2026 AHA科学声明：心脏外科手术围术期贫血和患者血液管理
Figure. Anemia in cardiac surgery.
Overview of perioperative anemia prevalence, association with postoperative outcomes, and risk mitigation strategies. ANH indicates acute normovolemic hemodilution; $B_{12}$, vitamin $B_{12}$; Epo, erythropoietin; Hb, hemoglobin; IV, intravenous; MUF, modified ultrafiltration; PO, per os (oral); POC, point of care; and RAP, retrograde autologous priming.
on nadir hemoglobin is present in up to 90% of patients undergoing elective cardiac surgery with cardiopulmonary bypass (CPB),$^{9}$ and often leads to red blood cell (RBC) transfusions. Intraoperative RBC transfusion, in addition to anemia, is also independently associated with morbidity and mortality after cardiac surgery.$^{13,14,16,17}$ Thus, preoperative identification and treatment of anemia is imperative to mitigate anemia as a risk factor and minimize the need for RBC transfusions.
Per Harle and Chong,$^{18}$ "That unnecessary blood transfusion is risky is beyond question...The crucial question
and the holy grail of this field of research would be to identify the actual trigger at which transfusion becomes beneficial to each individual patient." Adequate hemoglobin concentration is required for optimal oxygen delivery to maintain normal cellular metabolism, and platelets and plasmatic coagulation factors are necessary for adequate hemostasis. However, the goal is to maintain these functions while minimizing the need for RBC transfusions. Despite published clinical guidelines for patient blood management, treatment protocols$^{1,6}$ and practices vary widely among clinicians and institutions, and there
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are additional considerations regarding what treatment options are available for patients undergoing emergent surgery or who are hemodynamically unstable.$^{15}$ Multi-disciplinary preoperative patient assessment, pharmacologic treatments, and intraoperative blood conservation strategies must work harmoniously to minimize the risk of anemia and transfusion for each patient. This scientific statement reviews the established evidence and identifies areas where further research is needed to minimize the impact of preoperative anemia, intraoperative blood loss, and hemodilution on cardiac surgery outcomes.
# PREOPERATIVE ASSESSMENT: ANEMIA AND IRON DEFICIENCY
# Anemia and Iron Deficiency Risk Assessment
The World Health Organization defines anemia as hemoglobin <13 g/dL in men and <12 g/dL in women.$^{19}$ Both the British Society of Haematology $^{20}$ guidelines on identification and management of preoperative anemia in adults and the International Consensus Conference on Anemia Management in Surgical Patients $^{3}$ recommend considering hemoglobin <13 g/dL, regardless of sex, the threshold for which preoperative patients are likely to benefit from screening for iron and other nutrient deficiencies. Despite the prevalence of preoperative iron-deficiency anemia in cardiac surgery and the simplicity of its diagnosis and treatment, it often remains untreated. Given that anemia and RBC transfusions contribute to poor outcomes, timely diagnosis is essential for initiating preoperative treatment.
Iron deficiency itself, irrespective of concomitant anemia, is a predictor of adverse outcomes. Therefore, obtaining a hemoglobin level alone is inadequate, given that 20% to 50% of cardiac surgery patients have iron deficiency but are not anemic.$^{21}$ On a cellular level, the manifestations of iron deficiency are seen even in the absence of anemia. Systemic iron deficiency and hence myocardial iron deficiency results in myocardial oxidative stress and pathologic remodeling that manifests as left ventricular dilation and heart failure (HF).$^{22}$ This was initially reported in a meta-analysis including 3373 patients with HF in whom correction of iron deficiency, with or without anemia, reduced the composite outcomes of recurrent hospitalization and cardiovascular death by a rate ratio of 0.75 (CI, 0.61–0.93; P<0.01).$^{23}$ The adverse effects of iron deficiency have been found in patients undergoing cardiac surgery as well. A prospective analysis of 730 cardiac surgery patients found that preoperative iron deficiency was independently associated with increased adverse cardiac events, prolonged hospital stay, and mortality (odds ratio, 3.5 [95% CI, 1.5–8.4]; P=0.004).$^{24}$ To further compound this risk, after cardiac surgery, iron stores become further depleted, exacerbating any preexisting deficiency.$^{25}$
Despite the relationship between iron deficiency and poor surgical outcomes, routine screening for iron deficiency in nonanemic cardiac surgery patients is not common practice, whereas such screening is routine in patients with HF.$^{26}$ Iron deficiency screening is recommended in the European Society of Cardiology guidelines for all patients with HF, regardless of anemia status. Intravenous iron therapy is recommended by the European Society of Cardiology (Class I) and the American Heart Association (Class IIa) to improve functional status.$^{27,28}$ Guidelines for patients undergoing cardiac surgery have not been updated to include routine preoperative iron screening, but a recent modified RAND Delphi study found that a multidisciplinary panel of experts in cardiovascular surgery, cardiac anesthesia, cardiology, critical care medicine, hematology, and patient blood management recommend that all cardiac surgery patients should be screened for iron deficiency, whether or not anemia is present.$^{21}$ This screening should be performed within a preoperative time interval that would allow for adequate treatment with intravenous iron.$^{21}$ Although specific cost-effectiveness analyses for this intervention have not been published, this approach is likely cost-effective, as patients already present for preoperative evaluation and the costs of laboratory testing and iron therapy are relatively low.$^{26}$
In an effort to capture all patients with iron deficiency, with anemia or without, routine preoperative testing should include serum ferritin, transferrin saturation, and C-reactive protein, in addition to a complete blood count. A serum ferritin level <30 µg/L indicates iron deficiency; levels from 30 to 100 µg/L could indicate functional iron deficiency if combined with anemia of inflammation (chronic disease), indicated by elevated CRP (C-reactive protein).$^{21}$ In the presence of comorbidities such as HF, however, the guidelines are more liberal. A ferritin level <300 µg/L in the setting of transferrin saturation <20% would indicate functional iron deficiency and warrant treatment.$^{29,30}$ If testing for iron deficiency is nondiagnostic, further testing can be considered to determine the cause of anemia before surgery (Table 1).
