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Volume 12
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10.3390/jcdd12080287
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This is an early access version, the complete PDF, HTML, and XML versions will be available soon.
Article

The Influence of Blood Transfusion Indexed to Patient Blood Volume on 5-Year Mortality After Coronary Artery Bypass Grafting—An EuroSCORE II Adjusted Spline Regression Analysis

by
Joseph Kletzer
1,2,*,
Maximilian Kreibich
1,2,
Martin Czerny
1,2,
Tim Berger
1,2,
Albi Fagu
1,2,
Laurin Micek
1,2,
Ulrich Franke
1,2,
Matthias Eschenhagen
1,2,
Tau S. Hartikainen
2,3,
Mirjam Wild
2,3 and
Dalibor Bockelmann
2,4
1
Department of Cardiovascular Surgery, University Heart Center Freiburg—Bad Krozingen, University Medical Center Freiburg, 79110 Freiburg, Germany
2
Faculty of Medicine, University of Freiburg, 79085 Freiburg, Germany
3
Department of Cardiology and Angiology, University Heart Center Freiburg—Bad Krozingen, University Medical Center Freiburg, 79110 Freiburg, Germany
4
Staff Unit for Medical Strategy and Cooperation, University Clinic Freiburg, 79110 Freiburg, Germany
*
Author to whom correspondence should be addressed.
J. Cardiovasc. Dev. Dis. 2025, 12(8), 287; https://doi.org/10.3390/jcdd12080287
Submission received: 16 June 2025 / Revised: 12 July 2025 / Accepted: 21 July 2025 / Published: 28 July 2025
(This article belongs to the Special Issue 2nd Edition: Interventional Therapies and Management in Coronary Artery Disease)
Versions Notes

Abstract

Background: While timely blood transfusion is critical for restoring oxygen-carrying capacity after coronary artery bypass grafting (CABG), allogeneic blood product transfusions are independently associated with increased long-term mortality, necessitating a risk-stratified approach to balance oxygen delivery against immunological complications and infection risks. Methods: We retrospectively analyzed 3376 patients undergoing isolated CABG between 2005 and 2023 at a single tertiary center. Patients who died during their perioperative hospital stay within 30 days were excluded. Transfusion burden was assessed both as the absolute number of blood product units (packed red blood cells, platelet transfusion, fresh frozen plasma) and as a percentage of calculated patient blood volume. The primary outcome was all-cause mortality at 5 years. Flexible Cox regression with penalized smoothing splines, adjusted for EuroSCORE II, was used to model dose–response relationships. Results: From our cohort of 3376 patients, a total of 137 patients (4.05%) received >10 units of packed red blood cells (PRBC) perioperatively. These patients were older (median 71 vs. 68 years, p < 0.001), more often female (29% vs. 15%, p < 0.001), and had higher preoperative risk (EuroSCORE II: 2.53 vs. 1.41, p < 0.001). After 5 years, mortality was 42% in the massive transfusion group versus 10% in controls. Spline regression revealed an exponential increase in mortality with transfused units: 14 units yielded a 1.5-fold higher hazard of death (HR 1.46, 95% CI 1.31–1.64), rising to HR 2.71 (95% CI 2.12–3.47) at 30 units. When transfusion was indexed to blood volume, this relationship became linear and more tightly correlated with mortality, with lower maximum hazard ratios and narrower confidence intervals. Conclusion: Indexing transfusion burden to the percentage of patient blood volume replaced provides a more accurate and clinically actionable predictor of 5-year mortality after CABG than absolute unit counts. Our findings support a shift toward individualized, volume-based transfusion strategies to optimize patient outcomes and resource stewardship in a time of limited availability of blood products.
Keywords: coronary artery bypass grafting; blood transfusion; survival analysis; cardiac surgery; coronary artery disease coronary artery bypass grafting; blood transfusion; survival analysis; cardiac surgery; coronary artery disease

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MDPI and ACS Style

Kletzer, J.; Kreibich, M.; Czerny, M.; Berger, T.; Fagu, A.; Micek, L.; Franke, U.; Eschenhagen, M.; Hartikainen, T.S.; Wild, M.; et al. The Influence of Blood Transfusion Indexed to Patient Blood Volume on 5-Year Mortality After Coronary Artery Bypass Grafting—An EuroSCORE II Adjusted Spline Regression Analysis. J. Cardiovasc. Dev. Dis. 2025, 12, 287. https://doi.org/10.3390/jcdd12080287

AMA Style

Kletzer J, Kreibich M, Czerny M, Berger T, Fagu A, Micek L, Franke U, Eschenhagen M, Hartikainen TS, Wild M, et al. The Influence of Blood Transfusion Indexed to Patient Blood Volume on 5-Year Mortality After Coronary Artery Bypass Grafting—An EuroSCORE II Adjusted Spline Regression Analysis. Journal of Cardiovascular Development and Disease. 2025; 12(8):287. https://doi.org/10.3390/jcdd12080287

Chicago/Turabian Style

Kletzer, Joseph, Maximilian Kreibich, Martin Czerny, Tim Berger, Albi Fagu, Laurin Micek, Ulrich Franke, Matthias Eschenhagen, Tau S. Hartikainen, Mirjam Wild, and et al. 2025. "The Influence of Blood Transfusion Indexed to Patient Blood Volume on 5-Year Mortality After Coronary Artery Bypass Grafting—An EuroSCORE II Adjusted Spline Regression Analysis" Journal of Cardiovascular Development and Disease 12, no. 8: 287. https://doi.org/10.3390/jcdd12080287

APA Style

Kletzer, J., Kreibich, M., Czerny, M., Berger, T., Fagu, A., Micek, L., Franke, U., Eschenhagen, M., Hartikainen, T. S., Wild, M., & Bockelmann, D. (2025). The Influence of Blood Transfusion Indexed to Patient Blood Volume on 5-Year Mortality After Coronary Artery Bypass Grafting—An EuroSCORE II Adjusted Spline Regression Analysis. Journal of Cardiovascular Development and Disease, 12(8), 287. https://doi.org/10.3390/jcdd12080287

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