Current views on topical tranexamic acid in cardiac surgery—literature and guidelines review

Abstract Background Tranexamic acid (TXA) is commonly utilized across multiple medical fields. This review evaluates the efficacy of its topical administration in cardiac surgery. Main body of the abstract A comprehensive search of the PubMed database has been conducted using the keywords “tranexamic acid local cardiac surgery” and “tranexamic acid topical cardiac surgery.” In addition to PubMed, other relevant sources were reviewed, resulting in the selection of 23 meta-analyses, systematic reviews, and randomized controlled trials. This review evaluates the efficacy of topical TXA compared to intravenous (IV) TXA alone, saline, and the combination of IV and topical TXA in adult patients undergoing cardiac surgery. Results In comparisons with placebo, topical TXA reduced postoperative blood loss; however, its impact on transfusion rates remains unclear. When compared to IV TXA, topical administration demonstrated similar efficacy in minimizing blood loss and was associated with a lower risk of postoperative seizures. However, topical TXA was linked to a higher incidence of blood transfusions. Studies comparing combined topical and IV TXA with IV administration alone reported no significant differences in blood loss or transfusion rates. Variability in patient populations and study protocols limited the ability to make direct comparisons. In off-pump coronary artery bypass grafting (OPCAB), topical TXA may reduce postoperative blood loss, but no studies have directly compared its effectiveness to IV TXA in this context. Furthermore, graft patency, a critical measure for assessing the safety of antifibrinolytic agents, was not evaluated. Conclusions Topical TXA has shown promising results in reducing blood loss after cardiac procedures. Nevertheless, further research is needed due to the significant heterogeneity and limited sample sizes in existing studies. Current clinical guidelines indicate that topical TXA is less effective than IV TXA for reducing transfusion requirements, suggesting that topical TXA should not be administered routinely in every case (Class III, Level B). Topical TXA may be considered when standard hemostatic methods are insufficient (Class II, Level B). Furthermore, guidelines recommend the use of topical TXA after cardiopulmonary bypass (CBP) to decrease postoperative drainage and transfusion requirements (Class IIA, Level B-R).