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Ann Thorac Surg 2007;83:2260
© 2007 The Society of Thoracic Surgeons

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Correspondence

Blood Transfusion After Cardiac Surgery: Damned if You Don’t. Damned if You Do?

Lancashire Cardiac Centre, Blackpool Victoria Hospital, Whinney Heys Rd, Blackpool, Lancashire, FY3 8NR England

(Email: mr.zacharias{at}bfwhospitals.nhs.uk).

To the Editor:

We would like to thank the authors in attempting to once again draw our attention to the important aspect of blood conservation in cardiac surgery [1]. We have also read with interest the previous article from the same authors suggesting a reduction in morbidity and mortality [2] in patients transfused with blood after coronary surgery.

We agree with the authors that blood transfusion must be avoided in all patients, if at all possible, but we believe that this article may spur some to consider withholding a blood transfusion to the needy in trying to maximize the perceived long-term benefits of blood avoidance. We believe that patients who postoperatively drop their hematocrit will benefit from blood, and it should be used when it is believed to be justified. The difficulty lies in patients who need a blood transfusion. Ethically we are not in a position to randomize that group to either have blood or not have it, as that would really be the best way to assess the true impact that blood transfusion has on mortality, or for that matter eventual quality of life. Hence observational studies like this will be all we have to make us aware of the potential impact that blood transfusion could have on survival and quality of life.

The authors have tried to make the best possible case despite starting with two completely different groups (on Duke University Status Index scoring preoperatively) in which the impact on quality of life is purely related to blood transfusion. For unexplained reasons, previous publications have already shown that by nature it seems that females do not to have as good an improvement on Duke University Status Index scoring after cardiac surgery [3]. Of course, smaller body surface area, lower hematocrit, and higher age at surgery in the transfused group compared with the nontransfused group makes the conclusion even more difficult to accept. The statement that usage of internal thoracic artery grafts are associated with better postoperative functional recovery suggests that even though all things may appear equal on the database, more patients are probably selected by the surgeon for a reason to have internal thoracic artery grafts compared with saphenous vein grafts, and this may have had an impact borne out in the long term.

We have no doubt that the statistical rigor the authors will have applied to correct the many unequal variables in the two groups, but we wonder if there were any unknown variables that may not have been corrected, which could have affected the outcomes. One such variable could be the lack of the usage of leukocyte-depleted blood. The authors did not mention the type of blood used during the period of the study from 1995 to 1999. Did all blood transfusions have leukocyte depletion as a standard? If not, was there a difference between the groups? There is some evidence that leukocyte-depleted blood in itself may have a beneficial short-term impact in comparison with nonleukocyte-depleted blood after cardiac surgery [4], although no long-term outcomes have been published to date. If all patients had nonleukocyte-depleted blood, could these findings be influenced by this specific factor?

Despite these reservations regarding the conclusions reached by the authors, we continue to strive to maintain as low a transfusion rate as possible. However, it is interesting to read that in the laboratory setting older mice exposed to blood from younger mice derive a protective benefit on its long-term survival [5], although this hypothesis is far from being tested to transfer from the bench to the bedside.

	References

Top References

 

1. Koch CG, Khandwala F, Li L, Estafanous FG, Loop FD, Blackstone EH. Persistent effect of red cell transfusion on health-related quality of life after cardiac surgery Ann Thorac Surg 2006;82:13-20.[Abstract/Free Full Text]
2. Koch CG, Li L, Duncan AI, Mihaljevic T, et al. Morbidity and mortality risk associated with red blood cell and blood-component transfusion in isolated coronary artery bypass grafting Crit Care Med 2006;34:1608-1616.[Medline]
3. Phillips Bute B, Mathew J, Blumenthal JA, et al. Female gender is associated with impaired quality of life 1 year after coronary artery bypass surgery Psychosom Med 2003;65:944-951.[Abstract/Free Full Text]
4. Bilgin YM, van de Watering LM, Eijsman L, et al. Double-blind, randomized controlled trial on the effect of leukocyte-depleted erythrocyte transfusions in cardiac valve surgery Circulation 2004;109:2755-2760.[Abstract/Free Full Text]
5. Conboy IM, Conboy MJ, Wagers AJ, Girma ER, Weissman IL, Rando TA. Rejuvenation of aged progenitor cells by exposure to a young systemic environment Nature 2005;433:760-764.[Medline]

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				C. G. Koch and E. H. Blackstone Reply Ann. Thorac. Surg., June 1, 2007; 83(6): 2260 - 2261. [Full Text] [PDF]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Joseph Zacharias Daniel Lerman Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Zacharias, J. Articles by Knowles, A. Search for Related Content PubMed PubMed Citation Articles by Zacharias, J. Articles by Knowles, A. Related Collections Cardiac - other Related Article