Combined Minimally Invasive Surgical and Percutaneous Approaches for a Patient on Hemodialysis With Severe Aortic Stenosis and Complex Coronary Artery Disease

Patients on hemodialysis with concomitant severe aortic stenosis (AS) and multivessel coronary artery disease (CAD) are at high risk for surgical aortic valve replacement (SAVR) and coronary artery bypass grafting (CABG). Transsubclavian-transcatheter aortic valve implantation (TSc-TAVI) is a well-established alternative approach to transfemoral TAVI for patients with unfavorable femoral access. Herein, we report a case in which minimally invasive surgical treatment and TSc-TAVI were performed simultaneously in a patient with severe AS and multivessel CAD undergoing hemodialysis. An 85-year-old man undergoing hemodialysis for end-stage renal disease owing to severe AS (mean pressure gradient, 46 mmHg; aortic valve area, 0.75 cm²; and left ventricular ejection fraction, 59%) presented to our hospital with chest pain on exertion. Preoperative coronary angiography revealed significant stenosis of the left anterior descending (LAD) coronary artery and right coronary artery (RCA), requiring revascularization. However, the patient was not a good candidate for transfemoral TAVI because of a porcelain ascending aorta and a shaggy descending aorta observed on computed tomography. He was scheduled for concomitant right TSc-TAVI and minimally invasive cardiac surgery (MICS)-CABG after percutaneous coronary intervention (PCI) for the RCA. The treatment was successful. Simultaneous TSc-TAVI and MICS-CABG with PCI may be applied as a minimally invasive surgical treatment modality for patients with AS and CAD undergoing hemodialysis.