Early Results of Simultaneous Transaortic Transcatheter Aortic Valve Implantation and Total Arterial Off-Pump Coronary Artery Revascularization in High-Risk Patients

Abstract

Background: Transcatheter aortic valve implantation (TAVI) has become an alternative procedure for treating aortic stenosis (AS) in patients with advanced age and severe comorbidities. Ischemic heart disease (IHD) is present with AS in 40-50% of patients with typical angina. Considering the high operative mortality and morbidity rates in these patients, hybrid TAVI and off-pump CABG (OPCAB) have become realistic treatment options. Methods and Results:Between August 2014 and November 2015, 12 patients were evaluated for simultaneous TAVI and OPCAB. Because of their advanced age and comorbidities these patients were not considered suitable for standard open heart surgery. PCI was also considered unsuitable, because of left anterior descending artery (LAD) proximal lesions and/or high SYNTAX score. TAVI was conducted through a median sternotomy after left internal thoracic artery (LITA) to LAD anastomosis. In 11 cases OPCAB with LITA and composite RA graft was performed using an aorta no-touch technique. Mean age at operation was 81±6.3 years. Average number of distal anastomoses was 2.6. Perivalvular leakage was mild in 3 patients, trivial in 8, and none in 1. There was no conversion to on-pump procedure and no hospital deaths. Conclusions:Simultaneous transaortic TAVI and OPCAB in high-risk patients with severe AS and IHD is a reasonable option. This method could be an alternative to surgical aortic valve replacement and CABG. (Circ J 2016; 80: 1946 -1950

Simultaneous transaortic transcatheter aortic valve implantation and off‐pump coronary artery bypass: An effective hybrid approach

“…Several studies described the concomitant TAVI procedure and OPCAB coronary revascularization and reported the similar 30‐day mortality as in our cohort 22,29,30 . In our study we observed 10% 30‐day mortality.…”

Access Sites for TAVI: Patient Selection Criteria, Technical Aspects, and Outcomes

“…The advantage of an upper mini-sternotomy is that pleural spaces are not open. Full sternotomy is usually performed in high-risk patients requiring combined procedures such as off-pump coronary artery bypass grafting and/or tricuspid valve repair on cardiopulmonary bypass and beating heart can be considered in selected cases ( 35 – 37 ). The device insertion is similar to the upper mini-sternotomy.…”

Transcatheter aortic valve replacement- management of patients with significant coronary artery disease undergoing aortic valve interventions: surgical compared to catheter-based approaches in hybrid procedures

“…Guidelines now tentatively recommend this combination for severe AS patients with concomitant coronary stenosis occupying > 70% of the artery diameter [2]; however not all coronary lesions are treatable with PCI. More recently, off-pump CABG (OPCAB) has been proposed as a method of complete coronary revascularisation in patients with complex stenosis and/or high SYNTAX scores [5, 6], with the off-pump technique avoiding the harmful effects of cardiopulmonary-bypass (CPB) [7]. OPCAB has been used to treat multi-vessel disease requiring a larger operative area, with a recent 4-patient series outlining its successful use immediately prior to transaortic (TAo) TAVR [8].…”

“…A modified version of OPCAB, known as minimally invasive direct CABG (MIDCAB), has been developed for the treatment of single-vessel disease, achievable through a smaller incision. Since the first documented MIDCAB plus transapical (TA) TAVR hybrid in 2010 [9], several other successful cases have been reported [5, 10]. However, only one larger study has evaluated the safety and feasibility of TAVR+OPCAB/MIDCAB to date [11], and no comparisons with TAVR+PCI and SAVR+CABG have been performed.…”