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Aortic valve stenosis after previous coronary bypass: Transcatheter valve implantation or aortic valve replacement?
© Jegaden et al.; licensee BioMed Central Ltd 2012
- Received: 7 January 2012
- Accepted: 29 May 2012
- Published: 29 May 2012
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.
- Transcatheter Aortic Valve Implantation
- Aortic Valve Stenosis
- Paravalvular Leak
- Transcatheter Aortic Valve Implantation Procedure
- Severe Aortic Valve Stenosis
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 . 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 . We report a prospective comparison between TAVI and AVR using our technique in patients with severe aortic valve stenosis (AS) and previous CABG.
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 (55–88), mean logistic Euroscore was 25 ± 15 (5.8–52) and mean delay after CABG was 11 ± 5 years (0.2–19). 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 life-sciences, 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 off-pump 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.
Outcome of patients after the procedure
AVR n = 10
TAVI n = 13
Extubation time (hours)
6.5 ± 2.8
2.8 ± 1.9
ICU Stay (Days)
1.2 ± 0.8
1 ± 0.8
Tropinin (24th hours)
6.7 ± 7
3 ± 1.2
Tranfusion requirement (%)
Pacemaker implantation (%)
Paravalvular leak (%)
30-day Mortality (%)
11 ± 2,5
10 ± 3
MACCE (Infarctus, stroke)
Our series presents several limitations, mainly the lack of randomization and the small number of patients. However, it emphasizes the hypothesis from the PARTNER trial  that surgical replacement is maybe better than TA-TAVI in patients with previous CABG.
Our series confirms that if TAVI can be considered as a good alternative to AVR in patients with previous CABG in order to avoid technical challenges of conventional surgery, it is maybe not the best option when previous CABG is the lone surgical risk factor for AVR and when transfemoral TAVI is not possible. Nowadays, in such patients without a porcelain aorta, we are thinking about a transaortic approach for TAVI procedure, through a right anterior mini thoracotomy (2nd ICS), as an alternative to the transapical approach. Another alternative could be the subclavian approach but it is not suitable to Sapien prothesis.
- Farhat F, Aubert S, Rosamel P, Jegaden O: Inferior T hemisternotomy after previous bypass grafting with the in situ RITA in front of the aorta. Ann Thorac Surg. 2005, 80: 1532-1533. 10.1016/j.athoracsur.2004.04.075.View ArticlePubMedGoogle Scholar
- Yann TD, Cao C, Martens-Hielsen J, Padang R, Ng M, Vallely M, Bannon PG: Transcatheter aortic valve implantation for high-risk patients with severe aortic stenosis: A systematic review. J Thorac Cardiovasc Surg. 2010, 139: 1519-1528. 10.1016/j.jtcvs.2009.08.037.View ArticleGoogle Scholar
- Khaladj N, Shrestha M, Peterss S, Kutschka I, Strueber M, Hoy L, Haverich A, Hagl C: Isolated surgical valve replacement after previous coronary artery bypass grafting with patent grafts: is the old-fashioned technique obsolete?. Eur J Cardiothorac Surg. 2009, 35: 260-264. 10.1016/j.ejcts.2008.09.051.View ArticlePubMedGoogle Scholar
- Dewey TM, Brown DL, Herbert MA, Culica D, Smith CR, Leon MB: Effect of concomitant coronary artery disease on procedural and late outcome of transcatheter aortic valve implantation. Ann Thorac Surg. 2011, 89: 758-767.View ArticleGoogle Scholar
- Smith CR, Leon MB, Mack MJ, Miller CD, Moses JW, Svensson LG: Transcatheter versus surgical aortic-valve replacement in high-risk patients. N Engl J Med. 2011, 364: 2187-2198. 10.1056/NEJMoa1103510.View ArticlePubMedGoogle Scholar
- Drews T, Pasic M, Buz S, Unbehaun A, Dreysse S, Kukucka M: Transapical aortic valve implantation after previous heart surgery. Eur J Cardiothorac Surg. 2011, 39: 625-630. 10.1016/j.ejcts.2010.06.023.View ArticlePubMedGoogle Scholar
- Ducrocq G, Al-Attar N, Himbert D, Messika-Zeitoun D, Lung B, Descoutures F: Early and mid-term outcomes in patients undergoing transcatheter aortic valve implantation after previous coronary artery bypass grafting. Eur J Cardiothorac Surg. 2012, 41: 499-504. 10.1093/ejcts/ezr041.View ArticlePubMedGoogle Scholar
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