Advanced Cardiac Care
Last spring, Chester County Hospital began offering bloodless heart surgery to help meet growing demand in the Greater Philadelphia area. Bloodless surgery does not require a blood transfusion or blood product, according to Patricia A. Ford, MD, director of the Center for Transfusion-Free Medicine at The Hospital of Pennsylvania.
Dr. Ford helped establish the revered center 25 years ago. At the time, it was one of the few of its kind in the United States. Today, she estimates there are more than 150 bloodless medicine centers across the country.
Satoshi Furukawa, MD, chief of cardiovascular surgery at the Hospital of Pennsylvania and surgeon who will perform all bloodless heart surgeries at Chester County Hospital, says the method has had a significant impact on his approach to care. “I decided that for each case, we would do everything necessary to minimize blood transfusions,” he continues. “That would be our new standard of care.”
The vast majority of patients at the Penn center are Jehovah’s Witnesses, says Dr. Ford. Jehovah’s Witnesses adhere to a literal interpretation of biblical scripture, Acts 15:29which says, “to abstain from things sacrificed to idols, from blood, from strangulation and from sexual immorality”.
“Our position is that we reject whole blood and its four major components: red blood cells, white blood cells, plasma, and platelets,” says Terry Robinson, minister of the Hospital Liaison Committee for Jehovah’s Witnesses in Philadelphia.
It is practice makes perfect
In a career that has spanned the better part of three decades, Dr. Furukawa has risen through the ranks of the nation’s first bloodless cardiac surgeons.
“In terms of bloodless cardiovascular surgery, I think he’s the best in that area. He’s definitely got the most experience,” says Dr. Ford. “I see Jehovah’s Witness patients all over the country, and that’s the only name I give for cardiovascular surgery. Along with his expertise, he is also kind, compassionate, and respectful.
In this approach, it is essential to ensure that the patient’s hemoglobin is at an appropriate level for surgery.
“Transfusion-free cardiovascular procedures are particularly complicated because it is difficult for the heart to compensate for anemia,” says Dr. Ford. “We need to have a good starting hemoglobin.”
While bloodless heart surgery will be performed at Chester County Hospital, patients will receive outpatient diagnosis and therapeutic correction of anemia at the Center for Transfusion-Free Medicine at Pennsylvania Hospital.
Once a diagnosis is made and the need for surgery becomes apparent, Dr. Ford, a hematologist, meets with the patient to determine if he is anemic. Anemia is a condition in which there is a shortage of healthy red blood cells to carry oxygen to body tissues. An estimated three million Americans are anemic, making it the most common blood
With patient approval, raw materials used to make hemoglobin (intravenous iron) and agents to stimulate red blood cell production in the bone marrow can be used to increase red blood cell count, Dr. Ford says. Treatment is usually given on a weekly basis at the center until the patient reaches what she and Dr. Furukawa deem acceptable to proceed with surgery.
The hematologist will also assess the patient’s risk of bleeding before surgery. For example, if a patient is taking a blood thinner that might cause them to bleed more easily, the hematologist will work with the patient’s cardiologist to determine if it is safe to temporarily take the patient off the blood thinner.
Constantly building trust
While Dr Furukawa is a central part of the new bloodless heart surgery program at Chester County Hospital, caring for patients is a team effort. Much of his motivation for aiming to approach every cardiac surgery as a bloodless procedure had to do with fostering cohesion among his support staff. He began gathering and training his support staff with the help of Robinson and Dr Ford over a year ago in April 2020.
“We’ve spent the last year working to get everyone on the same page,” says Dr Furukawa.
“There are nuances in the pre-operative, inter-operative and post-operative settings that need to be considered.”
“One of the first things I said to the administration when I opened the center 25 years ago was that I can’t do it myself,” says Dr Ford, emphasizing the value of a team for such an enterprise.
“It’s not the surgery itself that’s complex. It’s just the mindset, the culture that needs to be established from start to finish that’s different from conventional circumstances.”
As Program Coordinator, Joseph Riddick Jr. oversees Dr. Ford’s Trusted Patient Care Coordinators, the vital links between patient and physician at the center. Last September, he began his 22nd year at the center. Respect for the beliefs and wishes of patients permeates all aspects of the care provided there, as is the case with Dr. Furukawa’s program at Chester County Hospital. However, it is the responsibility of the coordinators to ensure that the understanding is formalized.
When diagnosing and recommending surgery, Riddick carefully walks through a thorough documentation process with the patient, explaining medical terminology and the implications of certain procedures and blood fractions, as needed. The process is designed to clarify and formalize intent at every phase, before, during and after their surgery, eliminating any risk of miscommunication or misinterpretation. Once complete, everything is recorded in the patient’s electronic medical record, which is accessible to all health care providers in the Penn Medicine system.
At all stages of the process, Riddick says patient care coordinators act primarily as patient advocates. “We want to make sure they know they have someone they can count on to respect their wishes and protect their position until they’re released,” he says. “We are constantly and consciously building trust.”
From a change of perspective comes new advances
Dr. Furukawa’s unique approach to heart surgery has another reason: it benefits his patients.
Shortly after the establishment of the Center for Transfusion-Free Medicine at the Pennsylvania Hospital, it and similar operations in the United States formed the Society for the Advancement of Blood Management encourage the sharing of new information and develop pathways and guidelines for the care of people who have refused blood transfusions.
“Ten to 15 years ago, we recognized that our strategies would help treat all patients, not just Jehovah’s Witnesses,” says Dr. Ford. “In 30% to 50% of cases where blood products are administered, they do not improve the outcome.”
From this awareness was born a new practice called Patient blood managementwhich refers to the use of evidence-based medical and surgical strategies to avoid unnecessary blood transfusions while improving patient outcomes.
“The core of what I do is always to deal with Jehovah’s Witnesses. I see about 1,200 a year for all sorts of reasons,” says Dr. Ford. “But I also now see a lot of patients who are not Jehovah’s Witnesses.”
Along with bloodless heart surgeries, Dr. Furukawa has also perfected a developing approach called Early recovery after heart surgery. The goal is simple: put patients in a position where they are eligible to be discharged sooner after their surgery. Patients who undergo bloodless surgery are at an advantage in this regard, he says.
“The fewer transfusions we end up doing, the more likely we are that patients will go home sooner,” says Dr. Furukawa. “Transfusions can help to some extent, but complications are more common in transfused patients. So by avoiding unnecessary transfusions, we can minimize complications and bring patients back to their own environment – it all works together.”