First Successful Bloodless Combined Heart‐Liver Transplantation in a Jehovah's Witness

BACKGROUND: Combined heart-liver transplantation (CHLT) represents an infrequent and highly intricate surgical intervention characterized by substantial risk. While isolated cases documenting bloodless heart transplantation or transfusion-free liver transplantation exist, a successful bloodless CHLT had not previously been recorded. This case report details the inaugural instance of such a procedure performed for a Jehovah's Witness patient. CASE PRESENTATION: A 67-year-old male Jehovah's Witness with severe multi-vessel coronary artery disease and refractory angina, heart failure with preserved ejection fraction, and metabolic dysfunction-associated steatohepatitis (MASH)-related cirrhosis (stage III-IV) was admitted for transplant evaluation at Tampa General Hospital. Listed as UNOS Status 2e, he underwent bloodless CHLT. Preoperative hemoglobin was 15 g/dL, and platelet count was 157 000/µL, optimized with erythropoietin and iron supplementation. Intraoperative blood conservation strategies included meticulous surgical techniques, acute normovolemic hemodilution (ANH, two units), cell salvage (675 mL), cryoprecipitate (600 mL), aminocaproic acid, and FEIBA (factor eight inhibitor bypassing activity). Both transplantations were uneventful. The patient was extubated on postoperative day 1 (POD 1). Endomyocardial biopsy on POD 16 showed no rejection. An echocardiogram on POD 18 confirmed preserved biventricular function (LVEF 60-65%). The patient was discharged on POD 24 with hemoglobin of 9.6 g/dL and platelet count of 227 000/µL. At POD 60, he exhibited excellent function of both transplanted organs. CONCLUSIONS: This report expands the scope of bloodless medicine, offering a model for managing complex multi-organ transplants in patients with religious restrictions to blood products, with the patient continuing to exhibit excellent recovery approximately ten months post-transplant.