Blood transfusion is surprisingly common in the peri-transplant period, although rates have declined with the shift from cardiopulmonary bypass to ECMO. At TGH, two-thirds of patients receive pRBCs intraoperatively or within 24 h. Tranexamic acid appears safe in thoracic and transplant surgery, with evidence supporting early administration (≤50 mg/kg) to reduce blood loss. Transfusion decisions are individualized, guided by hemodynamics, bleeding, and coagulation targets.