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Hybrid offâpump coronary artery bypass grafting surgery and transaortic transcatheter aortic valve replacement: Literature review of a feasible bailout for patients with complex coronary anatomy and poor femoral access
Background and Aim of Study
The treatment of inoperable patients with concomitant complex coronary artery disease and severe aortic stenosis unsuitable for conventional transcatheter aortic valve replacement (TAVR) poses a significant challenge. Effective treatment is even more difficult in those patients with complex coronary anatomy unamenable to percutaneous revascularization. Our manuscript aims to enlighten clinicians on the management of this complex patient.
Methods
We conducted a contemporary review of the literature of combined offâpump coronary artery bypass grafting and transaortic TAVR in this patient population and describe our own successful experience in an inoperable patient with a porcelain aorta.
Results
Including our report, 17 cases have been described in the literature. All patients had multiple comorbidities with elevated STS (range, 2.6â25; 6%) and EuroScore I (range, 13.7â83; 7%) and were not considered candidates for conventional CABG and SAVR. Most had severe, complex, multivessel CAD deemed unsuitable for PCI and structural findings precluding them from other standard percutaneous or alternative TAVR approaches (transfemoral/subclavian/transcaval/transapical). Out of the 17 cases, 5 (29%) had porcelain aortas. Most reports specify the decisionâmaking process is driven by a multidisciplinary team.
Conclusion
This report demonstrates that hybrid offâpump CABG surgery and transaortic TAVR can be successfully performed in highârisk patients with porcelain aortas who are not candidates for percutaneous methods, onâpump revascularization, transfemoral, subclavian, or transcaval valve implantations. It also highlights that careful study of the CTA scan could predict adequate access for a transaortic approach even in the presence of porcelain aorta in selected patients