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

Abstract

Introduction Transcatheter aortic valve implantation (TAVI) techniques are increasingly being adopted into clinical routine for various risk groups. Coronary artery disease (CAD) is seen in up to 75% of patients with severe aortic valve stenosis (AS) presenting with typical angina pectoris. Due to high mortality rates and procedural complications in these patients, a hybrid concept of simultaneous transaortic TAVI and off‐pump coronary artery bypass (OPCAB) can be a feasible treatment option. Methods Between April 2014 and July 2020, 10 consecutive high‐risk patients underwent concomitant transaortic TAVI and OPCAB at our institution. All indications were discussed in Heart Team and decisions were made based on patients' comorbidities and complexity of CAD. The study endpoints were 30‐day mortality, device success, and development of postoperative adverse events defined by the Valve Academic Research Consorium. Results The mean age of the patients was 77.9 ± 7.1 years old. All patients presented with multiple comorbidities (mean logistic EuroSCORE 26.5 ± 12.3%, median EuroSCORE II 5.13% [interquartile range 4.2–9.5], mean STS‐Score 6.04 ± 1.6%). Five patients (50%) presented with porcelain aorta. No conversion to conventional procedures was needed. 30‐day mortality occurred in one patient (10%). Complete revascularization was achieved in seven (70%) of the patients. Device success rate was 100%. No paravalvular leakage was detected. No stroke, myocardial infarction or vascular complications were observed. Conclusions A hybrid approach combining transaortic TAVI and OPCAB might be a safe and feasible method of treatment in high‐risk patients presenting with severe AS and CAD who are not eligible for conventional surgical or interventional solutions.

Transapical transcatheter mitral valve implantation in patients with degenerated mitral bioprostheses or failed ring annuloplasty

“…A correlation between the amount of contrast agent used and post-procedural acute kidney injury was reported by Yamamoto et al in patients undergoing TAVR (19). In our cohort, the median amount of contrast dye used was 40.0 mL (IQR 0-75.0), which is quite low and even less compared to the contrast dye amount reported by Kamioka et al (13,20). We believe that due to the fluoroscopic qualities of prior implanted surgical mitral valve prostheses and mitral rings acting as a `docking station´, the amount of contrast could be further reduced or even completely waived.…”

Mitral surgical redo versus transapical transcatheter mitral valve implantation

“…Similar outcomes have also been reported by Simonetto et al [ 22 ]. We believe that thanks to the fluoroscopic qualities of prior implanted surgical mitral valve prostheses and mitral rings, the amount of contrast dye could be further reduced or completely excluded [ 5 ].…”

“…Then, via a Pigtail catheter, an Extra-Stiff wire for further guidance exchanged the soft wire, and a transapical sheath was advanced. The reversely crimped transcatheter valve was finally deployed under ventricular overpacing (120 bpm) [ 5 ]. The landing zone was identified mainly with fluoroscopic guidance.…”

“…qualities of prior implanted surgical mitral valve prostheses and mitral rings, the amount of contrast dye could be further reduced or completely excluded [5].…”

Management of concomitant coronary artery disease and aortic valve stenosis in the era of transcatheter aortic valve treatment

“…Brinster et al [75] , before the spread of hybrid operating rooms, demonstrated the feasibility of a same-day PCI approach followed by SAVR. George et al [76] described the possibility of performing in the hybrid room first PCI followed by valve surgery (11 patients of 20 underwent SAVR). After four years there, was only one event (a stroke during hospitalization) in the absence of in-hospital mortality.…”