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Ann Thorac Surg 2002;74:1180-1186
© 2002 The Society of Thoracic Surgeons
a Department of Anesthesiology, Toledo, Ohio, USA
b Department ofCardiovascular Surgery, Toledo, Ohio, USA
c St. Vincent Mercy Medical Center, Toledo, Ohio, USA
d Medical College of Ohio, Toledo, Ohio, USA
Accepted for publication May 7, 2002.
* Address reprint requests to Dr Engoren, Department of Anesthesiology, St. Vincent Mercy Medical Center, 2213 Cherry St, Toledo, OH, USA 43608
e-mail: engoren{at}pol.net
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Abstract |
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Methods. We studied 1,915 patients who underwent first-time isolated coronary artery bypass operations between July 6, 1994 and December 31, 1997 at our institution. Patients with transfusions were compared with those who had not been transfused. Long-term survival data were obtained from the United States Social Security Death Index. Groups were compared by Cox proportional hazard models, Kaplan-Meier survival plots, and hazard functions.
Results. Six hundred forty-nine of 1,915 study patients (34%) received a transfusion during their hospitalization. Transfused patients were older, smaller, and more likely to be female, and had more comorbidity. Transfused patients also had twice the 5-year mortality (15% vs 7%) of nontransfused patients. After correction for comorbidities and other factors, transfusion was still associated with a 70% increase in mortality (risk ratio = 1.7; 95% confidence interval = 1.4 to 2.0; p = 0.001). By multivariate analysis, transfusion, peripheral vascular disease, chronic obstructive pulmonary disease, New York Heart Association functional class IV, and age were significant predictors of long-term mortality.
Conclusions. We found that blood transfusions during or after coronary artery bypass operations were associated with increased long-term mortality.
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Introduction |
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TopAbstractIntroductionMaterial and methodsResultsCommentAcknowledgmentsReferences |
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Material and methods |
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TopAbstractIntroductionMaterial and methodsResultsCommentAcknowledgmentsReferences |
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Subjects
All patients who underwent first-time, isolated coronary artery bypass grafting with cardiopulmonary bypass (n = 1,953) between July 6, 1994 and December 31, 1997, were considered for this study. Patients who had valvular, carotid endarterectomy, or other operation simultaneously with coronary artery bypass grafting were excluded, as were redo operations. The start date of the study was chosen as the first date when intraoperative and postoperative transfusions were prospectively separated in the database, whereas the end date was chosen to achieve the power analysis requirements and maintain a minimum 2-year follow-up for all patients. Thirty-five patients (1.8%) with operative mortality (defined by The Society of Thoracic Surgeons as in-hospital death or out-of-hospital death within 30 days of operation) were excluded. Three patients were excluded for missing intraoperative data. The remaining 1,915 patients comprised the study population. All data were prospectively entered into the database. The definitions of The Society of Thoracic Surgeons were used for all entries in the database.
Data analysis
Long-term patient survival data were secured from the United States Social Security Death Index database (http://ssdi.genealogy.rootsweb.com), which was queried in September 2001, using patient name and social security number combinations for all patients. This corresponds to minimum and maximum follow-up times of 39 months (December 1997 patients) and 81 months (July 1994 patients), respectively. Then the database of cardiac operations was updated for all deceased patients with the exact date of death. Then 5-year Kaplan-Meier survival plots were determined and compared for all study subgroups. Hazard functions depicting the rate of death per month for each of the groups were derived from the survival data. These functions are useful to identify the between-group variation in survival trends, and the most critical period determining postoperative survival [18].
Statistical methods
The effect of transfusion on survival was tested in two ways: (1) a two-level approach of transfusion (any) versus no transfusion, and (2) a four-level approach of transfusion (intraoperative only, postoperative only, or both intraoperative and postoperative) versus no transfusion. Thirty-two preoperative, intraoperative, and postoperative variables were analyzed. Univariate analysis for categorical variables was done with either 
2 statistic or Fischer’s exact test depending on applicability (Windows Version 8; SAS, Cary, NC). Continuous variables were analyzed using either the unpaired t-test or the nonparametric Mann-Whitney rank sum test depending on normality. A p value less than 0.05 was used to indicate significance.
