Abstract
An 80-year-old man with a supra-annular transcatheter aortic valve (TAV) prosthesis presented with severe transvalvular aortic regurgitation 18 months after the TAV replacement procedure. The authors report the first ever valve-in-valve procedure using BASILICA (bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction) in such a supra-annular TAV prosthesis. Minimal paravalvular leakage, normal coronary artery flow, and easy coronary access were seen postimplantation. (Level of Difficulty: Advanced.)
Key Words: BASILICA procedure, laceration, left main coronary artery, transcatheter aortic valve replacement
Central Illustration
History of Presentation
An 80-year-old man presented with decompensated heart failure (New York Heart Association functional class IV) and atrial fibrillation 18 months after implantation of a supra-annular transcatheter aortic valve (TAV) prosthesis (ACURATE neo, size large, Boston Scientific).
Learning Objectives
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To understand the concept of the BASILICA procedure and specific challenges encountered when performed in a supra-annular TAV.
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To appreciate the role of TEE and fluoroscopy to guide and confirm positioning and results before, during, and after the BASILICA procedure prior to TAV-in-TAV.
Medical History
The patient had a medical history of type 2 diabetes mellitus, heart failure, and atrial fibrillation. Because of aortic stenosis, he had undergone TAV replacement (TAVR).
Investigations
On admission, transesophageal echocardiography (TEE) revealed severe transvalvular aortic regurgitation (Figure 1), caused primarily by prolapse of the noncoronary scallop (Videos 1 and 2), possibly due to any TAV defect or unobserved interruption during implantation.
Figure 1.
Preoperative, Perioperative, and Postoperative Echocardiograms of TAV-in-TAV With Prior BASILICA
(A, B) Preoperative severe transvalvular leakage. (C, D) Aggravated transvalvular leakage after BASILICA (bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction). (E, F) Minimal paravalvular leakage after transcatheter aortic valve (TAV) deployment.
Coronary angiography showed no significant stenoses.
Blood cultures and positron emission tomography with computed tomography showed no signs of infective endocarditis.
Cardiac computed tomography was analyzed using 3mensio software (Pie Medical Imaging) and showed an inner valve diameter of 25.2 mm (area derived), leaflet height in the supra-annular prosthesis of 30 mm, sinotubular junction (STJ) height of 28 mm, left coronary artery (LCA) height of 18 mm, and right coronary artery (RCA) height of 18.5 mm. Dimensions were considered suitable for an intra-annular 26-mm SAPIEN 3 prosthesis (Edwards Lifesciences). Virtual valve to coronary distance (VTC) to LCA was 6 mm, VTC to RCA was 5 mm. Although the supra-annular valve was slightly misaligned, the misalignment had a greater effect on the RCA, so we decided not to perform BASILICA (bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction) for the right scallop, but there was a high risk for coronary obstruction and impaired coronary access because of sinus sequestration to the LCA, as the prosthesis was touching the STJ over the left coronary sinus, and the prosthesis leaflets extended above the STJ (Figure 2). The intended implantation depth was at the level of, or slightly above, the upper crown, so as not to have excessive leaflet overhang.
Figure 2.
Preoperative Computed Tomography of a Patient With a Supra-Annular TAV
(A to C) Aortic root with red dot indicating the left coronary artery (LCA), whose origin is close to where the left scallop is assumed to be aligned when the TAV-in-TAV is deployed (LCA height 18 mm, virtual valve-to-coronary distance [VTC] to LCA 6 mm). Green dot indicates the right coronary artery (RCA) (B, C), closer to the stent post (RCA height 18.5 mm, VTC to RCA 5 mm). The sinotubular junction height was 28 mm. TAV = transcatheter aortic valve.
Management
The patient was evaluated at a multidisciplinary conference and considered high risk for redo surgery. The decision was made to undertake a TAV-in-TAV procedure using a 26-mm intra-annular valve, preceded by laceration of the left supra-annular TAV scallop using the BASILICA technique.
The procedure was guided by TEE and fluoroscopy. A Sentinel device (Boston Scientific) was used for neuroprotection. An 8-F introducer was placed in the left femoral artery and a 14-F DrySeal (W.L. Gore & Associates) introducer in the right femoral artery. The left scallop of the supra-annular TAV was perforated using electrocautery through an Astato (Asahi-Intec) 0.014-inch wire through a PiggyBack (Teleflex) microcatheter, supported by a 5-F IM catheter in an 8-F AL2 guide catheter. The 0.014-inch wire was snared in the left ventricular outflow tract using a 25-mm gooseneck snare to be externalized through the left femoral artery. This wire and microcatheter setup conformed to a “flying V” and was used to lacerate the left coronary scallop from its base with the aid of electrocautery (Videos 3 and 4). During retraction of the “flying V” after laceration, an inadvertent passage of the wire and catheter through the arch was identified by fluoroscopy, causing a possible capture of the arch itself (Video 3, Figure 3). The 0.014-inch wire was withdrawn to release the stabilization arch before proceeding with the TAVR procedure. A Safari wire (Boston Scientific) was placed in the left ventricle. A 26-mm intra-annular TAV was implanted with nominal filling and intended implantation depth at the level of the upper crown so as not to have excessive leaflet overhang (to prevent potential future stenosis or increased gradient), which was achieved (Supplemental Figure 1). The implantation followed the approach to TAVR in a failed TAV presented by Tarantini et al.1 Minimal paravalvular leakage, normal coronary artery flow, and easy coronary access were seen postimplantation (Figure 1, Supplemental Figure 1). The LCA cannulation was conducted inside the valve frame through the arches. Further cannulation techniques after TAV-in-TAV are explained by Khokhar et al2 and Tarantini et al.1 The total procedure time (skin to skin) was 3 hours, 10 minutes.
