Preventing Coronary Obstruction During Transcatheter Aortic Valve Replacement

Abstract

Coronary artery obstruction is an uncommon but devastating complication of transcatheter aortic valve replacement (TAVR). Computed tomography appears to be a sensitive but nonspecific predictor of coronary artery obstruction. Transcatheter approaches to prevent and treat coronary artery obstruction, such as “snorkel” stenting, are unsatisfactory because of serious early and late ischemic complications. Bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction during TAVR (BASILICA) is an early-stage transcatheter procedure to prevent coronary artery obstruction. It works by splitting the native or bioprosthetic leaflets so that they splay after TAVR and preserve coronary artery inflow. Because of the paucity of suitable alternatives, there is interest in the BASILICA technique despite its infancy. This tutorial review summarizes current thinking about how to predict and prevent coronary artery obstruction using BASILICA. First, the authors depict the main pathophysiological mechanisms of TAVR-associated coronary artery obstruction, along with the factors thought to contribute to coronary obstruction. Next, the authors provide a step-by-step guide to analyzing pre-procedural computed tomographic findings to assess obstruction risk and, if desirable, to plan BASILICA. Next, the authors describe the mechanisms underlying transcatheter electrosurgery. Finally, they provide step-by-step guidance on how to perform the procedure, along with a required equipment list.

Clinical Outcomes of Transcatheter Aortic Valve Implantation for Native Aortic Valves in Patients with Low Coronary Heights

“… 23 Meanwhile, another novel approach, the bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction (BASILICA) technique, was developed to prevent coronary artery obstruction in high-risk patients during TAVI. 24 When using the BASILICA technique, equipment, such as an electrosurgery pencil and electrosurgery generator for laceration, is required. In addition, this procedure includes many unfamiliar steps, and side effects of anatomical limitations and stroke have been reported.…”

“…In addition, this procedure includes many unfamiliar steps, and side effects of anatomical limitations and stroke have been reported. 24 …”

Challenging Anatomies for TAVR—Bicuspid and Beyond

“…In high-risk patients, this involves pre-emptive stenting of the coronary ostia using the chimney technique, as this strategy has been associated with improved outcomes compared to pre-emptive wiring alone (114,136). In addition, the aforementioned BASILICA procedure has emerged as a novel leaflet splitting technique in TAVR patients, especially in those undergoing ViV procedures (137).…”

Transcatheter aortic valve replacement aortic root orientation: implications for future coronary access and redo transcatheter aortic valve replacement

“…This may make them more likely to implant a biologic versus mechanical prosthesis. With a surgical bioprosthesis, TAVR-in-SAVR can be performed even when there is a risk of surgical leaflet-to-coronary obstruction if BASILICA (Bioprosthetic or native Aortic Scallop Intentional Laceration to prevent Iatrogenic Coronary Artery obstruction) can be successfully performed for the deficient sinus/sinus sequestration (11). Performing BASILICA does not provide immunity to neo-commissure/coronary overlap; one has to ensure that the THV neo-commissure does not cover the lacerated opening or it would still cause coronary obstruction.…”