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

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.

Another controversial aspect is whether PCI and TAVI should be performed simultaneously or as a 2-staged procedure.

The arguments in favor of performing both procedures separately are:

The arguments in favor of performing both procedures simultaneously are:

Taking all this into consideration, and only if the patient’s clinical situation allows it, the first step would be to plan the PCI with aortic valvuloplasty and 4-6 weeks later, the TAVI procedure.

Therefore, this is how the management of the LMS should be:

Regarding the type of valve, in this decision it is of paramount importance to take into consideration the possible need to access the LMS after the TAVI especially if we think that the rate of restenosis in trifurcations treated with 2 or more stents is usually high. The height of the LMS ostium the length and calcification of the leaflets and the width of the sinuses should all be studied by computed tomography scan prior to planning the implantation and choosing the device. The advantage of the expandable balloon device is that it is shorter preventing in many cases the jailing of the LMS; the setback is that overpacing is required for implantation purposes. Self-expandable and fully recapturable devices can be implanted without overpacing and with little contrast if using fusion imaging technology or transesophageal ultrasound; the setback is that, although these devices have wider cells, the LMS is jailed, which could make access difficult after implantation. Nevertheless, the interventional team should use the model they are most experienced with.