Combined Minimally Invasive Surgical and Percutaneous Approaches for a Patient on Hemodialysis With Severe Aortic Stenosis and Complex Coronary Artery Disease

Background: Type 2 diabetes mellitus is often associated with severe Coronary artery disease (CAD). Since patients with higher risk of severe disease are likely to get better benefit from aggressive management, it is essential to identify factors which are associated with severe macrovascular disease. We looked at the possibility of hyperinsulinemia being a marker for severe and complex coronary artery disease in type 2 diabetes mellitus, to select patients who would benefit from aggressive treatment. Methods: A cross sectional study of 290 type 2 diabetic patients, who underwent coronary angiogram for the evaluation of clinically suspected CAD at a tertiary care hospital were recruited. Biochemical and anthropometric parameters were analysed. Insulin resistance was measured by homeostasis model assessment method. Angiographically measured syntax score of more than 22 is considered to be severe and complex CAD. Receiver operating curve characteristic was performed to find out the optimal cut-off value for insulin resistance and fasting insulin. Predictors of syntax score greater than 22 were identified by multiple logistic regression analysis. Results: An insulin level > 20 μIU/ml (OR: 6.86, 95% CI: 2.25-20.88) emerged as an independent predictor of severe and complex CAD. The optimal cut-off of insulin for predicting severe CAD was 20 with sensitivity and specificity of 80% (95% CI: 0.68 - 0.88) and 79% (95% CI: 0.73 - 0.83) respectively. Conclusion: Hyperinsulinemia could serve as a marker to identify severe and complex CAD in type 2 diabetes at an earlier stage of diabetes. Key words: Coronary Artery Disease, Hyperinsulinemia, Insulin resistance, Syntax score, Type 2 diabetes mellitus.

TransCatheter aortic valve implantation and fractional flow reserve-guided percutaneous coronary intervention versus conventional surgical aortic valve replacement and coronary bypass grafting for treatment of patients with aortic valve stenosis and complex or multivessel coronary disease (TCW): an international, multicentre, prospective, open-label, non-inferiority, randomised controlled trial

In this article, we present our initial clinical experience with staged minimally invasive direct coronary bypass (MIDCAB), percutaneous coronary intervention (PCI), and transcatheter aortic valve implantation (TAVI) in high-risk octogenarians (Hybrid). The use of percutaneous techniques for managing structural heart diseases, especially in elderly high-risk patients, has revolutionized the treatment of structural heart diseases. These procedures are present predominantly being offered as isolated interventions. The feasibility, clinical benefit, and outcomes of combining these techniques with MIDCAB have not been sufficiently explored and have subsequently been underreported in the contemporary literature. Four consecutive octogenarians with severe aortic stenosis (AS) and complex coronary artery disease (CAD) that were at high risk for conventional surgery with extracorporeal circulation (ECC) were discussed in our Multidisciplinary Heart Team (MDH). Our MDH consisted of an interventional cardiologist, cardiac surgeon, and cardiac anesthesiologist. A hybrid approach with the alternative strategy comprising of MIDCAB, PCI, and TAVI in a staged fashion was agreed on. All 4 patients had both PCI/stenting and MIDCAB prior to deployment of the TAVI-prosthesis. From January 2019 to December 2020, 4 consecutive patients aged between 83 and 85 (3 male/1 female) years were scheduled for MIDCAB/PCI followed by percutaneous treatment of severe symptomatic AS. Intraoperatively, one patient was converted to full sternotomy, and surgery was performed by off-pump coronary artery bypass grafting. The overall procedural success rate was 100% in all 4 patients with resolution of their initial presenting cardiopulmonary symptoms. There were no severe complications associated with all hybrid procedures. There was no 30-day mortality in all patients. All patients were discharged home with a median hospital stay ranging between 9 and 25 days. All patients have since then been followed-up regularly. There was one noncardiac-related mortality at 6-months postsurgery. All other patients were well at 1-year follow-up with improved New York Heart Association Class II. In a selected group of elderly, high prohibitive risk patients with CAD and severe symptomatic AS, a staged approach with MIDCAB and PCI followed by TAVI can be safely performed with excellent outcomes. We advocate a MDH-based preliminary evaluation of this patient cohort in selecting suitable patients and appropriate timing of each stage of the hybrid procedure.

