{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T01:32:43Z","timestamp":1760059963119,"version":"build-2065373602"},"reference-count":40,"publisher":"MDPI AG","issue":"8","license":[{"start":{"date-parts":[[2025,7,28]],"date-time":"2025-07-28T00:00:00Z","timestamp":1753660800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Berta-Ottenstein-Programme for Clinician Scientists, Faculty of Medicine, University of Freiburg."}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCDD"],"abstract":"<jats:p>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\u2013response relationships. Results: From our cohort of 3376 patients, a total of 137 patients (4.05%) received &gt;10 units of packed red blood cells (PRBC) perioperatively. These patients were older (median 71 vs. 68 years, p &lt; 0.001), more often female (29% vs. 15%, p &lt; 0.001), and had higher preoperative risk (EuroSCORE II: 2.53 vs. 1.41, p &lt; 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\u20131.64), rising to HR 2.71 (95% CI 2.12\u20133.47) 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. Conclusions: 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.<\/jats:p>","DOI":"10.3390\/jcdd12080287","type":"journal-article","created":{"date-parts":[[2025,7,28]],"date-time":"2025-07-28T16:00:37Z","timestamp":1753718437000},"page":"287","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["The Influence of Blood Transfusion Indexed to Patient Blood Volume on 5-Year Mortality After Coronary Artery Bypass Grafting\u2014An EuroSCORE II Adjusted Spline Regression Analysis"],"prefix":"10.3390","volume":"12","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-1644-1754","authenticated-orcid":false,"given":"Joseph","family":"Kletzer","sequence":"first","affiliation":[{"name":"Department of Cardiovascular Surgery, University Heart Center Freiburg\u2014Bad Krozingen, University Medical Center Freiburg, 79110 Freiburg, Germany"},{"name":"Faculty of Medicine, University of Freiburg, 79085 Freiburg, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3099-7254","authenticated-orcid":false,"given":"Maximilian","family":"Kreibich","sequence":"additional","affiliation":[{"name":"Department of Cardiovascular Surgery, University Heart Center Freiburg\u2014Bad Krozingen, University Medical Center Freiburg, 79110 Freiburg, Germany"},{"name":"Faculty of Medicine, University of Freiburg, 79085 Freiburg, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Martin","family":"Czerny","sequence":"additional","affiliation":[{"name":"Department of Cardiovascular Surgery, University Heart Center Freiburg\u2014Bad Krozingen, University Medical Center Freiburg, 79110 Freiburg, Germany"},{"name":"Faculty of Medicine, University of Freiburg, 79085 Freiburg, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6263-9123","authenticated-orcid":false,"given":"Tim","family":"Berger","sequence":"additional","affiliation":[{"name":"Department of Cardiovascular Surgery, University Heart Center Freiburg\u2014Bad Krozingen, University Medical Center Freiburg, 79110 Freiburg, Germany"},{"name":"Faculty of Medicine, University of Freiburg, 79085 Freiburg, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9317-4303","authenticated-orcid":false,"given":"Albi","family":"Fagu","sequence":"additional","affiliation":[{"name":"Department of Cardiovascular Surgery, University Heart Center Freiburg\u2014Bad Krozingen, University Medical Center Freiburg, 79110 Freiburg, Germany"},{"name":"Faculty of Medicine, University of Freiburg, 79085 Freiburg, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Laurin","family":"Micek","sequence":"additional","affiliation":[{"name":"Department of Cardiovascular Surgery, University Heart Center Freiburg\u2014Bad Krozingen, University Medical Center Freiburg, 79110 Freiburg, Germany"},{"name":"Faculty of Medicine, University of Freiburg, 79085 Freiburg, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ulrich","family":"Franke","sequence":"additional","affiliation":[{"name":"Department of Cardiovascular Surgery, University Heart Center Freiburg\u2014Bad Krozingen, University Medical Center Freiburg, 79110 Freiburg, Germany"},{"name":"Faculty of Medicine, University of Freiburg, 79085 Freiburg, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Matthias","family":"Eschenhagen","sequence":"additional","affiliation":[{"name":"Department of Cardiovascular Surgery, University Heart Center Freiburg\u2014Bad Krozingen, University Medical Center Freiburg, 79110 Freiburg, Germany"},{"name":"Faculty of Medicine, University of Freiburg, 79085 Freiburg, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Tau S.","family":"Hartikainen","sequence":"additional","affiliation":[{"name":"Faculty of Medicine, University of Freiburg, 79085 Freiburg, Germany"},{"name":"Department of Cardiology and Angiology, University Heart Center Freiburg\u2014Bad Krozingen, University Medical Center Freiburg, 79110 Freiburg, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Mirjam","family":"Wild","sequence":"additional","affiliation":[{"name":"Faculty of Medicine, University of Freiburg, 79085 Freiburg, Germany"},{"name":"Department of Cardiology and Angiology, University Heart Center Freiburg\u2014Bad Krozingen, University Medical Center Freiburg, 79110 Freiburg, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Dalibor","family":"Bockelmann","sequence":"additional","affiliation":[{"name":"Faculty of Medicine, University of Freiburg, 79085 Freiburg, Germany"},{"name":"Staff Unit for Medical Strategy and Cooperation, University Clinic Freiburg, 79106 Freiburg, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2025,7,28]]},"reference":[{"key":"ref_1","first-page":"e15184","article-title":"Frequency of Blood Transfusion in Elective Coronary Artery Bypass Grafting and Its Correlation with Acute Kidney Injury at a Tertiary Care Hospital in a Lower Middle-Income Country","volume":"13","author":"Suleman","year":"2021","journal-title":"Cureus"},{"key":"ref_2","doi-asserted-by":"crossref","unstructured":"Benk, J., Berger, T., Gottardi, R., Walter, T., Kondov, S., Rylski, B., Czerny, M., and Kreibich, M. 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