Abstract

OBJECTIVES

Data are scarce and mixed regarding the impact of preoperative dual antiplatelet therapy (DAPT) on the surgical outcomes of acute type A aortic dissection (ATAAD). We seek to evaluate the impact of DAPT on bleeding-related events and early- and mid-term mortality after total arch replacement and frozen elephant trunk in such patients.

METHODS

This study comprised 48 ATAAD patients on preoperative DAPT and 418 without DAPT (the whole series, i.e. unmatched cohort), from which 45 matched pairs were selected by propensity score (matched cohort). Bleeding-related events (reoperation for bleeding, bleeding of ≥1500 ml within the first 12 h postoperatively or transfusion of ≥10 units of red blood cell or use of recombinant activated factor VII), operative mortality and mid-term survival were compared in the unmatched and matched cohorts. The impact of preoperative DAPT was evaluated with multivariable analysis.

RESULTS

In the unmatched cohort, bleeding of ≥1500 ml/12 h postoperatively was more common in the DAPT group (18.8% vs 8.4%, P = 0.020); operative mortality was 9.7%, which did not differ with DAPT (12.5% vs 9.3%, P = 0.48). Nor did bleeding-related events (54.2% vs 43.5%, P = 0.16) differ significantly between 2 groups. In the matched cohort, neither were drainage of ≥1500 ml/12 h (20% vs 6.7%, P = 0.063) and bleeding-related events (53.3% vs 42.2%, P = 0.30), nor operative mortality (13.8 vs 8.9%, P = 0.50) and mid-term survival (79.3% vs 76.4%, P = 0.93) significantly different between 2 groups. DAPT was not identified as a predictor for operative mortality [odd ratio (OR) 0.97, 95% confidence interval (CI) 0.31–3.08; P = 0.96; adjusted OR 1.28, 95% CI 0.22–7.20; P = 0.78] and bleeding-related events (OR 1.50, 95% CI 0.76–2.95; P = 0.24; adjusted OR 2.03, 95% CI 0.80–3.66; P = 0.14).

CONCLUSIONS

In patients with ATAAD undergoing total arch replacement and frozen elephant trunk, although preoperative DAPT led to more postoperative bleeding, it did not increase bleeding-related events nor operative mortality nor mid-term death. The results of this study imply that for patients with ATAAD, emergency surgical repair, even if as extensive as total arch repair, should not be contraindicated or delayed simply because of ongoing DAPT.

中文翻译：

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术前双重抗血小板治疗是否会影响急性 A 型夹层全牙弓修复后的出血和死亡率？

摘要

目标

关于术前双重抗血小板治疗 (DAPT) 对急性 A 型主动脉夹层 (ATAAD) 手术结果的影响的数据稀少且参差不齐。我们寻求评估 DAPT 对此类患者在全弓置换和冷冻象鼻后出血相关事件以及早期和中期死亡率的影响。

方法

本研究包括 48 名术前 DAPT 的 ATAAD 患者和 418 名未进行 DAPT 的患者（整个系列，即不匹配队列），通过倾向评分从中选择 45 对匹配对（匹配队列）。出血相关事件（再次手术出血、术后前 12 小时内出血≥1500 ml 或输注≥10 个单位红细胞或使用重组活化因子 VII）、手术死亡率和中期生存率在不匹配和匹配的队列。通过多变量分析评估术前 DAPT 的影响。

结果

在无与伦比的队列中，DAPT 组术后出血≥1500 ml/12 h 更为常见（18.8% vs 8.4%，P  = 0.020）；手术死亡率为 9.7%，与 DAPT 无差异（12.5% vs 9.3%，P  = 0.48）。两组出血相关事件（54.2% vs 43.5%，P  = 0.16）也没有显着差异。在匹配队列中，引流≥1500 ml/12 h（20% vs 6.7%，P  = 0.063）和出血相关事件（53.3% vs 42.2%，P  = 0.30）和手术死亡率（13.8 vs 8.9）均未发生%, P  = 0.50) 和中期生存率 (79.3% vs 76.4%, P = 0.93) 两组之间存在显着差异。DAPT 未被确定为手术死亡率的预测因子 [优势比 (OR) 0.97, 95% 置信区间 (CI) 0.31-3.08；P  = 0.96; 调整后的 OR 1.28, 95% CI 0.22–7.20；P  = 0.78] 和出血相关事件（OR 1.50，95% CI 0.76–2.95；P  = 0.24；调整后的 OR 2.03，95% CI 0.80–3.66；P  = 0.14）。

结论

在接受全弓置换术和冷冻象鼻的 ATAAD 患者中，虽然术前 DAPT 导致更多的术后出血，但它并未增加出血相关事件、手术死亡率或中期死亡。这项研究的结果表明，对于 ATAAD 患者，紧急手术修复，即使与全牙弓修复一样广泛，也不应该仅仅因为正在进行的 DAPT 而成为禁忌或延迟。