For patients with severe aortic stenosis and coronary artery disease, the completely percutaneous approach to aortic valve replacement and revascularization has not been compared with the standard surgical approach. The prospective SURTAVI trial (Safety and Efficiency Study of the Medtronic CoreValve System in the Treatment of Severe, Symptomatic Aortic Stenosis in Intermediate Risk Subjects Who Need Aortic Valve Replacement) enrolled intermediate-risk patients with severe aortic stenosis from 87 centers in the United States, Canada, and Europe between June 2012 and June 2016. Complex coronary artery disease with SYNTAX score (Synergy Between PCI with Taxus and Cardiac Surgery Trial) >22 was an exclusion criterion. Patients were stratified according to the need for revascularization and then randomly assigned to treatment with transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR). Patients assigned to revascularization in the TAVR group underwent percutaneous coronary intervention, whereas those in the SAVR group had coronary artery bypass grafting. The primary end point was the rate of all-cause mortality or disabling stroke at 2 years. Of 1660 subjects with attempted aortic valve implants, 332 (20%) were assigned to revascularization. They had a higher Society of Thoracic Surgeons risk score for mortality (4.8±1.7% versus 4.4±1.5%; P<0.01) and were more likely to be male (65.1% versus 54.2%; P<0.01) than the 1328 patients not assigned to revascularization. After randomization to treatment, there were 169 patients undergoing TAVR and percutaneous coronary intervention, 163 patients undergoing SAVR and coronary artery bypass grafting, 695 patients undergoing TAVR, and 633 patients undergoing SAVR. No significant difference in the rate of the primary end point was found between TAVR and percutaneous coronary intervention and SAVR and coronary artery bypass grafting (16.0%; 95% CI, 11.1-22.9 versus 14.0%; 95% CI, 9.2-21.1; P=0.62), or between TAVR and SAVR (11.9%; 95% CI, 9.5-14.7 versus 12.3%; 95% CI, 9.8-15.4; P=0.76). For patients at intermediate surgical risk with severe aortic stenosis and noncomplex coronary artery disease (SYNTAX score ≤22), a complete percutaneous approach of TAVR and percutaneous coronary intervention is a reasonable alternative to SAVR and coronary artery bypass grafting. URL: https://www. gov. Unique identifier: NCT01586910.

Background: Surgical correction of ascending aortic aneurysm in conjunction with severe aortic stenosis and complex coronary artery disease carries substantial operative risk, particularly in frail or elderly patients. To improve outcomes in this population, we present a novel hybrid strategy combining transaortic transcatheter aortic valve replacement (TAVR), off-pump coronary artery bypass grafting (OPCABG), and ascending aortic wrapping in a single-stage procedure. Case: A 74-year-old man was referred to our center with severe bicuspid aortic valve stenosis (mean gradient: 96 mmHg; peak velocity: 4.9 m/s), a 54-mm ascending aortic aneurysm (Panels A-B), and complex coronary artery disease, including significant stenoses in the LMCA (50%), LAD (90%), Cx (85%), and RCA (70%). Additional comorbidities included carotid thrombosis, hyperlipidemia, bilateral pleural effusion, and hepatic steatosis. The calculated EuroSCORE II was 8.91, indicating high surgical risk. Management Strategy: Given the patient’s high-risk profile, a one-stop hybrid approach was adopted. The procedure began with transaortic TAVR (Panel C), followed by OPCABG using LIMA to LAD and a LIMA-(Y)-SV sequential graft to D1, Cx, and OM (Panels D-E). Finally, ascending aortic wrapping was performed to reinforce the aneurysmal aorta (Panel F). Intraoperative angiography (Panel G) and transesophageal echocardiography confirmed successful valve deployment, no regurgitation, a mean transvalvular gradient of 7 mmHg, and reduction of the aortic diameter to 36 mm. Postoperative cardiac CT and 3D reconstruction on day 8 (at discharged) demonstrated a stable aortic diameter (37 mm) with excellent graft patency (Panels H-J). The patient remained in sinus rhythm without complications at 1-month follow-up. Conclusion: To our knowledge, this is the first reported case of a single-stage hybrid procedure combining transaortic TAVR, OPCABG, and ascending aortic wrapping in a high-risk patient with severe aortic stenosis, ascending aortic aneurysm, and multivessel coronary artery disease. This approach appears to offer a safe and effective alternative to conventional surgery in frail patients, with favorable early outcomes and promising graft integrity. Further studies with larger sample sizes and long-term follow-up are warranted.

