Impact of Peri-Procedural Red Blood Cell Transfusion on Clinical Outcomes in Transcatheter Aortic Valve Replacement: A Propensity-Matched Cohort Study

BACKGROUND: Red blood cell (RBC) transfusion is common after transcatheter aortic valve replacement (TAVR) to manage peri-procedural bleeding and has been associated with adverse outcomes in various studies. However, the prognostic impact of peri-procedural transfusion in TAVR patients remains unclear. This study aimed to assess the impact of peri-procedural RBC transfusion on cardiovascular outcomes in TAVR patients compared to those without transfusion.

METHODS: A retrospective cohort study was conducted using the TriNetX US Collaborative Research Network, including adults undergoing TAVR until August 31, 2025. Patients were divided into those receiving RBC transfusion (n = 3,176) and those without (n = 79,664) on the day of receiving TAVR. Propensity score matching (1:1) balanced cohorts (n = 3161 each) for demographics, comorbidities, medications, and laboratory values. Relative risks (RR) and hazard ratios (HR) were calculated using propensity-matched and Cox proportional hazard models.

RESULTS: Transfused patients had significantly higher all-cause mortality (RR 3.933; 95% CI: 2.27-6.92; p < 0.001 at 7 days; RR 1.824; 95% CI: 1.466-2.268; p < 0.001 at 3 months). Secondary outcomes showed elevated risks for MACE (RR 1.324; 95% CI: 1.073-1.633; p = 0.009 at 7 days; RR 1.199; 95% CI: 1.060-1.358; p = 0.004 at 3 months), hemodynamic instability (RR 2.063; 95% CI: 1.655-2.571; p < 0.001 at 7 days; RR 1.638; 95% CI: 1.368-1.962; p < 0.001 at 3 months), acute kidney injury (RR 1.615; 95% CI: 1.295-2.013; p < 0.001 at 7 days; RR 1.379; 95% CI: 1.196-1.591; p < 0.001 at 3 months), and post-TAVR sepsis (RR 1.184; 95% CI: 0.771-1.819; p = 0.439 at 30 days; RR 0.899; 95% CI: 0.667-1.211; p = 0.483 at 3 months). Ischemic stroke/TIA risk was modestly increased in unadjusted analyses but attenuated post-matching (RR 1.123; 95% CI: 0.823-1.534; p = 0.464 at 7 days; RR 1.219; 95% CI: 0.995-1.493; p = 0.056 at 3 months). Cox models showed statistically significant risk elevations for most outcomes, including heart failure exacerbation (HR 1.418; 95% CI: 1.311-1.533; p < 0.001).

CONCLUSIONS: Peri-procedural RBC transfusion was associated with increased risks of mortality and complications after TAVR, with attenuation over time. These findings support consideration of restrictive transfusion strategies.