73. Blood Refusal During Cardiac Surgery: Two Decades of Trends and Outcomes

Document Type

Conference Proceeding

Publication Date

5-1-2026

Publication Title

J Thorac Cardiovasc Surg

Keywords

oxygen, adult, aged, blood transfusion, clinical decision making, cohort analysis, complication, conference abstract, controlled study, coronary artery bypass graft, coronary artery bypass surgery, drug therapy, female, heart surgery, hematocrit, hemodynamics, human, major clinical study, male, morbidity, mortality, mortality rate, perioperative care, qualitative analysis, religion, retrospective study, surgery, surgical mortality, total quality management

Abstract

Background: Allogenic blood transfusion is a therapeutic strategy to mitigate hemodynamic instability and improve oxygen delivery in patients undergoing cardiac surgery; however, some patients refuse blood transfusions for personal or religious beliefs. We aimed to characterize trends and outcomes for patients refusing peri-operative blood transfusion during cardiac surgery to inform clinical decision-making. Methods: Using data from The Society of Thoracic Surgeons Adult Cardiac Surgery Database within a statewide quality improvement collaborative (N = 33 centers), we performed a retrospective observational review of cardiac surgery procedures from 2008 to 2024. Qualitative analysis of trends in the annual frequency of operations performed in patients refusing blood transfusion was performed by individual sites. Data are shown as count (%), median (Q1-Q3) or mean ± SD as appropriate. A subgroup analysis was performed for isolated coronary artery bypass grafting (CABG) cases given heterogeneity of the overall cohort. Results: Of 197,306 procedures, 729 (0.37%) were performed with patients refusing peri-operative blood transfusion. Mean annual volume was 42.9±11.7, with most centers averaging fewer than 2 procedures per year (Figure). Patients refusing blood transfusion were more likely to undergo isolated CABG (51% vs 48%) and valve (16% vs 13%) versus CABG/valve (5% vs 7%) and other procedures (28% vs 32%), p<0.001. Of cases with blood refusal, 15% (76/508) met intraoperative criteria for transfusion (hematocrit <21%). Postoperative transfusion occurred in 66/729 (9.1%) cases with initial blood refusal. Operative mortality was significantly higher for blood refusal cases (4.9% vs 3.2%, p=0.009), but highest for blood refusal cases that then received transfusions (12.1%). Major morbidity was not different between groups (13.3% vs 14.9%, p=0.223). For isolated CABG, blood refusal was associated with 330% higher risk-adjusted odds of operative mortality [ORadj 3.35 (2.04-5.51), p<0.001) but no difference in major morbidity [ORadj 0.89 (0.63-1.28), p<0.001]. Conclusion: Cardiac surgery in patients who refuse blood transfusion is uncommon but associated with more than 300% higher mortality in isolated CABG cases. Salvage transfusion occurred in 9.1% of cases with a 12.1% mortality rate. The high-risk nature of this cohort highlights a quality improvement opportunity to expand transfusion sparing practices. [Formula presented] PERIOPERATIVE CARE

Volume

171

Issue

4

First Page

S47

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