The optimal treatment of patients with severe aortic stenosis (AS) and complex coronary artery disease (CAD) remains controversial. We conducted a meta-analysis to investigate outcomes of transcatheter aortic valve replacement (TAVR) with percutaneous coronary intervention (PCI) versus surgical aortic valve replacement (SAVR) with coronary artery bypass grafting (CABG). We searched PubMed, Embase, and Cochrane databases from its inception up to 17 December 2022 for studies that assessed TAVR + PCI versus SAVR + CABG in patients with AS and CAD. The primary outcome was perioperative mortality. Six observational studies including 135,003 patients assessing TAVI + PCI (n = 6988) versus SAVR + CABG (n = 128,015) were included. Compared to SAVR + CABG, TAVR + PCI was not significantly associated with perioperative mortality (RR, 0.76; 95% CI, 0.48-1.21; p = 0.25), vascular complications (RR, 1.85; 95% CI, 0.72-4.71; p = 0.20), acute kidney injury (RR, 0.99; 95% CI, 0.73-1.33; p = 0.95), myocardial infraction (RR, 0.73; 95% CI, 0.30-1.77; p = 0.49), or stroke (RR, 0.87; 95% CI, 0.74-1.02; p = 0.09). TAVR + PCI significantly reduced the incidence of major bleeding (RR, 0.29; 95% CI, 0.24-0.36; p < 0.01) and length of hospital stay (MD, -1.60; 95% CI, -2.45 to -0.76; p < 0.01), but increased the incidence of pacemaker implantation (RR, 2.03; 95% CI, 1.88-2.19; p < 0.01). At follow-up, TAVR + PCI was significantly associated with coronary reintervention (RR, 3.17; 95% CI, 1.03-9.71; p = 0.04) and a reduced rate of long-term survival (RR, 0.86; 95% CI, 0.79-0.94; p < 0.01). In patients with AS and CAD, TAVR + PCI did not increase perioperative mortality, but increased the rates of coronary reintervention and long-term mortality.

Case presentation: A 66-year-old man is referred to a cardiologist for the evaluation of a heart murmur. The patient claims to be entirely asymptomatic, although his wife notes that he has decreased his physical activity over the past two years because he is “getting old.” At physical examination, his blood pressure was 120/70 mm Hg; pulse, 80 bpm; respiration, 13 breaths per minute; and temperature, 99.0°F. Cardiovascular examination revealed normal central venous pressure. His carotid upstrokes were reduced in volume and delayed in upstroke. Cardiac examination revealed a forceful sustained apical impulse in its normal position. There was a 3/6 late-peaking systolic ejection murmur heard at the right upper sternal border radiating to the neck. The rest of the physical examination was unremarkable. Echo-Doppler evaluation revealed an ejection fraction of 0.60, a left ventricular free wall thickness of 1.3 cm, and a peak transaortic flow velocity of 4.5 m/s. How should this patient be managed? Should he undergo aortic valve replacement now? Should he undergo longitudinal follow-up to monitor progression of his aortic stenosis? Over the past 40 years, diagnostic techniques, substitute cardiac valves, and valve implantation surgery have undergone continued improvement, reducing the risk of the valve replacement and enhancing its benefits. Thus, the risk-benefit analysis of valve surgery has tilted in favor of increasingly early intervention for valve disease. The following is a summary incorporating this concept into the current strategy for managing patients with aortic stenosis such as the one described above. The patient with severe aortic stenosis who presents with symptoms represents the most straightforward management strategy for the disease. Survival is nearly normal until the classic symptoms of angina, syncope, or dyspnea develop.1 However, only 50% of patients who present with angina survive 5 years, whereas 50% survival is 3 years for patients who …