Next, Cox proportional hazard models were used to explain the affect of explanatory variables (including transfusion) on survival times. Given the biphasic nature (Figs 1 and 2) of the survival, differentiating postoperative year 1 from the succeeding years, these Cox proportional hazard models were applied separately to (1) all patients and (2) only those patients surviving at least 1 year. In either case, model selection was first done with backward elimination, and variables significant at the p less than 0.05 level were retained in the model as independent predictors. The model was then confirmed using forward selection and stepwise selection. After confirming with the two-level approach that any transfusion was a highly significant risk factor for increased mortality, the Cox proportional hazard model was repeated using the four-level approach for the variables.
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Then the 1,092 patients matched by propensity scores were analyzed using the previously described Cox proportional hazard model with the two-level approach. The propensity score was forced to remain in the model.
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We found that transfused patients were older, smaller, and stayed longer in the hospital, and were more likely to be female and to have cerebrovascular disease, peripheral vascular disease, hypertension, higher Society of Thoracic Surgeons (STS) scores, New York Heart Association (NYHA) functional class IV symptoms, and intraaortic balloon pumps. Their operation was more commonly done on an emergency basis and required greater cardiopulmonary bypass time (Table 1). They also had twice the late mortality (15% vs 6%) of nontransfused patients. After correction for comorbidities and other factors, transfusion was still associated with a 70% increase in mortality (risk ratio, 1.7; 95% confidence interval, 1.4 to 2.0; p = 0.001). By multivariate analysis, older age, the presence of peripheral vascular disease (PVD), the presence of chronic obstructive pulmonary disease (COPD), a worse NYHA functional class status, and transfusion were significant predictors of late mortality (Table 2).
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After removing the 53 patients who died within 12 months of operation, and reanalyzing the remaining 1,862 patients, transfusion remained a significant predictor of death (risk ratio, 1.5; 95% confidence interval, 1.1 to 1.9; p = 0.04) from 1 to 5 years after operation. By multivariate analysis, older age, the presence of PVD or COPD, NYHA functional class IV status, and transfusion were significant predictors of late mortality (1 to 5 years) (Table 4).
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Comment |
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TopAbstractIntroductionMaterial and methodsResultsCommentAcknowledgmentsReferences |
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Transfusion with cardiac operations is not inevitable. Lowering the transfusion threshold had no effect on hospital morbidity or mortality [24]. High hematocrits (
34%) may even be harmful. Spiess and colleagues [25] found that patients with hematocrits 34% or greater on arrival to the intensive care unit after cardiac operation were more likely to suffer a myocardial infarction and cautioned against transfusion to an arbitrary value. Aprotinin decreased blood transfusion, surgical reexploration for bleeding, and perioperative mortality (odds ratio, 0.55; 95% confidence interval, 0.34 to 0.90) [26]. Using a thromboelastograph to guide coagulation [27], or using a smaller cardiopulmonary bypass circuit or prime volume decreased transfusions [28, 29].
We found that blood transfusion during or after cardiac operation is associated with an increased risk of death over the subsequent 5 years. Although we could not find any previous study that evaluated long-term transfusion risk after cardiac operation, several studies have found transfusion to have short-term deleterious effects after cardiac operation. It increases the risk of nosocomial pneumonia [7], sternal wound infections [6], severe sepsis [9], and renal dysfunction [8]. Utley and colleagues [30] found that transfusion explained the increased perioperative mortality in women. In addition the number of units of blood transfused intraoperatively or on the first postoperative day was a significant predictor of hospital mortality [10]. Using leukocyte-depleted blood for transfusion decreased 60-day mortality after cardiac operation [31]. Defoe and colleagues [32] found that patients who had a lower hematocrit during cardiopulmonary bypass were associated with a higher risk of in-hospital mortality. However they did not provide data on transfusion or try to separate the effect of transfusion versus anemia on in-hospital mortality. They also did not evaluate long-term mortality.
