EPOETIN DOSING FOR BLOOD CONSERVATION IN JEHOVAH’S WITNESS PATIENTS UNDERGOING CARDIAC SURGERY - A SYSTEMATIC REVIEW

Abstract

BACKGROUND: Transaortic septal myectomy is the gold standard for the treatment of symptomatic hypertrophic obstructive cardiomyopathy. The aim of this study was to assess perioperative outcomes and early clinical results of minimally invasive septal myectomy performed via a small right parasternal thoracotomy. METHODS: Between May 2011 and February 2014, 26 consecutive patients underwent isolated minimally invasive septal myectomy via a 5-cm right parasternal minithoracotomy in the second intercostal space. The procedure was carried out using femoro-femoral cannulation for cardiopulmonary bypass. Antegrade cardioplegia was administered in the aortic root and consisted in a single dose of Custodiol. One patient underwent concomitant resection of an aortic fibroelastoma. Preoperative and pre-discharge transthoracic echocardiograms (TTE) were obtained for each patient. RESULTS: Mean age was 55 11 years and 15 (58%) patients were male. Nineteen patients (73%) were in NYHA class III or IV preoperatively and 4 patients (15%) had a previous percutaneous alcohol septal ablation attempt that failed. One patient (4%) had a permanent pacemaker prior to surgery. Preoperative TTE evaluation showed the presence of systolic anterior motion (SAM) of the mitral valve in all patients and median mitral regurgitation grade was 2/4. Mean cardiopulmonary bypass time was 73.4 18.0 minutes and mean aortic cross-clamp time was 56.8 14.1 minutes. Intraoperative conversion to sternotomy was required in one patient due to an uncontrollable venous bleeding. There was no in-hospital mortality. Reintervention was required for one patient (4%) in whom the aortic valve was damaged at the time of the septal myectomy. This patient underwent aortic valve replacement during the index hospitalization and was discharged in good condition. Reexploration for bleeding was performed in one patient (4%). Postoperative implantation of a permanent pacemaker was necessary in 7 (27%) patients, including 4 (15%) who suffered from complete atrioventricular block. Pre-dicharge TTE evaluation showed marked reduction in septal thickness (20.6 3.6 to 15.3 4.7 mm, p<0.001). In two patients, relief of LVOT obstruction was unsatisfactory with residual SAM and moderate mitral regurgitation. In the remaining patients, peak LVOT gradient was significantly reduced at discharge (82 33 to 18 9 mmHg, p<0.001) with no residual SAM. CONCLUSION: This study demonstrates the feasibility of transaortic septal myectomy through a right minithoracotomy. Our early results suggest that when successful, this technique is effective and yields good clinical and echocardiographic outcomes. However, this procedure is technically challenging and is associated with a significant learning curve. Further studies with larger cohorts and long term follow-up are warranted.