A single-center retrospective study was initialized to investigate the occurrence of acute kidney injury (AKI) and its impact on short- and long-term outcomes after aortic valve replacement in patients with aortic stenosis (AS) and complex coronary artery disease (CAD). Between January 2010 and December 2020, 1,232 patients with severe AS and CAD were treated. Propensity score matching generated 40 patient pairs with intermediate Society of Thoracic Surgeons (STS) risk scores (3.2 ± 0.3) and EuroSCORE II (4.1 ± 0.3) undergoing percutaneous (transcatheter aortic valve replacement [TAVR] + percutaneous coronary intervention [PCI]) or surgical (surgical aortic valve replacement [SAVR] + coronary artery bypass grafting [CABG]) combined procedures. The renal function-corrected ratio of contrast medium to body weight was calculated to determine the risk of postprocedural contrast medium-associated AKI. Renal retention values were recorded daily until the 7th day after the procedure. The overall incidence of postprocedural AKI was similar between the groups. There was no correlation between the contrast medium volume to serum creatinine to body weight ratio and AKI occurrence. During the first 7 postprocedural days, creatinine clearance values were comparable: 68.97 ± 4.92 mL/min (SAVR + CABG) vs. 64.95 ± 9.78 mL/min (TAVR + PCI), mean difference 4.02, 95% CI (-24.5 to 16.4), p = 0.691. On the 7th day after the procedure, 35% (8/23) of patients with renal impairment had improved renal function. No correlation between impaired renal function and short- or long-term mortality was found in multivariable models. Contrast agents may temporarily impair renal function during a minimally invasive percutaneous approach; however, occurrence of AKI was not related to the amount of contrast medium, and AKI was not associated with short- and long-term mortality.

Coronary atherosclerosis is a common finding in patients with severe aortic stenosis. Indeed, aortic stenosis is associated with risk factors similar those of coronary atherosclerosis such as older age, hypertension, diabetes, hypercholesterolemia and smoking. In light of the evolution of percutaneous aortic valve implantation (PAVI) and ongoing improvements in techniques of PCI, a combined approach using PCI and PAVI can be proposed for patients with complex coronary artery and aortic valve disease. This report describes the feasibility of the combination of percutaneous coronary intervention and percutaneous aortic valve implantation with peripheral left ventricular assist device (TandemHeart) support in 3 elderly patients with complex coronary artery disease and aortic stenosis considered too high risk for conventional surgical therapy.

BackgroundPatients with severe aortic stenosis (AS) and complex coronary artery disease with a clinical indication to both transcatheter aortic valve implantation (TAVI) and percutaneous coronary intervention (PCI) pose a clinical dilemma since it is unclear which lesion should be treated first and careful planning is required.Case summaryWe report two cases of AS with complex PCI (ASCoP) features. In the first one, easy coronary cannulation with an Acurate Neo2 valve and commissural alignment was predicted; therefore, TAVI was performed first, and subsequently complex high-risk PCI of the left main was performed in the same procedure but without the burden of ongoing severe AS. In the second case, complex coronary cannulation after TAVI with an Evolut PRO valve was predicted; therefore, balloon aortic valvuloplasty and Impella placement were performed first to allow for complex, high-risk multivessel PCI and subsequent TAVI. In both cases, a single-stage approach was preferred to reduce the use of large-bore arterial access with possible consequent adverse events.DiscussionIn this case series, we illustrate a possible approach to the treatment of ASCoP patients. In such complex cases, a thorough preprocedural planning is mandatory, and clinical decision-making should be centred upon the predicted chance of cannulation of coronary arteries after TAVI.

