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Cangemi et al. Mini-invasive Surg 2022;6:3 https://dx.doi.org/10.20517/2574-1225.2021.99 Page 7 of 13

by the Heart Team. It should be noted that, in all patients who had to implant self-expanding valve, the
[64]
Heart Team always chose to perform PCI before TAVI . According to the current studies, the best
approach is to customize revascularization timing considering clinical characteristics, type of transcatheter
aortic valve chosen, and complexity of CAD. A recent multicenter registry found that unplanned PCI after
TAVR is rare and its incidence declines over time after TAVR . Moreover, in this study , the main
[66]
[65]
indication to PCI was acute coronary syndrome in the first two years after TAVR. Multicenter registries [65-67]
showed that coronary angiography and PCI in TAVI patients affected by acute coronary syndrome is
usually successful but coronary ostia cannulation failure was associated with poorer outcomes. Although a
difficult access to the coronaries after TAVR is a great concern, it may be even more difficult to engage the
coronary ostia after TAVR-in-TAVR. Commissural alignment is not the only factor to be considered in this
particular setting. Nai Fovino et al. evidenced that female sex, reduced sinotubular junction diameter,
[68]
implantation of supra-annular prosthesis, and reduced left coronary cannulation height are independent
predictors of unfavorable coronary access after TAVR-in-TAVR.

HYBRID APPROACHES
In very high surgical risk patients with severe AS and CAD, not eligible for traditional percutaneous
therapy, the use of off-pump coronary artery bypass (OPCAB) and TAVI has been proposed. OPCAB is a
technique of surgical coronary revascularization without the use of cardiopulmonary bypass. Minimally
invasive direct CABG (MIDCAB) is an even less invasive surgical technique used to treat a single vessel
CAD (usually left anterior descending artery). Baumbach et al. , in a single-center prospective registry,
[69]
compared outcomes of patients undergoing TAVI + OP/MIDCAB with those undergoing TAVI + PCI and
SAVR + CABG. TAVI (58% transapical and 42% transaortic) + OP/MIDCAB was associated with the
highest mortality and rehospitalization rate compared to TAVI (mainly transfemoral) + PCI (staged
approach) and SAVR + CABG. This worrying in-hospital mortality rate for TAVI + OP/MIDCAB patients
(18%) was likely due to the fact these patients were sicker and older compared to the SAVR + CABG ones;
this procedure is more invasive than percutaneous treatments and probably requires a steeper learning
curve. This mortality rate is comparable to the one previously reported for this particular hybrid procedure
in a comparable patient population , but in another population of fewer patients there were no in-hospital
[70]
deaths . This difference is probably in relation with the patient condition and the surgeon’s skills. To
[71]
reduce the complexity of the procedure, mortality, and complications, it has recently been proposed to
perform first MIDCAB and in a subsequent hospitalization TAVI (staged approach) [Table 2].
[72]

The use of minimally invasive valve surgery and PCI has been proposed as an alternative approach to
concomitant CABG + SAVR. The aim of this approach is to prevent a standard median sternotomy. In
relation to timing, there are two types of approaches, “staged” and “concomitant”. Santana et al. [73,74]
demonstrated that a strategy of performing PCI with a median of 30 days before a minimally invasive aortic
valve replacement was a safe and effective approach which permitted to reduce complications and length of
hospital stay. The problems associated with the staged approach are the need to discontinue anti-platelets
therapy during the perioperative period or the high risk of bleeding if the intervention is performed under
anti-platelets therapy. In addition, the development of TAVI and the inferiority of PCI in the case of
complex coronary anatomy has reduced enthusiasm for this approach. Brinster et al. , before the spread of
[75]
hybrid operating rooms, demonstrated the feasibility of a same-day PCI approach followed by SAVR.
George et al. described the possibility of performing in the hybrid room first PCI followed by valve
[76]
surgery (11 patients of 20 underwent SAVR). After four years there, was only one event (a stroke during
hospitalization) in the absence of in-hospital mortality. Outcomes were comparable to those of traditional
surgery [Table 3].