The effects of transfusion on survival after an oncologic operation is controversial, with some studies finding increased mortality in transfused patients [11–13] and others finding no difference in mortality [33, 34]. Similar conflicting data were reported by Corry and colleagues, [35] who found decreased survival in patients transfused before undergoing renal transplant, and Solheim and colleagues [36], who found no difference in survival among transfused and nontransfused renal transplant recipients. Both the beneficial effects of transfusion on renal graft survival and the deleterious effects on cancer patients have been attributed to suppression of immune function by an unknown factor in the transfusion. However, blood transfusion given to women during childbirth did not influence the development of malignant tumors, but there was a trend toward higher long-term mortality (22 to 32 years) in the transfused group (5.5 vs 4.2%) [37]. A population-based epidemiological study found that transfusion was an independent predictor of long-term mortality (10 years), with the increased risk being present from all three components of transfusion: packed red cells, fresh frozen plasma, and platelets [38]. Recently a randomized study examined hospital mortality in intensive care unit patients transfused to maintain higher hemoglobin endpoints and found that transfusion was associated with an increased risk of death [39].
The biphasic response we found (ie, a short-term large increase in mortality and then a sustained, long-term increase in mortality in the transfused patients), suggests two separate processes (Fig 1A, 1B). This short-term increase may be caused by the transfusions or the transfusions may be a marker for functionally sicker patients. For example, we may have been more likely to check hemoglobin levels and transfuse patients if they had more dyspnea on exertion from cardiopulmonary dysfunction. Therefore the increased short-term mortality would be caused by the cardiopulmonary dysfunction, and the transfusion would only indicate the marker of a sicker patient. However, with the increased long-term mortality, we find it difficult to hypothesize that transfusion acted as a marker of a sicker patient. In addition there was greater mortality in those patients who received transfusions Both intraoperatively and postoperatively compared with those who received transfusions only intraoperatively or postoperatively (Fig 2A, 2B). Although the number of units transfused was not available, the higher mortality in patients who received transfusions at both times may indicate a dose-dependent relationship.
A limitation of this study is its retrospective nature, which can only find associations and not show causality. Because criterion for transfusion was not established a priori and patients were not randomized to different thresholds for transfusion, transfusion may merely be a marker for sicker, more symptomatic patients. That is, given two patients with equally severe anemia (one symptomatic and transfused and one not symptomatic and therefore not transfused), the increased risk of mortality may be related to the cause of the symptoms, such as worse cardiopulmonary function or muscle deconditioning and not to the transfusion itself. Against this, we found that intraoperative transfusion is a risk factor for increased mortality. In our practice, blood is usually transfused intraoperatively based on hemoglobin levels and not on signs and symptoms.
Another limitation is that hemoglobin levels were not included in the study. Because we routinely do not check hemoglobin levels more than 24 hours postoperatively, but check it only as clinically indicated (eg, elevated sanguineous chest tube drainage, pallor, or dyspnea), including hemoglobin levels would have introduced a bias. Because virtually all patients who died in-hospital or within 30 days of operation received transfusions, we eliminated these patients from the study. Including them would have overestimated the risk of blood transfusions. A fourth limitation is that we examined all-cause mortality and were unable to determine the cause of death (cardiac or noncardiac). Although death certificates may have been helpful, they may be less than accurate in the absence of autopsies. A final limitation is that while the study was designed to look for and did find a difference in mortality between transfused and nontransfused patients, the study may have been underpowered for the four-group analysis.
In conclusion, we found that transfusing blood during or after cardiac operation is associated with an increased 5-year mortality.
