Bloodless heart transplantation in patients who refuse transfusion: An 11-year case series

The study objective was to evaluate the outcomes of bloodless heart transplantation in patients who definitively refuse blood transfusions at a single center specializing in bloodless cardiac surgery.

We retrospectively reviewed all heart transplants at a single center from 2013 to 2024 and identified 53 patients who definitively refuse blood transfusions undergoing bloodless heart transplantation. Bloodless heart transplant recipients received specialized perioperative hemoglobin optimization protocols and perioperative patient blood management strategies, including acute normovolemic hemodilution and specialized surgical techniques to decrease blood loss. Primary outcomes were survival at 30 days, 1 year, and 5 years; secondary outcomes were postoperative major complications.

Patients who definitively refuse blood transfusions achieved a mean preoperative hemoglobin of 12.6 g/dL before surgery. Preoperative hemoglobin optimization was achieved through the use of erythropoietin (87%) and iron supplementation (68%). Mean nadir hemoglobin after bloodless heart transplantation occurred on postoperative day 3 at 10.3 (9.3-11.8) and increased to 11.3 g/dL (10.2-12.7) at discharge. Patients who definitively refuse blood transfusions did not receive any perioperative blood transfusions. Postoperative complications were low overall with 1 patient (2%) developing primary graft dysfunction, 2 patients (4%) developing a stroke, and 1 patient (2%) developing respiratory failure requiring tracheostomy. Mortality at 30 days, 1 year, and 5 years was 2%, 8%, and 33%, respectively.

Bloodless heart transplantation can be performed safely with outcomes comparable to national standards when comprehensive perioperative optimization, blood conservation protocols, and meticulous surgical technique are used. These findings demonstrate that bloodless heart transplantation is a viable option for this traditionally underserved patient population and highlight the potential need for broader adoption of blood conservation strategies across patient populations and centers to expand access to lifesaving therapies.