Pattakos Gregory, Koch Colleen G, Brizzio Mariano E, Batizy Lillian H, Sabik Joseph F, Blackstone Eugene H, Lauer Michael S
Heart and Vascular Institute, Departments of Thoracic and Cardiovascular Surgery, Cleveland Clinic, OH 44195, USA.
Arch Intern Med. 2012 Aug 13;172(15):1154-60. doi: 10.1001/archinternmed.2012.2449.
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.
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.
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).
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.
接受心脏手术的耶和华见证会患者（见证者）提供了一个独特的重度血液保护自然实验，因为贫血、输血、促红细胞生成素和抗纤维蛋白溶解剂都有相应风险。我们的目标是比较接受心脏手术的见证者与一组匹配的接受输血患者的发病率和长期生存率。
1983年1月1日至2011年1月1日期间，共有322名见证者和87453名非见证者在我们中心接受了心脏手术。所有见证者均前瞻性地拒绝输血。在非见证者中，38467人未接受输血，48986人接受了输血。我们使用倾向评分法对患者组进行匹配，并使用参数化多阶段风险法评估长期生存率。我们的主要结局指标是术后发病并发症、住院死亡率和长期生存率。
与接受输血的匹配患者相比，见证者的急性并发症更少，住院时间更短：心肌梗死，0.31%对2.8%（P = 0.01）；因出血进行二次手术，3.7%对7.1%（P = 0.03）；机械通气时间延长，6%对16%（P < 0.001）；重症监护病房住院时间（第15、50和85百分位数），24、25和72小时对24、48和162小时（P < 0.001）；以及住院时间（第15、50和85百分位数），5、7和11天对6、8和16天（P < 0.001）。见证者的1年生存率更高（95%；95%CI，93%-96%；对89%；95%CI，87%-90%；P = 0.007），但20年生存率相似（34%；95%CI，31%-38%；对32%，95%CI，28%-35%；P = 0.90）。
当根据输血状态进行适当比较时，见证者手术并发症或长期死亡率似乎并未增加。因此，目前极端的血液管理策略似乎并未使患者面临长期生存率降低的更高风险。
