Heart, Lung and Circulation

Efficacy of Off-Pump Coronary Artery Bypass Grafting with Concomitant Transcatheter Aortic Valve Replacement

Published:September 20, 2022DOI:


      This study aimed to evaluate the early and intermediate-term outcomes of patients who underwent concomitant off-pump coronary artery bypass grafting (CABG) and transcatheter aortic valve replacement (TAVR).


      Between January 2014 and June 2021, 49 patients underwent concomitant off-pump CABG and TAVR via median sternotomy (TAVRCAB group) and 143 underwent concomitant on-pump CABG and surgical aortic replacement. Of the 143 patients who underwent on-pump surgery, 80 (SAVRCAB group) were eligible for comparison. The composite event included all-cause death, heart failure rehospitalisation, repeat revascularisation, brain infarction, and repeat aortic valve replacement.


      The Society of Thoracic Surgeons’ predicted risk for mortality and age were higher in the TAVRCAB group than in the SAVRCAB group (7.1% vs 3.1% [p<0.001]; 81 years vs 75 years [p<0.001], respectively), while the surgical time was shorter (289 min vs 352 min; p<0.001). There was no conversion to on-pump surgery in the TAVRCAB group. The postoperative maximum creatinine kinase-MB value was lower in the TAVRCAB group. There was no deep sternal wound infection or repeat revascularisation in either group. Hospital death and brain infarction developed in one patient (1.3%) each in the SAVRCAB group, but in no patients in the TAVRCAB group. The rates of freedom from the composite event were similar between the two groups during the follow-up period.