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References |
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TopAbstractIntroductionMaterial and methodsResultsCommentAcknowledgmentsReferences |
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nberg J., Frisk B. Blood transfusion does not influence the development of malignant tumours. Eur J Surg 1999;165:528-534.[Medline]
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M. Ranucci, D. Conti, S. Castelvecchio, L. Menicanti, A. Frigiola, A. Ballotta, and G. Pelissero Hematocrit on Cardiopulmonary Bypass and Outcome After Coronary Surgery in Nontransfused Patients Ann. Thorac. Surg., January 1, 2010; 89(1): 11 - 17. [Abstract] [Full Text] [PDF]
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L. H. Edmunds Jr Managing Fibrinolysis Without Aprotinin Ann. Thorac. Surg., January 1, 2010; 89(1): 324 - 331. [Abstract] [Full Text] [PDF]
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A. H. M. van Straten, M. W. A. Bekker, M. A. Soliman Hamad, A. A. J. van Zundert, E. J. Martens, J. P. A. M. Schonberger, and A. M. de Wolf Transfusion of red blood cells: the impact on short-term and long-term survival after coronary artery bypass grafting, a ten-year follow-up Interact CardioVasc Thorac Surg, January 1, 2010; 10(1): 37 - 42. [Abstract] [Full Text] [PDF]
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S. Senay, F. Toraman, H. Karabulut, and C. Alhan Is it the patient or the physician who cannot tolerate anemia? A prospective analysis in 1854 non-transfused coronary artery surgery patients Perfusion, November 1, 2009; 24(6): 373 - 380. [Abstract] [PDF]
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M. C. Christensen, S. Krapf, A. Kempel, and C. von Heymann Costs of excessive postoperative hemorrhage in cardiac surgery J. Thorac. Cardiovasc. Surg., September 1, 2009; 138(3): 687 - 693. [Abstract] [Full Text] [PDF]
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 R. A. J. M. Huybregts, R. de Vroege, E. K. Jansen, A. W. van Schijndel, H. M. T. Christiaans, and W. van Oeveren The Association of Hemodilution and Transfusion of Red Blood Cells with Biochemical Markers of Splanchnic and Renal Injury During Cardiopulmonary Bypass Anesth. Analg., August 1, 2009; 109(2): 331 - 339. [Abstract] [Full Text] [PDF]
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 R. Gill, M. Herbertson, A. Vuylsteke, P. S. Olsen, C. von Heymann, M. Mythen, F. Sellke, F. Booth, and T. A. Schmidt Safety and Efficacy of Recombinant Activated Factor VII: A Randomized Placebo-Controlled Trial in the Setting of Bleeding After Cardiac Surgery Circulation, July 7, 2009; 120(1): 21 - 27. [Abstract] [Full Text] [PDF]
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M. Engoren, R. H. Habib, J. Hadaway, A. Zacharias, T. A. Schwann, C. J. Riordan, S. J. Durham, and A. Shah The Effect on Long-Term Survival of Erythrocyte Transfusion Given for Cardiac Valve Operations Ann. Thorac. Surg., July 1, 2009; 88(1): 95 - 100. [Abstract] [Full Text] [PDF]
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S. D. Surgenor, R. S. Kramer, E. M. Olmstead, C. S. Ross, F. W. Sellke, D. S. Likosky, C. A. S. Marrin, R. E. Helm Jr, B. J. Leavitt, J. R. Morton, et al. The Association of Perioperative Red Blood Cell Transfusions and Decreased Long-Term Survival After Cardiac Surgery Anesth. Analg., June 1, 2009; 108(6): 1741 - 1746. [Abstract] [Full Text] [PDF]
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G. S. Murphy, E. A. Hessel II, and R. C. Groom Optimal Perfusion During Cardiopulmonary Bypass: An Evidence-Based Approach Anesth. Analg., May 1, 2009; 108(5): 1394 - 1417. [Abstract] [Full Text] [PDF]
