Surgery for Acute Type A Aortic Dissection on Preoperative Anticoagulants and Antiplatelet Agents

Abstract

Background: Patients taking direct oral anticoagulants (DOACs), warfarin, or dual antiplatelet therapy (DAPT) who present with acute Type A aortic dissection (ATAAD) are a unique challenge. Our objective was to investigate the surgical outcomes of this patient population. Methods: A retrospective cohort study was performed of 20,530 patients who underwent first-time sternotomy repair of ATAAD in the Society of Thoracic Surgeons Adult Cardiac Surgery Database from 2017 to 2022. Propensity score matching was used to pair each DOAC (n=625), warfarin (n=245), and DAPT (n=525) patient with 2 controls. Outcomes included operative mortality and reoperation for bleeding. Results: Compared to matched controls, mortality was higher for patients on DOACs (24.8% vs 17.9%, OR 1.50 [1.2,2.0], p<0.001), warfarin (26.7% vs 19.2%, OR 1.6 [1.1,2.4], p=0.02), or DAPT (27.4% vs 20.1%, OR 1.5 [1.2,2.0], p=0.001). Reoperation for bleeding was higher for DOACs (12.0% vs 7.0%, OR 1.8 [1.3,2.5], p=0.001) and DAPT (15.2% vs 7.3%, OR 2.2 [1.6,3.2], p<0.001), and trended that way for warfarin (11.4% vs 7.8%, OR 1.5 [0.9,2.6], p=0.11). Most DOAC (76.5% [478/625]) and DAPT (71.2% [374/525]) patients underwent surgery on the day of admission. While there was a non-significant difference toward lower mortality for DOAC patients who had surgery on day ≥1 (17.4% vs 25.0%, p=0.08), there was no difference for those on DAPT. Conclusions: Patients undergoing first-time surgery for ATAAD on DOACs, DAPT, or warfarin preoperatively had increased mortality and bleeding complications. For those on DOACs or DAPT, further study is required to investigate whether delaying surgery impacts outcomes.

Bo Zhang

Assistant Professor of Biostatistics

My research interests include design of observational studies, instrumental variables, application of causal inference in medicine and applied statistics in general.