Figure 3.
The “Flying V” Catching One of the Stabilization Arches of the Prosthesis During the BASILICA Procedure Prior to TAV-in-TAV
Abbreviations as in Figure 1.
Discussion
Coronary artery obstruction during TAVR is a rare complication that might occur when native or prosthetic valve scallops are pushed toward the coronary artery ostia or STJ during transcatheter valve deployment.3 However, patients requiring TAV-in-TAV may be at the highest risk because of reduced size of the neosinus, taller valve leaflets (eg, supra-annular valve frames), and supra-annular valve design.4 The aim of the BASILICA technique is to prevent coronary artery obstruction by intentional scallop laceration.3 The technique has been used for native and bioprosthetic valves with no reported related cases of late stroke, myocardial infarction, or death.5 Other leaflet modification techniques and procedures available are balloon-assisted BASILICA, the CATHEDRAL (catheter electrosurgical debulking and removal) technique, and the ShortCut device (Pi-Cardia).6, 7, 8 This case is, to our knowledge, the first BASILICA procedure prior to TAV-in-TAV in such a supra-annular TAV prosthesis. An in vitro study showed that the results of the BASILICA procedure prior to TAV-in-TAV depend on commissural alignment and depth of implantation of the new TAVR device.4
One of the challenges in this case was how to approach the left sinus without catching the upper crown of the prosthesis and ending up below the stent frame when traversing the scallop (Figures 4 and 5). Positioning to the left sinus is crucial to avoid laceration of the stable components of the prosthesis, such as the upper crown. A further challenge was confronted directly after laceration of the scallop, when an inadvertent passage of the wire and catheter outside the stabilization arches was identified by fluoroscopy, causing a possible capture of the arch (Video 3, Figure 3). The arch was released by withdrawing the 0.014-inch wire before implantation of the valve and could have been avoided by careful wire and catheter insertion and manipulation and by evaluation on fluoroscopy during insertion.
Figure 4.
Approaching the Left Sinus for the BASILICA Procedure Prior to TAV-in-TAV, Guided by Echocardiography
(A) Catheter for laceration incorrectly positioned outside the upper crown of the supra-annular TAV. (B, C) Correct approach to the left sinus ready to perforate the scallop in the supra-annular TAV. Abbreviations as in Figure 1.
Figure 5.
Approaching the Left Sinus for the BASILICA Procedure Prior to TAV-in-TAV, Guided by Fluoroscopy
(A) Catheter for perforation incorrectly positioned above the upper crown of the supra-annular TAV. (B) Correct approach to the left sinus (below the upper crown) ready to perforate the scallop in the supra-annular TAV. Abbreviations as in Figure 1.
Follow-Up
Perioperative TEE, angiography, and next-day transthoracic echocardiography showed minimal paravalvular leakage. Perioperative angiography showed no obstruction of the coronary arteries, and the LCA was easily catheterized. The patient had an uneventful recovery and was discharged 2 days postprocedure.
Conclusions
Until now, the BASILICA procedure prior to TAV-in-TAV has been performed in a limited number of cases, and there are no published data on using the BASILICA technique on such supra-annular TAV. Herein, we demonstrate a successful BASILICA procedure prior to TAV-in-TAV in such a supra-annular TAV. It is foreseeable that the need for TAV-in-TAV will increase in the future. Refinement of the procedure as well as development of dedicated equipment could make those interventions safer and more efficient and will be highly rewarded.
Funding Support and Author Disclosures
Dr Damlin has received speaker compensation from Edwards Lifesciences. Drs Settergren, Meduri, Rück, and Linder serve as proctors for Boston Scientific. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
Acknowledgment
The authors thank the nurses in the Department of Cardiology, Karolinska University Hospital, for their most valuable support during the procedure.
Footnotes
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the Author Center.
Appendix
For a supplemental figure and videos, please see the online version of this paper.
Appendix
Transesophageal Short-Axis Echocardiography Showing Suboptimal Coaptation by the Noncoronary Scallop of a Supra-Annular Transcatheter Aortic Valve Prosthesis
Transesophageal Long-Axis Echocardiography Showing Suboptimal Coaptation by the Noncoronary Scallop of a Supra-Annular Transcatheter Aortic Valve Prosthesis
Perforation of the Base of the Aortic Scallop
Laceration of the Aortic Scallop
References
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Associated Data
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Supplementary Materials
Transesophageal Short-Axis Echocardiography Showing Suboptimal Coaptation by the Noncoronary Scallop of a Supra-Annular Transcatheter Aortic Valve Prosthesis
Transesophageal Long-Axis Echocardiography Showing Suboptimal Coaptation by the Noncoronary Scallop of a Supra-Annular Transcatheter Aortic Valve Prosthesis
Perforation of the Base of the Aortic Scallop
Laceration of the Aortic Scallop