Background
Coronary artery disease (CAD) is associated with poorer outcomes after aortic valve replacement (AVR). For high-risk patients with complex CAD, combined transcatheter aortic valve replacement (TAVR) plus off-pump/minimally-invasive coronary artery bypass (OPCAB/MIDCAB) has been proposed.
Methods
A prospective registry analysis was performed to compare the characteristics and outcomes of patients undergoing TAVR+OP/MIDCAB with those undergoing TAVR plus percutaneous coronary intervention (PCI) and surgical AVR plus coronary artery bypass grafting (CABG) between 2008 and 2015 at a single site in Germany.
Results
464 patients underwent SAVR+CABG, 50 underwent TAVR+OP/MIDCAB, and 112 underwent TAVR+PCI. The mean ages (
p
< 0.001) and logistic EuroSCOREs (p < 0.001) were similarly higher in TAVR+OP/MIDCAB and TAVR+PCI patients compared to SAVR+CABG patients. Prior cardiac surgery was more common in TAVR+PCI than in TAVR+OP/MIDCAB and SAVR+CABG patients (p < 0.001). Procedural times were shortest (p < 0.001), creatine kinase (muscle brain) levels least elevated (p < 0.001), pericardial tamponade least common (
p
= 0.027), and length of hospital stay shortest (
p
= 0.011) in TAVR+PCI, followed by TAVR+OP/MIDCAB and SAVR+CABG patients. In-hospital mortality was highest for TAVR+OP/MIDCAB patients (18.0%) with comparable rates for TAVR+PCI and SAVR+CABG groups (9.0 and 6.9%;
p
= 0.009). Mortality by 12 months was more probable after TAVR+OP/MIDCAB (HR: 2.17,
p
= 0.002) and TAVR/PCI (HR: 1.63,
p
= 0.010) than after SAVR+CABG, with the same true of rehospitalisation (HR: 2.39,
p
= 0.003 and HR: 1.63,
p
= 0.033).
Conclusions
TAVR+OP/MIDCAB patients share many characteristics with TAVR+PCI patients, with only slightly poorer long-term outcomes. In patients ineligible for SAVR+CABG and TAVR+PCI, hybrid interventions are reasonable second-line options.
Electronic supplementary material
The online version of this article (10.1186/s12872-019-1087-2) contains supplementary material, which is available to authorized users.
We report about a 61-year-old man who, 6 years after initial uncomplicated mitral valve repair and 3 months after treatment of a pseudo-aneurysm of the ascending aorta with a Dacron patch, was admitted in our institution with an infection of the vascular graft, which was associated with sternal osteomyelitis and purulent cutaneous fistula. In a re-redo procedure, the proximal aortic arch and the ascending aorta were replaced with a cryopreserved aortic homograft. The infected part of the sternum was resected and the defect was covered by mobilizing the mediastinal tissue and with a bilateral muscle flap. The patient was discharged 20 days after surgery. This treatment concept outlines the benefit of cryopreserved aortic homograft when faced with a complex thoracic aortic infection.
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