6-year-old among youngest ever to receive a new heart with no new blood
(COLUMBUS, Ohio) – Using a blood conservation technique often referred to as “bloodless” surgery, a 6-year-old boy has undergone a successful heart transplant without receiving a single drop of donated blood. In doing so, Andrew Craver became “one of the smallest children ever to receive a heart transplant without blood”, said his surgeon, Dr. Mark Galantowicz, Chief of Cardiothoracic Surgery at Nationwide Children’s Hospital.
Typically, patients rely on several transfusions of blood from donors to maintain safe levels of blood cells, especially in complicated surgeries like transplants. “Most children would probably have received one or two blood transfusions before transplant in the intensive care unit, one or two units of blood during the procedure and potentially a unit of blood or so after the procedure” said Galantowicz, but that wasn’t the case with little Andrew.
Ian and Rachel Carver, Andrew’s parents, made the decision last December to proceed with the transplant without the use of transfusions. While their decision was rooted primarily in religious preferences, Galantowicz says there are medical benefits to that approach as well.
“The more foreign blood and the more foreign ‘stuff’ you’re exposed to, the more revved up your immune system is, and the potential for rejecting the transplanted heart becomes more and more real” said Galantowicz. In fact, one study shows that blood transfusions can more than double the risk of infection*.
“Nationwide Children’s Hospital was pretty much the only option for us” said Ian Craver, who made the one thousand mile round trip with his family from southern New Jersey for the transplant, and continues to make it for Andrew’s follow up care. “They not only have heart transplant program, they also have a blood conservation program”, he said, adding “it wasn’t just one particular doctor, they have a whole program that helps to support blood conservation.”
It is a program that starts long before surgery. To conserve as much of the patient’s blood as possible, doctors limit how many blood samples they take for preoperative testing. They also work with nurses, anesthesiologists and therapists to meticulously plan their operation. By the time surgery begins, the plan is well in place. “If you have a systematic approach and you use it every day, it’s safer. Everybody gets used to it, everybody knows what to expect and how to use it” Galantowicz said.
In the operating room, doctors use heart-lung bypass machines fitted with smaller, child-size components to limit exposure to foreign material. Anesthesiologists dose their medications with the goal of getting children off of ventilators immediately after surgery, and high-tech equipment is used to recover and reuse a patient’s own blood.
“We used what’s called a cell saver, which captures any shed blood during the procedure, processes it, and puts it right back into the body” said Galantowicz.
Doctors also use a technique to sew up patients using a lot of small, tight sutures to minimize bleeding, and even pay close attention to the temperature of the patient during and after the procedure. “Manipulation of temperature is an important aspect. If we cool (the patient), it’s important that we re-warm them all the way. If you’re cold, your blood doesn’t clot very well” Galantowicz said.
It’s an approach that worked well for Andrew. Remarkably, “he was up and walking around the next day” said Rachel Craver, Andrew’s mother. “And I think within a few days he was riding a bicycle again - after he had a heart transplant!”
The technique first gained attention in the 1960’s and has been steadily growing over the last decade. In 2002 there were about 70 hospitals around the country that offered blood conservation programs for surgery on children and adults. Today, there are a hundred.**
Because of cases like Andrew’s, Nationwide Children’s Hospital has developed a reputation as a leader in “bloodless” pediatric surgery. Primarily, says Galantowicz, because it a team approach, that everyone on the team has bought into. “We incorporate those techniques, strategies and thinking at every level - pre-surgery, or pre-transplant, in this case, and then at the surgery, or transplant in this case, and then afterwards.”
In June, Andrew celebrated his 6-month anniversary with his new heart. So far, he is healthy and growing, and doesn’t even seem to mind the one thousand mile round trip form New Jersey to Columbus, Ohio to see his doctors for follow ups. “They’re very caring. They take a personal interest, in not only the patient, but also the family” said his father Ian. “We were looking for the best care for our son, and we feel that’s what we got at Nationwide Children’s Hospital.”
*Hospital variation in transfusion and infection after cardiac surgery: a cohort study, BMC Medicine, Volume 7, Number 37, July 2009. Online: http://www.biomedcentral.com/1741-7015/7/37
**Bloodless Surgery Grows in Popularity, MDNews, April 2011.
http://www.mdnews.com/news/2011_04/bloodless-surgery-grows-in-popularity
