body. After surgery, the goal is to wean patients off the ventilator as quickly as possible to aid in blood conservation.

"He's doing great," Dr. Galantowicz said.

The bloodless transplant can reduce the risk of infection, but there is an increased risk of cell death and brain injury. For Andrew, the surgery was successful.

"He was up walking around the next day. In a few days he was even riding his bike," Rachel Craver, Andrew's mom said.

"He's got these big puffy cute cheeks, he's grown. He's got energy," Dr. Galantowicz said.

It's a medical first that may set the standard of saving lives and saving blood. The doctor says the bloodless transplants could ease blood shortages across the country, as well as reduce infection rates, rejection rates and time spent in the ICU.

RESEARCH SUMMARY

BACKGROUND: With someone needing blood every two seconds in the US for one reason or another, surgeries and medical procedures performed without the use of blood are preferable choice by many today. Reasons why bloodless surgeries are catching on across America include religious beliefs. Jehovah's Witnesses believe that the blood carries the soul and that would make a blood transfusion sacrilegious . Also thousands of people are dying each year after being given contaminated blood. Bloodless surgery is an approach to health care that began in the 1960s as simple avoidance of the use of transfused blood. It has grown over the last four decades, however, to include changed attitudes toward blood conservation as well as new technologies that minimize the need for transfusions during surgery. The Center for Bloodless Medicine and Surgery at Hartford Hospital in Connecticut defines bloodless surgery as "...surgical and medical treatment without the administration of blood or blood-related products."

TECHNIQUES: Patients who are considering a bloodless surgery will be given a list of recommendations and techniques to be used to help the procedure's safety. They include: diet management, medications, anesthesia techniques, and surgical methods to minimize blood loss and conserve blood.

  • DIET MANAGEMENT: Diet and nutrition is vital. Some recommendations would be take other vitamin supplements such as B-12 or folic acid, take other iron supplements such as ferrous sulfate or ferrous gluconate, maintain a nutritious diet high in iron to increase the amount of iron in your blood, and increase intake of vitamin C so the iron is absorbed more effectively.
  • MEDICATIONS: The body may require certain medications to help increase red or white blood cells or hemoglobin levels. Medications may assist with minimizing blood loss and maximizing the amount of oxygen in your blood. Oxygen carriers including perfluorocarbons and hemoglobin substitutes, Vitamin K, Vasopressin, Desmopressin, and Aminocaproic acid are all recommended medications prescribed by doctors.
  • ANESTHESIA TECHNIQUES: Some specific techniques used by the doctor include: Volume expanders (crystalloids/colloids), Hypotensive anesthesia, Hypothermia, and Normovolemic hemodilution.
  • SURGICAL METHODS TO MINIMIZE BLOOD LOSS AND CONSERVE BLOOD: Some methods would be Electrocautery, ultrasonic scalpel, laser surgery, argon beam coagulator, auto transfusion devices, and selective embolization (www.bloodlesssurgery.org).

A SUCCESS STORY: At Nationwide Children's hospital, bloodless techniques have been taken to a whole new level. In December 2010, the hospital performed its first successful bloodless heart transplant on the youngest person to ever receive a heart transplant, a 6 year old boy, Andrew Craver. Andrew suffered from a condition known as dilated cardiomyopathy, where the heart is weakened and enlarged. Some techniques used by Dr. Galantowicz, M.D., chief of Cardiothoracic Surgery at Nationwide Children's, include limiting how much blood was taken for pre-operative testing; utilizing modified tubes and heart bypass machines that have smaller components to reduce necessary blood; and using a machine, "cell saver," during the surgery that captures shed blood and processes it to be put back into the body. Andrew is now back to being a normal energized young boy thanks to Dr. Galantowicz and his medical staff. Studies have shown that using a patient's own blood cuts infection rates by more than half. Dr. Galantowicz hopes to treat patients with as few transfusions as possible in the future. (Source: www.nationwidechildrenshospital.org).

INTERVIEW

Dr. Mark Galantowicz, Chief of Cardiothoracic Surgery at Nationwide Children's Hospital discusses bloodless transplant surgery.

Why do a bloodless transplant in the first place?

Dr. Galantowicz: Well, let's start with why attempt to do bloodless surgery of any type. I think the body of evidence is growing that blood transfusions are not necessarily all good. There are down sides to a blood transfusion. It is a foreign substance that is being entered into the body and your body always responds to something foreign. That, in general response, is called an inflammatory response. It is sort of the red welts you get when you get stung by a bee. If you have something into your blood stream, you get a total body bee sting if you will. That impacts many systems in your body; your immune system, your coagulation system and so on. So, there is a downside to blood transfusions.

