Bloodless ECMO Rescue: A Cardiac Arrest Survival Without a Single Transfusion

When a 61-year-old man’s heart stopped in a hospital ward, the medical team facing him confronted a problem that goes far beyond ordinary resuscitation. The patient, a Jehovah’s Witness, had a deeply held religious conviction that forbids blood transfusions, yet he was in cardiogenic shock with a failing heart valve, a blocked coronary stent, kidneys that no longer functioned, and a heart pumping at a fraction of normal capacity. Standard emergency care for such a collapse often depends on blood products to replace what is lost during invasive procedures. A team at Lewis Katz School of Medicine at Temple University in Philadelphia has now reported, in the Journal of Artificial Organs, how they kept this man alive through extracorporeal cardiopulmonary resuscitation and a complex valve procedure without administering a single unit of blood, offering a detailed template for one of the most ethically and technically fraught corners of critical care medicine.

The clinical story began weeks before the arrest. The patient had previously undergone a transcatheter aortic valve replacement for severe aortic stenosis, a narrowing of the heart’s outflow valve that forces the heart to pump against crushing resistance. When that bioprosthetic valve began failing again, he developed the classic signs of congestive heart failure: worsening shortness of breath, an inability to lie flat, and chest pain. His medical history compounded the danger. He had coronary artery disease treated with a drug-eluting stent in the left anterior descending artery, and he was on long-term hemodialysis for end-stage renal disease. An echocardiogram revealed a mean gradient of 43 mmHg across the valve with a peak velocity of 3.98 meters per second, both indicating severe obstruction, while his left ventricular ejection fraction had collapsed from 35 to 40 percent a year earlier to just 5 to 10 percent. Cardiac catheterization pinpointed the likely culprit: in-stent restenosis, a re-narrowing inside the previously placed coronary stent.

Interventional cardiologists opened the blocked stent with angioplasty and deployed a second drug-eluting stent, loading the patient with aspirin and clopidogrel, two antiplatelet drugs that further raise bleeding risk. Despite the revascularization, his requirement for inotropic drugs, medications that force the weakened heart to contract harder, kept climbing over the next 24 hours. The team planned an urgent TAVR-in-TAVR, meaning a new valve delivered by catheter inside the failing one, to relieve the persistent shock. Before that could happen, the patient deteriorated into pulseless electrical activity, a rhythm in which the heart’s electrical system fires but no mechanical pumping follows. Advanced cardiovascular life support protocols were initiated, and the ECMO team was mobilized for extracorporeal cardiopulmonary resuscitation, in which a machine takes over circulation while the underlying cause is treated.

The cannulation itself was engineered to waste as little blood as possible. Over a no-flow period of just one minute followed by a low-flow period of 44 minutes, for a total of 45 minutes of CPR, the team percutaneously inserted a 25 French drainage cannula into the right common femoral vein and a 17 French return cannula into the left common femoral artery. Manual pressure was applied continuously whenever dilators were exchanged, a simple but critical maneuver to prevent ooze from the access site. A 6 French distal perfusion cannula, placed with a micropuncture needle, protected the leg from ischemia. Before anything else proceeded, the team confirmed with the family exactly which interventions the patient’s faith permitted: cardiopulmonary bypass, ECMO, and cell saver technology, which recovers and returns the patient’s own blood, were all acceptable, while allogeneic transfusions were not.

With mechanical support running, the bloodless medicine protocol swung into action. The patient received daily infusions of epoetin alfa, a synthetic version of the hormone that drives red blood cell production in the bone marrow, at 20,000 units per day with a boost of 40,000 units on the day of cannulation and valve replacement. Intravenous ferric gluconate supplied the iron raw material for hemoglobin synthesis, while daily cobalamin and folic acid supported the cellular machinery of hematopoiesis. Blood draws, a notorious cause of hospital-acquired anemia in the critically ill, were minimized, clustered together, and performed with pediatric collection tubes that require only tiny volumes. Nutrition was carefully maintained, because malnutrition worsens both anemia and coagulopathy. All of this had to coexist with therapeutic heparin anticoagulation and dual antiplatelet therapy, a pharmacological tightrope walk between clotting in the circuit and bleeding from every puncture site.

Three days after ECMO cannulation, the patient underwent the transfemoral TAVR-in-TAVR procedure. Every vascular access was obtained under combined ultrasound and fluoroscopic guidance using micropuncture needles in a single pass, a technique that maximizes the chance of first-stick success and minimizes hematoma formation. Ten days after cannulation, the team successfully weaned him from V-A ECMO and decannulated him, returning the blood remaining in the circuit to his body and repairing both cannulation sites primarily. The numbers tell the story of how close the margins were. His hemoglobin stood at 11.7 grams per deciliter on the day of cannulation, fell to 7.5 by decannulation, and touched a nadir of 6.3 during the admission. Platelets dropped from 180,000 per cubic millimeter at ECMO initiation to 92,000 at decannulation, with a low of 73,000 on the circuit. He remained therapeutically anticoagulated throughout the entire support period.

