Demands for allogeneic blood transfusion in cardiac surgery were still high two decades ago. Today there is a gradual decline in transfusion requirements owing to recent advances in cardiac surgery and related specialties that have together developed techniques for perioperative blood salvage and its autotransfusion; this trend continues to progress towards bloodless surgery. Its milestones have included a refinement of surgical methods, a better understanding of bleeding pathology related to extracorporeal circulation and an introduction of coagulation monitoring during surgery, using point-of-care testing [1,2,3,4,5]. A significant advancement in extracorporeal circulation came with the development of less aggressive, more biocompatible and miniature-circuit systems [6, 7]. As a result, allogeneic blood transfusion is currently not needed in over 50% of all surgical procedures and in almost 100 % of coronary heart operations [8,9]. However, over 40 % of patients undergoing cardiac surgery still require allogeneic blood transfusion; of them, 5-7 % show an excessive blood loss (more than a normal circulating blood volume), 10-15 % have a large blood loss (more than 2000 ml) and about 15-20 % have a moderate blood loss (1000 ml to 2000 ml) during the day of surgery up to 7 am next day. The average transfusion requirement ranges between 2 and 4 units of packed red blood cells (PRBC) per adult patient, depending on the centre. Cardiac surgery centers commonly utilize 10 to 15 % of the RBCs production of the regional blood bank centers [10]. In the last two decades, the efforts to develop techniques for refinements of surgical methods and peri-operative blood salvage have intensified because of an increase in the number of reoperations and surgery on elderly, polymorbid patients with preoperative anemia. These are the major components of a multi-modality strategy that involves the preoperative preparation of a patient, surgical procedures, drug administration and homeostatic maintenance (Table 1).