Inclusion Criteria:

- >= 12 years old

- >= 40 kg body weight

- Scheduled complex cardiac surgery with planned use of median sternotomy.

- Patients ≥ 18 years must have a Transfusion Risk Understanding Scoring Tool (TRUST)
probability score ≥ 3

Exclusion Criteria:

- Refusal of blood products

- Planned surgery is minimally invasive

- Known transfusion reaction history

- Requirement for washed products, volume reduced products, or products with additive
solution removed

- Expected residual cyanosis with O2 saturation < 90

- Left ventricular assist device (LVAD) or Extracorporeal membrane oxygenation (ECMO)
support pre-operatively or planned need post-operatively

- Cardiogenic shock requiring pre-operative placement of an Intra-aortic balloon pump
(IABP) (IABP done for unstable angina or prophylactically for low ejection fraction
is not excluded)

- Planned Deep Hypothermic Circulatory Arrest (DHCA)

- Renal dysfunction requiring pre-operative renal replacement therapies such as
hemodialysis (HD) or continuous venovenous hemofiltration (CVVH)

- Planned use of alternative to heparin, e.g. bivalirudin

- Planned use of autologous or directed donations

- Prior RBC transfusion during hospitalization for the study-qualifying surgery

- Prior randomization into the RECESS study