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

• Published in: Interactive cardiovascular and thoracic surgery Vol. 35; no. 1
• Main Authors: Sromicki, Juri, Van Hemelrijck, Mathias, Schmiady, Martin O, Krüger, Bernard, Morjan, Mohammed, Bettex, Dominique, Vogt, Paul R, Carrel, Thierry P, Mestres, Carlos-A
• Format: Journal Article
• Language: English
• Published: England Oxford University Press 15.06.2022
• Subjects: Vascular; Oral anticoagulation; Type A dissection; NOAC; Acute aortic syndrome; Aortic dissection; Coumadin; DOAC; Bleeding
• ISSN: 1569-9293; 1569-9285
• DOI: 10.1093/icvts/ivac037

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. The increasingly liberal use of new oral anticoagulants (NOAC) represents a challenge when dealing with patients at high risk of bleeding.