In addition to iron, deficiencies of other nutrients should be considered and evaluated. Although less common, deficiencies of vitamin B₁₂ and folate result in a macrocytotic anemia; however, the mean corpuscular volume may be in the normal range when presenting along with iron deficiency. These deficiencies have not been studied specifically in patients undergoing cardiac surgery, but vitamin B₁₂ and folate deficiency are more commonly observed in elderly, malnourished, or chronically ill individuals, or those with malabsorption after gastric surgery.$^{34}$ Vitamin B₁₂ deficiency can be treated with intramuscular injection or orally, and folate deficiency is easily corrected with oral supplementation. Correction of these deficiencies before surgery is important: untreated B₁₂ or folate deficiency may
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Table 1. Preoperative Tests
|Tests|Diagnostic threshold|Notes| |---|---|---| |Hemoglobin (CBC)|<13 g/dL for both sexes|Screening threshold for further preoperative anemia $evaluation^{3,20}$| |Ferritin|<30 µg/L|Suggests absolute iron deficiency; in inflammatory states, ferritin may be normal or $high^{20}$| |Transferrin saturation|<20%|Indicates iron-restricted erythropoiesis and is robust across settings, including heart $failure^{29}$| |CRP|>10 mg/L|Elevated CRP levels support functional iron deficiency when ferritin is $equiv^{20}$| |RET-He/CHr|<29-30 pg|Low RET-He/CHr suggests iron-restricted erythropoiesis and may detect deficiency earlier than Hb $change^{31}$| |Vitamin $B_{12}$|<200 pg/mL (borderline 200-300 pg/mL)|Confirm with methylmalonic acid if $indeterminate^{32}$| |Folate|<2 ng/mL|Serum folate preferred; 2-4 ng/mL is borderline and may require additional $testing^{33}$|
CBC indicates complete blood count; CRP, C-reactive protein; Hb, hemoglobin; and RET-He/CHr, reticulocyte hemoglobin equivalent/reticulocyte hemoglobin content.
contribute to impaired erythropoiesis and suboptimal response to iron supplementation or erythropoiesis-stimulating agents.$^{20,35}$
Preoperative Therapy Options for Iron Deficiency in Cardiac Surgery
Iron infusions are often preferred over oral preparations due to preoperative time constraints. Patients may be diagnosed with anemia or iron deficiency only days before surgery. Intravenous iron increases iron levels more rapidly and reliably than oral formulations and is generally better tolerated. A sucrosomial-bound oral iron formulation shows promise for more rapid iron repletion than standard oral treatments and may represent an alternative to traditional enteral iron formulations.$^{36}$ Studies have demonstrated that even a single iron infusion has the potential to significantly affect iron stores.$^{37}$ The selection of which intravenous iron formulation to use often depends on surgical timing, hospital formulary, patient convenience, and health insurance coverage (Table 2). An increase in hemoglobin level may not be documented before surgery, but erythropoiesis begins immediately and will continue throughout the perioperative period.
Hemoglobin levels will typically rise within 1 to 2 weeks, with a noticeable increase observed 2 to 4 weeks after infusions begin, with most patients seeing an increase of 1 to 2 g/dL.$^{38}$ However, response times may vary depending upon the severity of the anemia and confounding factors affecting RBC production, such as
chronic kidney disease or inflammation. Full response time to intravenous iron repletion can take up to 6 to 8 weeks; therefore, reassessment should follow that time-frame.$^{38}$ Reassessing before cardiac surgery is crucial to ensure sufficient response to the treatment and adequate oxygen-carrying capacity during and after surgery. Repeat hemoglobin levels 1 to 2 weeks after initial treatment is reasonable to understand early response trends.
When preoperative anemia with iron deficiency is not treated early, an ultrashort treatment interval may be effective. In a single-center, randomized, double-blind, parallel-group controlled study of 1006 patients with anemia undergoing elective cardiac surgery, treatment with iron, vitamin B₁₂, folate, and erythropoetic agents with an ultrashort interval was effective in reducing transfusion requirements by a median of 1 unit in the treatment group compared with the placebo group.$^{37}$ Iron administration on or close to the date of surgery, and postoperative iron replacement when indicated, can be administered to achieve improved erythropoesis and enhanced postoperative functional capacity.$^{39}$
Enhanced Recovery After Surgery is an evidence-based perioperative care model that relies upon a multidisciplinary team to enact the components of care that minimize stress and expedite recovery. Anemia management is a key component of Enhanced Recovery After Surgery protocols for cardiac surgery.$^{40}$ Optimizing hemoglobin levels and addressing anemia perioperatively can improve patient outcomes by restoring iron levels and reducing the need for RBC transfusions. Involving
Table 2. Intravenous Iron Formulations
|Iron formulations|Dose, mg|Infusions, n|Considerations| |---|---|---|---| |Iron sucrose|200|5|Undiluted slow IV injection over 2-5 min on 5 different days over a 14-d period| |Iron dextran|1000|1|Requires a test dose; infusion over ≥1 h| |Ferric gluconate|125|8|Requires multiple doses, affecting time to surgery| |Ferumoxytol|510|2|Two doses, 3-8 d apart| |Ferric derisomaltose|1000|1|For patients <50 kg, dosing is 20 mg/kg actual body weight; short infusion time| |Ferric carboxymaltose|750|1-3|Two doses 7 d apart; short infusion time; for patients <50 kg, dosing is 15 mg/kg body weight|
IV indicates intravenous.
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patients in decision-making regarding options and educating patients about the role of anemia management is vital. Coordination of a multidisciplinary approach to anemia and iron deficiency among the care team is essential. Enhanced Recovery After Surgery in cardiac surgery has been successfully practiced in patients of different comorbidity status and in the elderly.$^{41}$ By addressing anemia comprehensively and incorporating evidence-based practices into Enhanced Recovery After Surgery protocols, the perioperative outcomes and recovery trajectories of cardiac surgery patients may be greatly improved.
INTRAOPERATIVE MAINTENANCE OF HEMOGLOBIN AND IRON STORES
A large body of evidence links both anemia and RBC transfusion with short- and long-term morbidity and mortality after cardiac surgery.$^{26,42,43}$ Preoperative anemia, which may result in low hematocrit on bypass (nadir hemoglobin), is widely reported to have an adverse effect on outcomes after cardiac surgery, including increased mortality, renal dysfunction, myocardial injury, and hospital length of stay. However, as previously mentioned, RBC transfusion is also associated with increased postoperative complications, and several studies have indicated that intraoperative RBC transfusion is associated with higher risk of postoperative renal failure, stroke, and mortality when compared with anemia alone.$^{44-46}$ Current guidelines recommend restrictive transfusion strategies (hemoglobin ≤7.5 g/dL) over liberal strategies (hemoglobin ≤9.0–9.5 g/dL) if the clinical condition of the patient allows for perioperative blood conservation.$^{5-785}$ During CPB, transfusion may be considered when the hematocrit is reduced (18%–24%) to ensure adequate tissue oxygenation as supported by oxygen delivery or cerebral tissue oxygen saturation monitoring. In addition to preoperative hemoglobin and iron optimization, multiple guidelines and expert consensus statements have highlighted the importance of a structured multidisciplinary approach to intraoperative blood conservation. These recommendations include preoperative discontinuation and reversal of antiplatelet and anticoagulant medications, guided by pharmacodynamics and case urgency; decreasing hemodilution associated with CPB and following physiologic goal-directed transfusion strategies while on pump CPB; autologous whole blood transfusion to reduce transfusion and postoperative bleeding; meticulous surgical technique that minimizes tissue dissection and blood loss; perioperative administration of antifibrinolytic medications to mitigate hyperfibrinolysis and coagulopathy; and protocols guiding postoperative RBC transfusions in the operating room and intensive care unit.$^{26,42}$ This comprehensive approach includes previously highlighted methods for preoperative risk stratification as well as optimization and recognition that each
intervention or practice change may result in cumulative incremental benefit.
