Aortic valve stenosis after previous coronary bypass: Transcatheter valve implantation or aortic valve replacement?

Journal of Cardiothoracic Surgery Aortic valve stenosis after previous coronary bypass: Transcatheter valve implantation or aortic valve replacement? Olivier Jegaden 0 Joel Lapeze 0 Fadi Farhart 0 Guy de Gevigney 0 0 Department of Cardiac Surgery and Transplantation, Hospital Louis Pradel, University Claude Bernard Lyon 1, INSERM Carmen , 28 Avenue du doyen LEPINE, Bron 69677 , France We report a prospective comparison between transcatheter valve implantation (TAVI, n = 13) and surgical aortic valve replacement (AVR, n = 10) in patients with severe aortic valve stenosis and previous coronary bypass surgery (CABG). All patients had at least bilateral patent internal thoracic arteries bypass without indication of repeat revascularization. After a similar post-procedure outcome, despite one early death in TAVI group, the 1-year survival was 100% in surgical group and in transfemoral TAVI group, and 73% in transapical TAVI group. When previous CABG is the lone surgical risk factor, indications for a TAVI procedure have to be cautious, specially if transfemoral approach is not possible. - Background Aortic Valve surgery (AVR) after previous coronary artery bypass (CABG) is always challenging and usually the indication of redo surgery is delayed because of the risk of reoperation in old patients with patent arterial grafts. Few years ago, we have described a surgical approach through an inferior T hemisternotomy for aortic valve surgery in patients with an in situ right internal mammary artery to left anterior descending artery passing in front of the ascending aorta, allowing a good surgical exposure and providing good results with an adapted surgical strategy [1]. Since the introduction of transcatheter aortic valve implantation (TAVI), these patients are now referred to this alternative therapeutic option as high risk patients with an adverse thorax even if they only present technical challenges to conventional AVR [2]. We report a prospective comparison between TAVI and AVR using our technique in patients with severe aortic valve stenosis (AS) and previous CABG. Methods From May 2009 and December 2010, 23 patients with AS and previous CABG were referred to our department for a TAVI procedure. Mean age was 76 9 years (5588), mean logistic Euroscore was 25 15 (5.852) and mean delay after CABG was 11 5 years (0.219). All patients had at least both IMA grafting and all arterial grafts were patent without indication for repeat revascularization. After the screening, 13 patients underwent a TAVI procedure with the implantation of a Sapien prothesis (Edwards lifesciences, Irvine, CA) using a transapical approach (TA) in 9 or a transfemoral approach (TF) in 4, according to the available vascular access, and 10 patients underwent a AVR procedure with the implantation of a Magna bioprothesis (Edwards life-sciences, Irvine, CA): 3 patients had refused the new TAVI procedure and 7 patients had a too large aortic annulus (>25 mm). In both group (TAVI and AVR), patients were similar in age (76 11 vs 76 6,) and logistic Euroscore (25 14 vs 25 16 respectively). In TAVI group, the impairment of left ventricular ejection fraction was higher (49 12 vs 57 9, ns) and the delay from CABG surgery was shorter (9 6 vs 14 2, p < 0.01); in this group, 3 patients had a severe porcelain aorta and in 2 of them, AS was known at the time of CABG surgery and the decision of a further TAVI procedure was decided during the offpump CABG procedure in front of a untouchable aorta. Written informed consent was obtained from the patient for publication of this report and any accompanying images. Results All TAVI procedures were done in catheterization laboratory under general anesthesia. In one patient with porcelain aorta, an intra-ventricular migration of the prothesis occurred during the TA procedure, leading to the implantation of a second valve and then a surgical removal of the first prothesis was successfully done through a right mini-thoracotomy using a left atrial and trans-mitral approach under beating heart. All other TAVI and AVR procedures were successfully done. One patient after TAVI procedure died on day 20th from general weakness; he was 88-year old with logistic euroscore 52 and the indication was probably overtaken. The outcomes of the patients are summarized in Table 1. After AVR, extubation time was significantly longer and Tropinin level (24th hours) was significantly higher. Transfusion requirement was higher after AVR (ns). After TAVI, pacemaker implantation was higher (ns) and 2 patients had a paravalvular leak (grade 2). ICU stay and hospital stay were similar in both group. There was no major adverse event in both group as myocardial infraction, stroke or vascular complication. The mean follow-up was 1.2 year; one sudden death occurred 3 months after a TAVI procedure. At 1 year, actuarial survival was 100% in AVR group and 84 21% in TAVI group (ns): 100% in TF and 78 28% in TA (ns). Comments Patients w (...truncated)