Patient blood management in cardiac valve surgery: combined effects of preoperative hemoglobin optimization and intraoperative blood conservation

BACKGROUND: Transfusion practices in cardiac valve surgery remain variable despite evidence supporting integrated patient blood management strategies. This study evaluated the independent and combined effects of preoperative hemoglobin status and intraoperative blood conservation techniques on transfusion requirements in elective open cardiac valve surgery. METHODS: We conducted a nationwide retrospective multicenter cohort study using data from the national Maturity Assessment Model for Patient Blood Management registry. Adult patients undergoing elective open cardiac valve surgery between 2016 and 2022 in 23 Spanish hospitals were included. Anemia was defined as preoperative hemoglobin <13 g/dL, irrespective of sex. The primary outcome was red blood cell transfusion during the index hospital admission. RESULTS: A total of 9889 patients were analyzed, with an overall transfusion rate of 53%. Anemic patients (37.3%) had higher transfusion rates than non-anemic patients (70.2% vs. 42.7%). In a separate model restricted to 5763 patients with intraoperative data, combined use of tranexamic acid and intraoperative cell salvage was associated with lower transfusion risk compared with no blood conservation strategy (47.7% vs. 52.3%; adjusted odds ratio 0.83; 95% confidence interval 0.71-0.97), whereas use of either strategy alone showed no meaningful transfusion reduction. When preoperative hemoglobin status and intraoperative strategies were analyzed jointly, the lowest transfusion rate (37.6%) occurred in non-anemic patients receiving both strategies, whereas anemic patients without blood conservation had the highest rate (74.9%; adjusted odds ratio 4.95; 95% confidence interval 4.10-5.97). CONCLUSIONS: Combined implementation of adequate preoperative hemoglobin levels and intraoperative blood conservation strategies was associated with lower transfusion rates in elective cardiac valve surgery, supporting the value of integrated perioperative patient blood management pathways in real-world practice.