Surgical, Pharmacologic, and Technologic
Blood-Sparing Strategies
Surgical strategies that have been associated with improved bleeding outcomes include judicious utilization of minimally invasive approaches at centers with appropriate expertise,$^{26}$ the use of point of care (preferably viscoelastic) hemostasis assays,$^{6,35}$ incorporation of a surgical bleeding checklist at the time of closure,$^{47,48}$ and prompt reoperation for bleeding guided by formal postoperative bleeding criteria.$^{49,50}$ In addition, some consideration should be given to the use of topical hemostatic agents, although the literature is limited by inconsistencies in existing data.$^{51,52}$
Guidelines for the conduct of CPB support using acute normovolemic hemodilution,$^{5-735}$ using autologous pump priming (antegrade or retrograde), minimizing prime volume and circuit surface area, increasing circuit biocompatibility, and using modified ultrafiltration (ultrafiltration performed after CPB, and before decannulation).$^{5-735}$ In contrast, conventional ultrafiltration (performed during CPB) is not an evidence-based recommendation. Acute normovolemic hemodilution is used in cardiac surgery and included in patient blood management guidelines.$^{5-7}$ This technique may result in a low degree of hemodilutional anemia, but its simplicity and low cost, and the fact that the patient is transfused with autologous whole blood after CPB, have contributed to its wide practice. This was initially supported by a 2017 meta-analysis of 29 randomized trials that showed a reduction in RBC transfusions and blood loss with acute normovolemic hemodilution.$^{753}$ However, a recent large, multinational, single-blind trial in 2010 patients undergoing cardiac surgery reported no difference in allogenic RBC transfusions in patients randomized to acute normovolemic hemodilution compared with standard of care.$^{54}$ These differing results highlight the fact that patient blood management strategies need to be individualized for each patient and include a multifactorial approach to reducing the need for RBC transfusion, and that a single intervention is not likely to show significant differences. Additional robust research with randomized controlled trials is important to evaluate the efficacy of individual components and combinations of patient blood management strategies.
Cell salvage is strongly recommended to reduce peri-operative anemia and postoperative allogeneic RBC transfusions.$^{26,42,55}$ When possible, the use of minimally invasive extracorporeal circulation is recommended.$^{6,26}$ Additional recommendations include avoidance of post-CPB hypothermia and the confirmation of post-CPB complete neutralization of heparin. These techniques are not used concomitantly but should be evaluated
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individually as part of a comprehensive bleeding management strategy. When implemented with or without a comprehensive restrictive blood transfusion protocol, autologous priming is associated with significant reductions in transfusion.$^{56-58}$
Prophylactic administration of antifibrinolytic medication remains a mainstay; prohemostatic coagulation factor concentrates are being offered as effective alternatives to allogeneic blood products, as a part of point-of-care viscoelastic-based transfusion algorithms.$^{26,42,55}$ A recent multicenter, unblinded, randomized, noninferiority controlled trial compared hemostatic effectiveness between 4-factor prothrombin complex concentrate and frozen plasma in 538 patients undergoing cardiac surgery with coagulopathic bleeding.$^{59}$ In this trial, 4-factor prothrombin complex concentrate was found to have better hemostatic effectiveness with fewer RBC transfusions and adverse events, including a lower incidence of postoperative acute kidney injury, compared with frozen plasma. Prohemostatic agents carry some risk of complications due to excessive coagulation (for example, clotting of fresh coronary bypass grafts), and should be used predominantly when there is clarity about control of surgical bleeding.$^{60}$
Alloimmunization Risk
Among cardiac surgery patients, perioperative allogeneic blood transfusion is associated with increased rates of alloimmunization to HLAs (human leukocyte antigens).$^{61}$ Although the adoption of prestorage leukocyte reduction has reduced these rates,$^{62}$ ≈5% to 15% of previously unsensitized patients still develop new anti-HLA antibodies after transfusion during cardiac surgery.$^{63-65}$ HLA all-immunization has important downstream consequences, including platelet transfusion refractoriness and difficulty identifying compatible donors for organ transplantation, which can lead to prolonged wait times and an increased risk of antibody-mediated allograft rejection.$^{66}$ Preoperative anemia optimization to minimize transfusion exposure, along with restrictive thresholds and blood-sparing strategies, are key practices to reduce HLA alloimmunization risk in cardiac surgery, particularly for patients with potential future transplant candidacy.
Bloodless Cardiac Surgery
Bloodless cardiac surgery provides important insights into hemoglobin maintenance in the unique situation of transfusion impermissibility. Much of the data on this topic come from analyses exploring outcomes in Jehovah's Witnesses (JW).$^{67,68}$ JWs do not accept blood components derived from “major fractions,” which includes RBCs, white blood cells, platelets, and plasma.$^{69}$ The literature suggests comparable post-cardiac surgery mortality and morbidity when comparing JWs with populations of
patients who accept blood products.$^{70-77}$ A retrospective review and meta-analysis of 10 studies including 2302 patients (950 JWs and 1352 controls) demonstrated no significant differences in short-term mortality, myocardial infarction rates, or reexploration for bleeding between JWs and controls.$^{73}$ However, a retrospective review of 137 JWs who underwent complex cardiovascular surgery revealed that preoperative hemoglobin levels ≥12 g/dL were crucial for reducing adverse events. Mortality was significantly lower in the optimized group (2.2%) compared with the unoptimized group (15.9%), as were major adverse outcomes (22.6% versus 50%), highlighting the importance of preoperative anemia management in this patient population.$^{74}$
Reports of successful bloodless cardiac surgery programs for JWs highlight several concepts in patient blood management and hemoglobin maintenance that may be extended to other patient populations. Key preoperative practices include early involvement of a multidisciplinary bloodless surgery team, careful consideration for preoperative enhancement of iron and hemoglobin stores using iron supplementation, erythropoietin-stimulating agents, consideration for hyperbaric oxygen therapy (if anemia is severe), and thoughtful planning of invasive preoperative testing and blood draws to limit bleeding exposure and hospital-acquired anemia.$^{75}$ Preoperative optimization should be focused on early identification and treatment of anemia with the target hemoglobin concentration calculated on the basis of the patient's circulating blood volume and anticipated surgical blood loss.$^{76}$ Potential nutritional deficiencies, including of iron, folate, and vitamin B₁$^{2}$, should be assessed and corrected.$^{77}$ Sources of occult bleeding should be ruled out and the presence of chronic kidney disease investigated. A thorough bleeding history should be performed and medication lists reviewed for any drugs or supplements that could impair hemostasis.
In addition to previously highlighted surgical and perfusion practices for blood conservation, the liberal use of topical hemostatic agents, and optimization of perfusion interventions to limit hemodilution, it is important to recognize that some procedures and blood products (eg, cell salvage, cryoprecipitate), may be acceptable to an individual JW.$^{70,75}$ It is therefore important to conduct a thorough individual patient discussion, carefully documented using a structured worksheet, regarding consent or refusal of each blood product or procedure.$^{75}$
Bloodless medicine and surgery practices support the concepts of patient autonomy and shared clinical decision-making and have been safely applied to medical and surgical patients.$^{78}$ Nevertheless, the risk of life-threatening bleeding without access to blood product transfusions remains substantial, particularly during cardiac surgery. Informed consent must therefore involve a detailed discussion with the patient about the risks, benefits, and alternatives to the proposed procedure.
