Combining Off-Pump CABG and Transaortic TAVR May Be an Option in Some Cases

A hybrid procedure combining off-pump CABG and transaortic TAVR appears feasible as a treatment approach for select patients with complex coronary disease and severe aortic stenosis, a small case series suggests.

Over a 10-month period, operators performed the hybrid procedure in four men, all of whom had uneventful recoveries and remained complication-free through 6 months, Imthiaz Manoly, FRCS (C-Th) (Central Manchester University Hospitals Foundation Trust, England), and colleagues report in a study published online July 12, 2016, ahead of print in Catheterization and Cardiovascular Interventions. One patient died of a noncardiac cause (community-acquired pneumonia) at 8 months.

The remaining three patients—and another two not included in the paper—are currently doing well, Manoly told TCTMD.

“For patients who are deemed high risk just because of the technical challenge or a few comorbid factors, we should definitely consider transaortic TAVI and off-pump CABG,” he said, noting that not all patients would be suitable. “Such a procedure is possible for high-risk patients if we select them properly.”

The authors say the combined procedure is an attractive option for patients with complex coronary anatomy, poor femoral access, and a need for urgent TAVR. “It may also be considered as a good option for any patient with any two of these three features, as well as patients requiring TAVI and revascularization who cannot tolerate dual antiplatelet treatment,” they write.

Members of the heart team deemed all four of the patients described in the current case series—who ranged in age from 67 to 87—unsuitable for conventional on-pump CABG. Three patients had severe aortoiliac disease that precluded femoral access for TAVR and had coronary disease for which PCI was not considered to be a good option. The fourth had such severe three-vessel coronary disease that surgical revascularization was indicated.

After consideration of alternate strategies, including combined balloon valvuloplasty, PCI followed by transaortic TAVR, and transsubclavian TAVR without revascularization, the team opted for the hybrid approach.

Physicians performed the procedures in a hybrid operating room, using general endotracheal anesthesia and standard monitoring lines, including a transesophageal echocardiography probe. For the bypass phase of the procedure, two patients received left internal mammary arteries and two received only saphenous vein grafts.

Transaortic TAVR with either a Sapien 3 or Sapien XT valve (Edwards Lifesciences) was then successfully completed without procedure-related complications in all four patients. After a day in intensive care followed by transfer to the ward patients were discharged home, spending, on average, 5.5 days in hospital. No complications occurred through up to 6 months of follow-up.

“This case series demonstrates that the hybrid procedure of transaortic TAVI and off-pump bypass grafting is a feasible option to treat concomitant coronary artery disease and severe symptomatic aortic stenosis in patients who are high risk for conventional surgery,” the authors say.

“Whilst this hybrid procedure requires a full sternotomy to perform coronary artery bypass grafting, and almost doubles the risk compared to a single non-CABG procedure, it avoids the well-recognized risks of aortic cross-clamping and establishment of cardiopulmonary bypass,” they note. “This is therefore an attractive option for patients with a highly calcified ascending aorta or comorbidity that would make them unsuitable for conventional on-pump CABG and valve replacement.”

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