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 M. Engoren and C. Arslanian-Engoren Long-term Survival in the Intensive Care Unit After Erythrocyte Blood Transfusion Am. J. Crit. Care., March 1, 2009; 18(2): 124 - 131. [Abstract] [Full Text] [PDF]
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J. Brevig, J. McDonald, E. S. Zelinka, T. Gallagher, R. Jin, and G. L. Grunkemeier Blood Transfusion Reduction in Cardiac Surgery: Multidisciplinary Approach at a Community Hospital Ann. Thorac. Surg., February 1, 2009; 87(2): 532 - 539. [Abstract] [Full Text] [PDF]
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R Rimpilainen, F Biancari, J. Wistbacka, P Loponen, S. Koivisto, J Rimpilainen, K Teittinen, and J Nissinen Outcome after coronary artery bypass surgery with miniaturized versus conventional cardiopulmonary bypass Perfusion, November 1, 2008; 23(6): 361 - 367. [Abstract] [PDF]
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G. M. T. Hare, A. K. Y. Tsui, A. T. McLaren, T. E. Ragoonanan, J. Yu, and C. D. Mazer Anemia and Cerebral Outcomes: Many Questions, Fewer Answers Anesth. Analg., October 1, 2008; 107(4): 1356 - 1370. [Abstract] [Full Text] [PDF]
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G. Lindvall, U. Sartipy, T. Ivert, and J. van der Linden Aprotinin is Not Associated With Postoperative Renal Impairment After Primary Coronary Surgery Ann. Thorac. Surg., July 1, 2008; 86(1): 13 - 19. [Abstract] [Full Text] [PDF]
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J. Dunning, J. R.L. Waller, B. Smith, S. Pitts, S. W.H. Kendall, and K. Khan Coronary Artery Bypass Grafting is Associated With Excellent Long-Term Survival and Quality of Life: A Prospective Cohort Study Ann. Thorac. Surg., June 1, 2008; 85(6): 1988 - 1993. [Abstract] [Full Text] [PDF]
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L. J. Bowman, W. E. Uber, M. R. Stroud, L. R. Christiansen, J. Lazarchick, A. J. Crumbley III, J. M. Kratz, J. M. Toole, F. A. Crawford Jr, and J. S. Ikonomidis Use of Recombinant Activated Factor VII Concentrate to Control Postoperative Hemorrhage in Complex Cardiovascular Surgery Ann. Thorac. Surg., May 1, 2008; 85(5): 1669 - 1677. [Abstract] [Full Text] [PDF]
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S. Dunkley, L. Phillips, P. McCall, J. Brereton, R. Lindeman, G. Jankelowitz, and P. Cameron Recombinant Activated Factor VII in Cardiac Surgery: Experience From the Australian and New Zealand Haemostasis Registry Ann. Thorac. Surg., March 1, 2008; 85(3): 836 - 844. [Abstract] [Full Text] [PDF]
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D. Pagano, N. J. Howell, N. Freemantle, D. Cunningham, R. S. Bonser, T. R. Graham, J. Mascaro, S. J. Rooney, I. C. Wilson, R. Cramb, et al. Bleeding in cardiac surgery: The use of aprotinin does not affect survival J. Thorac. Cardiovasc. Surg., March 1, 2008; 135(3): 495 - 502. [Abstract] [Full Text] [PDF]
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A. Rigamonti, A. T. McLaren, C. D. Mazer, K. Nix, T. Ragoonanan, J. Freedman, A. Harrington, and G. M. T. Hare Storage of strain-specific rat blood limits cerebral tissue oxygen delivery during acute fluid resuscitation Br. J. Anaesth., March 1, 2008; 100(3): 357 - 364. [Abstract] [Full Text] [PDF]
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J.F. M. Bechtel, C. Detter, T. Fischlein, T. Krabatsch, B. R. Osswald, F.-C. Riess, F. Scholz, M. Schonburg, C. Stamm, H.-H. Sievers, et al. Cardiac Surgery in Patients on Dialysis: Decreased 30-Day Mortality, Unchanged Overall Survival Ann. Thorac. Surg., January 1, 2008; 85(1): 147 - 153. [Abstract] [Full Text] [PDF]