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Likewise, a thorough conversation regarding which blood products and derivatives a patient accepts or declines should take place privately and be fully documented. An institutional consent form to decline blood products can be useful as both an educational tool and legal document summarizing the patient's wishes.$^{79}$
INFLUENCE OF PERIOPERATIVE ANEMIA ON POSTOPERATIVE OUTCOMES
Studies have consistently shown that preoperative anemia is associated with increased short-term morbidity and mortality as well as higher hospitalization costs and longer length of stay.$^{45,80}$ A summary of these studies is presented in Table 3. In a meta-analysis of 22 studies, including 114277 cardiac surgery patients, Padmanabhan et al$^{81}$ reported that patients with preoperative anemia required RBC transfusion more frequently (33.3% of anemic patients were transfused versus 11.9% of non-anemic patients) and demonstrated a higher incidence of acute kidney injury, stroke, infection, and operative mortality. Furthermore, studies suggest that both anemia and iron deficiency (without anemia) are strong predictors of perioperative RBC transfusion in cardiac surgery.$^{24,45,82}$
Anemia has also been associated with increased risk for long-term complications and mortality after cardiac surgery. A retrospective analysis of 4494 patients reported that long-term survival was lower in anemic cardiac surgery patients as well as those who received RBC transfusion, with the combination of anemia and RBC transfusion having the strongest negative effect on survival.$^{17}$ These results are further supported by a large Dutch national prospective multicenter registry analysis demonstrating that preoperative anemia was linked to increased risk of mortality as well as morbidities, such as renal failure, pneumonia, and myocardial infarction.$^{42}$ Furthermore, in a retrospective analysis of the Society of Thoracic Surgeons Database, including 258398 patients undergoing coronary artery bypass grafting (CABG), perioperative anemia was associated with lower long-term survival.$^{13}$ Other studies have shown that anemia is a significant risk factor for unplanned readmission after surgery$^{83,84}$ and is also associated with reduced postoperative health-related quality of life and disability-free survival.$^{85,86}$ Anemia has also been incorporated into frailty measures in cardiac surgery patients, including the Essential Frailty Toolset.$^{87,88}$ The Essential Frailty Toolset has been shown to be associated with death and disability after cardiac surgery, outperforming other frailty measures that do not incorporate anemia.$^{87}$ Taken together, there is a large body of evidence (albeit mostly derived from retrospective observational trials and data registries) linking preoperative anemia with short- as well as long-term postoperative morbidity and mortality in addition to increased health care-related costs, longer recovery, and
lower postoperative quality of life in patients undergoing cardiac surgery.
The literature exploring the association between anemia and outcomes in cardiac surgery is dominated by analyses that either include only isolated CABG or have majority representation of patients undergoing $CABG.^{11,81,89}$ Studies including only isolated patients undergoing CABG highlight the associations between preoperative anemia and worse short- and long-term outcomes, including acute kidney injury,$^{90,91}$ in-hospital mortality,$^{92}$ and long-term mortality,$^{93}$ However, a few robustly powered studies with sizeable CABG populations—including the previously noted Dutch study and a Department of Veterans Affairs study including 36658 patients—report adjusted analyses with dissipation of associations between anemia and long-term mortality, after accounting for relevant risk factors.$^{42,94}$ Notably, 25% of patients included in the Dutch national registry study underwent isolated valve replacement.$^{42}$ The authors report a persistent association between anemia and increased mortality among patients undergoing valve operations, even after robust risk adjustment. These findings are consistent with other exclusively or majority valve surgery studies that reinforce associations between anemia and poor outcomes in the short and long term.$^{93,95,96}$ Patients undergoing other cardiac operations (eg, heart transplantation, aortic surgery) have traditionally been excluded from studies or make up small proportions of participants.
CONSIDERATIONS FOR PERIOPERATIVE BLOOD MANAGEMENT IN UNDERREPRESENTED POPULATIONS
Extremes of age, female sex, non-White race, and lower socioeconomic status are associated with increased incidence of anemia, greater rates of transfusion, and increased surgical morbidity and mortality, necessitating further consideration of anemia diagnosis and blood management in these patient populations.$8^{-12}$ Furthermore, management of anemia in pediatric patients with congenital heart disease represents unique challenges. Additional considerations in this patient population include the increased risk of complications due to the heart defect itself, the potential for iron deficiency even with seemingly normal hemoglobin levels, the need for careful monitoring of blood measures, and often the requirement for intravenous or oral iron supplementation, depending on the child's condition and the specific congenital heart defect present.
Effect of Sex on Anemia and Blood Management
There is a large and compelling body of research indicating that biologic sex is an important factor in the pathogenesis of cardiovascular disease, postoperative outcomes, and
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Table 3. Influence of Perioperative Anemia on Postoperative Outcomes
|Studies|Study type|Patients, n (% of patients with anemia, if reported)|Population|Major findings| |---|---|---|---|---| |Cladellas et al $(2006)^{96}$|Prospective cohort|201 (21%) [Hb <12])|Elderly patients undergoing valve surgery|Preoperative anemia was a strong predictor of morbidity (OR, 4.67 [95% CI, 2.03–10.71]) and mortality (OR, 3.23 [95% CI, 1.09–9.55])| |Bell et al $(2008)^{94}$|Retrospective cohort|36658 (16.8%)|CABG|Preoperative Hb <10 g/dL showed a trend toward increased 30-d mortality (aOR, 1.29 [95% CI, 0.99–1.68]) and statistically significant increase in morbidity (aOR, 1.20 [95% CI, 1.02–1.43])| |Karkouti et al $(2008)^{11}$|Multicenter cohort|3500 (26%)|Cardiac surgery|Preoperative anemia was associated with increased postoperative morbidity (OR, 2.0 [95% CI, 1.4–2.8]) and mortality (OR, 1.8 [95% CI, 1.2–2.7])| |De Santo et al $(2009)^{51}$|Prospective cohort|1047 (30%)|CABG|Preoperative anemia was associated with postoperative AKI (OR, 2.06 [95% CI, 1.414–3.70])| |van Straten et al $(2009)^{93}$|Retrospective cohort|10025 (22%)|CABG|Preoperative anemia was associated with increased mortality (OR, 1.42 [95% CI, 1.20–1.69]) and stroke (OR, 1.58 [95% CI, 1.12–2.21])| |Klein et al $(2016)^{92}$|National audit (UK)|19033 (31%)|Cardiac surgery|Anemia was independently associated with RBC transfusion (OR, 2.75 [95% CI, 2.55–2.95]), mortality (OR, 1.42 [95% CI, 1.18–1.71]), and increased hospital stay| |von Heymann et al $(2016)^{17}$|Multicenter observational cohort|4494 (21% mild; 13% severe)|Cardiac surgery|Severe anemia was the strongest predictor of