Can it have a long-term effect or is just basically an immediate effect?

Dr. Galantowicz: It is usually an immediate effect and so, there is more and more evidence that it prolongs hospital stays. Patients have more infections, have longer times in the ICU on ventilators, and then that puts them at risks of complications such as infections and other things. In heart surgery, traditionally, it has always been thought that a higher blood count is better. And, again, it is becoming clearer that that is not necessarily the case; that the body and the person can tolerate very low blood counts and sometimes they do better with a lower blood count without getting a blood transfusion.

When you say blood counts, what would be a normal blood count that you would use in surgery and then what do you use for?

Dr. Galantowicz: I think part of the challenge is in general, medicine taught us, young doctors and then the older doctors that the best blood count would be somewhere in the range of hematocrit of 40. Then, as more and more information and data is coming out then it has been pushed down to 35 and 30 and even less than that depending on the setting. So, it is not exactly known what the optimum blood count is. What is becoming clearer that a blood transfusion does have a down side, so you have to take that into consideration any time you are looking to transfuse a patient.

So, why not always just do bloodless surgery?

Dr. Galantowicz: Well, there is a too low of a blood count. What the blood hematocrit does, the right red blood cells, they carry oxygen to the cells and to the tissue and that is the fuel that keeps those cells alive and keeps that organ alive and keeps the body alive. There is a too low of a level. It is this balance between oxygen delivery and oxygen consumption. As long as your brain and kidney and liver and vital organs are getting enough delivery to match their consumption, everything is fine. As we have more and more tools to measure that balance, we can be more exact about what blood count that patient needs on that particular day.

Tell me a little bit about Andrew. He had a special kind of request.

Dr. Galantowicz: In children's heart surgery, the challenge has always been that the main tool for heart surgery is the heart/lung bypass machine. The heart/lung bypass machine, if you try and do bloodless surgery, what the bypass machine is, is we divert all the blood from the blood through an artificial lung, artificial pump, filters, etc. and then bring it back to the body to mimic the function of the heart and lungs. Well, if you do not put any blood in that bypass machine, there is a certain volume that you have to fill the machine with saline or nonblood and it dilutes the blood count of the now child. If it gets too low, while you can do a successful heart surgery in terms of the repair, but you do not have adequate oxygen delivery to the brain and kidney and can have a dead child. So, in children's heart surgery especially, the belief has been that it is impossible and unsafe to do it without filling or priming the bypass machine with blood, so that there is no dilution. Again, there is more and more evidence that that is not necessary and we have been very focused on miniaturizing the heart/lung bypass machine and conserving blood in many different steps and many different ways with the ultimate goal of a bloodless heart repair in children.

It seems risky. Why would you risk it?

Dr. Galantowicz: Well, the risks are worth the benefits; that the introduction of foreign blood has its downsides in terms of infection, stimulating the inflammatory response, stimulating the immune response or blunting the immune response in some cases and leading to worse outcomes. Not even to mention the cost. Blood transfusion is a very expensive therapy. It is a rare resource that is in demand around the country and if you could preserve it for those that absolutely need it that would be a benefit nationally. Andrew Craven was a child who was suffering from, what is called dilated cardiomyopathy. It means the heart is not pumping well and you have heart failure, basically pump failure. He was somewhat compensated for a year or so with medicines, but gradually deteriorated as his heart strength got weaker and weaker and the only treatment for that is a heart transplantation.

Now, did you know Andrew before the surgery?

Dr. Galantowicz: I met Andrew about a year before the surgery when his parents tracked me down and our Heart Center down because of our focus on blood conservation and our treatment of Jehovah Witness families in a way that is consistent with their beliefs.

When you met Andrew a year before, not so much in medical terms, but if you would see him, what was he like?

Dr. Galantowicz: Well, you could tell that Andrew had heart failure. He was small for his age which is typical when you have a heart that is not pumping or functioning optimally. You have poor oxygen delivery to the body and the body sort of does not have the energy or the strength to grow and thrive. So, he just looked like a tired, frail, small child.

He is just like 4 or 5 at this time?

Dr. Galantowicz: At that time, he was younger than that. I do not remember exactly. He was younger than that. But there are various milestones that you expect at a certain age and he was behind. There is certain size. There is normal growth charts and he was well below where he should have been.