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 Z. I. Khalpey, R. B. Ganim, and J. D. Rawn Postoperative Care of Cardiac Surgery Patients , January 1, 2008; 3(2008): 465 - 486. [Full Text]
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F. E. Ralley Programmatic Blood Conservation in Cardiac Surgery Seminars in Cardiothoracic and Vascular Anesthesia, December 1, 2007; 11(4): 242 - 246. [Abstract] [PDF]
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A. F. Merry Focus on Thrombin: Alternative Anticoagulants Seminars in Cardiothoracic and Vascular Anesthesia, December 1, 2007; 11(4): 256 - 260. [Abstract] [PDF]
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J. D. Rawn Blood Transfusion in Cardiac Surgery: A Silent Epidemic Revisited Circulation, November 27, 2007; 116(22): 2523 - 2524. [Full Text] [PDF]
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P. J. Van der Linden, J.-F. Hardy, A. Daper, A. Trenchant, and S. G. De Hert Cardiac surgery with cardiopulmonary bypass: does aprotinin affect outcome? Br. J. Anaesth., November 1, 2007; 99(5): 646 - 652. [Abstract] [Full Text] [PDF]
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K. Charette, Y. Hirata, A. Bograd, L. Mongero, J. Chen, J. Quaegebeur, and R. Mosca 180 ml and less: Cardiopulmonary bypass techniques to minimize hemodilution for neonates and small infants Perfusion, September 1, 2007; 22(5): 327 - 331. [Abstract] [PDF]
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T. J. Gardner To Transfuse or Not to Transfuse Circulation, July 31, 2007; 116(5): 458 - 460. [Full Text] [PDF]
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M. Perthel, L. El-Ayoubi, A. Bendisch, J. Laas, and M. Gerigk Clinical advantages of using mini-bypass systems in terms of blood product use, postoperative bleeding and air entrainment: an in vivo clinical perspective Eur J Cardiothorac Surg, June 1, 2007; 31(6): 1070 - 1075. [Abstract] [Full Text] [PDF]
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The Society of Thoracic Surgeons Blood Conservatio, V. A. Ferraris, S. P. Ferraris, S. P. Saha, E. A. Hessel II, C. K. Haan, B. D. Royston, C. R. Bridges, R. S.D. Higgins, G. Despotis, et al. Perioperative Blood Transfusion and Blood Conservation in Cardiac Surgery: The Society of Thoracic Surgeons and The Society of Cardiovascular Anesthesiologists Clinical Practice Guideline Ann. Thorac. Surg., May 1, 2007; 83(5_Supplement): S27 - S86. [Abstract] [Full Text] [PDF]
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S. Gould, M. J. Cimino, and D. R. Gerber Packed Red Blood Cell Transfusion in the Intensive Care Unit: Limitations and Consequences Am. J. Crit. Care., January 1, 2007; 16(1): 39 - 48. [Abstract] [Full Text] [PDF]
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M. Perthel, A. Klingbeil, L. El-Ayoubi, M. Gerick, and J. Laas Reduction in blood product usage associated with routine use of mini bypass systems in extracorporeal circulation Perfusion, January 1, 2007; 22(1): 9 - 14. [Abstract] [PDF]
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G. J. Murphy and G. D. Angelini Indications for Blood Transfusion in Cardiac Surgery Ann. Thorac. Surg., December 1, 2006; 82(6): 2323 - 2334. [Abstract] [Full Text] [PDF]
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G. J. Murphy, E. Mango, V. Lucchetti, F. Battaglia, D. Catapano, C. A. Rogers, and G. D. Angelini A randomized trial of tranexamic acid in combination with cell salvage plus a meta-analysis of randomized trials evaluating tranexamic acid in off-pump coronary artery bypass grafting. J. Thorac. Cardiovasc. Surg., September 1, 2006; 132(3): 475 - 480.e8. [Abstract] [Full Text] [PDF]
