Stanford Medicine Newsletter Updates For the Local Community

 

Pediatric surgery breakthrough

Stanford cardiologists fix infant's heart without a transfusion

C.J. Garcia holds his baby sister, Lola, who underwent an innovative heart surgery.

   

A 10-day-old girl was the smallest infant in North America to undergo open-heart surgery without a blood transfusion in a procedure performed by specialists at Lucile Packard Children's Hospital Stanford.

The child, born in October with a severe heart defect, made a quick recovery from the operation, which required meticulous planning and execution to overcome the technical challenges of avoiding the use of blood products.

"If you can do surgery safely and effectively without transfusion, there are several medical benefits," said Frank Hanley, MD, chief of pediatric cardiac surgery at the hospital's Betty Irene Moore Children's Heart Center and one of two surgeons on the case. He said that patients who do not receive blood products have fewer post-surgical complications, provided they do not lose too much blood.

"You have to be able to do the surgery safely and not have the patient's red blood cell count drop too low," said Hanley,  who is he Lawrence Crowley, MD, Professor in Child Health at the Stanford School of Medicine.

A severe heart defect

From the moment of her birth on Oct. 21, little Lola Garcia struggled to breathe. She and her parents, Felisa and Jared Garcia of Hemet, California, were rushed to a children's hospital near the family's home.

Lola was diagnosed with transposition of the great arteries, a rare condition in which the heart's major arteries are not connected correctly. Normally, the blood follows a single figure-eight-shaped circuit through the heart and lungs, then back to the heart and out to the body to supply oxygen to the internal organs and the brain. In Lola's heart, the blood made two separate circuits — from the heart to the lungs and back, and from the heart to the body and back. As a result, her brain and other organs received too little oxygen.

"They said she would definitely need heart surgery, and most likely a blood transfusion, to correct the problem," said Felisa. "We were happy there was a solution, but when they said 'transfusion,' my heart dropped." The Garcia family are Jehovah's Witnesses; they requested that Lola's surgery be done without a blood transfusion because of their religious beliefs.

Although many hospitals offer bloodless surgery for adults, avoiding transfusion is more difficult in newborns. Several hospitals around the country turned the family down. But the pediatric cardiothoracic surgery team at Packard Children's offered to attempt baby Lola's operation without transfusing blood.

Technical hurdles

During the surgery, performed by a team led by Hanley and cardiothoracic surgeon Katsuhide Maeda, MD, Lola needed to be connected to a heart-lung machine, which would pump her blood through a circuit of tubing and membranes for re-oxygenation.

The machine carries a solution of saline that mixes with the patient's blood. For an adult, the volume of saline in a heart-lung machine does not dilute the blood much, but a seven-pound newborn has less blood to begin with. Connecting Lola to a standard heart-lung circuit would have dangerously lowered her red blood cell count.

In the past, the problem has been solved by transfusing blood. For Lola, the Packard Children's team took a different approach.

"We used a miniaturized heart-lung circuit with a much lower priming volume of saline," Hanley said. The medical team also planned every step of Lola's care to minimize blood loss, including her blood draws, surgical techniques and materials.

Still, the team could not guarantee that Lola would not need a transfusion. California state law gives physicians authority to administer blood to minors in emergencies, even if the parents disagree. Before surgery, the physicians explained to the parents how they would monitor Lola.
During and after the seven-hour surgery, Lola's red blood cell count stayed in the safe range; no transfusion was required. She recovered more quickly than expected, which her doctors say may be due to avoiding transfusion.

"I couldn't believe how fast she was healing," Jared said. "We went home in less than two weeks. It was great."

"Lola is doing fantastic; she looks phenomenal," Hanley said. "Our team is excited to build this bloodless surgery program that will help many other children and families in the future."

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