acute aortic dissection surgery usually requires the transfusion of blood or blood components . the reported case involved a unique approach to the cardiac patient . the dilemma involved two factors : on the one hand , we had to perform surgery for an acute aortic dissection , while , on the other , the patient had a significant hemostatic disorder due to platelet dysfunction and did not express consent for the transfusion of blood or its components . a 76-year - old man was urgently transferred to our institution from a local hospital with suspected acute aortic dissection . after experiencing severe chest pain the ambulance paramedics administered a loading dose of aspirin ( 300 mg ) and clopidogrel ( 600 mg ) for suspected acute coronary syndrome . the patient was then taken to the district hospital , where he was diagnosed with acute aortic dissection ( type a ) . on admission to the cardiac surgery department , 1 ) was performed , confirming the presence of dissection at the aortic root level . blood impedance platelet aggregometry measured with a multiplate analyzer ( dynabyte ) demonstrated impaired platelet function ( asp test : 5 u , norm : 75136 ; adp test : 8 u , norm : 53122 ) . laboratory tests : hemoglobin ( hb ) 8.3 mmol / l , hematocrit ( htc ) 40% , red blood cell count ( rbc ) 4.53 t / l , platelet ( plt ) 141 g / l ; activated prtial thromboplastin time ( aptt ) 41.7 s ( norm : 2235 ) , international normalized ratio ( inr ) 1.58 ( norm : 0.91.15 ) , antithrombin iii 40% ( norm : 80120% ) , creatinine 0.73 mg / dl , glomerular filtration rate ( gfr ) 90 ml / min/1.73 m. transesophageal echocardiography ( tee ) confirmed dissection at the ascending aorta the patient was informed about the natural course of the disease as well as the risks and benefits associated with surgical treatment . the patient 's comorbidities included coronary artery disease , type 2 diabetes , and rheumatoid arthritis . the patient was also informed about the very high risk of postoperative bleeding in the presence of coagulation disorders . however , he still refused to undergo transfusion of blood or blood products even in case of life - threatening complications . under these circumstances , we decided to proceed with the surgical treatment of the patient , but the operation was postponed in order to correct the coagulation disorders . the situation was described in the patient 's records , and written consent was obtained from the patient . while waiting for the postponed surgery , the patient did not complain of pain , and his condition remained stable . the patient received iron supplementation , folic acid , and erythropoietin . on the tenth day of hospitalization , after demonstrating normal platelet function with platelet aggregometry , with inr decreased to 1.28 and antithrombin iii increased to 65% , the patient was operated on . heparin was administered intravenously at a dose of 37 500 iu ( 400 iu / kg ) . the efficacy of heparinization was controlled by the measurement of activated clotting time  act ( hepcon hms , medtronic , minneapolis , mn ) . subsequently , cardiopulmonary circulation was established , and the chest was opened through sternotomy . there were inflammatory adhesions of the heart with the pericardium , which were easily released . a vent suction line was introduced into the left ventricle through the right upper pulmonary vein . after the aorta was opened , cold crystalloid cardioplegia was administered into the coronary ostia . the proximal and distal parts of the aorta were reinforced with teflon strips , and repair was performed using a vascular prosthesis ( vascutec 30 mm ) . before the end of cardiopulmonary bypass , hemofiltration was performed , and 2000 ml of filtrate was withdrawn . the aorta cross - clamping time was 84 minutes , and the duration of reperfusion was 52 minutes . in total , heparin activity was reversed by the administration of protamine sulfate  375 mg ( a dose corresponding to the amount of heparin in the ratio of 1 mg : 100 iu ) . the sternotomy wound was then closed without suturing the pericardium ; two drains ( 32 fr ) were left in the pericardium . during the operation , tranexamic acid was administered ( 2 g as an intravenous infusion and 500 mg into the extracorporeal circulation circuit with priming ) . postoperative drainage was 220 ml , and the drains were removed on the second day after the operation . on the first postoperative day , the patient was conscious and had no neurological deficits . laboratory tests on the first postoperative day showed : hb 6.8 mmol / l , htc 35% , rbc 3.96 the lowest value of blood cell counts was observed on the 7 day after the surgery ( hb 4.3 mmol / l , htc 24% , rbc 2.5 t / l , plt 244 the patient received additional doses of erythropoietin ( 8000 iu on the 5 postoperative day and 4000 iu each subsequent day ) in addition to folic acid and iron supplementation . the postoperative course was complicated by cardiovascular instability requiring inotropic medication ( discontinued on the 5 day after the surgery ) . on the first postoperative day , acute renal failure was diagnosed , necessitating the use of continuous renal replacement therapy , which was completed 7 days after the surgery , after satisfactory urine output was obtained . because of respiratory failure , the patient was intubated again on the third postoperative day ( 60 hours after the operation ) and remained on a ventilator until the seventh postoperative day . twenty days after the surgery , he was transferred to the district hospital . there , during the second month after the operation ( 58 postoperative day ) he died from respiratory failure due to severe pneumonia . the proportion of patients not expressing consent to a blood transfusion after cardiac surgery is minimal . according to the literature if the surgery is planned , there is ample time to prepare such a patient . only a few cases of surgical treatment for acute aortic dissection in jehovah 's witnesses have been described in the medical literature . in addition , there have been no cases in which urgent surgery was needed for an acute aortic dissection in a jehovah 's witness with completely blocked platelet function who would not express consent for a blood transfusion . the available case reports of acute aortic dissection in jehovah 's witnesses show that such an operation can be safely performed without the need for a transfusion of blood or blood products . however , in the presence of significant coagulation disorders that can not be leveled out immediately and in the absence of consent for blood transfusion , we believe that surgery should be postponed until optimal clotting is achieved . the patient needs to be informed about the enormous risk of operating without blood transfusions and about the risk of postponing acute aortic dissection surgery . according to the international registry of acute aortic dissection , the mortality rate for acute aortic dissection without surgical treatment exceeds 60% , while the surgical mortality rate in such cases is approximately 25% . furthermore , the coagulation system should be assessed with thromboelastometry . during the waiting period for the restoration of normal hemostasis , iron preparations , vitamin b12 , folic acid , and erythropoietin may be administered [ 25 ] . it is mandatory to control and normalize the patient 's blood pressure . after obtaining optimal results , blood counts , and clotting hemodilution during the cardiopulmonary bypass is not deleterious as it protects the formed elements of blood . before the end of cardiopulmonary bypass , hemofiltration may be used in order to bring the hematocrit back to the baseline level . desmopressin can also be administered , improving the function of platelets and the endothelium [ 3 , 7 ] . moreover , if the patients are willing , they receive cryoprecipitate and recombinant coagulation factor viia at a dose of 90 mg / kg i.v . near the end of the cardiopulmonary bypass . the surgical approach requires special attention to hemostasis from the very beginning of the operation . we recommend introducing cardiopulmonary circulation cannulas to the femoral vessels under the control of transesophageal echocardiography ( tee ) to assess their proper position . it allows blood to return to the circuit in case of bleeding and facilitates the dissection of adhesions . in our case , we tried to minimize the extent of the operation by using a simple vascular prosthesis for the ascending aorta and to improve hemostasis by using felt strips in order to secure the anastomosis . in addition , fibrin glue may be used to seal the anastomosis provided that the patient does not object to it . after the operation , blood pressure should remain under 100 mm hg to minimize post - operative bleeding . the blood left in the reservoir , oxygenator , and drains of the cardiopulmonary circulation set may be used for autologous re - transfusion with the help of a cell saving device ( cell saver system ) , to which our patient did not object . we also recommended supplements of iron and folic acid . the strategy adopted in this particular case gave the patient an opportunity to survive the operation and the postoperative period . unfortunately , the patient died due to severe pneumonia , which was not directly related to postoperative anemia . this paper was presented during the 7 congress of the polish society of cardio - thoracic surgeons in warsaw and during the 16 gdask cardiac surgery meeting in 2014 .
in this case report , we present the treatment of an acute type a aortic dissection in a jehovah 's witness patient . in accordance with the will of the patient , blood products were not used . 
 additionally , the patient had significant hemostatic disorders due to the use of antiplatelet drugs .