The outcome, measured over a full year, was remarkable. At discharge, his ejection fraction had recovered to 15 to 20 percent and the valve gradient had fallen from 43 to 12.7 mmHg. At one year, the ejection fraction reached 30 to 35 percent with a gradient of 9 mmHg and only trace aortic insufficiency. Neurologically, he was intact, oriented to person, place, time, and situation, with no deficits despite 45 minutes of resuscitation. He spent 46 days in the hospital and was discharged to a long-term acute care facility, initially requiring maximum assistance with daily activities alongside occupational and physical therapy. The only ECMO-related complication was a polymicrobial infection at the surgical cutdown site, involving E. coli, S. marcescens, and E. faecium, which required antibiotics, surgical re-exploration, and a vacuum-assisted closure device. Notably, he received no transfusions at any point despite multiple cardiovascular interventions.

The case matters because the statistics for bleeding during extracorporeal resuscitation are sobering. Depending on how bleeding is defined, between 9 and 40 percent of ECPR patients experience hemorrhage requiring transfusion, and the SAVE-J II trial demonstrated that as many as 64 percent of ECPR patients need blood, sometimes up to ten units of packed red cells on top of fresh frozen plasma and platelets. Known risk factors include thrombocytopenia at presentation, older age, elevated D-dimer, surgical or central cannulation, and renal replacement therapy, and this patient carried several of them. Jehovah’s Witnesses, whose faith prohibits blood product transfusion, have therefore often been considered poor candidates for ECMO, and published reports of successful bloodless ECPR remain scarce. The Temple team argues that being a Witness is not an absolute contraindication, provided an algorithmic approach is followed and decisions are made jointly with the patient and family.

The protocol they describe extends well beyond this single case. Ultrasound-guided vascular puncture avoids repeated needle sticks that cause hematomas and limb ischemia, and a two-person cannulation team allows continuous manual pressure during equipment exchanges. Retrograde autologous priming, in which the patient’s own blood displaces the crystalloid fluid that fills the circuit, can prevent hemodilution when time permits. Once on support, the authors suggest considering anticoagulation targets below the standard ELSO recommendation of an aPTT 1.5 to 2.5 times baseline or an anti-Xa level of 0.3 to 0.7 IU/mL, balancing thrombotic risk against bleeding, guided by institutional protocols. Should hemorrhage occur, they recommend a predetermined multidisciplinary plan: stop systemic anticoagulation immediately, administer acceptable hemostatic alternatives, and intervene early for mechanical control. Shortening the duration of support matters too, since rapid liberation from V-A ECMO is independently associated with fewer bleeding complications, and weaning should proceed only once hemodynamics are unequivocal to avoid re-cannulation.

What elevates this report from a curious anecdote to a reference point is its demonstration that bloodless medicine, usually planned weeks in advance for elective surgery, can be executed in the chaos of an emergency resuscitation. The key elements, careful cannulation technique, hematopoietic support, minimized phlebotomy, nutritional optimization, and meticulous circuit management, are all deployable once a patient is stabilized on the machine. With well-defined goals of care agreed upon in advance and a disciplined, algorithmic approach, the authors conclude that extracorporeal cardiopulmonary resuscitation can be a viable option for Jehovah’s Witness patients in cardiac arrest. Given how few such cases have been reported with successful outcomes, this experience offers clinicians a practical roadmap for one of the most challenging scenarios in critical care, and a reminder that respecting a patient’s religious convictions and delivering aggressive, life-saving technology need not be mutually exclusive.

Subject of Research: Bloodless extracorporeal cardiopulmonary resuscitation with ECMO in a Jehovah's Witness patient

Article Title: Extracorporeal cardiopulmonary resuscitation for cardiogenic shock in a Jehovah’s witness

Article References: Afflu, D. K., F. Chai, L., Kehara, H., Baskin, S. M., Toyoda, Y., & Yanagida, R. (2026). Extracorporeal cardiopulmonary resuscitation for cardiogenic shock in a Jehovah’s witness. Journal of Artificial Organs, 29(4), Article 65. https://doi.org/10.1007/s10047-026-01591-6

Image Credits: AI Generated

DOI: 10.1007/s10047-026-01591-6

Keywords: ECMO, ECPR, cardiogenic shock, Jehovah's Witness, bloodless medicine, mechanical circulatory support, TAVR, cardiac arrest, blood conservation, anticoagulation, epoetin, cardiac surgery