Combining topical and intravenous tranexamic acid in cardiac surgery: does it really matter? - a systematic review and meta-analysis.

Background: The benefit-to-risk ratio of administration of intravenous (IV) and topical tranexamic acid (TXA) together in cardiac surgery has not yet been determined. This study aims to evaluate whether the combined approach (IV plus topical TXA) offers superior bleeding control compared to IV TXA alone, while maintaining an acceptable safety profile. Methods: We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) and observational studies comparing combined topical and intravenous TXA administration versus IV TXA alone in patients undergoing cardiac surgery. The primary outcome was cumulative blood loss. Secondary outcomes included all-cause mortality, transfusion-free status, and the number of transfused blood products. A random-effects model was used for all pooled analyses. Results: We included a total of five studies (four RCTs, one observational; n = 880). Pooled analysis showed that the combined approach significantly, but modest, reduced total blood loss when compared to an IV-only TXA strategy (MD -39.84, 95 %CI -74.80 to -4.88; p = 0.03; I2 = 39 %). However, this benefit did not translate into a significant reduction in transfusion requirements (OR 1.00, 95 %CI 0.72 to 1.37; p = 0.98; I2 = 0 %), volume of blood products used (MD -0.01, 95 %CI -0.04 to 0.02; p = 0.51; I2 = 0 %), or all-cause mortality (OR 0.85, 95 %CI 0.24 to 3.08; p = 0.81; I2 = 0 %). Conclusion: Combined topical and IV TXA application is associated with reduced total blood loss after cardiac surgery compared to an IV-only approach. However, no significant differences were observed in transfusion rates, blood product utilization, or mortality.