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Blood transfusion in percutaneous left atrial appendage occlusion: a nationwide analysis of incidence, predictors, and outcomes

BMC Cardiovascular Disorders volume 25, Article number: 303 (2025) Cite this article

Abstract

Background

Patients with atrial fibrillation (AF) may benefit from PLAAO, a method proven to reduce the risk of stroke. However, the risk of requiring blood transfusion during the perioperative period has not been adequately evaluated.

Objectives

Using a comprehensive nationwide database, this study aimed to evaluate the frequency of transfusion events, identify contributing factors, and assess clinical outcomes in individuals who underwent PLAAO.

Methods

A retrospective evaluation of 61,445 PLAAO procedures, documented in the Nationwide Inpatient Sample database from 2015 to 2019, was conducted. The analysis compared patient characteristics, underlying conditions, medical complications, institutional features, and clinical results between groups requiring and not requiring transfusion support. A multivariable logistic regression model was used to identify key predictors of blood transfusion.

Results

Transfusion support was necessary in 1.8% of procedures (1,090/61,445), with a decrease from 5.0% in 2015 to 1.7% by 2019. Independent factors associated with an increased need for transfusion included female sex, pre-existing conditions (chronic blood loss anemia, coagulopathy, fluid and electrolyte disorders, metastatic cancer, other neurological disorders, and peripheral vascular disorders), and complications (hemorrhage/seroma/hematoma, postoperative shock, urinary tract infections, gastrointestinal bleeding, acute heart failure, dialysis). Protective factors included elective admission and hospital location in the Midwest/North central, South, or West regions. The transfusion group experienced significantly poorer outcomes, with higher mortality (3.2% vs. 0.1%, P < 0.05), longer hospitalizations (median 3 vs. 1 day, P < 0.05), and greater hospital expenses (median $159,635 vs. $101,953, P < 0.05).

Conclusion

Patients undergoing PLAAO who require blood transfusion face significantly higher risks of death, extended hospital stays, and increased healthcare expenses. A thorough pre-procedure risk assessment could improve patient selection and minimize transfusion requirements.

Peer Review reports

Background

PLAAO serves as a critical therapeutic option for stroke prevention in patients with atrial fibrillation (AF), particularly when conventional anticoagulation therapy is unsuitable or poses excessive risks [1,2,3,4,5]. Despite its efficacy in preventing thromboembolism, this interventional procedure carries certain risks, including significant bleeding concerns. Current data indicate that approximately 5% of individuals undergoing PLAAO require blood product support [1].

While the administration of red blood cells (RBCs) is crucial for maintaining adequate tissue oxygenation, it can lead to several complications. These adverse events include acute pulmonary compromise, volume overload, thrombotic complications, and altered immune responses [6, 7]. Additionally, the administration of blood transfusion is associated with increased healthcare utilization, higher costs, a greater likelihood of in-hospital complications, and elevated mortality rates [6, 7]. Understanding the prevalence and predictors of transfusion requirements following PLAAO procedures is essential for developing preventive strategies and optimizing patient outcomes. To our knowledge, there have been no large-scale, cross-sectional studies specifically investigating the incidence of transfusion and the associated risk factors in the PLAAO patient population.

Our investigation aims to address this knowledge gap by analyzing a nationwide database to determine the frequency of and risk factors associated with blood transfusion in patients undergoing PLAAO. We hypothesize that specific patient demographics, comorbidities, and perioperative complications significantly increase the likelihood of blood transfusion in PLAAO procedures and correlate with adverse outcomes.

Methods

Data source

Data for our study was obtained from the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample (NIS), the largest all-payer hospitalization database in the United States. This resource accounts for approximately one-fifth of annual hospital discharge records from over 1,000 medical facilities across the nation [8]. The database includes comprehensive details on patient characteristics, hospital attributes such as location, capacity, and academic status, and financial metrics. As the research involved publicly accessible, de-identified data, an ethics committee review was not required.

