A Concomitant Off-Pump Coronary Artery Bypass to TAV-in-TAV in a Patient with a High Risk of Coronary Artery Occlusion.

We report a case of a 90-year-old woman with prior transcatheter aortic valve replacement (TAVR) who presented with symptomatic structural valve deterioration. Imaging revealed a critically short valve-to-coronary distance (< 4 mm), suggesting a high risk for coronary obstruction during valve-in-valve (TAV-in-TAV) procedure. Although preventive techniques such as BASILICA and chimney stenting have been considered, these approaches require advanced technical expertise and are associated with procedural risks. Given the patient's advanced age and high surgical risk, we therefore opted for a hybrid strategy combining TAV-in-TAV with concomitant off-pump coronary artery bypass grafting to the left anterior descending artery for coronary protection. The procedure was successfully completed without complications. Postoperative imaging confirmed good prosthetic valve function, graft patency, and preserved coronary flow. To our knowledge, few reports have described TAV-in-TAV with simultaneous surgical coronary revascularization as a preventive approach for coronary obstruction. This case highlights the potential utility of surgical-transcatheter hybrid strategy in anatomically high-risk patients unsuitable for conventional transcatheter preventive techniques.