Did he know what was going on?

Dr. Galantowicz: Did he know? No, I think his insight at that age was really just that he was tired and small. He did not really know any different because that is the way he had more or less felt his entire conscious life. But, his parents certainly knew that he was not able to keep up with his peers; that he was smaller than his peers and that was hard as a parent for them to see and to know.

As a Jehovah Witness, they did not want a blood transfusion?

Dr. Galantowicz: As a Jehovah Witness, one of the main tenants of the faith is that the blood carries the soul and so a blood transfusion is sacrilege. It is not that they are not loving parents or neglecting parents. It is a drive to seek out medical care providers who will respect that and do their best within the modern medicine and techniques available to try and reach a bloodless repair and in this case, a bloodless heart transplant.

Did you ever think there might be a point where, he was too sick or you would not be able to do it bloodless?

Dr. Galantowicz: Oh, of course. The conversation with the family up front is that we cannot promise a bloodless repair. The laws of the land in children are that if the child is dying of severe anemia that can be reversed by blood transfusion, we are obliged by law to give blood. But what we can promise to the family is that we will use every strategy and technique that is known on the face of the planet to attempt a blood less repair and we can share our team's philosophy, the way our team works towards blood conservation, and our history of success doing these types of bloodless repairs.

It was really important too, I mean I was reading some articles that Ohio in general had been through some kind of tough times when it comes to blood with storms and just really bad shortages?

Dr. Galantowicz: Absolutely. There are always intermittent shortages around the country and Ohio has gone through its share of shortages. As we talked about, blood is a very, very vital life giving therapy, but it is in demand and the availability of blood in blood banks nationally is less and less because the criterion to be a blood donor is very stringent, which is appropriate to maintain the safety of this. So, if there are ways to limit the number of transfusions, it helps nationally really.

How exactly does it work? How does the bloodless transplant work?

Dr. Galantowicz: The thing about transplantation as opposed to a regular heart surgery is you cannot plan it. You cannot plan when it is going to happen. Elective surgeries, you know, it is scheduled for next Tuesday at 8:00 a.m. whereas heart transplantation, you are completely dependent on the graciousness of a donor family and a tragedy that they are facing. The idea of doing a bloodless heart transplant adds on a whole another level of complexity. First, just managing the child before transplantation; they are in terrible heart failure which means they barely have enough heart function to get adequate oxygen delivery to the body and one of the key agents of oxygen delivery is red blood cells. One of the traditional therapies in bridging to transplant is to push the blood count up. So, if we are talking about trying to get a child, like Andrew, through a bloodless transplant, it really starts pre-transplantation in terms of how you manage them, how you manage their blood count.

How do you get the blood count up?

Dr. Galantowicz: Well, there are a couple of strategies. One is reduce the loss of blood. So, reduce the number of blood tests, be cognizant of why you are taking a blood test, the volume of blood samples. There are now microsamplers that take much less blood to get the same information. There are other analyzers that give you information about the body without a blood test and so using those noninvasive monitors. Then you can build the blood count a little bit by, nutrition is very important to your body's ability to build blood. Iron is the building block of red blood cells so making sure that they have adequate iron and iron supplements and then finally erythropoietin or Epo as it is called, is a synthetic version of the body's natural hormone that stimulates the body to make red blood cells. So, you can treat a child with erythropoietin and boost their blood count up. So, all those strategies were used for Andrew pre-transplantation.

Then, there are intraoperative strategies and techniques that help again this balance. Certainly, miniaturizing the heart/lung bypass machine to reduce the dilutional component of bypass. We do what is called, cell saver. It can be used to capture any shed blood during the procedure, so that it is reprocessed right back into the bloodstream. At the end of the procedure, you can process all the blood that is in the bypass machine and redeliver it back to a child that is in a system that is compatible with a Witness's belief. So, intraoperatively, there are a lot of strategies and techniques of blood conservation that afford the opportunity to have a bloodless repair.

Would you ever bank their own blood?

Dr. Galantowicz: Well that is not consistent with a Jehovah Witness, at least, belief. The blood cannot physically leave the body, so they could not donate their own blood a week in advance for example and be used. It all has to be continuously in the circulation and that is why bypass alone is consistent with the beliefs of Jehovah's Witnesses.

Is the machine a little bit like a dialysis machine in a way?