      Concomitant off-pump CABG and TAVR would be a less-invasive alternative procedure for treating intermediate or high surgical risk patients with aortic stenosis and coronary artery disease unsuitable for percutaneous coronary intervention.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Heart, Lung and Circulation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Kvidal P.
        • Bergström R.
        • Hörte L.G.
        • Ståhle E.
        Observed and relative survival after aortic valve replacement.
        J Am Coll Cardiol. 2000; 35: 747-756
        • Cao D.
        • Chiarito M.
        • Pagnotta P.
        • Reimers B.
        • Stefanini G.G.
        Coronary revascularisation in transcatheter aortic valve implantation candidates: why, who, when?.
        Interv Cardiol. 2018; 13: 69-76
        • Falk V.
        • Baumgartner H.
        • Bax J.J.
        • De Bonis M.
        • Hamm C.
        • Holm P.J.
        • et al.
        2017 ESC/EACTS guidelines for the management of valvular heart disease.
        Eur J Cardiothorac Surg. 2017; 52: 616-664
        • Otto C.M.
        • Nishimura R.A.
        • Bonow R.O.
        • Carabello B.A.
        • Erwin 3rd, J.P.
        • Gentile F.
        • et al.
        2020 ACC/AHA Guideline for the Management of Patients with Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.
        Circulation. 2021; 143: e72-e227
        • Popma J.J.
        • Deeb G.M.
        • Yakubov S.J.
        • Mumtaz M.
        • Gada H.
        • O'Hair D.
        • et al.
        Transcatheter aortic-valve replacement with a self-expanding valve in low-risk patients.
        N Engl J Med. 2019; 380: 1706-1715
        • Mack M.J.
        • Leon M.B.
        • Thourani V.H.
        • Makkar R.
        • Kodali S.K.
        • Russo M.
        • et al.
        Transcatheter aortic-valve replacement with a balloon-expandable valve in low-risk patients.
        N Engl J Med. 2019; 380: 1695-1705
        • Abugroun A.
        • Osman M.
        • Awadalla S.
        • Klein L.W.
        Outcomes of transcatheter aortic valve replacement with percutaneous coronary intervention versus surgical aortic valve replacement with coronary artery bypass grafting.
        Am J Cardiol. 2020; 137: 83-88
        • Søndergaard L.
        • Popma J.J.
        • Reardon M.J.
        • Van Mieghem N.M.
        • Deeb G.M.
        • Kodali S.
        • et al.
        Comparison of a complete percutaneous versus surgical approach to aortic valve replacement and revascularization in patients at intermediate surgical risk: results from the randomized SURTAVI trial.
        Circulation. 2019;
        • Ali Z.A.
        • Horst J.
        • Gaba P.
        • Shaw L.J.
        • Bangalore S.
        • Hochman J.S.
        • et al.
        Standardizing the definition and analysis methodology for complete coronary artery revascularization.
        J Am Heart Assoc. 2021; 10e020110
        • Généreux P.
        • Piazza N.
        • Alu M.C.
        • Nazif T.
        • Hahn R.T.
        • et al.
        • VARC-3 Writing Committee
        Valve Academic Research Consortium 3: updated endpoint definitions for aortic valve clinical research.
        Eur Heart J. 2021; 42: 1825-1857
        • Shimahara Y.
        • Fujita T.
        • Kobayashi J.
        • Asaumi Y.
        • Kanzaki S.
        • Nishimura K.
        • et al.
        Optimal target vessel selection for composite and sequential radial artery grafting with an in situ internal thoracic artery.
        J Card Surg. 2017; 32: 613-620
        • van Swieten J.C.
        • Koudstaal P.J.
        • Visser M.C.
        • Schouten H.J.
        • van Gijn J.
        Interobserver agreement for the assessment of handicap in stroke patients.
        Stroke. 1988; 19: 604-607
        • Nakajima H.
        • Kobayashi J.
        • Toda K.
        • Fujita T.
        • Shimahara Y.
        • Kasahara Y.
        • et al.
        Angiographic evaluation of flow distribution in sequential and composite arterial grafts for three vessel disease.
        Eur J Cardiothorac Surg. 2012; 41: 763-769
        • Shimahara Y.
        • Fukushima S.
        • Kawamoto N.
        • Tadokoro N.
        • Nakai M.
        • Kobayashi J.
        • et al.
        Additional survival benefit of bilateral in situ internal thoracic artery grafting with composite radial artery graft in total arterial off-pump coronary artery bypass grafting.
        J Thorac Cardiovasc Surg. 2021; S0022-5223: 01733-01735
        • Kobayashi J.
        • Shimahara Y.
        • Fujita T.
        • Kanzaki H.
        • Amaki M.
        • Hata H.
        • et al.
        Early results of simultaneous transaortic transcatheter aortic valve implantation and total arterial off-pump coronary artery revascularization in high-risk patients.
        Circ J. 2016; 80: 1946-1950
        • Zhao D.F.
        • Edelman J.J.
        • Seco M.
        • Bannon P.G.
        • Wilson M.K.
        • Byrom M.J.
        • et al.
        Coronary artery bypass grafting with and without manipulation of the ascending aorta: a network meta-analysis.
        J Am Coll Cardiol. 2017; 69: 924-936
        • Mayr B.
        • Firschke C.
        • Erlebach M.
        • Bleiziffer S.
        • Krane M.
        • Joner M.
        • et al.
        Transcatheter aortic valve implantation and off-pump coronary artery bypass surgery: an effective hybrid procedure in selected patients.
        Interact Cardiovasc Thorac Surg. 2018; 27: 102-107
        • Zubarevich A.
        • Zhigalov K.
        • Szczechowicz M.
        • Thielmann M.
        • Rabis M.
        • Van den Eynde J.
        • et al.
        Simultaneous transaortic transcatheter aortic valve implantation and off-pump coronary artery bypass: an effective hybrid approach.
        J Card Surg. 2021; 36: 1226-1231
        • Ahad S.
        • Wachter K.
        • Rustenbach C.
        • Stan A.
        • Hill S.
        • Schäufele T.
        • et al.
        Concomitant therapy: off-pump coronary revascularization and transcatheter aortic valve implantation.
        Interact Cardiovasc Thorac Surg. 2017; 25: 12-17
        • Fujita B.
        • Ensminger S.
        • Bauer T.
        • Möllmann H.
        • Beckmann A.
        • Bekeredjian R.
        • et al.
        Trends in practice and outcomes from 2011 to 2015 for surgical aortic valve replacement: an update from the German Aortic Valve Registry on 42776 patients.
        Eur J Cardiothorac Surg. 2018; 53: 552-559
        • Goel S.S.
        • Ige M.
        • Tuzcu E.M.
        • Ellis S.G.
        • Stewart W.J.
        • Svensson L.G.
        • et al.
        Severe aortic stenosis and coronary artery disease--implications for management in the transcatheter aortic valve replacement era: a comprehensive review.
        J Am Coll Cardiol. 2013; 62: 1-10
        • Kaihara T.
        • Higuma T.
        • Izumo M.
        • Kotoku N.
        • Suzuki T.
        • Kameshima H.
        • et al.
        Influence of coronary artery disease and percutaneous coronary intervention on mid-term outcomes in patients with aortic valve stenosis treated with transcatheter aortic valve implantation.
        Clin Cardiol. 2021; 44: 1089-1097
        • Raut M.S.
        • Hanjoora V.M.
        • Chishti M.A.
        Sudden, new-onset aortic regurgitation during off pump coronary bypass surgery.
        Ann Card Anaesth. 2019; 22: 430-431
        • Ahad S.
        • Baumbach H.
        • Hill S.
        • Franke U.F.
        Transapical aortic valve implantation and minimally invasive off-pump bypass surgery.
        Interact Cardiovasc Thorac Surg. 2014; 18: 248-249
        • Garcia S.
        • Sandoval Y.
        • Roukoz H.
        • Adabag S.
        • Canoniero M.
        • Yannopoulos D.
        • et al.
        Outcomes after complete versus incomplete revascularization of patients with multivessel coronary artery disease: a meta-analysis of 89,883 patients enrolled in randomized clinical trials and observational studies.
        J Am Coll Cardiol. 2013; 62: 1421-1431
        • Faroux L.
        • Guimaraes L.
        • Wintzer-Wehekind J.
        • Junquera L.
        • Ferreira-Neto A.N.
        • Del Val D.
        • et al.
        Coronary artery disease and transcatheter aortic valve replacement: JACC state-of-the-art review.
        J Am Coll Cardiol. 2019; 74: 362-372