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Riojas et al. Vessel Plus 2024;8:6 https://dx.doi.org/10.20517/2574-1209.2023.122 Page 11 of 16

Figure 3. Coronary angiogram images of a 75-year-old man with a history of STEMI and PCI to RCA, LAD, and LCF who presented with
angina and was discussed by a Heart Team (Patient #2). (A) representative image of the right coronary artery showing several areas of
distal stenoses (yellow arrows). (B) A representative image of the left coronary arteries and in-stent restenosis of the LAD (yellow
arrow). STEMI: ST elevation myocardial infarction; PCI: percutaneous intervention; RCA: right coronary artery; LAD: left anterior
descending; LCF: left circumflex.

best option would be a hybrid approach and to proceed with a one-vessel CABG using the LIMA to the
LAD. This was in agreement with the 2021 ACC/AHA/SCAI Guideline for coronary artery
revascularization; the use of the LIMA as a conduit to bypass the LAD is a class 1 recommendation. He
underwent successful surgery and was discharged home. A plan was to continue optimal medical
management and PCI to the RCA only if he subsequently developed angina.

Patient 3
A 71-year-old man with a history of bicuspid aortic valve status post aortic valve replacement with a 25 mm
CE Perimount Magna bioprosthetic valve and mitral valve repair with a 34 mm Cosgrove band annuloplasty
about 10 years prior. Post-operatively, he underwent sternal wound debridement and eventual sternal
fixation with plates and bilateral pectoralis flap advancement. That hospital course was also significant for
heparin-induced thrombocytopenia. On workup, he was found to have moderate pulmonary hypertension,
reduced cardiac index, severe bioprosthetic aortic valve stenosis, moderate to severe mitral stenosis, and
severe RCA stenosis [Figure 4]. The surgeon recommended a re-do sternotomy, aortic valve replacement,
mitral valve replacement and a one-vessel CABG to the RCA, but the patient was a high-risk surgical
candidate. He wanted to explore other options, so he was presented at the Heart Team conference. During
the interim, he was placed on optimal medical therapy. The Heart team discussion included his primary
cardiologist, interventional cardiologists, structural heart cardiologists, and surgeons. Although the patient
could potentially undergo percutaneous coronary intervention and transcatheter aortic valve-in-valve, the
structural heart cardiologists recommended against a transcatheter approach to his mitral valve since he had
an incomplete mitral annulus band, which was not ideal for a transcatheter approach due to the anatomic
constraints given the need for concomitant aortic valve-in-valve. Thus, the recommendation of the Heart
Team was to proceed with surgery based on the 2020 ACC/AHA Guideline for the management of patients
with valvular heart disease, which has a Class 2 recommendation for CABG if a patient is undergoing a
concomitant valvular surgery . The patient underwent high-risk re-do sternotomy, aortic valve
[54]
replacement, mitral valve replacement, and one-vessel CABG. This case also highlights the patient-
centeredness and shared-decision making, which is also a Class 1 recommendation . He had an acceptable
[1]
postoperative course and is recovering well.