Data collection

The investigation analyzed NIS entries from 2015 to 2019. PLAAO procedures were identified using the ICD-10-CM procedural classification 02L73DK. Cases involving transfusion were detected through specific diagnostic codes within the ICD-10-CM system. The study population excluded individuals younger than 18 years and those with missing data including death, age, gender, elective admission, LOS, race, type of insurance, bed size of hospital and total charge (Fig. 1).

Fig. 1
figure 1

Inclusion/exclusion process of PLAAO

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Subjects were categorized into two groups based on their perioperative transfusion requirements. Our analysis compared population characteristics, institutional features, and clinical outcomes between these groups, including hospitalization duration, expenditures, and mortality rates. Pre-existing conditions and medical complications were documented using ICD-10-CM diagnostic classifications (Table 1). The complications encompassed included cardiac arrest, hemorrhage/seroma/hematoma, stroke, postoperative shock, acute myocardial infarction, deep vein thrombosis, continuous trauma ventilation, postoperative delirium, convulsion, urinary tract infections, gastrointestinal bleeding, thrombocytopenia, sepsis, dialysis, and acute heart failure (Table 1).

Table 1 Variables used in binary logistic regression analysis
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Data analysis

Statistical evaluation was performed using SPSS software (version 25.0). Independent t-tests assessed continuous variables, and chi-square analysis was used for categorical data comparisons. To identify predictors of transfusion requirements, multivariable logistic regression was employed, incorporating patient attributes, facility characteristics, and clinical variables (Table 1). This analysis produced odds ratios with associated 95% confidence intervals, considering p < 0.05 as statistically significant [9]. To ensure nationally representative findings, appropriate survey weights, stratification variables, and cluster adjustments were implemented, accounting for the NIS's complex sampling methodology [5]. The risk assessment model was determined by studying the risk factors that occur in patients with PLAAO.

Results

Transfusion Frequency in PLAAO Interventions

A review of 61,445 PLAAO interventions from 2015 to 2019 indicated that blood transfusion was required in 1,090 cases, representing 1.8% of procedures. The annual transfusion rate decreased steadily from 5.0% in 2015 to 1.7% by 2019 (Fig. 2).

Fig. 2
figure 2

Annual incidence of blood transfusion in PLAAO

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Patient demographics and hospital characteristics

Statistical analysis revealed significant variations in demographic and clinical parameters between patients who received transfusions and those who did not. Although the median age for both groups was 77 years, age distribution patterns differed significantly (P = 0.016). Women constituted a higher proportion of the transfusion recipients (51.4% compared to 41.5% in non-recipients, P = 0.004). Elective admissions were less common among transfusion recipients (71.6% vs. 92.2%, P < 0.001) (Table 2).

Table 2 Patient characteristics and outcomes after percutaneous left atrial appendage occlusion (PLAAO) (2015–2019)
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Clinical outcomes associated with blood transfusion

Transfusion recipients experienced less favorable health outcomes. Mortality rates during hospitalization were significantly higher in this group (3.2% compared to 0.1%, P < 0.001). These individuals also required longer hospital stays (median duration 3 days vs. 1 day, P < 0.001) and incurred higher healthcare costs ($159,635 vs. $101,953, P < 0.001) (Table 2).

Risk Factors for Blood Transfusion

Multiple regression analysis identified several predictors of the need for transfusion: female sex (Fig. 3, Table 3), chronic blood loss anemia, coagulopathy, fluid and electrolyte disorders, metastatic cancer, other neurological disorders, and peripheral vascular disorders (Fig. 4).

Fig. 3
figure 3

Risk factors associated with blood transfusion in PLAAO

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Table 3 Risk factors associated with transfusion in PLAAO
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Fig. 4
figure 4

Relationship between blood transfusion and preoperative comorbidities

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Protective factors included elective admission and hospital locations in the Midwest/North Central, South, or West regions (Fig. 3, Table 3).

