TAVR Explant After CABG With MVR

This article is part of CTSNet’s series, Perfecting TAVR Removal | Skills Sharpening With Vince Gaudiani. CTSNet Senior Editor Dr. Vince Gaudiani presents nine surgical videos on the technical aspects of aortic valve replacement after TAVR. This series will conclude in three live learning roundtable events, scheduled at three different times to accommodate participants in multiple regions of the world. 

This video shows a patient who had undergone coronary artery bypass grafting (CABG) 20 years prior and transcatheter aortic valve replacement (TAVR) two years prior to developing aortic regurgitation. 

First, a redo sternotomy was performed while preserving the vein grafts. The angiogram of the vein to the left anterior descending artery (LAD) showed that the patient was suffering from classical angina preoperatively. During the operation, this graft was found to be profoundly calcified. 

Next, the TAVR valve was explanted using the handlebar mustache technique. A small area of the aorta was damaged but was repaired using the pledged sutures for the annulus, which would be used to suture the aortic valve replacement (AVR) into place.  

A mitral valve replacement was then performed to treat the patient’s mitral valve regurgitation. This was performed through the roof of the left atrium rather than Sondegaarde’s groove. Although the incision was not as wide as in Sondegaarde's groove, the view of the valve was still satisfactory. One advantage of this approach is that sutures can be placed from the aortic side into the left atrium. 

Next, the calcified vein to the LAD was resected, and the vein was cut down across the anastomosis with the LAD. A vein patch was sutured to the proximal vein where it was not calcified to revise the 20-year-old graft. Finally, after the valves were placed with Cor-Knots and the atrium and aorta were closed with a single layer 3-0 Prolene suture, a left ventricular (LV) pacing lead was placed lateral to the posterior descending artery (PDA) since the patient already had a pacing system in place. His ejection fraction (EF) was only 30 percent, so the pacemaker was upgraded to a cardiac resynchronization therapy (CRT) device postoperatively to optimize biventricular contraction. 

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