Journal of Thrombosis and Thrombolysis

, Volume 47, Issue 2, pp 179–185 | Cite as

Restrictive versus liberal red blood cell transfusion for cardiac surgery: a systematic review and meta-analysis of randomized controlled trials

  • Babikir Kheiri
  • Ahmed Abdalla
  • Mohammed Osman
  • Tarek Haykal
  • Sai Chintalapati
  • James Cranford
  • Jason Sotzen
  • Meghan Gwinn
  • Sahar Ahmed
  • Mustafa Hassan
  • Ghassan Bachuwa
  • Deepak L. BhattEmail author


Patients undergoing cardiac surgery are among the most common recipients of allogeneic red blood cell (RBC) transfusions. However, whether restrictive RBC transfusion strategies for cardiac surgery achieve a similar clinical outcome in comparison with liberal strategies remains unclear. We searched electronic databases from inception to December 2017 for randomized controlled trials (RCTs). We calculated the risk ratios (RRs) and weighted-mean difference (MD) using a random-effects model. We included 9 RCTs with a total of 9005 patients. There was no significant difference in mortality between groups [RR 1.03; 95% confidence interval (CI) 0.74–1.45; P = 0.86]. In addition, there were no significant differences between groups in the clinical outcomes of infections (RR 1.09; 95% CI 0.94–1.26; P = 0.26), stroke (RR 0.98; 95% CI 0.72–1.35; P = 0.91), respiratory morbidity (RR 1.05; 95% CI 0.89–1.24; P = 0.58), renal morbidity (RR 1.02; 95% CI 0.94–1.09; P = 0.68), myocardial infarction (RR 1.00; 95% CI 0.80–1.24; P = 0.99), cardiac arrhythmia (RR 1.05; 95% CI 0.88–1.26; P = 0.56), gastrointestinal morbidity (RR 1.93; 95% CI 0.81–4.63; P = 0.14), or reoperation (RR 0.90; 95% CI 0.67–1.20; P = 0.46). There was a significant difference in the intensive care unit length of stay (h) (MD 4.29; 95% CI 2.19–6.39, P < 0.01) favoring the liberal group. However, there was no significant difference in the hospital length of stay (days) (MD 0.15; 95% CI − 0.18 to 0.48; P = 0.38). In conclusion, this meta-analysis showed that restrictive strategies for RBC transfusion are as safe as liberal strategies in patients undergoing cardiac surgery with regards to short-term clinical outcomes.


Cardiac surgery Red blood cell transfusion Restrictive Meta-analysis 



We would like to thank Katherine Negele, Editorial Assistant, Research Department, Hurley Medical Center, for assistance with manuscript editing.

Compliance with ethical standards

Conflict of interest

Dr. Mustafa Hassan has received a Research Grant from Abbott. Dr. Deepak L. Bhatt discloses the following relationships—Advisory Board: Cardax, Elsevier Practice Update Cardiology, Medscape Cardiology, Regado Biosciences; Board of Directors: Boston VA Research Institute, Society of Cardiovascular Patient Care, TobeSoft; Chair: American Heart Association Quality Oversight Committee; Data Monitoring Committees: Baim Institute for Clinical Research (formerly Harvard Clinical Research Institute, for the PORTICO trial, funded by St. Jude Medical, now Abbott), Cleveland Clinic, Duke Clinical Research Institute, Mayo Clinic, Mount Sinai School of Medicine, Population Health Research Institute; Honoraria: American College of Cardiology (Senior Associate Editor, Clinical Trials and News,; Vice-Chair, ACC Accreditation Committee), Baim Institute for Clinical Research (formerly Harvard Clinical Research Institute; RE-DUAL PCI Clinical Trial Steering Committee funded by Boehringer Ingelheim), Belvoir Publications (Editor in Chief, Harvard Heart Letter), Duke Clinical Research Institute (Clinical Trial Steering Committees), HMP Global (Editor in Chief, Journal of Invasive Cardiology), Journal of the American College of Cardiology (Guest Editor; Associate Editor), Population Health Research Institute (COMPASS Clinical Trial Steering Committee funded by Bayer), Slack Publications (Chief Medical Editor, Cardiology Today’s Intervention), Society of Cardiovascular Patient Care (Secretary/Treasurer), WebMD (CME Steering Committees); Other: Clinical Cardiology (Deputy Editor), NCDR-ACTION Registry Steering Committee (Chair), VA CART Research and Publications Committee (Chair); Research Funding: Abbott, Amarin, Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Chiesi, Eisai, Ethicon, Forest Laboratories, Idorsia, Ironwood, Ischemix, Lilly, Medtronic, PhaseBio, Pfizer, Regeneron, Roche, Sanofi Aventis, Synaptic, The Medicines Company; Royalties: Elsevier (Editor, Cardiovascular Intervention: A Companion to Braunwald’s Heart Disease); Site Co-investigator: Biotronik, Boston Scientific, St. Jude Medical (now Abbott), Svelte; Trustee: American College of Cardiology; Unfunded Research: FlowCo, Merck, Novo Nordisk, PLx Pharma, Takeda. The remaining authors declare that they have no conflict of interest.