Factors Associated with Blood Transfusions during PLAAO

The requirement for blood transfusion was strongly correlated with various postoperative complications: hemorrhage/seroma/hematoma, postoperative shock, urinary tract infections, gastrointestinal bleeding, acute heart failure, and dialysis (Fig. 5). Hosmer–Lemeshow goodness of fit test shows that the model works well (p = 0.651).

Fig. 5
figure 5

Relationship between blood transfusion and postoperative complications

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The VIF of all variables is less than 5, and the correlation between these variables can be considered negligible.

Discussion

The management of atrial fibrillation has evolved considerably in recent years, with oral anticoagulant therapy for patients with stroke risk factors and surgical treatments (ablation/PLAAO) offering alternatives for those unsuitable for or intolerant to pharmacological approaches [10]. Patients with nonvalvular AF can be treated with PLAAO to reduce the risk of cardiogenic stroke, but the probability of postoperative massive bleeding is higher [11]. This study provides a comprehensive evaluation of blood transfusion frequency and its determinants following PLAAO procedures. Our research identified multiple significant predictors of transfusion requirements, including patient sex, underlying health conditions, hospital setting, medical complications. Earlier research exploring transfusion risk factors in this context was predominantly published as brief letter, lacking sufficient statistical power due to limited participant numbers [1]. Understanding these factors is crucial for developing targeted prevention strategies.

The observed downward trend in transfusion requirements from 2015 (5%) to 2019 (1.7%) (Fig. 2) can be attributed to several advancements: improved operative techniques, device improvements, adoption of conservative transfusion strategies, enhanced blood conservation methods, and improved adherence to transfusion guidelines [1, 12,13,14,15].Our analysis revealed an aggregate transfusion rate of 1.8%, markedly lower than the previously reported rate of 5% [1]. This reduction is likely due to two key factors. First, variation in data sources exist between studies, as previous investigations utilized multi-institutional registries with relatively small cohorts of 396 participants [1, 16]. Second, the temporal gap in data collection reflects ongoing improvements in surgical approaches and clinical practices [17]. Future prospects indicate potential for further reductions in transfusion frequency through enhanced blood management protocols and increased focus on high-risk patient populations [15].

Our study demonstrated that being female is a significant independent predictor of requiring blood transfusions during the perioperative period (Fig. 3 and Table 3). Clinical data strongly supports this gender-specific risk pattern [18,19,20]. The increased transfusion requirements among female patients can be attributed to their higher susceptibility to complications and generally less favorable clinical outcomes [18, 20]. Studies have shown that women tend to experience greater age-related thickening and stiffness of blood vessels as they age than men, which puts women at higher risk for bleeding [21]. Furthermore, the correlation between gender and transfusion needs seems partly rooted in basic physiological differences: women's normal hemoglobin ranges are characteristically lower than men's, yet current practice rarely incorporates sex-specific adjustments to transfusion threshold values [19, 20].

Our study corroborates existing findings that blood transfusions are associated with prolonged hospital stays, increased healthcare costs, and elevated mortality rates (Table 2). Notably, each unit of blood transfused is associated with an approximate direct cost of $2,500 to the hospital, aside from contributing to a higher frequency of perioperative complications [22,23,24,25,26,27]. Research by Murphy and colleagues highlights a significantly higher mortality risk, six times greater within 30 days in patients undergoing cardiac surgery who received transfusions compared to their non-transfused counterparts [25].

Elective admissions are associated with lower requirements for blood transfusions, likely due to superior preoperative patient health and adequate preparation time [23]. Supporting this, Long and colleagues found that emergency admissions considerably elevate the probability of needing perioperative blood transfusions in the surgical treatment of colorectal cancer liver metastases, as evidenced by their analysis of U.S. NIS data [28]. The proportion of patients undergoing PLAAO among elective admissions was significantly higher at Northeast Hospital compared to other regions, potentially identifying Northeast Hospital as a risk factor in this cohort (Fig. 6). Geographic disparities in U.S. transfusion rates reflect variability in healthcare technology access, institutional protocols, socioeconomic disparities, and guideline adherence across healthcare facilities [17, 29, 30].

