Heart failure and "inoperable" aortic stenosis: staged balloon aortic valvuloplasty and aortic valve bypass.

The prognosis for patients with symptomatic aortic stenosis is poor but is improved significantly by surgical aortic valve replacement. Unfortunately, many patients are refused surgery because of age, comorbidities, and hemodynamic instability. This report describes the successful use of balloon aortic valvuloplasty as a bridge to aortic valve bypass surgery (apicoaortic conduit) in an elderly patient with class IV congestive heart failure and severe left ventricular systolic dysfunction as a consequence of aortic stenosis who was not a candidate for traditional surgical valve replacement.

Simultaneous "hybrid" percutaneous coronary intervention and minimally invasive surgical bypass grafting: feasibility, safety, and clinical outcomes.

Surgical and percutaneous coronary artery intervention revascularization are traditionally considered isolated options. A simultaneous hybrid approach may allow an opportunity to match the best strategy for a particular anatomic lesion. Concerns regarding safety and feasibility of such an approach exist. We examined the safety, feasibility, and early outcomes of a simultaneous hybrid revascularization strategy (minimally invasive direct coronary bypass grafting of the left anterior descending [LAD] artery and drug-eluting stent [DES] to non-LAD lesions) in 13 patients with multivessel coronary artery disease that underwent left internal mammary artery to LAD minimally invasive direct coronary bypass performed through a lateral thoracotomy, followed by stenting of non-LAD lesions, in a fluoroscopy-equipped operating room. Assessment of coagulation parameters was also undertaken. Inhospital and postdischarge outcomes of these patients were compared to a group of 26 propensity score matched parallel controls that underwent standard off-pump coronary artery bypass. Baseline characteristics were similar in both groups. All hybrid patients were successfully treated with DES and no inhospital mortality occurred in either group. Hybrid patients had a shorter length of stay (3.6 +/- 1.5 vs 6.3 +/- 2.3 days, P < .0001) and intubation times (0.5 +/- 1.3 vs 11.7 +/- 9.6 hours, P < .02). Despite aggressive anticoagulation and confirmed platelet inhibition, hybrid patients had less blood loss (581 +/- 402 vs 1242 +/- 941 mL, P < .05) and decreased transfusions (0.33 +/- 0.49 vs 1.47 +/- 1.53 U, P < .01). Six-month angiographic vessel patency and major adverse cardiac events were similar in the hybrid and off-pump coronary artery bypass groups. A simultaneous hybrid approach consisting of minimally invasive coronary artery bypass grafting with left internal mammary artery to LAD combined with revascularization of the remaining coronary targets using percutaneous coronary artery intervention with DES is a feasible option accomplished with acceptable clinical outcomes without increased bleeding risk.

A hybrid alternative for high risk left main disease.

Percutaneous revascularization strategies for bifurcation disease of the left main are complex and carry significant risk. These risks are magnified in the setting of a left main which trifurcates. In a patient with complex ostial disease of two of the three limbs of a left main trifurcation, turned down for conventional bypass surgery, we report on a hybrid approach for complete revascularization, consisting of minimally invasive bypass grafting of the LAD combined with simultaneous drug eluting stent placement.