Supplementary material

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Supplementary material 1 (DOCX 385 KB)


  1. 1.
    Hare GMT, Freedman J, David Mazer C (2013) Review article: risks of anemia and related management strategies: can perioperative blood management improve patient safety? Can J Anaesth 60:168–175CrossRefPubMedGoogle Scholar
  2. 2.
    Carson JL, Guyatt G, Heddle NM et al (2016) Clinical practice guidelines from the AABB: red blood cell transfusion thresholds and storage. JAMA 316:2025–2035CrossRefPubMedGoogle Scholar
  3. 3.
    Rohde JM, Dimcheff DE, Blumberg N et al (2014) Health care-associated infection after red blood cell transfusion: a systematic review and meta-analysis. JAMA 311:1317–1326CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Murphy GJ, Reeves BC, Rogers CA et al (2007) Increased mortality, postoperative morbidity, and cost after red blood cell transfusion in patients having cardiac surgery. Circulation 116:2544–2552CrossRefPubMedGoogle Scholar
  5. 5.
    Fusaro MV, Nielsen ND, Nielsen A et al (2017) Restrictive versus liberal red blood cell transfusion strategy after hip surgery: a decision model analysis of healthcare costs. Transfusion 57:357–366CrossRefPubMedGoogle Scholar
  6. 6.
    Shander A, Hofmann A, Ozawa S et al (2010) Activity-based costs of blood transfusions in surgical patients at four hospitals. Transfusion 50:753–765CrossRefPubMedGoogle Scholar
  7. 7.
    Farmer SL, Towler SC, Leahy MF, Hofmann A (2013) Drivers for change: Western Australia Patient Blood Management Program (WA PBMP), World Health Assembly (WHA) and Advisory Committee on Blood Safety and Availability (ACBSA). Best Pract Res Clin Anaesthesiol 27:43–58. CrossRefPubMedGoogle Scholar
  8. 8.
    Kilic A, Whitman GJR (2014) Blood transfusions in cardiac surgery: indications, risks, and conservation strategies. Ann Thorac Surg 97:726–734CrossRefPubMedGoogle Scholar
  9. 9.
    Gerber DR (2012) Risks of packed red blood cell transfusion in patients undergoing cardiac surgery. J Crit Care 27:737.e1–737.e9CrossRefGoogle Scholar
  10. 10.
    D’Agostino RS, Jacobs JP, Badhwar V et al (2017) The Society of Thoracic Surgeons adult cardiac surgery database: 2017 update on outcomes and quality. Ann Thorac Surg 103:18–24CrossRefPubMedGoogle Scholar
  11. 11.
    Patel NN, Murphy GJ (2017) Evidence-based red blood cell transfusion practices in cardiac surgery. Transfus Med Rev 31:230–235CrossRefPubMedGoogle Scholar
  12. 12.
    Stokes EA, Wordsworth S, Bargo D et al (2016) Are lower levels of red blood cell transfusion more cost-effective than liberal levels after cardiac surgery? Findings from the TITRe2 randomised controlled trial. BMJ Open 6:1–9Google Scholar
  13. 13.
    Moher D, Shamseer L, Clarke M et al (2015) Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Syst Rev 4:1–9CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Wan X, Wang W, Liu J, Tong T (2014) Estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range. BMC Med Res Methodol 14:1–13CrossRefGoogle Scholar
  15. 15.
    Mazer CD, Whitlock RP, Fergusson DA et al (2017) Restrictive or liberal red-cell transfusion for cardiac surgery. N Engl J Med 377:2133–2144CrossRefPubMedGoogle Scholar
  16. 16.
    Koch CG, Sessler DI, Mascha EJ et al (2017) A randomized clinical trial of red blood cell transfusion triggers in cardiac surgery. Ann Thorac Surg 104:1243–1250CrossRefPubMedGoogle Scholar
  17. 17.
    Murphy GJ, Pike K, Rogers CA et al (2015) Liberal or restrictive transfusion after cardiac surgery. N Engl J Med 372:997–1008CrossRefPubMedGoogle Scholar
  18. 18.
