Does preoperative dual antiplatelet therapy affect bleeding and mortality after total arch repair for acute type A dissection?

Abstract

OBJECTIVES Data are scarce and mixed regarding the impact of preoperative dual antiplatelet therapy (DAPT) on the surgical outcomes of acute type A aortic dissection (ATAAD). We seek to evaluate the impact of DAPT on bleeding-related events and early- and mid-term mortality after total arch replacement and frozen elephant trunk in such patients. METHODS This study comprised 48 ATAAD patients on preoperative DAPT and 418 without DAPT (the whole series, i.e. unmatched cohort), from which 45 matched pairs were selected by propensity score (matched cohort). Bleeding-related events (reoperation for bleeding, bleeding of ≥1500 ml within the first 12 h postoperatively or transfusion of ≥10 units of red blood cell or use of recombinant activated factor VII), operative mortality and mid-term survival were compared in the unmatched and matched cohorts. The impact of preoperative DAPT was evaluated with multivariable analysis. RESULTS In the unmatched cohort, bleeding of ≥1500 ml/12 h postoperatively was more common in the DAPT group (18.8% vs 8.4%, P = 0.020); operative mortality was 9.7%, which did not differ with DAPT (12.5% vs 9.3%, P = 0.48). Nor did bleeding-related events (54.2% vs 43.5%, P = 0.16) differ significantly between 2 groups. In the matched cohort, neither were drainage of ≥1500 ml/12 h (20% vs 6.7%, P = 0.063) and bleeding-related events (53.3% vs 42.2%, P = 0.30), nor operative mortality (13.8 vs 8.9%, P = 0.50) and mid-term survival (79.3% vs 76.4%, P = 0.93) significantly different between 2 groups. DAPT was not identified as a predictor for operative mortality [odd ratio (OR) 0.97, 95% confidence interval (CI) 0.31–3.08; P = 0.96; adjusted OR 1.28, 95% CI 0.22–7.20; P = 0.78] and bleeding-related events (OR 1.50, 95% CI 0.76–2.95; P = 0.24; adjusted OR 2.03, 95% CI 0.80–3.66; P = 0.14). CONCLUSIONS In patients with ATAAD undergoing total arch replacement and frozen elephant trunk, although preoperative DAPT led to more postoperative bleeding, it did not increase bleeding-related events nor operative mortality nor mid-term death. The results of this study imply that for patients with ATAAD, emergency surgical repair, even if as extensive as total arch repair, should not be contraindicated or delayed simply because of ongoing DAPT.

Standardized in vitro bleeding tests in a non-coated novel hybrid prosthesis for frozen elephant trunk demonstrates minimal oozing during full heparinization, supported by clinical data

“…In particular, the hemostasis system and coagulation cascade might be impaired by (deep) hypothermia and the cardiopulmonary bypass itself (13,(16)(17)(18)(19). In addition to these mandatory but potentially harmful intraoperative prerequisites, the coagulation system could also be significantly influenced or impaired in patients treated with P2Y 12 inhibitors or direct oral anticoagulants (DOACs) (20)(21)(22). In some patients, an aortic syndrome or dissection might be misdiagnosed as an acute coronary syndrome being loaded with potent P2Y 12 inhibitors such as ticagrelor.…”

Letter to the Editor: Outcomes of preoperative antiplatelet therapy in patients with acute type A aortic dissection

“…1 Yet, the authors did not include the dosage of preoperative DAPT medication administered to the patients. 3 Due to overlapping symptoms, ATAAD is often misdiagnosed as an acute coronary syndrome (ACS); thus, it is crucial to improve hospital emergency departments' diagnostic and treatment capabilities. Echocardiography (both transthoracic and transesophageal) should be used as the first-line method for ATAAD patients to identify intimal tears, dissection involvement, left ventricle contraction disturbance, and cardiac tamponade.…”