Bleeding and transfusion, common challenges in cardiac surgery, are influenced by comorbidity, the complexity of surgery, hypothermia, and the specifics of cardiopulmonary bypass inducing hemodilution, thrombin generation, fibrinolysis, and platelet dysfunction.1–4  Nearly 11% of patients with acute coronary syndromes undergo coronary artery surgery during dual antiplatelet therapy. Although preoperative P2Y12 receptor inhibitor therapy may reduce ischemic events, late preoperative exposure to P2Y12 receptor inhibitors increases the risk of surgery-associated bleeding and reoperation for bleeding.2,6–8 

Data from large observational studies suggest an association between the severity of coronary artery surgery–associated bleeding and 30-day postoperative morbidity and mortality.2,9–12  Suggested mechanisms are organ dysfunctions triggered by hypotension and decreased oxygen delivery after major blood loss in patients with arteriosclerotic disease and adverse effects of transfusion, such as hemolytic and immunologic...

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