intraoperative RBC transfusion (OR, 1.34 [95% CI, 1.11–1.62]) and higher long-term mortality (OR, 1.80 [95% CI, 1.34–2.44])| |LaPar et al $(2018)^{45}$|Multicenter retrospective cohort (VCSQI data 2007–2017)|33411|CABG|RBC transfusion was a stronger predictor than preoperative hematocrit for mortality (OR, 4.3 [95% CI, 3.47–5.19]), renal failure (OR, 6.3 [95% CI, 5.24–7.56]), and stroke (OR, 2.4 [95% CI, 1.90–2.92])| |Mehaffey et al $(2018)^{80}$|Retrospective cohort|36588|CABG|RBC transfusion was associated with an average additional cost of $6763 and an additional 24 h stay in the ICU| |Cho et al $(2019)^{84}$|Retrospective cohort|1552|CABG|Hb <8.0 g/dL at discharge is associated with increased risk for 30-d readmission (OR, 1.77 [95% CI, 1.05–2.88])| |Padmanabh et al $(2019)^{81}$|Systematic review and meta-analysis|114277 (21%)|Cardiac surgery|Preoperative anemia was associated with increased mortality (OR, 2.74 [95% CI, 2.32–3.24]), AKI (OR, 3.13 [95% CI, 2.37–4.12]), stroke (OR, 1.46 [95% CI, 1.24–1.72]), infection (OR, 2.65 [95% CI, 1.98–3.55]) and longer hospital stay| |Rössler et al $(2020)^{24}$|Prospective observational|730 (16.7% [21.4% iron deficient])|Cardiac surgery|Iron deficiency (with or without anemia) was associated with increased 90-d mortality (aOR, 3.5 [95% CI, 1.5–8.4]), serious adverse events (aOR, 2.5 [95% CI, 1.6–3.7]), and MACCEs (aOR, 2.1 [95% CI, 1.1–4.0])| |Ripoll et al $(2021)^{95}$|Observational cohort|4117 (30%)|CABG, valve, or combined CABG+valve surgery|Each 1 g/dL decrease in preoperative Hb <13 g/dL in women was associated with increased odds of AKI (OR, 1.49 [95% CI, 1.23–1.81]), RBC transfusion (OR, 2.9 [95% CI, 2.33–3.60]), and reoperation (OR, 1.27 [95% CI, 1.11–1.45]), as well as longer hospital stay; in men, each 1 g/dL decrease in preoperative Hb <14 g/dL was associated with increased odds of RBC transfusion (OR, 2.56 [95% CI, 2.27–2.88]) and longer hospital stay| |Hazen et al $(2022)^{42}$|Nationwide, prospective, multicenter Dutch registry|35484 (19%)|Elective cardiac surgery|Preoperative anemia was associated with increased risk of 120-d mortality (aOR, 1.7 [95% CI, 1.4–2.0]), myocardial infarction (aOR, 1.6 [95% CI, 1.4–1.8]), reoperation (aOR, 1.3 [95% CI, 1.1–1.4]), prolonged intubation (aOR, 1.4 [95% CI, 1.2–1.6]), renal failure (aOR, 2.4 [95% CI, 2.0–3.0]), pneumonia (aOR, 1.4 [95% CI, 1.2–1.6]), and ICU readmission (aOR, 1.9 [95% CI, 1.6–2.2])| |Woldendorp et al $(2023)^{89}$|Meta-analysis (39 studies)|180074|Cardiac surgery|Peroperative transfusion was associated with increased early mortality (OR, 3.87 [95% CI, 2.77–5.42]) and long-term mortality (OR, 2.01 [95% CI, 1.71–2.35]) independent of anemia| |Peri et al $(2024)^{82}$|Systematic review and meta-analysis (8 studies)|2683 (28% iron deficient)|Cardiac surgery|Nonanemic iron deficiency was associated with increased RBC transfusion (pooled OR, 1.39 [95% CI, 1.16–1.68])|
AKI indicates acute kidney injury; aOR, adjusted odds ratio; CABG, coronary artery bypass grafting; Hb, hemoglobin; ICU, intensive care unit; MACCE, major adverse cardiac and cerebrovascular events; OR, odds ratio; RBC, red blood cell; and VCSQI, Virginia Cardiac Services Quality Initiative.
survival.$^{97-106}$ Female patients presenting for cardiac surgery tend to be older and to have a greater number of comorbid medical conditions, a higher incidence of anemia, more malnutrition, increased frailty, and lower socioeco-
nomic status, compared with male patients.$^{95,99,103}$ Female patients, compared with male patients, also have a greater incidence of operative mortality, major adverse cardiac events, and hospital readmissions, even after controlling
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for age and increased comorbidities.$^{107,108}$ Biologic sex plays a vital role in anemia diagnosis, management, and treatment, as the routinely used cutoffs for anemia diagnosis and treatment are sex-dependent. Threshold hemoglobin values for anemia were originally defined by the World Health Organization in 1968, with differential cutoffs based on biologic sex; however, these values are based on surveys of asymptomatic individuals, and we now have a better understanding of the high prevalence of iron deficiency, particularly among female patients of reproductive age, which may partially explain this sex disparity.$^{109}$ Globally, female adolescents and adults experience significantly higher rates of anemia compared with male patients (33.7% versus 11.3%), as do individuals living in sub-Saharan Africa and South Asia (47.4% and 43.0%, respectively).$^{110}$
Among cardiac surgery patients, female sex is an independent risk factor for preoperative anemia and RBC transfusion.$^{111,112}$ Female patients undergoing cardiac surgery receive RBC transfusions at a rate 3 times greater than men.$^{9,12,113}$ The causes for higher transfusion rates are multifactorial and likely due to the lower body weight, body surface area, and blood volume of female patients, as well as greater hemodilution from priming volumes of CPB circuits, which are not adjusted for sex, and possible genetic differences in coagulation.$^{10,12,103,104,111}$ Along the same lines, RBC transfusion triggers are not adjusted on the basis of sex. Studies assessing the adequacy of preoperative hemoglobin thresholds suggest that using World Health Organization anemia criteria to guide treatment may result in a significant number of female patients being overlooked and may contribute to their increased risk of adverse outcomes, including acute kidney injury, RBC transfusion, reoperation, and extended hospital stays.$^{95,114}$
À recent retrospective cohort study in >1 million isolated patients undergoing CABG found that the association of female sex with increased operative mortality was mediated largely by intraoperative anemia.$^{10}$ It is important to note that anemia thresholds are based on hemoglobin concentrations, which do not accurately reflect total RBC mass and were not established on the basis of clinical outcomes. Therefore, patient blood management groups have suggested increasing the preoperative hemoglobin targets for female cardiac surgery patients to 13.0 g/dL and using sex-specific RBC transfusion triggers to more effectively optimize and treat perioperative anemia.$^{109,115}$
Associations Among Race, Ethnicity, Socioeconomic Factors, and Perioperative Anemia
There is strong evidence supporting the association between perioperative anemia and adverse postoperative outcomes, but whether anemia itself is causative
for the differential postoperative outcomes observed in underrepresented patient populations is unknown. Contributing factors to disparities on the basis of race and ethnicity in the relationship between anemia and postoperative outcomes can be complex and diverse, and include socioeconomic disparities leading to poorer nutrition and access to health care, higher baseline rates of anemia in non-White individuals (even after adjusting for socioeconomic factors), genetic variations affecting iron absorption, implicit bias in health care delivery, and potential differences in surgical practices applied to diverse populations.$^{116,117}$ Additional research is needed in diverse patient populations to better understand the effects of race, ethnicity, and socioeconomic status on perioperative anemia and postoperative outcomes.
