In This Article
- Massachusetts General Hospital's Cardiac Transplantation team completed its first bloodless heart transplant on a Jehovah's Witness patient
- Jehovah's Witnesses do not accept blood transfusions in their medical treatment due to their religious beliefs
- Careful patient selection is an important factor in bringing Jehovah's Witness patients safely and successfully through cardiac transplantation
- The surgical protocol involved key blood-conserving methods, including reduced pre- and postoperative blood draws, and iron and erythropoietin supplementation
The Massachusetts General Hospital Cardiac Transplantation Program performed its first bloodless heart transplant using innovative approaches to blood conservation. The patient, Fay Reid-Mensah, is a woman who suffered from advanced congestive heart failure. She would not accept blood products—including whole blood, red cells, white cells, and plasma—due to her religious beliefs as a Jehovah's Witness. Jehovah's Witnesses also do not pre-donate their own blood to be stored for later infusion.
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"There is a belief that Jehovah's Witness patients and others unwilling to accept blood transfusions are not eligible for transplant. But appropriately selected patients can safely undergo transplant and have good outcomes," says Dan Zlotoff, MD, PhD, Reid-Mensah's heart failure cardiologist at Mass General. The cardiac transplant team also included Greg Lewis, MD, medical director of the Cardiac Transplantation Program, and David D'Alessandro, MD, surgical director of Cardiac Transplantation and Ventricular Assist Devices. Dr. D'Alessandro had completed three other blood product-less cardiac transplants before coming to Mass General.
"This particular need drives innovation," says Dr. D'Alessandro. "Much of what we do with cell salvage and autotransfusion we now do in routine cardiac surgery. We learned these methods while trying to protect Jehovah's Witness patients and get them successfully through surgery. It's a good example of how changing the way we care to accommodate a certain segment of our patient population makes us better doctors and nurses."
Optimizing Bloodless Heart Transplant Outcomes Through Patient Selection
Reid-Mensah first came to Mass General in 2022 as an outpatient seeking care for advanced heart failure resulting from cardiac amyloidosis. She was extremely symptomatic and presented with shortness of breath as her predominant symptom.
"She wanted to establish care [in Boston] after moving [from New York] to be closer to family," notes Dr. Zlotoff. "She struggled to perform even everyday activities like walking around and getting dressed."
"Deciding her eligibility for transplant in our program was not an easy ethical decision. And it's one that each program needs to make for themselves," says Dr. D'Alessandro. "Right now, there are about 3,500 adult hearts available in the United States each year. All U.S. programs share them, so you can't have rogue programs doing things to put those organs in jeopardy. We all must ensure we're making the best use of them."
Dr. D'Alessandro says the standard should select patients with a 10% first-year risk. Reid-Mensah had no prior surgeries, did not take a blood thinner, and was starting with a normal blood count. After careful consideration, Mass General's transplant committee decided she was a candidate.
"Knowing how to manage difficult patients is a sign of a mature program. It changes the way you care for them beforehand, around the time of surgery, and afterwards," says Dr. D'Alessandro. "Our team is willing to work a little harder to allow access to organs for patients that other programs might not."
Dr. Zlotoff says bringing patients safely through transplant, particularly in higher-risk cases like this one, requires the efforts, expertise, and insights of dozens of people, including:
- Cardiac surgeons
- Cardiac anesthesia
- Critical care physicians
- Infectious disease physicians
Non-physician members of Mass General's cardiac transplant team included:
- Case managers
- Occupational therapists
- Nursing staff
- Physical therapists
- Social workers
- Speech pathologists
Bloodless Cardiac Surgery Protocols for Jehovah's Witness Patients
Discussions with Jehovah's Witness patients concerning what procedures and medical products they may or may not accept are critical to creating individualized, successful surgical protocols. To optimize Reid-Mensah's blood count before surgery, Mass General's team reduced the frequency and volume of her blood draws, utilizing pediatric tubes to collect samples. They also enhanced her red blood cell count by administering a combination of intravenous iron and erythropoietin.
"We typically do not do these things, and they have their risks. But as a program, we felt the overall benefit of making sure she had the highest blood counts going into surgery outweighed the relatively modest risks of using those types of medications," says Dr. Zlotoff. "We really felt she was as optimized as she could be."
During the procedure, Dr. D'Alessandro performed specific maneuvers to minimize blood loss. When possible, surgeons operating on Jehovah's Witness patients also collect the patient's blood in a blood salvage system. The blood stays in constant circulation with the bloodstream. This practice ensures they do not receive a blood transfusion of their own stored blood, which would violate their beliefs.
"We often do not transfuse because we absolutely have to but because we think the patient will be easier to manage if their blood count is a little higher. A blood transfusion is not a lifesaving maneuver, it is just a therapy," notes Dr. D'Alessandro. "If you are careful and choose your patients wisely, you do not need to have that safety net the majority of the time."
Postoperatively, the cardiac transplant team continued to manage her blood count to minimize the impact of potential complications. These measures included avoiding blood thinners and doing blood gases instead of blood draws for several days.
"She had a relatively uncomplicated, smooth post-transplant course in her index hospitalization. She was discharged to rehab and then went home, where she remains," says Dr. Zlotoff. "She's regaining her strength and has not been readmitted to the hospital, which happens frequently after transplant. She's meeting expectations with no significant complications thus far."
Expanding Bloodless Cardiac Transplantation at Mass General
Dr. Zlotoff says Mass General's institutional and programmatic experience and expertise prepared them to take on this unique case.
"Transplant patients are at tremendous risk due to the immunosuppression required. Our program collectively gains experience in handling all kinds of complications that occur, and in the vast majority of cases, successfully manages them," he says. "Dr. D'Alessandro's personal surgical experience with bloodless transplant also added a level of confidence that, as a program, we would be able to manage the risks appropriately and ethically."
Mass General's cardiac transplant team plans to consider and evaluate more patients who do not accept blood products on religious, medical, or personal grounds.
"The mark of a good program is one that wants to transplant as many of their patients as possible. When patients come to us needing a transplant, the safest thing for them is to get one. There's no safety sitting on a waiting list. In fact, that's their highest risk of dying," says Dr. D'Alessandro. "Our charge is to get them transplanted as quickly as possible with good organs and good outcomes. We are highly aggressive about evaluating organs, and our transplant rate is the highest in the region, which reflects that."
Learn more about the Cardiac Transplantation Program
Refer a patient to the Corrigan Minehan Heart Center