Simultaneous transfemoral TAVI and angioplasty of unprotected trifurcated left main coronary artery. How would I approach it?

Abstract

HOW WOULD I APPROACH IT? This is a a challenging case that combines severe coronary artery disease of trifurcated left main coronary artery and severe aortic stenosis in an elderly female patient with chronic kidney disease. According to the current clinical guidelines, this patient whose score in the Society of Thoracic Surgeons score is > 10% and with good femoral accesses has an I-B indication for a transcatheter aortic valve implantation (TAVI). No other factor supports performing surgery except for the existence of coronary artery disease, which could be considered eligible for coronary artery bypass graft given the complexity of the left main lesion and the presence of good distal beds. However, what makes this patient’s surgical risk nearly unacceptable is the combination of a valve replacement procedure plus coronary bypasses, so if a better percutaneous option is available, and we believe there is, such an option should be pursued. After establishing the indication for TAVI, there is a II-A indication for percutaneous revascularization since the percent diameter stenosis is > 70% in proximal segments, the Syntax I score estimated using the data available is 27 points (29 if intense calcification is considered) and after adding clinical data tinto consideration, the Syntax II score shows a 4-year mortality rate after percutaneous coronary intervention (PCI) of 44.2% vs 33.6% after surgery. All this leaves the decision making process open since the risk involved in both strategies is high. In this case we might choose PCI plus TAVI.