Abstract 4347146: One-Stop Hybrid TAVR, Off-Pump CABG, and Ascending Aortic Wrapping in a High-Risk Patient: A Case Report

Abstract

Background: Surgical correction of ascending aortic aneurysm in conjunction with severe aortic stenosis and complex coronary artery disease carries substantial operative risk, particularly in frail or elderly patients. To improve outcomes in this population, we present a novel hybrid strategy combining transaortic transcatheter aortic valve replacement (TAVR), off-pump coronary artery bypass grafting (OPCABG), and ascending aortic wrapping in a single-stage procedure. Case: A 74-year-old man was referred to our center with severe bicuspid aortic valve stenosis (mean gradient: 96 mmHg; peak velocity: 4.9 m/s), a 54-mm ascending aortic aneurysm (Panels A-B), and complex coronary artery disease, including significant stenoses in the LMCA (50%), LAD (90%), Cx (85%), and RCA (70%). Additional comorbidities included carotid thrombosis, hyperlipidemia, bilateral pleural effusion, and hepatic steatosis. The calculated EuroSCORE II was 8.91, indicating high surgical risk. Management Strategy: Given the patient’s high-risk profile, a one-stop hybrid approach was adopted. The procedure began with transaortic TAVR (Panel C), followed by OPCABG using LIMA to LAD and a LIMA-(Y)-SV sequential graft to D1, Cx, and OM (Panels D-E). Finally, ascending aortic wrapping was performed to reinforce the aneurysmal aorta (Panel F). Intraoperative angiography (Panel G) 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 CT and 3D reconstruction on day 8 (at discharged) demonstrated a stable aortic diameter (37 mm) with excellent graft patency (Panels H-J). The patient remained in sinus rhythm without complications at 1-month follow-up. Conclusion: To our knowledge, this is the first reported case of a single-stage hybrid procedure combining transaortic TAVR, OPCABG, and ascending aortic wrapping in a high-risk patient with severe aortic stenosis, ascending aortic aneurysm, and multivessel coronary artery disease. This approach appears to offer a safe and effective alternative to conventional surgery in frail patients, with favorable early outcomes and promising graft integrity. Further studies with larger sample sizes and long-term follow-up are warranted.