Successful combined minimally invasive direct coronary artery bypass and transapical aortic valve implantation

Video-assisted minimal access surgery for complicated mitral valve endocarditis, tricuspid valve insufficiency and progressive coronary disease after previous CABG - in the time of COVID-19: a case report

BACKGROUND

The timing for heart surgery following cerebral embolization after cardiac valve vegetation is vital to postoperative recovery being uneventful, additionally Covid-19 may negatively affect the outcome. Minimally invasive methods and upgraded surgical instruments maximize the benefits of surgery also in complex cardiac revision cases with substantial perioperative risk.

CASE PRESENTATION

A 68 y.o. patient, 10 years after previous sternotomy for OPCAB was referred to cardiac surgery on the 10th postoperative day after neurosurgical intervention for intracerebral bleeding with suspected mitral valve endocarditis. Mitral valve vegetation, tricuspid valve insufficiency and coronary stenosis were diagnosed and treated by minimally invasive revision cardiac surgery on the 14th postoperative day after neurosurgery.

CONCLUSION

The present clinical case demonstrates for the first time that the minimally invasive approach via right anterior mini-thoracotomy can be safely used for concomitant complex mitral valve reconstruction, tricuspid valve repair and aorto-coronary bypass surgery, even as a revision procedure in the presence of florid endocarditis after recent neurosurgical intervention. The Covid-19 pandemic and prophylactic patient isolation slow down the efficacy of pulmonary weaning and mobilisation and prolong the need for ICU treatment, without adversely affecting long-term outcome.

Early Results of Simultaneous Transaortic Transcatheter Aortic Valve Implantation and Total Arterial Off-Pump Coronary Artery Revascularization in High-Risk Patients

BACKGROUND

Transcatheter aortic valve implantation (TAVI) has become an alternative procedure for treating aortic stenosis (AS) in patients with advanced age and severe comorbidities. Ischemic heart disease (IHD) is present with AS in 40-50% of patients with typical angina. Considering the high operative mortality and morbidity rates in these patients, hybrid TAVI and off-pump CABG (OPCAB) have become realistic treatment options.

METHODS AND RESULTS

Between August 2014 and November 2015, 12 patients were evaluated for simultaneous TAVI and OPCAB. Because of their advanced age and comorbidities these patients were not considered suitable for standard open heart surgery. PCI was also considered unsuitable, because of left anterior descending artery (LAD) proximal lesions and/or high SYNTAX score. TAVI was conducted through a median sternotomy after left internal thoracic artery (LITA) to LAD anastomosis. In 11 cases OPCAB with LITA and composite RA graft was performed using an aorta no-touch technique. Mean age at operation was 81±6.3 years. Average number of distal anastomoses was 2.6. Perivalvular leakage was mild in 3 patients, trivial in 8, and none in 1. There was no conversion to on-pump procedure and no hospital deaths.

CONCLUSIONS

Simultaneous transaortic TAVI and OPCAB in high-risk patients with severe AS and IHD is a reasonable option. This method could be an alternative to surgical aortic valve replacement and CABG. (Circ J 2016; 80: 1946-1950).

Aortic Valve Stenosis and Left Main Coronary Disease: Hybrid Approach

We describe a technique of combined transcatheter aortic valve replacement (TAVR), off-pump single coronary artery bypass, and percutaneous coronary intervention (PCI) in a high-risk patient presenting with unstable angina and severe heart failure. This patient had documented moderate to severe aortic stenosis, left ventricular dysfunction, and a heavily calcified ascending aorta. A robotic-assisted left internal thoracic artery harvesting was aborted owing to inability to tolerate single-lung ventilation. A median sternotomy was done, then successful off-pump single-vessel bypass, PCI, and TAVR were achieved. The patient recovered and was discharged from hospital in stable condition.

Concurrent Coronary Artery and Valvular Heart Disease - Hybrid Treatment Strategies in 2013

Concomitant coronary artery disease (CAD) and valvular heart disease is an increasingly common problem in the ageing population. Hybrid procedures combine surgical and transcatheter approaches to facilitate minimally invasive surgery or to transform a single high-risk open surgery into two less risky procedures. In ideal circumstances, this strategy may decrease the surgical risk in elderly, high-risk and reoperative surgical candidates, while improving patient comfort, convenience and cost-effectiveness. Hybrid procedures can be performed in a staged fashion or as a 'one-stop' procedure in a hybrid operating suite. Increasing evidence supports the safety and short-term efficacy of hybrid valve repair or replacement and coronary revascularisation procedures. Nevertheless, important questions remain, including the optimal timing of the individual procedures and the optimal antiplatelet therapy after percutaneous coronary intervention. With ongoing advances in procedural techniques and anticoagulation strategies, as well as the accumulation of long-term outcomes data, hybrid approaches to concomitant CAD and valvular heart disease will likely become increasingly common.

Transapical aortic valve replacement through a chronic apical aneurysm

Transapical aortic valve replacement through an apical aneurysm is traditionally contraindicated because of the risk of severe systemic embolization when thrombi are present. However, a chronic fibrotic aneurysm without apical thrombi carries a low risk of distal embolization and can be safely employed for a transapical transcatheter aortic valve replacement in case of absence of an alternative access site (severe vascular disease, small vascular sizes and diseased calcified aorta). We illustrate our experience with a 73-year-old patient suffering from symptomatic aortic valve stenosis, coronary artery disease with occluded left anterior descending artery, left ventricular apical aneurysm and severe peripheral vascular disease, who successfully underwent a transapical 26 mm Sapien™ XT stent-valve implantation through the fibrotic thin akinetic apical wall.