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Bleeding is associated with severely impaired outcomes in surgery for acute type a aortic dissection
Sorosh Bratt1,2, Igor Zindovic3, Jacob Ede3
1Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
Insights
Massive bleeding during acute type A aortic dissection surgery significantly increases the risk of early death and severe complications. Optimizing surgical techniques and coagulation management is crucial for improving patient outcomes.
Area of Science:
- Cardiovascular Surgery
- Thoracic Surgery
- Aortic Diseases
Background:
- Surgery for acute type A aortic dissection carries a substantial risk of significant bleeding.
- Massive bleeding is a known complication that can impact patient outcomes.
Purpose of the Study:
- To analyze the impact of massive bleeding on complications after surgery for acute type A aortic dissection.
- To identify risk factors associated with massive bleeding in this patient population.
Main Methods:
- Retrospective analysis of patients undergoing surgery for acute type A aortic dissection from the NORCAAD database (2005-2014).
- Massive bleeding defined using the Universal Definition of Perioperative Bleeding.
- Propensity score matching used to adjust for covariates and compare outcomes between patients with and without massive bleeding.
Main Results:
- Massive bleeding occurred in 40.4% of patients (403/997).
- In the matched cohort, massive bleeding was associated with higher 30-day mortality (17.2% vs 7.6%), increased need for mechanical ventilation (>48h) (52.8% vs 22.6%), higher rates of perioperative stroke (24.3% vs 14.8%), new-onset dialysis (22.5% vs 4.9%), and longer ICU stays (6 vs 3 days).
- Risk factors for massive bleeding included prior cardiac surgery, specific antiplatelet therapies, DeBakey type I dissection, and malperfusion.
Conclusions:
- Massive bleeding following acute type A aortic dissection repair is linked to a significantly higher risk of severe complications and early mortality.
- Improvements in surgical techniques and pharmacological management of coagulation are essential for enhancing outcomes in acute type A aortic dissection surgery.
Abstract:
Background. Surgery for acute type A aortic dissection confers a risk for significant bleeding. We analyzed the impact of massive bleeding on complications after surgery for acute type A aortic dissection. Methods. Patients undergoing surgery for acute type A aortic dissection from the retrospective multicenter Nordic Consortium for Acute Type A Aortic Dissection (NORCAAD) database 2005-2014 were eligible. Massive bleeding was defined according to the Universal Definition of Perioperative Bleeding. The primary outcome measure was early mortality and secondary outcome measures were perioperative stroke, mechanical ventilation more than 48 h, new-onset dialysis, and intensive care unit stay. Propensity score matching was performed to adjust for differences in covariates. Results. Nine hundred ninety-seven patients were included, of whom 403 (40.4%) had massive bleeding. In the propensity score-matched cohort (344 pairs), patients with massive bleeding had higher 30-day mortality (17.2 versus 7.6%, p < .001), mechanical ventilation more than 48 h (52.8 versus 22.6%, p < .001), perioperative stroke (24.3 versus 14.8%, p = .002), new-onset dialysis (22.5 versus 4.9%, p < .001), and longer intensive care unit stay (6 versus 3 days, p < .001), compared with patients without massive bleeding. Risk factors for massive bleeding were previous cardiac surgery, preoperative clopidogrel or ticagrelor therapy, DeBakey type I dissection, and localized or generalized malperfusion. Conclusions. Massive bleeding in surgery for acute type A aortic dissection is associated with a markedly increased risk for severe complications as well as early death. Further improvement of surgical technique and pharmacological optimization of coagulation is paramount to possibly improve outcomes in acute type A aortic dissection repair.