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K. G. Shann, D. S. Likosky, J. M. Murkin, R. A. Baker, Y. R. Baribeau, G. R. DeFoe, T. A. Dickinson, T. J. Gardner, H. P. Grocott, G. T. O'Connor, et al. An evidence-based review of the practice of cardiopulmonary bypass in adults: A focus on neurologic injury, glycemic control, hemodilution, and the inflammatory response. J. Thorac. Cardiovasc. Surg., August 1, 2006; 132(2): 283 - 290.e3. [Full Text] [PDF]
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C. G. Koch, F. Khandwala, L. Li, F. G. Estafanous, F. D. Loop, and E. H. Blackstone Persistent Effect of Red Cell Transfusion on Health-Related Quality of Life After Cardiac Surgery Ann. Thorac. Surg., July 1, 2006; 82(1): 13 - 20. [Abstract] [Full Text] [PDF]
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A. DeAnda Jr, K. M. Baker, S. D. Roseff, J. A. Green, H. Mccarthy, T. Aron, and B. D. Spiess Developing a Blood Conservation Program in Cardiac Surgery American Journal of Medical Quality, July 1, 2006; 21(4): 230 - 237. [Abstract] [PDF]
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T. Jones and M. Elliott Paediatric CPB: Bypass in a High Risk Group Perfusion, July 1, 2006; 21(4): 229 - 233. [Abstract] [PDF]
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C. G. Koch, L. Li, A. I. Duncan, T. Mihaljevic, F. D. Loop, N. J. Starr, and E. H. Blackstone Transfusion in Coronary Artery Bypass Grafting is Associated with Reduced Long-Term Survival. Ann. Thorac. Surg., May 1, 2006; 81(5): 1650 - 1657. [Abstract] [Full Text] [PDF]
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E. I. Kapetanakis, D. A. Medlam, K. R. Petro, E. Haile, P. C. Hill, M. K.C. Dullum, A. S. Bafi, S. W. Boyce, and P. J. Corso Effect of Clopidogrel Premedication in Off-Pump Cardiac Surgery: Are We Forfeiting the Benefits of Reduced Hemorrhagic Sequelae? Circulation, April 4, 2006; 113(13): 1667 - 1674. [Abstract] [Full Text] [PDF]
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 S Purkayastha, T Athanasiou, V Malinovski, P Tekkis, R Foale, R Casula, B Glenville, and A Darzi Does clopidogrel affect outcome after coronary artery bypass grafting? A meta-analysis. Heart, April 1, 2006; 92(4): 531 - 532. [Full Text] [PDF]
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L. T. Goodnough, A. Shander, J. L. Spivak, J. H. Waters, A. J. Friedman, J. L. Carson, E. M. Keating, T. Maddox, and R. Spence Detection, Evaluation, and Management of Anemia in the Elective Surgical Patient Anesth. Analg., December 1, 2005; 101(6): 1858 - 1861. [Abstract] [Full Text] [PDF]
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P. Diprose, M. J. Herbertson, D. O'Shaughnessy, and R. S. Gill Activated recombinant factor VII after cardiopulmonary bypass reduces allogeneic transfusion in complex non-coronary cardiac surgery: randomized double-blind placebo-controlled pilot study Br. J. Anaesth., November 1, 2005; 95(5): 596 - 602. [Abstract] [Full Text] [PDF]
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R. H. Habib, A. Zacharias, T. A. Schwann, and C. J. Riordan The independent effects of cardiopulmonary bypass hemodilutional anemia and transfusions on CABG outcomes Eur J Cardiothorac Surg, September 1, 2005; 28(3): 512 - 513. [Full Text] [PDF]
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M. Kuduvalli, A. D. Grayson, M. J. Desmond, and B. M. Fabri Reply to Habib et al. Eur J Cardiothorac Surg, September 1, 2005; 28(3): 513 - 514. [Full Text] [PDF]
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