Background Prediction of severity or complexity of coronary artery disease (CAD) is valuableowing to increased risk for cardiovascular events. Although the associationbetween total coronary artery calcium (CAC) score and severity of CAD, Gensiniscore was not used, it has been previously demonstrated. There is no informationabout the association between total CAC score and complexity of CAD. ObjectivesTo investigate the association between severity or complexity of coronary arterydisease (CAD) assessed by Gensini score and SYNTAX score (SS), respectively, andcoronary artery calcium (CAC) score, which is a noninvasive method for CADevaluation in symptomatic patients with accompanying significant CAD. MethodsTwo-hundred-fourteen patients were enrolled. Total CAC score was obtained beforeangiography. Severity and complexity of CAD was assessed by Gensini score and SS,respectively. Associations between clinical and angiographic parameters and totalCAC score were analyzed. ResultsMedian total CAC score was 192 (23.0-729.8), and this was positively correlatedwith both Gensini score (r: 0.299, p<0.001) and SS (r: 0.577, p<0.001). Atmultivariate analysis, it was independently associated with age (ß: 0.154,p: 0.027), male gender (ß: 0.126, p: 0.035) and SS (ß: 0.481, p<0.001). Receiver-operating characteristic (ROC) curve analysis revealed a cut-offvalue > 809 for SS >32 (high SS tertile). ConclusionIn symptomatic patients with accompanying significant CAD, total CAC score wasindependently associated with SS and patients with SS >32 may be detectedthrough high Agatston score.

Hypertrophy is considered one of the major mechanisms of the myocardium for adapting to hemodynamic overload. More muscle mass provides more contractile elements for generating the extra work required by the overload. In pressure overload of aortic valve stenosis, concentric left ventricular hypertrophy (LVH) normalizes wall stress, a key determinant of ejection performance.1 Afterload is often expressed as wall stress (pressure×radius/thickness). As the pressure term in the numerator increases, it is offset by an increase in the thickness term of the denominator. In this way, the high systolic pressure required to drive blood through even a very stenotic aortic valve can be consistent with normal afterload and normal ejection fraction. See p 3170 Unfortunately, hypertrophy not only provides benefits but also has many pathological consequences. One of these is myocardial ischemia and the attendant angina reported by patients with aortic stenosis despite normal epicardial coronary arteries. The onset of angina greatly increases the risk of sudden death compared with the risk in asymptomatic patients with aortic valve stenosis.2,3 Angina occurs when myocardial oxygen demand exceeds supply. Demand is proportional to heart rate and wall stress, and the latter can be elevated in cases of aortic stenosis when hypertrophy is inadequate to normalize stress.1 After aortic valve replacement, there is marked regression of hypertrophy that may occur over the next several months to years,4 but angina is relieved immediately. Relief of angina immediately after surgery is probably due to the combination of sudden decreased oxygen demand after removal of pressure overload and increased oxygen supply of improved perfusion. However, there are remaining questions about the physiological mechanisms for reduced myocardial oxygen supply (coronary blood flow) in aortic stenosis and its improvement after relief of pressure overload. Specifically, what is it about critical aortic stenosis that is “critical” …

