Apixaban removal during emergency surgery for type A acute aortic dissection: a prospective cohort study

Background:Acute type A aortic dissection (ATAAD) has a high mortality, and acute aortic repair is the only curative treatment. In patients treated with factor Xa (FXa) inhibitors, the risk of severe disease-related complications such as cardiac tamponade and hemodynamic shock must be balanced against the potential for severe perioperative bleeding. The aim was to study intraoperative changes in plasma levels of the FXa inhibitor apixaban when using hemoadsorption during acute thoracic aortic repair.Materials and methods:This is a single-center prospective cohort study. Eight apixaban-treated patients presenting with ATAAD underwent acute thoracic aortic repair with intraoperative hemoadsorption with CytoSorb. Apixaban concentrations were measured at the start of cardiopulmonary bypass (CPB) and after 5, 15, 30, 60, and 90 min of CPB, at CPB weaning, 30 min after CPB weaning and 24 h postoperatively, using ultraperformance liquid chromatography-mass spectrometry (UPLC-MS).Results:After 30 min of CPB with hemoadsorption, mean apixaban concentration (+/- SD) was reduced by 59% from 108 (+/- 69) mu g/l to 44 (+/- 20) mu g/l (P=0.009). There was a further reduction to 37 (+/- 17) mu g/l at CPB weaning (P=0.008). Apixaban concentration displayed an increase to 56 (+/- 29) mu g/l 24 h postoperatively (P=0.01). In-hospital mortality was 25%. The mean 24H chest tube drainage volume was 621 (+/- 136) ml.Conclusion:Intraoperative hemoadsorption lowers apixaban levels in patients undergoing emergency surgery for ATAAD. Further research is needed to determine its impact on perioperative bleeding complications and mortality.