Prior intake of new oral anticoagulants adversely affects outcome following surgery for acute type A aortic dissection

Abstract

Objectives: Oral anticoagulation prior to emergency surgery is associated with an increased risk of perioperative bleeding, especially when this therapy cannot be discontinued or reversed in time. The goal of this study was to analyse the impact of different oral anticoagulants on the outcome of patients who underwent emergency surgery for acute type A aortic dissection (ATAAD).

Methods: This was a single-centre retrospective study of patients treated with oral anticoagulation at the time of surgery for ATAAD. Outcomes of patients on new oral anticoagulant (NOAC) therapy were compared to respective outcomes of patients on Coumadin. Additionally, a survival analysis was performed comparing these 2 groups with patients who were operated on with no prior anticoagulation.

Results: Between January 2013 and April 2020, a total of 437 patients (63.8 ± 11.8 years, 68.4% male) received emergency surgery for ATAAD; 35 (8%) were taking oral anticoagulation at the time of hospital admission: 20 received phenprocoumon; 14, rivaroxaban; and 1, dabigatran. Compared to Coumadin, NOAC was associated with a greater need for blood-product transfusions and haemodynamic compromise. Operative mortality was 53% in the NOAC group and 30% in the Coumadin group. A 5-year survival analysis showed no significant difference between the NOAC and the Coumadin group (P = 0.059). Compared to 402 patients treated during the study period without anticoagulation, patients taking NOAC had significantly worse survival (P = 0.001), whereas that effect was not observed in patients undergoing surgery who were taking Coumadin (P = 0.99).

Conclusions: Emergency surgery for ATAAD in patients taking NOAC is associated with high morbidity and mortality. NOAC are a major risk factor for uncontrollable bleeding and haemodynamic compromise. New treatment strategies must be defined to improve surgical outcomes in these high-risk patients.

Keywords: Acute aortic syndrome; Aortic dissection; Bleeding; Coumadin; DOAC; NOAC; Oral anticoagulation; Type A dissection.

Figure 1:

Anaesthetist’s view of a Cabrol fistula from the upper mediastinum into the right atrium after repair of acute type A aortic dissection. CB: Cabrol baffle in the upper mediastinum; DG: 8 -mm Dacron graft; RAA: right atrial appendage; RV: right ventricle.

Figure 2:

(a) Survival in patients treated for acute type A aortic dissection taking Coumadin, new oral anticoagulants and no anticoagulation. Coumadin versus new oral anticoagulants: P = 0.059; Coumadin versus no anticoagulation: P = 0.99; new oral anticoagulants versus no anticoagulation: P = 0.001. (b) Survival functions with 95% confidence intervals. Mean survival time [years]: new oral anticoagulants 2.2 ± 0.8; Coumadin 4.7 ± 0.8; no anticoagulation 5.2 ± 0.2.