The Year in Coagulation and Transfusion: Selected Highlights

The past year has yielded important advances in coagulation and transfusion practice across cardiothoracic and vascular care. Patient blood management remains central, with growing evidence supporting restrictive transfusion thresholds, structured anemia screening and treatment, and multidisciplinary bleeding protocols. Ultra-permissive anemia strategies in selected cardiac surgery populations appear feasible, while registry and prospective data reinforce the importance of preoperative hematocrit optimization. Four-factor prothrombin complex concentrate has been established as a preferred alternative to fresh frozen plasma for vitamin K antagonist reversal and management of post-cardiopulmonary bypass coagulopathic bleeding, demonstrating reduced transfusion requirements without increased thromboembolic risk. Hemadsorption techniques show promise for intraoperative drug removal of direct oral anticoagulants in urgent cardiac surgery, although evidence remains limited and largely investigational. Advances in viscoelastic testing enhance early identification of coagulation deficits, as well as monitoring of residual heparin effect, and support personalized, viscoelastic testing-guided transfusion algorithms. Heparin resistance and postoperative thrombocytopenia-including heparin-induced thrombocytopenia-require structured diagnostic and therapeutic approaches, with increasing use of direct thrombin inhibitors in cardiopulmonary bypass and extracorporeal support. Antithrombotic therapy research emphasizes careful escalation and de-escalation strategies to balance bleeding and thrombosis risk, including aspirin withdrawal in selected mechanical circulatory support patients and individualized approaches after valve interventions and coronary bypass surgery. Extracorporeal membrane oxygenation remains associated with increased rates of bleeding and thrombosis. Emerging data on platelet thresholds, direct thrombin inhibitors, and novel factor-targeted agents highlight the complexity of extracorporeal membrane oxygenation-associated coagulopathy. Collectively, recent studies underscore a continued shift toward individualized, viscoelastic testing-guided hemostatic management across adult and pediatric populations.