title: Outcome of patients who refuse transfusion after cardiac surgery: a natural experiment with severe blood conservation.
abstract: BACKGROUND
  Jehovah's Witness patients (Witnesses) who undergo cardiac surgery provide a unique natural experiment in severe blood conservation because anemia, transfusion, erythropoietin, and antifibrinolytics have attendant risks. Our objective was to compare morbidity and long-term survival of Witnesses undergoing cardiac surgery with a similarly matched group of patients who received transfusions.
  
  
  METHODS
  A total of 322 Witnesses and 87 453 non-Witnesses underwent cardiac surgery at our center from January 1, 1983, to January 1, 2011. All Witnesses prospectively refused blood transfusions. Among non-Witnesses, 38 467 did not receive blood transfusions and 48 986 did. We used propensity methods to match patient groups and parametric multiphase hazard methods to assess long-term survival. Our main outcome measures were postoperative morbidity complications, in-hospital mortality, and long-term survival.
  
  
  RESULTS
  Witnesses had fewer acute complications and shorter length of stay than matched patients who received transfusions: myocardial infarction, 0.31% vs 2.8% (P = . 01); additional operation for bleeding, 3.7% vs 7.1% (P = . 03); prolonged ventilation, 6% vs 16% (P < . 001); intensive care unit length of stay (15th, 50th, and 85th percentiles), 24, 25, and 72 vs 24, 48, and 162 hours (P < . 001); and hospital length of stay (15th, 50th, and 85th percentiles), 5, 7, and 11 vs 6, 8, and 16 days (P < . 001). Witnesses had better 1-year survival (95%; 95% CI, 93%-96%; vs 89%; 95% CI, 87%-90%; P = . 007) but similar 20-year survival (34%; 95% CI, 31%-38%; vs 32% 95% CI, 28%-35%; P = . 90).
  
  
  CONCLUSIONS
  Witnesses do not appear to be at increased risk for surgical complications or long-term mortality when comparisons are properly made by transfusion status. Thus, current extreme blood management strategies do not appear to place patients at heightened risk for reduced long-term survival.
authors: Heart and Vascular Institute, Departments of Thoracic and Cardiovascular Surgery, Cleveland Clinic, OH 44195, USA.
authors: Gregory
authors: G
authors: Pattakos
authors: Colleen G
authors: CG
authors: Koch
authors: Mariano E
authors: ME
authors: Brizzio
authors: Lillian H
authors: LH
authors: Batizy
authors: Joseph F
authors: JF
authors: Sabik
authors: Eugene H
authors: EH
authors: Blackstone
authors: Michael S
authors: MS
authors: Lauer
mesh_terms: D000368:Aged; D000740:Anemia / Q000208:ethnology / Q000209:etiology / Q000523:psychology / Q000628:therapy; D000933:Antifibrinolytic Agents / Q000627:therapeutic use; D001803:Blood Transfusion / Q000523:psychology / Q000706:statistics & numerical data; D006348:Cardiac Surgical Procedures / Q000009:adverse effects / Q000401:mortality; D004921:Erythropoietin / Q000627:therapeutic use; D005260:Female; D006397:Hematinics / Q000627:therapeutic use; D006801:Humans; D033221:Jehovah's Witnesses / Q000523:psychology*; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D019990:Perioperative Care / Q000379:methods / Q000523:psychology; D011183:Postoperative Complications / Q000208:ethnology / Q000523:psychology / Q000628:therapy; D012107:Research Design; D016019:Survival Analysis; D013997:Time Factors; D065227:Transfusion Reaction; D016312:Treatment Refusal / Q000208:ethnology / Q000523:psychology / Q000706:statistics & numerical data; D014481:United States / Q000453:epidemiology / Q000208:ethnology
chemical_list: D000933:Antifibrinolytic Agents; D006397:Hematinics; D004921:Erythropoietin