CONGRESS ABSTRACT

Introduction Staged hybrid strategies for combined cardiac diseases demonstrated to provide the best therapeutic option in high-risk patients while reducing drawbacks of surgical and/or percutaneous procedures alone. In particular, dividing the overall risk of morbidity and mortality of a concomitant procedure into a staged hybrid approach, factorization of each single intervention may lead to a reduced risk of complication per se. Clinical case We report a case of a 74yo female with hypertension, dyslipidemia and family history of coronary artery disease symptomatic for dyspnea and angina. Pre-operative echocardiogram showed severe aortic stenosis, ischaemic cardiomyopathy with dilated left ventricle, reduced ejection fraction (45%) and severe mitral valve regurgitation. Preoperative coronary angiography revealed significant multiple LAD stenosis, while thoracic CT-scan showed severely calcified ascending aorta. Due to the prohibitive risk for concomitant single staged surgical triple intervention (EuroscoreII 8.5%), Heart Team decision was to first refer the patient to TAVR with Evolut Fx 26 bioprosthesis. Then, a staged minimally invasive robot assisted myocardial LIMA to LAD revascularization surgery was performed. The postoperative course for both procedures was uneventful. The patient was discharged home 8 days later. The patient was finally readmitted one month later for completion of the third part of the hybrid strategy by means of percutaneous mitral valve edge-to-edge repair. Discussion The initial indication for a double valve and bypass surgery led to an extremely high pre-operative risk in a very fragile female patient.  Therefore, heart team decision was to fractionate the overall very high risk of mortality for a triple surgical procedure into a single step-by-step gold standard approach which accounted per se for a reduced procedural risk. Thus, the aortic valve was addressed first with the aim of reducing the cardiac afterload. Then minimally invasive robot-assisted revascularization surgery provided the best low-risk and long-lasting treatment option for LAD with the aim of improving global left ventricle function before reassessing mitral valve regurgitation. Thus, a staged approach showed to be a safe and effective tailored strategy providing the best of each procedure while minimizing overall procedural risk of mortality and should be taken into account for a complete multidisciplinary patients’ evaluation.