Fig. 6
figure 6

Geographic differences of institutional-level factor

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The identification of preoperative risk factors is essential in reducing the necessity for blood transfusions during surgical procedures [23]. Schiergens and colleagues highlighted key predictors, such as female gender, existing anemia, and significant operative blood loss, corroborating our research [28]. Our research identified correlations between medical conditions and transfusion requirements, particularly in patients with anemia, coagulopathies, and electrolyte imbalances, due to compromised hemoglobin levels [17, 23, 26, 31]. The transfusion further alters coagulation dynamics, resulting in dilutional phenomena and consumption coagulopathy, which, coupled with diminished platelet counts, may worsen outcomes for those with existing clotting abnormalities [32]. Munting and associates have also noted that insufficient preoperative hemoglobin levels can necessitate the deferral of surgeries while interventions are applied to improve hemoglobin concentrations [33].

Our study revealed that metastatic cancer significantly predicts the need for blood transfusions during surgical procedures (Fig. 4), affirming the hypothesis that patients in poor health are more susceptible to surgical blood loss [23]. Additionally, the study identified risk factors like peripheral vascular and neurological disorders. Huang et al. note surgical stress increases transfusion needs in patients with circulatory disorders [16]. Clinical data also shows that the blood transfusion correlates with a higher occurrence of infections, respiratory complications, blood-borne infections, and adverse cardiac outcomes [7]. These results highlight the critical need for early detection of patients at high risk for transfusions, promoting prompt participation in PBM programs to lessen dependency on transfusions [34].

Moreover, our study links post-PLAAO blood transfusions to acute heart failure, due to blood rheology changes affecting circulatory volume and cardiac stress, consistent with previous transfusion-related findings. [15, 23]. Our research also identified a significant association between UTIs and transfusions post-PLAAO (Fig. 5). The implicated mechanism, Transfusion-Related Immune Modulation (TRIM), temporarily diminishes immune function, compromising the body's defenses [22, 26, 28, 35, 36]. Furthermore, infections following surgery activate immune-mediated coagulation pathways, complicating the clinical environment by reducing blood volume and simultaneously increasing transfusion requirements [16]. Meta-analytical studies by Hill and associates have shown that transfusion recipients are over three times more likely to develop systemic infections post-surgery [32]. Our research confirms blood transfusion's link to complications (hemorrhage/seroma/hematoma, postoperative shock, gastrointestinal bleeding). Studies attribute these to reduced hemoglobin and increased bleeding susceptibility [17]. Additionally, our study revealed transfusion needs correlate with dialysis procedures, possibly due to enhanced red blood cell breakdown or compromised production in dialysis patients [37].

The study identified the risk factors for blood transfusion in PLAAO patients, and clinicians adopted more precise anticoagulation strategies based on the patient's risk factors. Studies have shown that different anticoagulation strategies help improve patient outcomes [38].

Limitation

This study presents several inherent limitations that merit attention. The reliance on administrative datasets introduces notable constraints, especially in terms of accessing detailed clinical metrics like specific measurements of blood loss, perioperative hemoglobin levels, and precise quantities of blood products used. Additionally, our dataset does not include details on the management of medications prior to procedures, particularly concerning protocols for anticoagulation and antiplatelet therapies, which are critical factors influencing bleeding outcomes. Due to the observational nature of this study, we are limited to identifying associations, not establishing causality. While the substantial size of our cohort provides robust statistical power, we must recognize that variations in coding practices over time and potential coding inaccuracies could influence the interpretation of our results. Our analysis was confined to inpatient data, precluding us from assessing complications or outcomes that occurred post-discharge and outpatient procedures. However, the broad scope of our patient base and the inclusion of multiple institutions still allow us to offer valuable perspectives on transfusion needs and related risk factors during left atrial appendage closure procedures.