Background: Coronary artery disease (CAD) is highly prevalent in veterans with severe aortic stenosis (AS). However, the optimal management of CAD in this patient population remains a topic of contention. Historical management was predicated on surgical aortic valve replacement (SAVR) with concomitant coronary artery bypass grafting (CABG). Transcatheter aortic valve replacement (TAVR) has demonstrated efficacy in managing aortic stenosis in this population, albeit without addressing the underlying CAD when performed in isolation. This has resulted in a debate regarding the management of CAD in the context of severe AS, which requires intervention. This manuscript aimed to provide evidence to assist physicians in choosing the optimal management of patients presenting with severe AS and CAD. Methods: This is a retrospective cohort study using the Veterans Affairs Surgical Quality Improvement Project (VASQIP) database. Perioperative data were extracted for patients with severe AS and high-grade (≥70%) left anterior descending (LAD) artery stenosis who underwent either SAVR + CABG or isolated TAVR between 2012 and 2020. Cohorts were propensity matched. The odds of myocardial infarction (MI) and stroke within 30 days of surgery were compared using logistic regression. The survival probability at 1 month, 6 months, 2 years, and 5 years was compared using a time-varying Cox regression. Results: A total of 587 patients were included (332 SAVR + CABG and 255 isolated TAVR). Propensity score matched (PSM) analysis alongside the nearest-neighbor method yielded a paired sample of 510 patients. MI was not observed within 30 days postoperatively for either group. The TAVR cohort had 92% lower odds of postoperative stroke (odds ratio (OR) = 0.08; 95% confidence interval (CI) [0.00, 0.50]; p = 0.027). No significant differences were observed in survival within the first 30 days. Between one and six months post-operation, the TAVR cohort had higher survival than the SAVR + CABG cohort (hazard ratio (HR) = 0.38; 95% CI [0.15, 0.95]; p = 0.038). However, between 2 and 5 years, the TAVR cohort exhibited a lower survival (HR = 1.69; 95% CI [1.05, 2.70]; p = 0.030). Overall, the TAVR cohort had a lower 5-year survival rate. Conclusions: Although SAVR + CABG may increase the risk of postoperative stroke, this combination is associated with improved long-term mortality in patients with severe AS and severe CAD. Furthermore, the need for additional revascularization is reduced in patients undergoing SAVR + CABG, including those with single-vessel CAD. In contrast, TAVR reduces 30-day stroke risk but does not demonstrate the same mortality benefit long-term when compared to SAVR + CABG.

Background— With the availability of transcatheter aortic valve replacement, management of coronary artery disease in patients with severe aortic stenosis (AS) is posing challenges. Outcomes of percutaneous coronary intervention (PCI) in patients with severe AS and coronary artery disease remain unknown. We sought to compare the short-term outcomes of PCI in patients with and without AS. Methods and Results— From our PCI database, we identified 254 patients with severe AS who underwent PCI between 1998 and 2008. Using propensity matching, we found 508 patients without AS who underwent PCI in the same period. The primary end point of 30-day mortality after PCI was similar in patients with and without severe AS (4.3% [11 of 254] versus 4.7% [24 of 508]; hazard ratio, 0.93; 95% confidence interval, 0.51–1.69; P =0.2). Patients with low ejection fraction (≤30%) and severe AS had a higher 30-day post-PCI mortality compared with those with an ejection fraction &gt;30% (5.4% [7 of 45] versus 1.2% [4 of 209]; P &lt;0.001). In addition, AS patients with high Society of Thoracic Surgeons score (≥10) had a higher 30-day post-PCI mortality than those with a Society of Thoracic Surgeons score &lt;10 (10.4% [10 of 96] versus 0%; P &lt;0.001). Conclusions— PCI can be performed in patients with severe symptomatic AS and coronary artery disease without an increased risk of short-term mortality compared with propensity-matched patients without AS. Patients with ejection fraction ≤30% and Society of Thoracic Surgeons score ≥10% are at a highest risk of 30-day mortality after PCI. This finding has significant implications in the management of severe coronary artery disease in high-risk severe symptomatic AS patients being considered for transcatheter aortic valve replacement.

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