Hybrid Minimally Invasive Approach for Combined Obstructive Coronary Artery Disease and Severe Aortic Stenosis

Q: What is the clinical evidence from this study?

Study design: Case Report. Population: Concomitant coronary artery disease (CAD) and severe aortic stenosis (AS) (n=6). Intervention: Staged transcatheter aortic valve replacement (TAVR) after hybrid minimally invasive direct coronary artery bypass surgery (MIDCAB). Primary outcome: Intraprocedural or hospital mortality, neurological deficits, and vascular complications.

Q: What does this research mean for the field?

A hybrid staged approach combining MIDCAB and TAVR is feasible and safe with low complication rates in high-risk patients with complex CAD and severe aortic stenosis. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Luigi Pirelli; Nirav Patel; Jacob Scheinerman; Derek R. Brinster; Jonathan M. Hemli; Craig Basman; Chad Kliger

doi:10.1177/1556984519896581

January 1, 2020Innovations Technology and Techniques in Cardiothoracic and Vascular Surgery

Hybrid Minimally Invasive Approach for Combined Obstructive Coronary Artery Disease and Severe Aortic Stenosis

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Key result

Staged MIDCAB followed by TAVR yields 0% hospital mortality and major complications in high-risk patients.

n=6

Why the study?

Concomitant CAD and AS are prevalent and can be managed with various invasive or percutaneous approaches, prompting evaluation of a staged hybrid MIDCAB and TAVR strategy.

Does a staged hybrid approach of MIDCAB and TAVR prevent intraprocedural and hospital mortality in high-risk patients with combined complex CAD and severe AS?

Key Points

To assess the feasibility, efficacy, and safety of a staged hybrid approach combining minimally invasive direct coronary artery bypass surgery and transcatheter aortic valve replacement for complex coronary artery disease and severe aortic stenosis.
Evaluated 6 consecutive patients with concomitant severe aortic stenosis and complex left main or left anterior descending (LAD) coronary artery stenosis not suitable for percutaneous intervention.
Treated patients with a staged strategy using minimally invasive direct coronary artery bypass (MIDCAB) followed by transcatheter aortic valve replacement (TAVR), supplemented by percutaneous coronary intervention or balloon aortic valvuloplasty as needed.
Patients presented with an average SYNTAX score of 22 ± 8 and a mean Society of Thoracic Surgeons predicted risk of mortality for surgical aortic valve replacement of 8 ± 3%.
All 6 patients successfully underwent single-vessel LAD MIDCAB, with 3 patients receiving adjunct PCI for non-LAD disease, 2 receiving pre-TAVR balloon aortic valvuloplasty, and 1 receiving MitraClip repair.
The staged strategy resulted in 0% intraprocedural mortality, 0% in-hospital mortality, and zero reported neurological deficits or vascular complications.

Study Design

Type

Case Report (n=6)

Structured PICO

Does a staged hybrid approach of MIDCAB and TAVR prevent intraprocedural and hospital mortality in high-risk patients with combined complex CAD and severe AS?

P

Population

6 high-risk patients with concomitant complex CAD and severe AS not amenable to PCI, undergoing staged MIDCAB and TAVR.

E

Exposure

Staged transcatheter aortic valve replacement (TAVR) after a hybrid minimally invasive direct coronary artery bypass surgery (MIDCAB).

O

Outcome

Intraprocedural or hospital mortality, neurological deficits, and vascular complicationssafety

A hybrid staged approach combining MIDCAB and TAVR appears feasible and safe for high-risk patients with complex CAD and severe AS.

Implication

Supports feasibility in select high-risk patients; leaves open need for larger prospective trials before wider adoption.

Abstract

OBJECTIVE: There is a high prevalence of concomitant coronary artery disease (CAD) and aortic stenosis (AS), and these conditions can be treated with a variety of invasive and/or percutaneous approaches. The aim of this study is to demonstrate the feasibility, efficacy, and safety of a staged transcatheter aortic valve replacement (TAVR) after a hybrid minimally invasive direct coronary artery bypass surgery (MIDCAB) to treat combined complex CAD and AS. METHODS: Six patients with concomitant CAD and severe AS underwent staged treatment of their CAD with MIDCAB and TAVR. All patients had significant complex left main or left anterior descending artery (LAD) stenosis deemed to be not amenable to percutaneous coronary intervention (PCI). RESULTS: The average syntax score was 22±8 and the Society of Thoracic Surgeons score for surgical AVR was 8±3%. All patients underwent a single vessel MIDCAB for revascularization of the LAD (three patients required additional PCI for non-LAD disease). Two patients had pre-TAVR balloon aortic valvuloplasty and one patient also required treatment of severe mitral valve regurgitation with percutaneous edge-to-edge repair (the MitraClip). There was no intraprocedural or hospital mortality. No neurological deficits or vascular complications were recorded. CONCLUSIONS: A hybrid staged approach for combined complex CAD and severe AS with MIDCAB, PCI, and TAVR is a valid option in high-risk patients. The order and timing of these procedures must be tailored to the patient's clinical symptoms, stability, and severity of disease.

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Cite This Study

Pirelli et al. (2020) conducted a case report in Concomitant coronary artery disease (CAD) and severe aortic stenosis (AS) (n=6). Staged transcatheter aortic valve replacement (TAVR) after hybrid minimally invasive direct coronary artery bypass surgery (MIDCAB) was evaluated on Intraprocedural or hospital mortality, neurological deficits, and vascular complications. A hybrid staged approach with MIDCAB followed by TAVR in 6 high-risk patients with complex CAD and severe AS resulted in 0% intraprocedural or hospital mortality and no neurological or vascular complications.

synapsesocial.com/papers/6aa93e6504014c990126433e https://doi.org/10.1177/1556984519896581