Pediatric Perioperative Blood Management and Congenital Heart Disease
Perioperative blood management in pediatric cardiac surgery has multiple challenges distinct from the adult population. A major hurdle is the lack of high-quality and large clinical studies in children. Multiple retrospective studies have shown that preoperative anemia defined according to age is an independent risk factor for increased morbidity, 30-day mortality and incidence of postoperative blood transfusion.$^{118-120}$ Preoperative iron supplementation can lead to improved outcomes in patients with iron deficiency.$^{121}$ Hence, identification and correction of preoperative iron deficiency anemia with oral or intravenous iron in pediatric patients undergoing cardiac surgery could lead to better intraoperative and postoperative outcomes. Administration of epoetin in children has not been studied well enough to make any broad recommendations on routine use.
Intraoperative patient blood management in pediatric patients is complicated by the fact that patients with congenital heart disease are a heterogeneous population with cyanotic and noncyanotic defects and ages ranging from neonates to adolescents, with varying hemoglobin thresholds, blood volumes, and cardiac physiology. Recent studies have supported use of restrictive transfusion thresholds in young children. In general, using cell saver solutions, using a miniature CPB circuit, and achieving adequate hemostatic control can lead to reduced blood RBC transfusions in the intraoperative setting, although the current evidence for these techniques are not as strongly supported as in the adult literature.$^{121,122}$
There is a paucity of data on specific hemoglobin thresholds for postoperative anemia management for patients of different ages and weights. However, a recent meta-analysis of 5 large randomized controlled trials in pediatric patients with cyanotic or noncyanotic heart disease showed that a restrictive transfusion strategy (7-9 g/dL) was noninferior compared with a liberal
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transfusion strategy (>9.5 g/dL).$^{123}$ This is consistent with many adult studies. Clinicians should consider the risks and benefits of RBC transfusions in the postoperative setting.
CONCLUSION, KNOWLEDGE GAPS, AND FUTURE DIRECTIONS
Perioperative anemia is more than a simple laboratory diagnosis: it is a complex clinical syndrome that is relat-ed to the unique clinical characteristics and physiologic reserve for each patient. Perioperative anemia and iron deficiency in cardiac surgery are associated with longer length of hospital stay, adverse postoperative outcomes, and increased mortality.$^{14,81,82,90,91,94,96,113}$ Each percentage point decrease in hemoglobin <24% has been shown to increase the odds of 30-day postoperative mortality by 2.5 times in surgical patients.$^{39,11,12,113}$ Therefore, it is imperative that anemia be diagnosed as early as possible in the preoperative course to allow time for ad-equate anemia treatment and hemoglobin optimization. Comprehensive patient blood management programs that focus on the avoidance of perioperative anemia at all stages, reduced intraoperative bleeding, and transfusion prevention may improve postoperative outcomes. Blood management programs are best implemented through multidisciplinary care teams and with hospital support that can be acquired through joint recognition that peri-operative anemia treatment and blood conservation strat-egies improve outcomes and reduce resource utilization at both the local and national health care system level.
Despite the recent increase in the publication of literature related to anemia, iron deficiency, and patient blood management, additional research is needed, because several important knowledge gaps remain. It is well-documented that anemia and RBC transfusions negatively affect postoperative outcomes after cardiac surgery; however, whether anemia and transfusions are in fact causative of these adverse outcomes remains unknown. Previous studies evaluating the effects of preoperative anemia treatment have demonstrated that pharmacologic therapies, such as intravenous or oral iron and erythropoiesis-stimulating agents (epoetin), increase preoperative hemoglobin and reduce intraoperative and postoperative RBC transfusions significantly in patients undergoing cardiac surgery.$^{2,3,3,124,125}$ However, these trials have not yet been able to demonstrate an improvement in postoperative morbidity and mortality with preoperative anemia therapies. There is a need for more robust research involving large multicenter randomized controlled trials that can more definitely evaluate the effi-
cacy of blood conservation strategies and the effect of these strategies on postoperative outcomes.
Furthermore, because the prevalence of perioperative anemia varies according to age, sex, race, and socioeconomic status, more research is needed in more diverse patient populations to better understand the mechanisms of these differences and how to best improve outcomes in various patient populations. The majority of published literature investigating the relationship between perioperative anemia and outcomes is based on clinical data from largely male and White patient populations. Questions remain as to the effect that adapting non-sex-specific anemia definitions or hemoglobin thresholds may have on outcomes in female patients undergoing cardiac surgery. There is a need to design stronger clinical trials with more diverse and underrepresented patient populations to better understand disparities across varying populations undergoing cardiac surgery to improve outcomes and quality of life after cardiac surgery. Future areas for research and clinical programmatic development may include more personalized preoperative care plans to determine which patients may benefit the most from individual components of comprehensive blood management strategies and better identification of patients at risk for anemia using artificial intelligence and electronic medical record information.
ARTICLE INFORMATION
The American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest.
This statement was approved by the American Heart Association Science Advisory and Coordinating Committee on January 22, 2026, and the American Heart Association Executive Committee on April 29, 2026. A copy of the document is available at https://professionalheart.org/statements by using either "Search for Guidelines & Statements" or the "Browse by Topic" area. To purchase additional reprints, call 215-356-2721 or email Meredith.Edelman@wolterskluwer.com
The American Heart Association requests that this document be cited as follows: Howard-Quijano K, Shore-Lesserson L, Osho A, Raphael J, Rove JY, Panigrahi AK, Morton-Bailey V, Kamlesh Vegrecha A, Baker RA; on behalf of the American Heart Association Council on Cardiovascular Surgery and Anesthesia; and the Council on Clinical Cardiology. Perioperative anemia and patient blood management in cardiac surgery: a scientific statement from the American Heart Association. Circulation. 2026;153:e***-e***. doi: 10.1161/CIR.0000000000001446
The expert peer review of AHA-commissioned documents (eg, scientific statements, clinical practice guidelines, systematic reviews) is conducted by the AHA Office of Science Operations. For more on AHA statements and guidelines development, visit https://professional.heartorg/statements. Select the "Guidelines & Statements" drop-down menu, then click "Publication Development."
