Key result
Preoperative DOAC use linked to ~50% higher operative mortality in acute Type A aortic dissection.
Why the study?
Patients with acute Type A aortic dissection on preoperative DOACs, warfarin, or DAPT present unique surgical challenges with unclear outcomes.
Does preoperative use of DOACs, warfarin, or DAPT increase operative mortality and bleeding complications in patients undergoing first-time surgery for acute Type A aortic dissection?
Cohort (n=20,530)
Yes
Does preoperative use of DOACs, warfarin, or DAPT increase operative mortality and bleeding complications in patients undergoing first-time surgery for acute Type A aortic dissection?
Odds Ratio: 1.5 (95% CI 1.2–2)
Absolute Event Rate: 24.8% vs 17.9%
p-value: p=<0.001
Preoperative use of DOACs, warfarin, or DAPT is associated with significantly increased operative mortality and bleeding complications in patients undergoing surgical repair for acute Type A aortic dissection.
Preoperative DOAC use was associated with higher operative mortality in Type A dissection repair; leaves open whether reversal or delay strategies mitigate risk.
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.
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Kelly et al. (2026) conducted a cohort in Acute Type A aortic dissection (n=20,530). Preoperative DOACs, warfarin, or dual antiplatelet therapy vs. Matched controls (no preoperative DOAC, warfarin, or DAPT) was evaluated on Operative mortality (OR 1.50, 95% CI 1.2-2.0, p=<0.001). Preoperative use of DOACs before surgery for acute Type A aortic dissection was associated with higher operative mortality compared to matched controls (24.8% vs 17.9%, OR 1.50; P<0.001).
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