Mechanical Support Escalation to Bridge Anemic Jehovah's Witness to Cardiac Transplantation

Background: Jehovah's Witness (JW) patients pose a unique challenge to cardiac surgery due to their refusal of blood products, typically precluding them from becoming candidates for orthotopic heart transplantation (OHT). While "bloodless" cardiac surgery has been described in ideal candidates, anemic or other hematologic-risk patients are typically excluded. We describe a successful "bloodless" OHT in a non-ideal JW patient with anemia and cardiogenic shock, with ventricular assist through a transvalvular pump to bridge and optimize hematologic status prior to operation. Case Presentation: A 58-year-old male JW with end-stage non-ischemic cardiomyopathy (NICM) and an ejection fraction of 15-20% experienced repeated decompensation despite maximal medical therapy and implantable cardioverter-defibrillator (ICD) implantation. Two years since first presentation, he developed cardiogenic shock and required intra-aortic balloon pump (IABP) support. Iatrogenic anemia occurred during IABP placement and required femoral re-access and upgrade to Impella^® 5.5 support. During mechanical support, he was given a total blood conservation plan that included intravenous iron, darbepoetin alfa, restricted phlebotomy, and nutritional supplementation. Hemoglobin was increased from 7.8 to 10.4 g/dL. Successful "bloodless" OHT was subsequently performed on him with an estimated blood loss of 200 mL, 72 min cardiopulmonary bypass duration, and no transfusion. He was discharged on the nineth day after surgery with a hemoglobin level of 9.9 g/dL and returned to full activity. Discussion: Despite inherent risks, bloodless OHT may safely be performed in selected JW patients by means of multidisciplinary coordination, modern mechanical circulatory support, and hematopoietic stimulation. Our case highlights the utility of Impella^® 5.5 as a bridge-to-transplant strategy for anemic, hemodynamically unstable JW patients. This is in harmony with evidence from previous studies indicating similar results for JW and non-JW transplant recipients under strict optimization protocols. It also supports the expansion of candidacy criteria if appropriate planning and modern blood conservation strategies are employed. Conclusions: Transfusion religious objection ought not preclude JW patients from lifesaving OHT. With judicious perioperative planning, third-generation transvalvular pumps, and hematologic optimization, "bloodless" heart transplantation is possible-potentially even in non-ideal candidates.