Patients with AS after previous CABG are often distinguished by high risk factors for AVR: elderly, symptomatic heart failure, long history of ischemic cardiomyopathy with left ventricular impairment. Redo-surgery is technically challenging regarding the surgical approach, the myocardial protection, the calcified aortic root, and specially in case of patent arterial grafts. However, conventional AVR as a redo procedure after CABG with patent grafts can be performed with excellent results and a lower mortality than estimated [
3], even in case of both IMA grafts, thanks to the use of an adapted surgical strategy [
1]. TAVI procedure with its less invasive nature has been believed to offer a safer treatment solution for high risk patients [
2] and we could expect to observe a benefit impact of TAVI in the specific situation of patients with previous CABG. According to our short series, the advantage of TAVI in comparison with AVR is not obvious. Early mortality and post-procedure outcome are quite similar: earlier extubation time, lower Troponin level and higher rate of pacemaker implantation after TAVI have to be balanced against higher rate of transfusion and no paravalvular leak after AVR. The 1-year survival are the same after AVR and transfemoral TAVI (100%) and lower after transapical TAVI (78%) as if TA approach was more aggressive than AVR for the ischemic and impaired underlying myocardium. Concomitant coronary artery disease has been demonstrated as a significant risk factor for mortality in patients having TAVI [
4]; in our series, the choice of operative approach, either TA or TF, was found to be a risk factor of mortality. In the randomized PARTNER trial [
5], TAVI and AVR were associated with similar rates of survival at 1-year; however, the results of the subgroup analyses suggested that TAVI was associated with higher mortality than AVR among patients with a history of CABG regardless the operative approach for TAVI; by experience, we could imagine that TA procedure had been more frequent in this subgroup.
In an observational study, Drews et al. [
6] reported that previous heart surgery was not a risk factor in TA-TAVI: early mortality and 1-year survival were similar in patients with or without previous surgery, but the 1.5 year survival observed was 73% in TAVI as first procedure and 52% in TAVI as second procedure. Recently, Ducrocq et al. [
7] evaluated the impact of previous CABG on the outcome of patients after TAVI procedure; conversely, previous CABG was identified as an independent predictive factor of better mid-trem survival, which is maybe related to residual bias in an observational study; however their study confirmed that TA approach is more frequent in previous CABG group (43% vs 26%) and that TA approach is a predictor of 2-year mortality.
Paradoxically, these data are not conflicting with the results of the randomized PARTNER trial [
5] and with the short contribution of our series: 1) In comparison with vascular approach, TA approach is a risk factor in TAVI procedure, 2) The impact of previous CABG on the outcome of patients after TAVI remains controversial, but seems to be, 3) In patients with previous CABG and eligible for TAVI or AVR, surgical replacement is maybe better than TA-TAVI.