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Hybrid Coronary Artery Bypass Grafting and TransAortic Transcatheter Aortic Valve Implantation
Esther M.A. Wiegerinck, MD, Riccardo Cocchieri, MD, Petr Symersky, MD, Karel T. Koch, MD, PhD, Ze-Yie Yong, MD, Jan Baan, MD, PhD, Bas A.J.M de Mol, MD, PhD.
Academical Medical Center Amsterdam, Amsterdam, Netherlands.
BACKGROUND:
Transcatheter aortic valve implantation (TAVI) is a less invasive alternative for patients with high or prohibitive risk for conventional aortic valve replacement (AVR), excluding patients who need additional cardiac surgery. Significant coexisting coronary artery disease (CAD) requires pre-procedural percutaneous coronary intervention (PCI). High-risk patients with significant CAD ineligible for PCI could be revascularized surgically in a hybrid procedure with a TAVI, reducing the time or even eliminating the necessity of aortic cross-clamping and cardio-pulmonary bypass and decreasing surgical risk. Limited data are available regarding this new application.
OBJECTIVE:To describe transaortic TAVI during coronary artery bypass graft surgery (CABG) in patients with significant aortic valve stenosis and CAD, ineligible for PCI.
METHODS:
Four patients with severe aortic valve stenosis and CAD ineligible for PCI, were treated with a hybrid CABG and TAVI. Main outcome was procedural and device success. Secondary outcomes included procedural characteristics, as well as clinical and hemodynamic outcomes.
RESULTS:
All patients were octogenarians, with STS scores of 11.1; 11.7; 11.1 and 32.4% and Euroscores of 33,5; 39.2; 31.2 and 65%. Procedural and device success was achieved in all patients. Three patients were treated with conventional CABG with excision of the native valve prior to TAVI under direct vision. One patient was treated with off-pump CABG and TAVI. Aortic-crossclamp time was 55, 26, and 35 minutes. Post implantation, peak aortic gradients were 7, 19, 11 and 9 mmHg. Mild paravalvular regurgitation was observed in only one patient. One non-cardiac death occurred three weeks postprocedural, due to aspiration pneumonia.
CONCLUSIONS:
We describe a hybrid procedure with TAVI during surgical revascularization in four patients, showing promising outcomes. This new application potentially shortens bypass and aortic cross-clamp time, providing an alternative for combined high-risk AVR and surgical revascularization. Furthermore, to our knowledge, this is the first successful implantation of a balloon expandable transcatheter valve with excision of the native valve. This could potentially expand the indication for TAVI to pure aortic regurgitation without valvular and annular calcification. More data in a larger patient sample with long-term outcomes are needed
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