One-Stop Hybrid TAVR, Off-Pump CABG, and Ascending Aortic Wrapping in a High-Risk Patient

This video submission is from the 2025 CTSNet Innovation Video Competition. Watch all entries from the competition, including the winning videos.   

This video demonstrates a novel hybrid strategy that combines transcatheter aortic valve replacement (TAVR), off-pump coronary artery bypass grafting (OPCABG), and ascending aortic wrapping in a case of ascending aortic aneurysm in conjunction with severe aortic stenosis and complex coronary artery disease. 

The authors present the case of a 74-year-old male patient, who was 158 cm in height and weighed 67 kg, with a body mass index (BMI) of 26.8. He complained of chest tightness and shortness of breath after exercise. 

Preoperative assessments revealed severe bicuspid aortic valve stenosis (mean gradient: 96 mmHg; peak velocity: 4.9 m/s), a 54 mm ascending aortic aneurysm, and complex coronary artery disease, including significant stenoses in the left main coronary artery (LMCA) (50 percent), left anterior descending artery (LAD) (90 percent), circumflex artery (Cx) (85 percent), and right coronary artery (RCA) (70 percent). Additional comorbidities included carotid thrombosis, hyperlipidemia, bilateral pleural effusion, and hepatic steatosis. The calculated European System for Cardiac Operative Risk Evaluation II (EuroSCORE II) was 8.91, indicating high surgical risk. 
 
Given the patient’s high-risk profile, a one-stop hybrid approach was adopted. The procedure began with transfemoral TAVR, followed by OPCABG using the left internal mammary artery (LIMA) to the LAD and a LIMA-(Y)-saphenous vein (SV) sequential graft to the first diagonal artery (D1), Cx, and obtuse marginal artery (OM). Finally, ascending aortic wrapping was performed to reinforce the aneurysmal aorta. 
 
Intraoperative angiography 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 computed tomography (CT) and angiography on day eight (at discharge) demonstrated a stable ascending aortic diameter of 37 mm with excellent graft patency. The patient remained in sinus rhythm without complications at one-month follow-up. 

Editor’s Note 

This is an interesting case that demonstrates potential alternatives for patients deemed too high risk for the conventional approach of coronary artery bypass grafting (CABG), aortic valve replacement (AVR), and ascending aortic replacement. The video did not provide clear details regarding the specific factors that rendered the patient too high risk for standard surgery, although some high-risk factors were mentioned. Notably, the patient’s EuroSCORE was under 10 percent, which suggests that he may have been a candidate for traditional surgical intervention—typically the preferred approach in the USA and Europe.  

In addition, one reviewer noted that the completion angiography indicated some distal and arch dilatation. This observation may be expected given the patient’s unsuitable profile for routine surgery, since an aortic wrap procedure cannot wrap the arch of the aorta. Certainly, this video shows some good alternative approaches and what is possible without the use of cardiopulmonary bypass if it is certain that the patient is unlikely to survive a significant period of cardiopulmonary bypass. 

References

1. Shimahara Y,et al. Efficacy of Off-Pump Coronary Artery Bypass Grafting With Concomitant Transcatheter Aortic Valve Replacement. Heart Lung Circ. 2022;31(12):1666-1676.
2. Hardisky D, et al. Concomitant anaortic OPCAB and transfemoral TAVR for high-risk patients: A case series. J Card Surg. 2022;37(11):3935-3942.

Disclaimer

The information and views presented on CTSNet.org represent the views of the authors and contributors of the material and not of CTSNet. Please review our full disclaimer page here.