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Disclosures
Writing Group Disclosures
|Writing group member|Employment|Research grant|Other research support|Speakers' bureau/ honoraria|Expert witness|Ownership interest|Consultant/ advisory board|Other| |---|---|---|---|---|---|---|---|---| |Kimberly Howard-Quijano|The University of Pittsburgh Medical Center|None|None|None|None|None|None|None| |Linda Shore-Lesserson|Donald and Barbara Zucker School of Medicine at Hofstra/North-well Anesthesiology|None|None|None|None|None|Vifor (Int) Ltd*|None| |Robert A. Baker|Flinders University (Australia)|South Australian Blood Management Council ("Impact of Adherence to Patient Blood Management Guidelines on Quality of Life [QoL] in Cardiac Surgery Patients")*; National CQR Automation and Innovation Capacity Building Grants (innovation grant to support moving ANZCPR Registry to cloud-based registry structure)*|None|None|None|None|LivaNova*|None| |Vicki Morton-Bailey|Novant Health Perioperative|None|None|None|None|None|None|None| |Asishana A. Osho|Massachusetts General Hospital|None|None|None|None|None|None|None| |Anil K. Panigrahi|Stanford University School of Medicine|None|None|None|None|None|None|None| |Jacob Raphael|Sidney Kimmel Medical College, Thomas Jefferson University|None|None|CSL Behring*|None|None|CSL Behring*; Oct-tapharma*|None| |Jessica Y. Rove|University of Colorado AMC Aurora|None|None|None|None|None|None|None| |Anshul Kamlesh Vagrecha|Cohen Children's Hospital|None|None|None|None|None|Sobi*|None|
This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire, which all reviewers are required to complete and submit. A relationship is considered to be “significant” if (a) the person receives ≥$5000 during any 12-month period, or ≥5% of the person’s gross income; or (b) the person owns ≥5% of the voting stock or share of the entity, or owns ≥$5000 of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition.
*Modest.
†Significant.
Reviewer Disclosures
|Reviewer|Employment|Research grant|Other research support|Speakers' bureau/honoraria|Expert witness|Ownership interest|Consultant/ advisory board|Other| |---|---|---|---|---|---|---|---|---| |Kiran Belani|Northwestern Feinberg School of Medicine|None|None|None|None|None|None|None| |Abe Deanda|The University of North Carolina System|None|None|None|None|None|None|None| |Andra Duncan|Cleveland Clinic|Hemosonics LLC*|None|None|None|None|None|None| |Kamrouz Ghadimi|Duke University School of Medicine|Octapharmat|None|None|None|None|None|None| |Lisa Rong|Weill Cornell Medicine|None|None|None|None|None|None|None|
This table represents the relationships of reviewers that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire, which all reviewers are required to complete and submit. A relationship is considered to be “significant” if (a) the person receives ≥$5000 during any 12-month period, or ≥5% of the person’s gross income; or (b) the person owns ≥5% of the voting stock or share of the entity, or owns ≥$5000 of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition.
*Modest.
†Significant.
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| Anemia in cardiac surgery patients is associated with: | ||
|---|---|---|
| x  3x increased risk of death  of kidney failure | 4x increased risk of  5x increased risk of being transfused | Increased length of hospital stay |
| Preoperative Anemia >30-50% of cardiac surgery patients | Intraoperative Anemia >90% of surgeries with cardiopulmonary bypass | Postoperative Anemia 30-90% of patients after cardiac surgery |
| Mitigate risk and improve outcomes through preoperative assessment and treatment of anemia, and intra- and postoperative blood management strategies | ||
|  |  |  |
| Preoperative | Intraoperative | Postoperative |
| Identify patients early Diagnose anemia ● Female vs. Male Hb cutoffs ● Determine underlying causes ● Identify iron deficiency ● Ferritin<100 mcg/L ● Transferrin sat<20% Treatments ● IV iron ● PO iron(if time allows) ● Other treatments as indicated ● Epo,B12,folate | Surgical techniques ● Minimally invasive approach ● Surgical bleeding checklist ● Topical hemostatic agents ● Prompt re-exploration Anesthesiology and Perfusion Techniques ● ANH ● Antifibrinolytics and procoagulants ● Avoid hemodilution-RAP,MUF, low prime volume ● POC coagulation testing + algorithms | Protocol driven postoperative blood management ● Minimize phlebotomy ● Individualized transfusion triggers ● POC coagulation testing + algorithms ● Prompt surgical re-exploration ● Antifibrinolytics and procoagulants Follow up treatment as needed to avoid anemia and treat iron deficiency ● Oral and IV iron treatments |
| Considerations for Blood Management in Individual Patient Populations | ||
| Congenital heart disease 8 8 |
| Tests | Diagnostic threshold | Notes |
|---|---|---|
| Hemoglobin (CBC) | <13 g/dL for both sexes | Screening threshold for further preoperative anemia $evaluation^{3,20}$ |
| Ferritin | <30 µg/L | Suggests absolute iron deficiency; in inflammatory states, ferritin may be normal or $high^{20}$ |
| Transferrin saturation | <20% | Indicates iron-restricted erythropoiesis and is robust across settings, including heart $failure^{29}$ |
| CRP | >10 mg/L | Elevated CRP levels support functional iron deficiency when ferritin is $equiv^{20}$ |
| RET-He/CHr | <29-30 pg | Low RET-He/CHr suggests iron-restricted erythropoiesis and may detect deficiency earlier than Hb $change^{31}$ |
| Vitamin $B_{12}$ | <200 pg/mL (borderline 200-300 pg/mL) | Confirm with methylmalonic acid if $indeterminate^{32}$ |
| Folate | <2 ng/mL | Serum folate preferred; 2-4 ng/mL is borderline and may require additional $testing^{33}$ |
| Iron formulations | Dose, mg | Infusions, n | Considerations |
|---|---|---|---|
| Iron sucrose | 200 | 5 | Undiluted slow IV injection over 2-5 min on 5 different days over a 14-d period |
| Iron dextran | 1000 | 1 | Requires a test dose; infusion over ≥1 h |
| Ferric gluconate | 125 | 8 | Requires multiple doses, affecting time to surgery |
| Ferumoxytol | 510 | 2 | Two doses, 3-8 d apart |
| Ferric derisomaltose | 1000 | 1 | For patients <50 kg, dosing is 20 mg/kg actual body weight; short infusion time |
| Ferric carboxymaltose | 750 | 1-3 | Two doses 7 d apart; short infusion time; for patients <50 kg, dosing is 15 mg/kg body weight |
| Studies | Study type | Patients, n (% of patients with anemia, if reported) | Population | Major findings |
|---|---|---|---|---|
| Cladellas et al $(2006)^{96}$ | Prospective cohort | 201 (21%) [Hb <12]) | Elderly patients undergoing valve surgery | Preoperative anemia was a strong predictor of morbidity (OR, 4.67 [95% CI, 2.03–10.71]) and mortality (OR, 3.23 [95% CI, 1.09–9.55]) |
