Outcome in patients operated for acute aortic dissection: Influence of preoperative antiplatelet therapy on mortality and bleeding complications

Abstract

Introduction. Outcome in patients with acute coronary syndrome (ACS) is improved when treated with dual antiplatelet therapy (DAPT). Patients with acute aortic dissection type A (AAD) often present with similar symptoms and may be prescribed DAPT before the diagnosis of AAD is established. Treatment with DAPT prior to AAD surgery has been associated with an increased 30-day mortality and intraoperative bleeding. European Society of Cardiology's (ESC) guidelines for ACS incorporated ticagrelor in 2011 and currently recommend DAPT with ticagrelor and aspirin as first line treatment. Method. We performed a retrospective single-centre observational study with inclusion of 171 patients operated for AAD type A from January 1, 2010 - December 31, 2014 at, Rigshospitalet, Copenhagen, Denmark. Patients were identified through a surgical database and data collected from patient records and the intensive care patient data management system. Primary endpoint was 30-day mortality. Secondary endpoints were intraoperative bleeding and perioperative transfusions requirements. Statistical analyses were performed using SPSS Statistics version 22. Results. Patients receiving any kind of antiplatelet therapy (APT) (n=73) did not show an increased 30-day mortality (29% vs. 20%, p=0.18). APT prior to surgery was associated with an increased intraoperative bleeding (4.8 ± 3.9 L vs. 3.3 ± 4.9 L, p<0.001) and transfusion requirements of red blood cells (3.8 ± 3.5 L vs. 2.3 ± 2.4 L, p<0.001), fresh frozen plasma (3.8 ±3.4 L vs. 2.5± 2.0, p=0.004) and platelets (2.4 ± 2.2 L vs. 1.6 ± 1.7 L, p=0.01), respectively. Echocardiography was less often performed among patients receiving APT compared to no APT (19% vs. 45%, p<0.001). There was no difference in 30-day mortality among patients receiving DAPT compared to APT and no APT (24% vs 24%, p=0.95). DAPT including ticagrelor (n=15) showed a significantly increased intraoperative bleeding compared to clopidogrel (n=29) (7.6 ± 3.1 L vs. 4.7 ± 4.1 L, p=0.004). Among patients receiving DAPT, 30% fulfilled ESC criteria for APT. Discussion. In agreement with previous studies, the use of APT was associated with increased intraoperative bleeding and transfusion requirement. However, no significant association was found between patients treated with platelet inhibitors and mortality. Pre-surgery DAPT with ticagrelor further increased intraoperative bleeding compared to clopidogrel. Only a minor proportion of patients fulfilled ESC criteria for DAPT. In the future, immediate echocardiography may contribute in establishing the diagnosis of AAD, although we cannot make any conclusions in this respect due to the observational design in the present study.