A Thai 85-year-old woman with history of prior myocardial infarction, AF, type 2 DM, HTN and DLP, presented with a 5-month history of exertional dyspnea. Physical examination revealed fine crepitations in both lower lung fields, irregularly irregular with lower volume of carotid pulse  and grade 3 systolic ejection murmur at right upper parasternal border with sign of left ventricular hypertrophy.

Initial ECG revealed AF. Transthoracic echocardiography revealed concentric LVH with a 70 % of left ventricular systolic function, normal right ventricular systolic function, bi-atrial enlargement and severe calcific aortic stenosis which classified as stage D1 (AVA 0.98 cm² by AV VTI, AV Vmax 4.03 m/s, mean AV pressure gradient 38.21 mmHg). Following as the Heart Team discussion, Transcatheter Aortic Replacement (TAVR) following coronary angiography (CAG) was scheduled as the optimal choice.

CACAG showed TVD without significant LM stenosis (90 % stenosis of prox-to-mid LAD, 70 % of DG1, 80 % of ostial LCX, 70 % of dis LCX, 90 % of mid RCA and 70 % of PDA). Consequently, the Heart Team's decision, lesion preparation and IVUS-guided stents implantation were completed for the mid RCA and prox-to-mid LAD. The patient was scheduled for TAVR on the next day. On that morning, she developed hematochezia with stable vital signs and  hemoglobin. So, the TAVR was proceeded.

Under local anesthesia and conscious sedation, femoral arteries (FA) were accessed by 8-Fr sheath at right FA and two of 8-Fr sheaths at left FA for pigtail catheter and snare-assisted device. Aortography was conducted by pigtail catheter to locate aortic cusp. An Amplatz left catheter over a 0.035-inchJ-tip wire was placed at aortic cusp via the RFA which was then exchanged with an Amplatz Super Stiff wire to upsized 16-Fr Braidin sheath. The aortic valve was crossed with an Amplatz left catheter over a straight-tip wire under cuspoverlap views (LAO16, CAU 30), peak-to-peak gradient of 19 mmHg. During RV pacing,  a Safari Extra Small guidewirewas positioned in LV and the AV was pre-dilated by an 18 × 40 mm Alwide balloon. Subsequently, a 27 mm VitaFlow valve was deployed in an optimal position under snare-assisted. Post-deployment aortography revealed mild AR, LVEDP of20 mmHg, and 4 mmHg of LVOT gradient. Post-dilation was performed by a 24 × 40mm VACC III balloon. The FA was closed by 6-Fr Proglide at the right and 8-Fr AngioSeal at the left. Post-TAVR TEE showed mild PVL without significant transvalvular gradient and preserved LVEF of 64%. One-month after the TAVR, she was diagnosed with early-stage colonic cancer. A laparoscopic hemicolectomy which completed pre-operative evaluation, coronary revascularization, TAVR and appropriated medication  was performed as time-sensitive surgery following by CMT with curative intent.

Conclusion              This case demonstrates a appreciated outcome of high-risk noncardiac surgery following after one-month of PCI and TAVR in an elderly patient. Although the timing for NCS after stable PCI was established, but was still in doubt for TAVR. There was no One-Fits-for-All, individual tailored approach with the multidisciplinary team and patient was very important to push the right outcome.