How should I treat a patient with a mechanical aortic valve prosthesis and recurrent intracranial bleeding on anticoagulation with a patent LIMA to LAD?

Background: A 62-year-old male underwent mechanical aortic valve replacement and coronary artery bypass grafting. Within 12 months of anticoagulation he developed intracranial haemorrhage requiring neurosurgery. He was referred for consideration of redo aortic valve replacement with a bioprosthesis. INVESTIGATION: TOE revealed moderate paraprosthetic leak. Diagnostic angiography demonstrated a chronic total occlusion (CTO) of the LAD and patent LIMA supplying a large area of the anterior wall; the graft was retrosternal, in close apposition to the posterior aspect of the manubrium on computerised tomography, suggesting a high risk of damage on redo surgery. DIAGNOSIS: A patient with a mechanical aortic valve replacement who has suffered recurrent intracranial bleeds and a patent LIMA in close apposition to the manubrium. TREATMENT: Percutaneous coronary intervention to the LAD CTO followed by a hybrid procedure to secure haemostasis and replace the aortic valve.