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Six-Month Outcomes after Restrictive or Liberal Transfusion for Cardiac Surgery.

C David Mazer1, Richard P Whitlock1, Dean A Fergusson1

  • 1From the Department of Anesthesia (C.D.M., G.M.T.H., N.M.) and the Department of Surgery, Division of Cardiac Surgery (S.V.), St. Michael's Hospital, Keenan Research Centre for Biomedical Science, the Li Ka Shing Knowledge Institute of St. Michael's Hospital (C.D.M., G.M.T.H., K.T., S.V., P.J.), Applied Health Research Centre (J.H., D.D., K.T., S.V., P.J.), Sunnybrook Health Sciences Centre (S.F.), Division of Hematology, Mount Sinai Hospital (N.S.), the Departments of Medicine (P.J., N.S.), Physiology (C.D.M., G.M.T.H), and Laboratory Medicine and Pathobiology (N.S.), Dalla Lana School of Public Health (K.T.), and Institute of Health Policy, Management and Evaluation, University of Toronto, and Canadian Blood Services (N.S.), Toronto, the Population Health Research Institute (R.P.W., E.B.-C.), Hamilton Health Sciences Center (R.P.W., E.B.-C., K.C., S.S.), McMaster University (R.P.W., E.B.-C., K.C., S.S.), Hamilton, ON, the Ottawa Hospital Research Institute, University of Ottawa, Ottawa (D.A.F.), the Cumming School of Medicine and Libin Cardiovascular Institute, University of Calgary, Calgary (A.J.G.), and the Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton (S.M.B.), CHUS-Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke (É.M.), and the Department of Anesthesiology and Critical Care Medicine, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Laval (F.L.), QC, the Departments of Anesthesia and Medicine, Division of Critical Care, Centre Hospitalier de l'Université de Montréal, Montreal (F.M.C.), and the Department of Anesthesia, Perioperative and Pain Medicine, St. Boniface Hospital, University of Manitoba, Winnipeg (H.P.G.) - all in Canada; the Department of Cardiothoracic Anesthesia, Rigshospitalet, Copenhagen University Hospital, Copenhagen (B.K.); Medical Research Institute of New Zealand, Wellington (S.M., P.J.Y.), and Waikato Hospital, Hamilton (K.B.) - both in New Zealand; Fundación Cardioinfantil-Instituto de Cardiología and Universidad Autónoma de Bucaramanga, Bucaramanga, Colombia (J.C.V.); the Department of Surgery, University of Melbourne (A.R., C.R.), and the Department of Anaesthesia and Pain Management, Royal Melbourne Hospital (C.R.), Melbourne, VIC, and the Department of Anaesthesia, Royal Adelaide Hospital, and the Discipline of Acute Care Medicine, University of Adelaide, Adelaide, SA (T.W.P.) - all in Australia; University of Basel, Department of Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, and Klinik Hirslanden Zurich, Zurich - both in Switzerland (M.D.S.); Heart Care Associates, SAL Hospital, Gujarat, India (C.M.); and the Department of Cardiothoracic Anaesthesia, National Heart Center, and the Department of Anaesthesiology, Singapore General Hospital - both in Singapore (N.-C.H.).

The New England Journal of Medicine
|August 28, 2018
PubMed
Summary

A restrictive red-cell transfusion strategy was noninferior to a liberal strategy for patients undergoing cardiac surgery at 6 months. This finding supports conservative transfusion thresholds in high-risk cardiac surgery patients.

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Area of Science:

  • Cardiology
  • Transfusion Medicine
  • Critical Care Medicine

Background:

  • Previous research indicated a restrictive transfusion strategy was noninferior to a liberal strategy at 28 days post-cardiac surgery for moderate-to-high risk patients.
  • This study aimed to evaluate the longer-term clinical outcomes at 6 months following cardiac surgery.

Purpose of the Study:

  • To compare the efficacy and safety of restrictive versus liberal red-cell transfusion strategies at 6 months post-cardiac surgery.
  • To assess the composite outcome of death, myocardial infarction, stroke, or renal failure with dialysis.

Main Methods:

  • A randomized controlled trial involving 5243 adults undergoing cardiac surgery.
  • Participants were assigned to either a restrictive (hemoglobin <7.5 g/dL) or liberal (hemoglobin <9.5 g/dL in ICU, <8.5 g/dL in ward) red-cell transfusion strategy.
  • The primary outcome was a composite of death, myocardial infarction, stroke, or new-onset renal failure with dialysis within 6 months.

Main Results:

  • The primary composite outcome occurred in 17.4% of the restrictive group and 17.1% of the liberal group at 6 months (absolute risk difference, 0.22 percentage points; P=0.006 for noninferiority).
  • Mortality rates were similar between groups: 6.2% in the restrictive group and 6.4% in the liberal group.
  • No significant differences were observed in secondary composite outcomes or individual components between the two transfusion strategies.

Conclusions:

  • A restrictive red-cell transfusion strategy is noninferior to a liberal strategy in moderate-to-high risk patients undergoing cardiac surgery at the 6-month follow-up.
  • These findings reinforce the safety and efficacy of more conservative transfusion thresholds in this patient population.
  • The study provides robust evidence supporting restrictive transfusion practices in cardiac surgery.