The least of 3 evils: exposure to red blood cell transfusion, anemia, or both?

J Thorac Cardiovasc Surg. 2013 Dec;146(6):1480-1487.e6. doi: 10.1016/j.jtcvs.2013.06.033. Epub 2013 Aug 30.


Background: Anemia and red blood cell (RBC) transfusions are both associated with morbidity and mortality after cardiac surgery. Patients with the lowest hematocrit (HCT) values during cardiopulmonary bypass (CPB) are the most likely to receive a transfusion, which results in a double-negative exposure. We aimed to clarify the effects of anemia, transfusion, and their combination to identify which imposes the greatest risk of end-organ dysfunction and mortality.

Methods: From November 1, 2004, to November 1, 2009, 7942 patients underwent procedures requiring CPB and did not receive intraoperative or postoperative RBC transfusion, and 1202 received intraoperative RBC transfusion alone. They were divided into 4 groups: intraoperative nadir HCT ≥25% without RBC transfusion, ≥25% with RBC transfusion, <25% without RBC transfusion, and <25% with RBC transfusion. The relationship among HCT, RBC, and outcomes was studied using generalized propensity-score analysis. Outcomes included estimated glomerular filtration rate (eGFR), troponin, ventilatory support time, length of stay, and mortality.

Results: After risk adjustment, comparison of all 4 groups showed that double exposure to anemia (HCT <25%) and RBC transfusion was associated with the highest risk: lowest eGFR (P = .008), highest troponin values (P = .01), longest ventilator requirement (P < .001), longest length of stay (P < .001), and highest mortality (P = .007). Single exposure to either HCT <25% or RBC transfusion alone was associated with the next risk category, and the lowest morbidity risk was associated with neither exposure.

Conclusions: Although single exposure to anemia or RBC transfusion alone was associated with risk, it was generally lower than that of anemia and RBC exposure in combination.

Keywords: CPB; HCT; LOS; RBC; cardiopulmonary bypass; eGFR; estimated glomerular filtration rate; hematocrit; length of stay; red blood cell.

Publication types

  • Comparative Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Aged, 80 and over
  • Anemia / blood
  • Anemia / diagnosis
  • Anemia / etiology
  • Anemia / mortality
  • Anemia / therapy*
  • Biomarkers / blood
  • Cardiac Surgical Procedures / adverse effects*
  • Cardiac Surgical Procedures / mortality
  • Cardiopulmonary Bypass / adverse effects
  • Chi-Square Distribution
  • Erythrocyte Count
  • Erythrocyte Transfusion / adverse effects*
  • Erythrocyte Transfusion / mortality
  • Female
  • Glomerular Filtration Rate
  • Hematocrit
  • Humans
  • Kaplan-Meier Estimate
  • Length of Stay
  • Linear Models
  • Logistic Models
  • Male
  • Markov Chains
  • Middle Aged
  • Monte Carlo Method
  • Multivariate Analysis
  • Patient Selection
  • Predictive Value of Tests
  • Propensity Score
  • Prospective Studies
  • Respiration, Artificial
  • Risk Assessment
  • Risk Factors
  • Time Factors
  • Treatment Outcome
  • Troponin / blood


  • Biomarkers
  • Troponin