Hybrid Management of Valve in Valve TAVI with Coronary Grafting

An 81-year-old woman with a history of aortic root replacement using a 23 mm Shelhigh homograft in 2004 was referred for elective transcatheter aortic valve implantation (TAVI) due to progressive symptoms of exertional dyspnoea (NYHA III), dizziness, and lethargy. She had multiple comorbidities, including severe coronary artery disease, prior breast, colon, and thyroid cancers, type 2 diabetes mellitus, osteoarthritis, and a history of multiple surgical procedures.Imaging revealed a failing bioprosthetic aortic valve with low coronary heights (LMS 1.1 mm) and significant ostial LMS and LAD disease. Given her high surgical risk, she was deemed unsuitable for redo Bentall’s procedure. A hybrid approach was planned involving left thoracotomy for LIMA-LAD grafting followed by transfemoral TAVI.The procedure was successfully performed using a 23 mm Evolut FX valve. Post-deployment, balloon dilation was required due to under-expansion. The patient developed transient anterolateral hypokinesia, likely due to competitive flow between the LMS and LIMA graft, which resolved spontaneously. She was discharged in stable condition after one week.Conclusion: This case highlights the feasibility of a hybrid approach combining minimally invasive coronary bypass and TAVI in patients with complex anatomy and high surgical risk, including those with prior bioprosthetic valves and low coronary take-off.