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DOI: 10.1055/s-0035-1544427
Combined Total Arterial Off-Pump Revascularization and Direct Aortictranscatheter Valve Implantation in High-Risk Patients with Coronary Artery Disease and Aortic Stenosis
Objective: Combined surgical aortic valve replacement and coronary artery bypass grafting (CABG) is the standard therapy for patients with aortic stenosis and coronary artery disease. Contraindications for cardiopulmonary bypass (CPB), cross-clamping or cardiac arrest such as severely reduced ejection fraction and/or porcelain aorta may preclude patients from conventional surgery. Thus, hybrid procedures with combined CABG in off-pump technique and direct aortic transcatheter aortic valve implantation (TAO-TAVI) may serve as a valuable option.
Methods: 8 patients unsuitable for conventional surgery were treated with combined off-pump CABG using bilateral internal thoracic artery T-grafts (BITA-TG) and TA-TAVI between September 2011 and February 2014. Data including comorbidities, preoperative risk (logistic EUROscore I and II, STS score), 30-day- and overall-mortality, as well as performance of the TAVI prosthesis, were evaluated acutely and at 3-month follow-up.
Results: Mean age was 81 ± 8 years. All patients were male. Mean log EUROscore was 22.4 ± 15.9%; EUROscore II 6.7 ± 17.8% and STS score 8.7 ± 10.7%; EF≤30%: 2/8; porcelain aorta:5/8. Mean number of peripheral anastomoses was 2.8(range 1–4). Direct aortic TAVI was performed with Edwards Sapien (?), SapienXT (2/8), Sapien3 (⅛) or Medtronic Corevalve (2/8) with 100% device success (no paravalvular leakage greater than trace). In-hospital- and 30-day mortality were 0%(0/8). No procedural complications occurred.Two non-cardiac related deaths occurred at 11 and 13 months.
Conclusion: Combining off-pump CABG and TAO-TAVI in patients with contraindication for CPB and cardiac arrest or aortic cross-clamping seems to be a safe treatment option with good early results even in high risk patients. The initial results of a small group of patients encourage our heart team to further follow that approach as an extended treatment option in selected patients.
|
Age |
Comorbidities |
Porcelain aorta |
EF (%) |
Log ES (%) |
ES II (%) |
STS (%) |
CABG (N° of anastomoses) |
TAO-TAVI |
Outcome, Follow-up |
|---|---|---|---|---|---|---|---|---|---|
|
79 |
Previous MI,peripheral ertery disease |
no |
20 |
57 |
12.3 |
4.7 |
BITA-TG (3) |
CoreValve 31 mm |
dead, 12 mts |
|
84 |
Peripheral artery disease,polycytaemia very,previous TIA,atrial fibrillation |
no |
20 |
29.9 |
8.1 |
6.2 |
BITA-TG (4) |
Sapien 29 mm |
alive, 24 mts |
|
74 |
Peripheral artery disease,previous GI bleeding,previous pulmonary embolism |
yes |
40 |
16.6 |
3.9 |
12.6 |
BITA-TG (3) |
CoreValve 31 mm |
dead, 11 mts |
|
86 |
pulmonary fibrosis,COPD,atrial fribrillation |
yes |
45 |
18.7 |
5.2 |
5.4 |
BITA-TG (2) |
Sapien XT 26 mm |
alive, 10 mts |
|
79 |
Non-Hodgkin-Lymphoma,previous radiatio,COPD,peripheral artery disease,renal insufficiency |
yes |
60 |
5.5 |
2.2 |
4.1 |
BITA-TG (2) |
Sapien XT 29 mm |
alive, 6 mts |
|
77 |
renal insufficiency,peripheral artery disease |
no |
60 |
24.4 |
17.5 |
18.1 |
BITA-TG (1) |
Sapien 3 26 mm |
alive, 4 mts |
|
85 |
renal insufficiency,peripheral artery disease |
yes |
52 |
13.2 |
2.4 |
3.2 |
BITA-TG (1) |
Sapien 3 26 mm |
alive, 4 mts |
|
85 |
peripheral artery disease,frailty |
yes |
65 |
13.5 |
1.8 |
5.7 |
BITA-TG (1) |
Sapien 3 23 mm |
alive, 2 mts |