    Shehata N, Burns LA, Nathan H et al (2012) A randomized controlled pilot study of adherence to transfusion strategies in cardiac surgery. Transfusion 52:91–99CrossRefPubMedGoogle Scholar
  19. 19.
    Hajjar LA, Vincent J-L, Galas FRBG et al (2010) Transfusion requirements after cardiac surgery: the TRACS randomized controlled trial. JAMA 304:1559–1567CrossRefPubMedGoogle Scholar
  20. 20.
    Slight RD, O’Donohoe P, Fung AKY et al (2008) Rationalizing blood transfusion in cardiac surgery: the impact of a red cell volume-based guideline on blood usage and clinical outcome. Vox Sang 95:205–210CrossRefPubMedGoogle Scholar
  21. 21.
    Murphy G, Rizvi S, Battaglia F et al (2007) A pilot randomized controlled trial of the effect of transfusion-threshold reduction on transfusion rates and morbidity after cardiac surgery. Transfus Altern Transfus Med 29:41–42Google Scholar
  22. 22.
    Bracey AW, Radovancevic R, Riggs SA et al (1999) Lowering the hemoglobin threshold for transfusion in coronary artery bypass procedures: effect on patient outcome. Transfusion 39:1070–1077CrossRefPubMedGoogle Scholar
  23. 23.
    Johnson R, Thurer R, Kruskall M et al (1992) Comparison of two transfusion strategies after elective operations for myocardial revascularization. J Thorac Cardiovasc Surg 104:307–314PubMedGoogle Scholar
  24. 24.
    Bennett-Guerrero E, Zhao Y, O’Brien SM et al (2010) Variation in use of blood transfusion in coronary artery bypass graft surgery. JAMA 304:1568–1575CrossRefPubMedGoogle Scholar
  25. 25.
    Slight RD, Demosthenous N, Nzewi OC et al (2006) The effect of gain in total body water on haemoglobin concentration and body weight following cardiac surgery. Heart Lung Circ 15:256–260CrossRefPubMedGoogle Scholar
  26. 26.
    Slight RD, Bappu NJ, Nzewi OC et al (2006) Factors predicting loss and gain of red cell volume in cardiac surgery patients. Transfus Med 16:169–175CrossRefPubMedGoogle Scholar
  27. 27.
    Slight RD, Bappu NJ, Nzewi OC et al (2006) Perioperative red cell, plasma, and blood volume change in patients undergoing cardiac surgery. Transfusion 46:392–397CrossRefPubMedGoogle Scholar
  28. 28.
    Fransen EJ, de Jong DS, Hermens WT, Maessen JG (2001) Is postoperative blood loss, loss of blood? A pilot study in cardiac surgical patients. Perfusion 16:301–308CrossRefPubMedGoogle Scholar
  29. 29.
    Slight RD, Fung AKY, Alonzi C et al (2007) Rationalizing blood transfusion in cardiac surgery: preliminary findings with a red cell volume-based model. Vox Sang 92:154–156CrossRefPubMedGoogle Scholar
  30. 30.
    Patel NN, Avlonitis VS, Jones HE et al (2015) Indications for red blood cell transfusion in cardiac surgery: a systematic review and meta-analysis. Lancet Haematol 2:e543–e553CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Babikir Kheiri
    • 1
  • Ahmed Abdalla
    • 2
  • Mohammed Osman
    • 3
  • Tarek Haykal
    • 1
  • Sai Chintalapati
    • 1
  • James Cranford
    • 1
  • Jason Sotzen
    • 1
  • Meghan Gwinn
    • 4
  • Sahar Ahmed
    • 1
  • Mustafa Hassan
    • 1
  • Ghassan Bachuwa
    • 1
  • Deepak L. Bhatt
    • 5
    Email author
  1. 1.Department of Internal MedicineHurley Medical Center/Michigan State UniversityFlintUSA
  2. 2.Division of Hematology & OncologyAscension St. John HospitalGrosse Pointe WoodsUSA
  3. 3.Division of CardiologyWest Virginia University School of MedicineMorgantownUSA
  4. 4.Michigan State University-College of Human MedicineFlintUSA
  5. 5.Brigham and Women’s Hospital Heart & Vascular CenterHarvard Medical SchoolBostonUSA

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