First Asian Experience with the BASILICA Technique in Failed Bioprosthetic Aortic Valve.

Coronary obstruction is a deadly complication of transcatheter aortic valve replacement (TAVR), more frequent in valve-in-valve (VIV) procedure.1) With smaller annulus and low coronary ostia, TAVR for Asians may increase the risk of coronary obstruction.2) A Bioprosthetic Aortic Scallop Intentional Laceration to prevent Iatrogenic Coronary Artery obstruction (BASILICA) reduces the risk of coronary obstruction.3) We report the first Asian experience with the BASILICA procedure.

An 84-year-old female with bioprosthetic aortic valve replacement 9 years ago visited our institution with dyspnea. Echocardiography confirmed bioprosthetic valve failure with severe aortic stenosis. Both coronary heights were low (Supplementary Video 1, Figure 1). The predicted valve-to-sinotubular junction distance in the left coronary cusp (LCC) side was 2.6 mm and the leaflet length of the 20 mm Soprano bioprosthesis at the LCC side was 11.1 mm. The heart team decided to perform VIV-TAVR (STS 8.257%) after BASICIA for the LCC given high risk of coronary obstruction due to sinus sequestration.4)

Figure 1

Heights of coronary ostia and sinus of Valsalva measured in reconstructed computed tomography imaging. Coronary ostium height was defined as vertical distance between neo-annulus to coronary ostium. Sinus of Valsalva height was defined as vertical distance between neo-annulus to sinotubular junction. (A) denotes coronary height from neo-annulus to left coronary ostium (short arrow, 4.4 mm) and sinus of Valsalva height from left coronary cusp side (long arrow, 13.1 mm). (B) denotes coronary height from neo-annulus to right coronary ostium (short arrow, 7.7 mm) and sinus of Valsalva height from right coronary cusp side (long arrow, 13.9 mm).

Gooseneck™ Snare (Medtronic, Minneapolis, MN, USA) was positioned in the left ventricle. 6Fr IM catheter within 7Fr AL3 catheter was positioned to the base of the LCC. Astato wire (Asahi Intecc, Aichi, Japan) within Finecross® microcatheter penetrated the LCC under 50W (Supplementary Video 2).

After traversal and snaring, the “flying-V” was created by denuding only the inner lacerating surface of the wire to deliver focused charge to the leaflet.5) The “flying-V” lacerated leaflet under 70W with dextrose flooding (Figure 2, Supplementary Video 3).4)

Figure 2

Transcatheter bioprosthetic valve leaflet laceration using Bioprosthetic Aortic Scallop Intentional Laceration to prevent Iatrogenic Coronary Artery technique.

After BASILICA, VIV-TAVR was performed using 23 mm Evolut™ R (Medtronic) with 5 mm depth. Coronary obstruction did not occur (Supplementary Video 4).