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Article pour les cliniciens

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Liberal or Restrictive Postoperative Transfusion in Patients at High Cardiac Risk: The TOP Randomized Clinical Trial.

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• Kougias P
• Sharath SE
• Zhan M
• Carson JL
• Norman LE
• Mi Z, et al.

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Commentaires cliniques (en anglais)

Anesthesiology

While this information is known, changing clinician behavior remains a challenge.

Anesthesiology

This is a well conducted parallel trial of 1428 adult patients in 16 centres across the USA. All patients has known IHD/previous CVA/peripheral arterial disease, underwent major vascular (91%) or general surgical procedures, and were randomised to liberal (L) (<10g/dL) or restrictive (R) (<7g/dL) transfusion triggers. Mean hemoglobin was 2g/dL higher in the L group at day 5 post-op. They found an overall lower morbidity and mortality than expected, leaving the study slightly underpowered. No difference was observed in the primary outcomes (all-cause mortality, MI, PCI, AKI or ischaemic stroke) (RR: 0.9 CI 0.65-1.24), an increase in cardiac complications (excluding MI) was seen in the R group, notably decompensated heart failure. The authors should be commended for this interesting and useful study showing no increase in cardiovascular morbidity and mortality in patients with increased risk. Future studies should include other types of major surgery and more female patients.

Hematology

This is not directly relevant to hematology except for transfusion medicine professionals. It is relevant to cardiology and cardio and vascular surgery.

Hematology

In the wake of the "MINT" trial (which randomized patients with myocardial infarction and suggested a benefit of liberal RBC transfusion), these results (from a surgical population at high-cardiac risk) certainly merit being highlighted.

Hospital Doctor/Hospitalists

This is an important and rigorous trial that any physician caring for postoperative patients should be familiar with. Unfortunately, the trial was underpowered to find a statistically significant difference in the primary outcome due to lower than expected event rates; however, several of the individual components of the primary outcome favored the liberal strategy, albeit not statistically significantly, and despite more than a 2 g difference in the mean hemoglobin level between the two groups. The results of this trial should lead to nuanced approaches for individual patients rather than firm conclusions about hemoglobin thresholds in postoperative patients with anemia.

Surgery - General

These results are expected.

Surgery - Vascular

As a vascular surgeon caring for high–cardiac-risk postoperative patients, I find this trial highly relevant. The methodology is solid with clear outcome adjudication and meaningful hemoglobin separation between groups. The lack of benefit from a liberal transfusion strategy reinforces current restrictive thresholds. The higher rate of non–MI cardiac complications in the restrictive group is a noteworthy signal that merits further investigation but does not outweigh the overall neutrality of the primary outcome. These findings provide valuable evidence to guide perioperative transfusion decisions in major vascular surgery.