Dr. Galantowicz: It is. It is much bigger, more complex. The dialysis machine allows blood to leave the body, go through a filtering system that acts like a kidney and then return to the body. A heart/lung bypass machine is similar in that the blood comes out of the body, goes through an artificial lung, an artificial heart, an artificial kidney, heater, cooler, filters and it needs to flow, it has to mimic the total heart flow, not just a portion of it. So, the size of it and the volume of blood going through there, well, it is your complete heart function, heart and lung function.

In terms of blood conservation after the surgery, it is very important what happens in the intensive care unit. It starts with team work. Everybody has to be on the same page that our goal is a bloodless procedure. So, preoperatively the team that takes care of them has to flow right into the intraoperative team with the anesthesiologist, perfusionist, surgeons and nurses and then into the intensive care unit with the intensivists, nurses, respiratory therapist and cardiology; all focused on blood conservation. Because it is a lot of little steps that add up to success. How many blood tests you take, using microsamplers, being confident in your noninvasive monitors, weaning off the ventilator as quickly as possible, minimizing the amount of fluids we give to the body that dilutes the blood count and so on and so forth. It is quite a team effort.

Was Andrew your first?

Dr. Galantowicz: Well, he was not the first patient that we have done a bloodless procedure on. It was not the first patient that I have done a bloodless heart transplant on. It was the first, smallest and youngest child at this institution to have a bloodless heart transplant and the smallest, youngest child really in the country and we think maybe the world to have had a bloodless heart transplant.

How is he doing?

Dr. Galantowicz: He is doing great. His recovery was remarkably smooth. He was off the ventilator that day of surgery. Only a couple of days in the intensive care unit and within a week to 10 days, he was home. So, he is doing beautifully. It turned out just terrifically well for him.

When is the last time you saw him?

Dr. Galantowicz: About 6 months ago.

What was the difference in him?

Dr. Galantowicz: Well, you can tell the difference, having a normally functioning heart. So, he has these big, puffy, cute cheeks and he has grown dramatically. He has energy and his personality… because I did not really meet him when he had his bright personality. His parents recalled before he was really getting sick, but now, he has this bright personality that just livens the room right up. So, it is very rewarding to see the difference it can make in a child.

Am I missing anything?

Dr. Galantowicz: No. That is good.

Can you just tell me what is the risk of this bloodless heart transplant.

Dr. Galantowicz: Well, I think, if you were to push it so far that there is not enough blood in the body to carry enough oxygen to meet the demands, meet the consumption for the brain, for example, that would lead to cell death of the brain or brain damage. So, the risk is really being confident that you have a way of knowing when it is too low. The kidneys and the brain are the two most sensitive organs to low blood count, low oxygen delivery and monitoring that and being confident or diligent in your monitoring of the brain and kidney and rest of the body and not pushing it too low is important.

Are there just some doctors that will not do it?

Dr. Galantowicz: Oh, most doctors will not do it.

Just because it is risky?

Dr. Galantowicz: Right. Just do not feel that the risk is worth the benefit. Here, we have come to believe that blood conservation and bloodless procedures are important and have a value and apply these strategies and techniques every day in every patient, non-Witness or Witness families and because of that, our team is very used to all the extra steps, the philosophy, the teamwork behind it and so when a Jehovah Witness comes, we do not really change what we do every single day. If your philosophy, if your system was one that was based on high blood counts and not blood conservation, trying to adapt your system, your philosophy, your teams mentality and attempt a bloodless procedure would be fraught with danger. There are not that many Jehovah Witnesses in the country, so each pediatric heart surgery program might confront one a career. So, to modify their whole system and their philosophy does not really work well. So, most of the Jehovah Witness families that come here for heart surgery, they have been told it is either impossible or that their home center will not do it and so they are happy to find a place where it is possible, but also we believe that there is a value to doing this and we do it every day.

Are you a Jehovah Witness or did you have to learn about this?

Dr. Galantowicz: I am not a Jehovah Witness. I learned about it when I was in a Heart Center in New York City. The international home for Jehovah Witnesses is the Watch Tower which is in Brooklyn, New York. While I was working there, I was in New York City, I got very interested in miniaturizing the heart/lung bypass machine, blood conservation, as a way to reduce the inflammatory response. I was approached by several Witness families and the administration of the Watch Tower to consider taking care of Jehovah Witnesses which I started 15 to 20 years ago and that has just built ever since then.

FOR MORE INFORMATION, PLEASE CONTACT:

Nationwide Children's Hospital
Media Relations
(614)355-0495

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