Introduction
A vast proportion of cardiac surgery manages conditions whose
pathophysiology is driven by shared biologic mechanisms of
atherosclerosis, such as coronary artery disease (CAD) and calcific
aortic stenosis (AS)[1]. A third member of this
cluster is aortic atherosclerotic disease[2,3],
which at its most severe, results in nearly circumferential heavy
calcification referred to as porcelain aorta (PA). Due to the common
pathophysiology, there is significant overlap in the risk factors
predisposing to each disease and thus it is not uncommon for patients to
develop concomitant disease. Indeed, severe aortic stenosis requiring
intervention is associated with significant coronary artery disease in
up to 50% of cases[4]. Porcelain aorta has been
found in 7.5% of all patients evaluated for AS and in up to 9.3% of
patients undergoing coronary artery bypass grafting
(CABG)[5].
These are diseases of the elderly - all are increasingly recognized in
patients older than 60 and their prevalence and severity worsen with
increasing age[1,5]. Clinicians and surgeons alike
must be prepared to manage these aging high-risk patients with
concomitant atherosclerotic disease as the elderly are the
fastest-growing segment of the population[6]. Life
expectancy is predicted to increase from 79.7 years in 2017 to 85.6
years, with people >65 forecasted to make up 1/4 of the US
population by 2060[7].
Management must carefully weigh the risks and benefits of intervention.
While old age, severe disease, and an accruing number of comorbidities
all increase the risk of negative outcomes, such as stroke and death,
surgical intervention is nonetheless necessary in this population. Once
symptomatic, mortality in patients with AS is >90% by 2
years[8]. There is no effective preventative nor
curative medical treatments for AS[1]. However
following aortic valve replacement, the 15-year survival rate returns to
that of an age- and sex-matched population without AS, even in the most
elderly[9]. Surgical revascularization in stable
coronary disease has been proven to decrease the rates of myocardial
infarction (MI) and emergency revascularization, both of which are
independent predictors of mortality[10]. Further,
surgical intervention has been proven to significantly improve quality
of life outcomes in both CAD and AS when compared to medical management
alone[6,11].
As CAD and AS commonly co-exist, extensive research has been done to
evaluate the best course of surgical management. Current 2021 American
Heart Association (AHA) guidelines recommend coronary artery bypass
grafting (CABG) to be performed on patients who have significant disease
burden and are undergoing other non-coronary cardiac surgery, as
concomitant management improves outcomes[12,13].
Conventionally, in patients not amenable to percutaneous coronary
intervention (PCI), CABG and surgical aortic valve replacement (SAVR)
are the treatment of choice. However, aortic manipulation employed in
CABG and SAVR carries prohibitive risk in patients with PA. These
techniques disrupt and dislodge atheromatous emboli which significantly
increase the risk of perioperative stroke[14,15].
Thus, a novel and entirely anaortic approach must be created and
utilized in the treatment of this select patient population. Anaortic
OPCAB is a Class I (EACTS 2018) and IIa (AHA 2021) indication for
surgical coronary revascularization in patients with a diseased
aorta[13,16]. Transcatheter aortic valve
replacement (TAVR) is non-inferior at all patient risk levels and
significantly decreases all-cause death and stroke in intermediate and
high risk populations compared to SAVR[17]. Like
anaortic OPCAB, the transfemoral approach for TAVR avoids all aortic
manipulation. Several authors have previously described concomitant
OPCAB and TAVR[18-21], however these series have
involved aortic manipulation during proximal anastomoses and/or
transaortic delivery of the TAVR. Herewith we describe a case series of
concomitant anaortic OPCAB and transfemoral TAVR for patients with
coronary artery and valve disease considered too high risk for
traditional CABG and SAVR due to porcelain aorta.