経心尖部経カテーテル的大動脈弁留置術と左開胸冠状動脈バイパス術の同時施行

Concomitant Transapical Transcatheter Aortic Valve Implantation and Coronary Artery Bypass Grafting via the Left Thoracotomy

わが国では高齢化に伴い，動脈硬化を原因とする大動脈弁狭窄症（AS）の患者が増加している．高齢であり併存疾患の多いAS患者に対して，近年は経カテーテル的大動脈弁留置術（TAVI）が広く行われている．また，動脈硬化が原因の代表疾患として冠状動脈疾患（CAD）もあげられ，TAVI適応患者の40〜75％にCAD合併が報告されている1）．ASに対しては外科的大動脈弁置換術（SAVR）とTAVI，CADに対しては冠状動脈バイパス術（CABG）と経皮的冠状動脈形成術（PCI）の選択肢があるが，CAD合併AS患者に対する明確な治療ガイドラインは存在せず，治療の順番・選択は個々の症例において検討が必要である．われわれは，CAD合併のAS患者でPCI困難かつSAVR高リスクであった症例に対して，経心尖部TAVI（TA-TAVI）および左開胸CABGを一期的に施行し，良好な結果を得たので報告する．

A 79-year-old man presented with progressive congestive heart failure symptom as a result of severe aortic stenosis. A rescue balloon aortic valvuloplasty was performed. After a transient improvement, computed tomographic scan revealed a porcelain aorta, and it showed a high risk for a surgical aortic valve replacement. Routine preoperative coronary angiography revealed tight stenosis of a proximal left anterior descending coronary artery. Percutaneous coronary intervention was performed unsuccessfully due to the severe calcification of the coronary artery. Therefore, a concomitant transapical transcatheter aortic valve implantation and coronary artery bypass grafting via the left thoracotomy was indicated. Under a veno-arterial extracorporeal circulatory support, we performed the transcatheter aortic valve implantation （TAVI） and coronary artery bypass grafting （CABG） successfully via a left thoracotomy. Even though the approach for TAVI is from fifth and CABG is from forth intercostal space respectively, it could be manipulated using the same skin incision. Concomitant TAVI and CABG via the left thoracotomy might be a reasonable and feasible option for the patients presented with severe aortic stenosis and coronary artery disease who are not eligible for conventional surgical solutions.