Patients Undergoing Surgery for Acute Type A Aortic Dissection on Preoperative Anticoagulants and Antiplatelets

J. J. Kelly¹, Z. Chen², J. E. Bavaria³, W. L. Patrick⁴, Y. Zhao¹, C. R. Brown¹, K. M. Lawrence¹, B. Zhang⁵, W. Y. Szeto¹, N. D. Desai^1
1University of Pennsylvania, Philadelphia, Pennsylvania ²Department of Statistics, University of Illinois Urbana-Champaign, Champaign,, Illinois ³Department of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA, Philadelphia, Pennsylvania ⁴Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, PA, Philadelphia, Pennsylvania ⁵Biostatistics, Bioinformatics and Epidemiology Program, Fred Hutch Cancer Center, University of Washington, Seattle, WA, Seattle, Washington

Purpose: Little is known about the surgical outcomes of patients taking direct oral anticoagulants (DOACs), warfarin, or dual anti-platelet therapy (DAPT) who present with acute Type A aortic dissection (ATAAD). We investigated this patient population using a national cohort in the Society of Thoracic Surgeons Adult Cardiac Surgery Database (STS ACSD).

Methods: A matched retrospective cohort study was conducted used data from 23,597 patients who underwent repair of ATAAD in the STS ACSD from 2017 to 2022. The primary analysis used optimal 1-to-2 matching within propensity score caliper to pair each DOAC (n=710), warfarin (n=387), and DAPT (n=610) patient to 2 control patients (n=20,230) with similar baseline characteristics. Mantel-Haenszel tests were used to assess the association between clinical outcomes and preoperative anticoagulant or antiplatelet use in each of the DOAC, DAPT, and warfarin matched comparisons. A second matched cohort analysis further compared the clinical outcomes among DOAC patients who had surgery on the day of admission and those for which surgery was delayed least one day post admission. The primary outcome was operative mortality. Secondary outcomes included reoperation for bleeding and blood product transfusion.

Results: Compared to their matched controls, the DOAC, warfarin, and DAPT groups had similar mean age (DOAC: 69.8 vs 69.2, p=0.235; warfarin: 68.1 vs 67.4, p=0.369; DAPT: 64.6 vs 64.2, p=0.462), incidence of prior cardiac surgery (DOAC: 45.6% vs 44.1%, p=0.527; warfarin: 61.2% vs 58.4%, p=0.386; DAPT: 59.0% vs 57.2%, p=0.493), and presentation in Penn class A malperfusion (DOAC: 63.2% vs 63.9%, p=0.968; warfarin: 56.6% vs 59.6%, p=0.758; DAPT: 49.2% vs 51.1%, p=0.217). Operative mortality was significantly higher for patients on DOACs (25.9% vs 21.5%, OR 1.30 [1.04,1.62], p=0.020) and DAPT (28.0% vs 23.6%, OR 1.28 [1.01,1.61], p=0.039), and trended higher for those on warfarin (25.0% vs 19.8%, OR 1.35 [0.99,1.84], p=0.053). Reoperation for bleeding was significantly higher for all 3 medication groups (DOAC: 11.7% vs 8.7%, OR 1.41 [1.03,1.93], p=0.027; warfarin 11.4% vs 7.6%, OR 1.56 [1.01,2.42], p=0.037; DAPT 14.4% vs 6.9%, OR 2.24 [1.62,3.11], p< 0.001). Blood products were more often transfused in patients on DOACs, warfarin, and DAPT (Table 1). Most DOAC patients (74.4% [520/699]) underwent surgery on day 0 of admission. There was a trend towards reduced mortality for those who underwent surgery on day ≥1 (17.6% vs 25.6%, OR 0.64 [0.4,1.01], p=0.06).

Conclusion: Patients undergoing surgery for ATAAD who were taking DOACs, warfarin, or DAPT preoperatively had increased mortality, reoperation for bleeding, and requirement for blood transfusions.

Identify the source of the funding for this research project: Penn Aorta Center, University of Pennsylvania, Philadelphia, PA