| Bell et al $(2008)^{94}$ | Retrospective cohort | 36658 (16.8%) | CABG | Preoperative Hb <10 g/dL showed a trend toward increased 30-d mortality (aOR, 1.29 [95% CI, 0.99–1.68]) and statistically significant increase in morbidity (aOR, 1.20 [95% CI, 1.02–1.43]) |
| Karkouti et al $(2008)^{11}$ | Multicenter cohort | 3500 (26%) | Cardiac surgery | Preoperative anemia was associated with increased postoperative morbidity (OR, 2.0 [95% CI, 1.4–2.8]) and mortality (OR, 1.8 [95% CI, 1.2–2.7]) |
| De Santo et al $(2009)^{51}$ | Prospective cohort | 1047 (30%) | CABG | Preoperative anemia was associated with postoperative AKI (OR, 2.06 [95% CI, 1.414–3.70]) |
| van Straten et al $(2009)^{93}$ | Retrospective cohort | 10025 (22%) | CABG | Preoperative anemia was associated with increased mortality (OR, 1.42 [95% CI, 1.20–1.69]) and stroke (OR, 1.58 [95% CI, 1.12–2.21]) |
| Klein et al $(2016)^{92}$ | National audit (UK) | 19033 (31%) | Cardiac surgery | Anemia was independently associated with RBC transfusion (OR, 2.75 [95% CI, 2.55–2.95]), mortality (OR, 1.42 [95% CI, 1.18–1.71]), and increased hospital stay |
| von Heymann et al $(2016)^{17}$ | Multicenter observational cohort | 4494 (21% mild; 13% severe) | Cardiac surgery | Severe anemia was the strongest predictor of intraoperative RBC transfusion (OR, 1.34 [95% CI, 1.11–1.62]) and higher long-term mortality (OR, 1.80 [95% CI, 1.34–2.44]) |
| LaPar et al $(2018)^{45}$ | Multicenter retrospective cohort (VCSQI data 2007–2017) | 33411 | CABG | RBC transfusion was a stronger predictor than preoperative hematocrit for mortality (OR, 4.3 [95% CI, 3.47–5.19]), renal failure (OR, 6.3 [95% CI, 5.24–7.56]), and stroke (OR, 2.4 [95% CI, 1.90–2.92]) |
| Mehaffey et al $(2018)^{80}$ | Retrospective cohort | 36588 | CABG | RBC transfusion was associated with an average additional cost of $6763 and an additional 24 h stay in the ICU |
| Cho et al $(2019)^{84}$ | Retrospective cohort | 1552 | CABG | Hb <8.0 g/dL at discharge is associated with increased risk for 30-d readmission (OR, 1.77 [95% CI, 1.05–2.88]) |
| Padmanabh et al $(2019)^{81}$ | Systematic review and meta-analysis | 114277 (21%) | Cardiac surgery | Preoperative anemia was associated with increased mortality (OR, 2.74 [95% CI, 2.32–3.24]), AKI (OR, 3.13 [95% CI, 2.37–4.12]), stroke (OR, 1.46 [95% CI, 1.24–1.72]), infection (OR, 2.65 [95% CI, 1.98–3.55]) and longer hospital stay |
| Rössler et al $(2020)^{24}$ | Prospective observational | 730 (16.7% [21.4% iron deficient]) | Cardiac surgery | Iron deficiency (with or without anemia) was associated with increased 90-d mortality (aOR, 3.5 [95% CI, 1.5–8.4]), serious adverse events (aOR, 2.5 [95% CI, 1.6–3.7]), and MACCEs (aOR, 2.1 [95% CI, 1.1–4.0]) |
| Ripoll et al $(2021)^{95}$ | Observational cohort | 4117 (30%) | CABG, valve, or combined CABG+valve surgery | Each 1 g/dL decrease in preoperative Hb <13 g/dL in women was associated with increased odds of AKI (OR, 1.49 [95% CI, 1.23–1.81]), RBC transfusion (OR, 2.9 [95% CI, 2.33–3.60]), and reoperation (OR, 1.27 [95% CI, 1.11–1.45]), as well as longer hospital stay; in men, each 1 g/dL decrease in preoperative Hb <14 g/dL was associated with increased odds of RBC transfusion (OR, 2.56 [95% CI, 2.27–2.88]) and longer hospital stay |
| Hazen et al $(2022)^{42}$ | Nationwide, prospective, multicenter Dutch registry | 35484 (19%) | Elective cardiac surgery | Preoperative anemia was associated with increased risk of 120-d mortality (aOR, 1.7 [95% CI, 1.4–2.0]), myocardial infarction (aOR, 1.6 [95% CI, 1.4–1.8]), reoperation (aOR, 1.3 [95% CI, 1.1–1.4]), prolonged intubation (aOR, 1.4 [95% CI, 1.2–1.6]), renal failure (aOR, 2.4 [95% CI, 2.0–3.0]), pneumonia (aOR, 1.4 [95% CI, 1.2–1.6]), and ICU readmission (aOR, 1.9 [95% CI, 1.6–2.2]) |
| Woldendorp et al $(2023)^{89}$ | Meta-analysis (39 studies) | 180074 | Cardiac surgery | Peroperative transfusion was associated with increased early mortality (OR, 3.87 [95% CI, 2.77–5.42]) and long-term mortality (OR, 2.01 [95% CI, 1.71–2.35]) independent of anemia |
| Peri et al $(2024)^{82}$ | Systematic review and meta-analysis (8 studies) | 2683 (28% iron deficient) | Cardiac surgery | Nonanemic iron deficiency was associated with increased RBC transfusion (pooled OR, 1.39 [95% CI, 1.16–1.68]) |
| Writing group member | Employment | Research grant | Other research support | Speakers' bureau/ honoraria | Expert witness | Ownership interest | Consultant/ advisory board | Other |
|---|---|---|---|---|---|---|---|---|
| Kimberly Howard-Quijano | The University of Pittsburgh Medical Center | None | None | None | None | None | None | None |
| Linda Shore-Lesserson | Donald and Barbara Zucker School of Medicine at Hofstra/North-well Anesthesiology | None | None | None | None | None | Vifor (Int) Ltd* | None |
| Robert A. Baker | Flinders University (Australia) | South Australian Blood Management Council ("Impact of Adherence to Patient Blood Management Guidelines on Quality of Life [QoL] in Cardiac Surgery Patients")*; National CQR Automation and Innovation Capacity Building Grants (innovation grant to support moving ANZCPR Registry to cloud-based registry structure)* | None | None | None | None | LivaNova* | None |
| Vicki Morton-Bailey | Novant Health Perioperative | None | None | None | None | None | None | None |
| Asishana A. Osho | Massachusetts General Hospital | None | None | None | None | None | None | None |
| Anil K. Panigrahi | Stanford University School of Medicine | None | None | None | None | None | None | None |
| Jacob Raphael | Sidney Kimmel Medical College, Thomas Jefferson University | None | None | CSL Behring* | None | None | CSL Behring*; Oct-tapharma* | None |
| Jessica Y. Rove | University of Colorado AMC Aurora | None | None | None | None | None | None | None |
| Anshul Kamlesh Vagrecha | Cohen Children's Hospital | None | None | None | None | None | Sobi* | None |
| Reviewer | Employment | Research grant | Other research support | Speakers' bureau/honoraria | Expert witness | Ownership interest | Consultant/ advisory board | Other |
|---|---|---|---|---|---|---|---|---|
| Kiran Belani | Northwestern Feinberg School of Medicine | None | None | None | None | None | None | None |
| Abe Deanda | The University of North Carolina System | None | None | None | None | None | None | None |
| Andra Duncan | Cleveland Clinic | Hemosonics LLC* | None | None | None | None | None | None |
| Kamrouz Ghadimi | Duke University School of Medicine | Octapharmat | None | None | None | None | None | None |
| Lisa Rong | Weill Cornell Medicine | None | None | None | None | None | None | None |
引用 / 出处
2026 AHA科学声明：心脏外科手术围术期贫血和患者血液管理. 2026.