Patient with aortic stenosis and extensive coronary artery disease – how to select the best treatment option? Treat aortic valve first or start with coronary artery stenting? Is there a clinical case that you could discuss? Dr. Anton Titov, MD. A patient’s story that illustrates well some of the points about cardiovascular disease that we discussed today? Dr. Jeffrey Popma, MD. Yes. I can leave you some uncertainties to what we are supposed to do. The most challenging and data-free zones in how we treat patients with heart disease every day is this. It is revascularisation of patients who have coronary disease and who have concomitant aortic stenosis. It is difficult to decide whether coronary artery disease treatment should be done before, during, or after the aortic valve replacement. Dr. Jeffrey Popma, MD. I'll make up a case which isn't dissimilar from a case we had a couple weeks ago. 85 year-old man, generally healthy, has a very long 90% proximal to mid-level Left Anterior Descending coronary artery occlusion. The patient also has 50% Right circumflex coronary artery occlusion. He also has severe aortic stenosis. The patient has chest discomfort symptoms. He has shortness of breath. Dr. Anton Titov, MD. This is what we know about aortic stenosis. It is new information. Dr. Jeffrey Popma, MD. We can simply relieve the aortic stenosis with transcatheter aortic valve replacement, TAVI. Or we can do an open heart surgery to replace aortic valve. Then we know that we have a falling of the left ventricular end diastolic pressure. Dr. Anton Titov, MD. This results in better coronary perfusion. This results in less myocardial oxygen demand. Those are all good things. The angina pectoris goes away. We have learned now that we do not have to be as aggressive with our coronary artery stenting procedures in patients with aortic valve disease. Dr. Jeffrey Popma, MD. Because often the myocardium oxygen supply and the demand all change in a very favorable way. After we do the aortic valve replacement, oxygen supply to the heart improves too. However, in this particular case, the patient also had a 90% LAD coronary artery obstruction. Dr. Jeffrey Popma, MD. Patients have left main proximal LAD coronary artery lesion or proximal right lesions. They are difficult to treat. Our current guideline recommendations are based on a guidance paper from the American College of Cardiology. It was authored by Dr. Steve Ramee. They suggest that perhaps coronary revascularisation should be indicated in those patients. Coronary artery stunting is indicated for two reasons. Dr. Jeffrey Popma, MD. One reason is to make the procedure safer. This makes the aortic valve replacement procedure safer. Secondly, there may be problems with coronary access with our transcatheter aortic valves. Then getting coronary artery disease treatment done before aortic valve replacement is better. Dr. Anton Titov, MD. It may be better than getting coronary artery stenting after aortic valve replacement. In this case we did the patient's LAD coronary artery stent therapy. Dr. Jeffrey Popma, MD. We put a long Synergy coronary stent in, we opened up the coronary vessel. The patient will then come back in a month. We will do the TAVR procedure. We still have not figured out what the right option to do. Dr. Anton Titov, MD. There is a combination of coronary artery disease and of aortic valve disease. That's certainly very interesting case. It is a very complex heart disease treatment case. Professor Popma, thank you very much for this very interesting conversation. We hope to come back to you with more questions in the future. Dr. Anton Titov, MD. I'm sure it will be very interesting for viewers around the world. Dr. Jeffrey Popma, MD. Thanks for having me!