Vol. 47 | No. 1 | January-June 2019 Back

Open Access

Hybrid, Transcatheter Aortic Valve Implantation (TAVI) and Total Arterial Off-Pump Coronary Artery Bypass (OPCAB) in a Patient with Severe Aortic Valve Regurgitation – A Case Report

Alinaya Cordero, Fontini Carbon, Erwin Ybañez, Fabio Enrique Posas
Jun 2019 DOI 10.69944/pjc.103c4e6da4

Abstract

BACKGROUND: Transcatheter aortic valve implantation (TAVI) has been shown to be an  effective growing strategy for severe, symptomatic aortic valve stenosis (AS) in patients who  are either not ideal candidates or who are at intermediate or high surgical risk for surgical aortic  valve replacement. Hybrid TAVI and off-pump coronary artery bypass graft (OPCAB) have been  previously reported in high-risk patients with severe AS and coronary artery disease (CAD). TAVI  data for severe aortic valve regurgitation (AR) is limited and currently considered an off-label  application. Reports on hybrid TAVI for severe AR and OPCAB in patients with severe co-morbid  CAD are limited.  

We report a hybrid TAVI and OPCAB in a 64-year-old female, with severe AR, severe left ventricular  systolic dysfunction and CAD with a low take-off of the left main (LM) and porcelain aorta.  

CASE REPORT: The patient is a 64-year-old morbidly obese Filipino female with porcelain aorta  and post-percutaneous coronary intervention with drug-eluting stent implantation for multivessel  CAD with LM involvement and was admitted for refractory heart failure. Her 2D echocardiography  demonstrated a dilated left ventricle with 19% left ventricular ejection fraction (LVEF) and severe AR.  Computed tomography angiography demonstrated porcelain aorta, a low take-off of the left main  with good femoral access.  

Hybrid TAVI with 26 mm Corevalve was done via the transfemoral approach after OPCAB of the  left internal mammary artery to left anterior descending artery. Valve-in-valve transcatheter aortic  valve replacement was required due to low valve implantation and severe paravalvular leak (PVL).  

Follow-up echo at 22 months demonstrated no PVL, 1.6 cm2 effective orifice aortic valve area, 12.4  mmHg mean gradient and 50% LVEF. She remains asymptomatic and in functional class I. 

CONCLUSION: Hybrid TAVI and OPCAB in patients with severe valvar AR, porcelain aorta and  CAD represents a feasible and effective option of care. There are few reports in the literature  documenting the effectiveness or feasibility of this approach for such patients.

References
  1. Kobayashi J, Shimahara Y, Fujita T, et al. Early results of simultaneous transaortic transcatheter aortic valve implantation and total arterial off-pump coronary artery revascularization in high-risk patients. Circ J. 2016;80(9):1946-50.
  2. Franzone A, Piccolo R, Siontis GC, et al. Transcatheter aortic valve replacement for the treatment of pure native aortic valve regurgitation. JACC Cardiovasc Interv. 2016;9:2308–17.
  3. Testa L, Latib A, Rossi ML, et al. CoreValve implantation for severe aortic regurgitation: a multicentre registry. Euro Intervention. 2014;10(6):739-45.
  4. Roy A, Schaefer U, Guetta V, et al. Transcatheter aortic valve implantation for pure severe native aortic valve regurgitation. J Am Coll Cardiol. 2013;61(15):1577-84.
  5. Huded C, Kapadia SR. Decision-making on the treatment of CAD in the age of TAVR. Expert Analysis. American College of Cardiology. 2016.
  6. Dewey TM, Brown DL, Herbert MA, et al. Effect of concomitant coronary artery disease on procedural and late outcomes of transcatheter aortic valve implantation. Ann Thorac Surg. 2010;89(3):758-67.
  7. Wiegerinck EMA, Cocchieri R, Baan Jr J, et al. Hybrid coronary artery bypass grafting and transaortic transcatheter aortic valve implantation. The Journal of Thoracic and Cardiovascular Surgery. 2013;145:600-2.
  8. Nishimura RA, Otto CM, Bonow RO, et al. AHA/ACC guideline for the management of patients with valvular heart disease. Circulation. 2014;129:e521-643.
  9. Puskas JD, Thourani VH, Kilgo P, et al. Off-pump coronary artery bypass disproportionately benefits high-risk patients. Annals Thoracic Surgery. 2009;88(4):1142-7.
License

Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License, which permits use, share — copy and redistribute the material in any medium or format, adapt — remix, transform, and build upon the material, as long as you give appropriate credit, provide a link to the license, and indicate if changes were made. You may do so in any reasonable manner, but not in any way that suggests the licensor endorses you or your use. You may not use the material for commercial purposes. If you remix, transform, or build upon the material, you must distribute your contributions under the same license as the original. You may not apply legal terms or technological measures that legally restrict others from doing anything the license permits. The images or other third party material in this article are included in the article’s Creative Commons license, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this license, visit https://creativecommons.org/licenses/by-nc-sa/4.0/.