Conclusion

Our research shows blood transfusion rates in PLAAO procedures decreased from 5.0% to 1.7% between 2015–2019. Female patients and those with pre-existing conditions showed higher transfusion risks. Major complications included hemorrhage, shock, UTIs, gastrointestinal bleeding, heart failure, and dialysis requirement. Transfusion recipients experienced extended hospitalizations, increased complications, higher costs, and elevated mortality. These findings emphasize the importance of thorough pre-procedural risk assessment and optimization strategies to improve PLAAO outcomes.

Data availability

This study is based on data provided by Nationwide Inpatient Sample (NIS) database, part of the Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality. The NIS database is a large publicly available full-payer inpatient care database in the United States and the direct web link to the database is https://www.ahrq.gov/data/hcup/index.html.Therefore, individual or grouped data cannot be shared by the authors.

Abbreviations

AF:

Atrial Fibrillation

PLAAO:

Percutaneous Left Atrial Appendage Occlusion

RBC:

Red Blood Cell

NIS:

Nationwide Inpatient Sample

ICD-10-CM:

International Classification of Diseases, Tenth Revision, Clinical Modification

PBM:

Patient Blood Management

TRIM:

Transfusion-Related Immune Modulation

UTIs:

Urinary Tract Infections

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Acknowledgements

Not applicable.

Clinical trial number

Not applicable.

Funding

1.National Natural Science Foundation of China (82172162 to Chunbo Chen).

2.National Natural Science Foundation of China (82,472,211 to Chunbo Chen).

3.Major Program of Summit Project, Guangdong Province High-level Hospital Construction Project of Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences (DFJH2020028 to Chunbo Chen).

Author information

Author notes

  1. Binbin Tian & Chengzhao Huang

    Present address: Department of Critical Care Medicine, Central People’s Hospital of Zhanjiang, Zhanjiang, 524045, Guangdong, China

  2. Chunbo Chen

    Present address: Department of Critical Care Medicine, Shenzhen People’s Hospital, The Second Clinical Medical College of Jinan University, The First Affiliated Hospital of South University of Science and Technology, Shenzhen, 518020, China

  3. Binbin Tian, Chunbo Chen and Chengzhao Huang contributed equally to this work.

Authors and Affiliations

  1. Department of Critical Care Medicine, Central People’s Hospital of Zhanjiang, Zhanjiang, 524045, Guangdong, China

    Qiuqiang Chen, Junde Mo, Guorong Zhong & Xiaozhuo Chen

  2. Department of Respiration, The Second Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, 524002, China

    Junfen Cheng

  3. Department of Neurosurgery II, Central People’s Hospital of Zhanjiang, Zhanjiang, Guangdong, 524045, China

    Haiqiang Wu

  4. Division of Orthopaedic Surgery, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, 510515, China

    Jian Wang

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Contributions

BT, CC, and CH were involved in the study design, data collection and analysis, result interpretation, as well as drafting and revising the manuscript. QC, HW and JC participated in the study design, result interpretation, and critical review of the manuscript. JW was responsible for data collection, analysis, and manuscript review. XC, JM and GZ contributed to designing the study, interpreting the results, and providing critical revisions. All authors have read and approved the final version of the manuscript.

Corresponding authors

Correspondence to Junde Mo, Guorong Zhong or Xiaozhuo Chen.

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Human Ethics and Consent to Participate declarations: not applicable. This article does not contain any studies with human participants or animals performed by any of the authors. This observational study was deemed exempt by the Institutional Review Board of Central People's Hospital of Zhanjiang because it used deidentified publicly available data.

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Tian, B., Chen, C., Huang, C. et al. Blood transfusion in percutaneous left atrial appendage occlusion: a nationwide analysis of incidence, predictors, and outcomes. BMC Cardiovasc Disord 25, 303 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12872-025-04662-3

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  • DOI: https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12872-025-04662-3

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BMC Cardiovascular Disorders

ISSN: 1471-2261

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