Preoperative predicted risk does not fully explain the association between red blood cell transfusion and mortality in coronary artery bypass grafting

ObjectivePerioperative red blood cell transfusion is associated with increased morbidity and mortality after coronary artery bypass grafting (CABG). Whether transfusion is a cause of these outcomes or serves as a surrogate for a high-risk patient population remains uncertain. This retrospective study tested the hypothesis that increased preoperative risk profile of patients receiving transfusion would explain the relationship between red blood cell transfusion and operative mortality in isolated CABG.MethodsA total of 31,818 patients undergoing isolated CABG were entered into a statewide collaborative database between January 2006 and June 2010. With the Society of Thoracic Surgeons risk calculator, patient cohorts were stratified into 4 groups by predicted risk of mortality (PROM) of less than 2%, 2% to 5%, more than 5% to 10% and more than 10%. The association between blood transfusion and mortality was tested at each stratum with a χ2 test. A Breslow-Day test for homogeneity of odds ratios was used to test whether the 4 odds ratios of the strata were similar, and a Cochran-Mantel-Haenszel test was used to test the association between blood transfusion and mortality while controlling for predicted risk mortality strata.ResultsIn all, 17,720 (55.7%) of all patients were transfused during the hospitalization. Incidence of transfusion increased stepwise with risk level; 93.3% of patients with PROM greater than 10% received blood. Operative mortality was 2.1% overall, 0.6% among the 44.3% of patients who were not transfused, and 3.3% in the transfused group (odds ratio, 6.19; P < .0001). The association between blood transfusion and mortality was significant within each predicted risk stratum. Increased mortality associated with transfusion was statistically equivalent across all predicted risk strata (P = .1778). The association between blood transfusion and mortality for all patients lessened somewhat when controlling for PROM (odds ratio, 2.99 vs 6.19), yet remained highly significant (P < .0001).ConclusionsThe association between red blood cell transfusion and mortality after CABG is highly significant and independent of increased preoperative risk status. The correlation persists after controlling for increased PROM.