National health expenditures rose to 3.8 trillion dollars in 2019, 18% of gross domestic product, and are continuing to rise at an unsustainable rate.¹ Aggregate costs for hospitalizations associated with blood transfusions are one of the fastest growing areas of expense, at 12.5%.² In addition, and more important, blood transfusions are associated with increased patient morbidity and mortality in cardiac surgery. Of all types of surgery, cardiac surgery demonstrates the highest rates of blood transfusion nationally, with approximately 50% of patients receiving a blood transfusion during hospitalization.^3–7 These data have highlighted the need for multimodal patient blood management programs to reduce unnecessary transfusions. In this review, we attempt to distill the cacophony of available blood conservation techniques down to the 7 most important pillars necessary for a cardiac surgery program to significantly reduce red blood cell (RBC) transfusions (Fig. 1).