Background ：Transcatheter Aortic Valve Implantation (TAVI) has become an alternative technique to surgical aortic valve replacement in high-risk patients. Off-Pump Coronary Artery Bypass (OPCAB) is a usual way to treat coronary artery disease (CAD) in many institutions in Japan. TAVI and OPCAB have common advantages; they are performed on the beating heart without cardiopulmonary bypass (CPB) or aortic cross-clamp.
Case report：78-year-old female with severe aortic stenosis (AS) and CAD was planned to undergo TAVI and OPCAB simultaneously. General anesthesia was induced smoothly with fentanyl and midazolam. We used arterial line, central venous catheter, sheath introducer and transesophageal echo. Anesthesia was maintained with sevoflurane and fentanyl. First, during left internal thoracic artery (LITA) was anastomosed to left anterior descending (LAD), we used continuous intravenous administration of phenylephrine(0.5mg/hr), norepinephrine(0.02mcg/kg/min). Next, transfemoral TAVI was started. Balloon aortic vavuloplasty was not performed. When the Evolut® was inserted through native aortic valve, complete atrioventricular block was developed, and we used temporary ventricular pacing. The Evolut® was deployed without rapid pacing, and after that, blood pressure rose up. Finally, great saphenous vein (SVG) was anastomosed to left circumflex artery (LCx) and aorta. During the heart was lifted, we increased the dose of norepinephrine (0.16mcg/kg/min). The aortic valve position was unchanged and coronary inlet was not occluded. The operation took 5 hours. The patient was moved to ICU, kept sedated and intubated Next day, the patient was extubated, but LCx restenosis and left femoral artery occlusion occurred. Then, percutaneous coronary intervention (PCI) for LCx and thrombectomy of left femoral artery were performed.
Discussion：CAD is sometimes present with AS patients. OPCAB is better than PCI for some patients. Hybrid TAVI and OPCAB is a challenging combination, and the number of reported cases is still limited1. During hybrid surgery, we have to be careful about valve insertion and position, hemodynamic changes, anastomosis of the graft to aorta, different target ACT, and complications of both operation. One operation has the influence on the other operation. In addition, the patients undergoing TAVI are high-risk. Considering the potential benefits of the hybrid surgery, it could be an option for high-risk patients, but we also need to consider the potential risk of the hybrid surgery. 
References：1 Junjiro Kobayashi, 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
Learning points：In our case, we had no trouble in anesthetic management during the operation. Hybrid TAVI and CABG can became a treatment options for high-risk patients. But, adaptation should be discussed and further studies are needed.

02 / Hybrid Transcatheter Aortic Valve Implantation and Off-Pump Coronary Artery Bypass in a High-Risk Patient-Case report