Simultaneous coronary artery bypass grafting and transcarotid transcatheter aortic valve implantation using a cardiopulmonary bypass-assisted carotid perfusion

Abstract

Managing severe aortic stenosis (AS) alongside complex coronary artery disease (CAD) in frail patients is challenging. A 79-year-old female with resting dyspnea was diagnosed with severe AS and CAD. While coronary artery bypass grafting (CABG) was the appropriate treatment for CAD, surgical aortic valve replacement was deferred due to a porcelain aorta and left ventricular dysfunction. The carotid approach was the only feasible option for transcatheter aortic valve implantation (TAVI), yet it posed an increased risk of ischemic stroke due to inadequate cerebral collateral circulation. She underwent simultaneous on-pump beating CABG and transcarotid TAVI using cardiopulmonary bypass with selective cerebral perfusion. A 20-mm Sapien 3 valve (Edwards Lifesciences, Irvine, CA, USA) was successfully implanted. Postoperatively, her condition improved without any signs of cerebral ischemia, and she was discharged in stable condition. This innovative approach ensured cerebral perfusion, minimized stroke risk, and effectively addressed severe CAD in a single procedure.

Learning objective

To demonstrate the clinical applicability of combining coronary artery bypass grafting and transcatheter aortic valve implantation (TAVI) via carotid artery access in a small-statured, high-risk patient.

To discuss the novel use of an extracorporeal cardiopulmonary bypass-assisted carotid perfusion or cerebral protection during TAVI in a patient with inadequate collateral cerebral circulation.