An Alternative Approach for Very High-risk Non-operative Patients with Severe Aortic Stenosis and Multivessel Coronary Disease - Staged Coronary Angioplasty and Transcatheter Aortic Valve Implantation – Case Report and Review of Literature

The Aim: The management of obstructive coronary artery disease before the transcatheter aortic valve implantation (TAVI) is not yet well established.
Presentation of Case: We describe a 68-year-old patient with severe aortic stenosis, multivessel coronary artery disease, severe left ventricle dysfunction and several co-morbidities, who was disqualified from aortic valve replacement concomitant to coronary artery by-pass grafting because of excessive operative risk (logistic EuroScore 27.62%, STS 13.3% risk of mortality). After careful assessment he was treated with staged percutaneous coronary intervention (PCI) of the left main and the left anterior descending artery and right coronary artery with drug-eluting stents implantation, followed by TAVI. In the postoperative period heart rhythm disturbances occurred and he required pacemaker implantation. At the 2 year follow-up he was doing well without angina and heart failure symptoms. An improvement in left ventricle contractility on echocardiography (EF-45%) with proper prosthesis function were noted. However, 25 months after the procedure he died from stroke.
Discussion and Conclusion: Coronary artery disease is frequent in patients referred for TAVI and is associated with worse prognosis. The approach to the management of these patients is still unclear. We present and discuss several procedural strategies. The staged procedure with time interval appears to be a better alternative for patients with severe aortic stenosis with significant coronary artery disease and severe left ventricular dysfunction and co-morbidities. In doubtful cases, if symptoms of aortic stenosis and coronary artery disease are difficult to differentiate, PCI as a first step and clinical observation enable proper selection of an appropriate method for further treatment.