Title : Letter To the Editor: Outcomes of Preoperative Antiplatelet Therapy in Patients With Acute Type A Aortic Dissection

Article Type : Letter To The Editor

Correspondence : 1. Sandhya Kumari

Contact no: +92-3321346164 Email: ssdsandhyajiwan@gmail.com

Institute: Ziauddin University Karachi

Address: Bungalow Number 7/2, 26^th Street, Tauheed Commercial Area, Phase 5 Defence Karachi.

ORCID: 0000-0001-8842-8738

Co-Author : 2. Roomi Raja

Contact No: +92-3342946940 Email: Romirajagoindani@yahoo.com

Institution: Ziauddin University Karachi

Address: Hemilton Courts Block G-1 Flat 408 Near Teen Talwar Clifton Karachi

ORCID: 0000-0001-9104-3644

Word Count : 340

Conflict of interest : None

Acknowledgement : None

Declaration : None

Disclosure : None

Funding : None

Dear Editor,

We have, in recent times, read with great interest the article entitled “ Outcomes of Preoperative Antiplatelet Therapy in Patients With Acute Type A Aortic Dissection” by Xuan Jiang MD et al.¹ We highly appreciate the author’s efforts towards this highly sensitive topic and it needs to be applauded by the readers.

We acknowledge the primary conclusion of the article that patients receiving antiplatelet therapy before having surgery for acute type A aortic dissection is associated with increased mortality and increased need for blood transfusions. However, some concerns appear, disturbing the validity of the study.

Even though the authors have highlighted the use of multiple different antiplatelet drugs before the surgery such as ticagrelor, clopidogrel and aspirin, there remains some factors that made an impact on the findings. Firstly, the authors should have considered the patients who are on Dual antiplatelet therapy because mortality and blood transfusion rate in patients using dual antiplatelet therapy is higher as compared to a single antiplatelet drug user.² Secondly, the authors should have widened their inclusion criteria and could have included patients with preoperative characteristic such as cardiac tamponade and lower systolic blood pressure, like the study of 2014 included these two as variables and found increased prevalence of mortality associated with these variables.³

Thirdly, the authors should have classified the patients using Debakey class 1,2 and Penn class A,B,C classifications. For example, a study in 2019 stated that the patients who experienced major bleeding were associated with Debakey class 1 and higher Penn class.⁴ Lastly, the authors should have taken into consideration some measures while transferring a patient to the ICU to minimize the mortality rate. For example, a study of 2022 stated that patients on new oral anticoagulants required norepinephrine and other inotropic agents while transferring to ICU as compared to patients taking warfarin (Coumadin).⁵

In last, additional new studies should be conducted on patients receiving antiplatelet therapy before undergoing mitral valve surgery so that incidents leading to mortality goes down and prognosis becomes better.

References:

1- Jiang X, Khan F, Shi E, Fan R, Qian X, Zhang H, Gu T. Outcomes of preoperative

antiplatelet therapy in patients with acute type A aortic dissection. J Card Surg. 2022

Jan;37(1):53-61. doi: 10.1111/jocs.16080. Epub 2021 Oct 17. PMID: 34657299.

2- Chemtob RA, Moeller-Soerensen H, Holmvang L, Olsen PS, Ravn HB. Outcome

After Surgery for Acute Aortic Dissection: Influence of Preoperative Antiplatelet

Therapy on Prognosis. J Cardiothorac Vasc Anesth. 2017 Apr;31(2):569-574. doi:

10.1053/j.jvca.2016.10.007. Epub 2016 Oct 11. PMID: 28017673.

3- Hansson EC, Dellborg M, Lepore V, Jeppsson A. Prevalence, indications and

appropriateness of antiplatelet therapy in patients operated for acute aortic dissection:

associations with bleeding complications and mortality. Heart. 2013 Jan;99(2):116-

21. doi: 10.1136/heartjnl-2012-302717. Epub 2012 Oct 9. PMID: 23048167.

4- Hansson EC, Geirsson A, Hjortdal V, Mennander A, Olsson C, Gunn J, et al.

Preoperative dual antiplatelet therapy increases bleeding and transfusions but not

mortality in acute aortic dissection type a repair [Internet]. OUP Academic. Oxford

University Press; 2019: doi: org/10.1093/ejctz/ezy469. Epub 2019 january 16.

5- Sromicki J, Van Hemelrijck M, Schmiady MO, Krüger B, Morjan M, Bettex D, Vogt

PR, Carrel TP, Mestres CA. Prior intake of new oral anticoagulants adversely affects

outcome following surgery for acute type A aortic dissection. Interact Cardiovasc

Thorac Surg. 2022 Jun 15;35(1):ivac037. doi: 10.1093/icvts/ivac037. PMID:

35258082; PMCID: PMC9252133.