Simultaneous Left and Right Aortic Leaflet Laceration to Prevent Coronary Obstruction Prior to TAVR.

Background:
Patients with low-lying coronary arteries remain a subset of patients that remain high risk for TAVR. Therapies are often limited to protection of the coronary arteries with “snorkeled” stents. This approach leads to stent under-expansion due to compression between a non-expandable valve frame and the aortic wall. BASILICA (Bioprosthetic or Native Leaflet Intentional Laceration to Prevent Coronary Obstruction) is a novel method utilizing an electrified guidewire to lacerate the leaflets splaying them around the coronary ostia to prevent coronary obstruction. We present a case of simultaneous “double BASILICA”. Case: A 79 year old female with liver cirrhosis, hypertension, diabetes, and COPD presented with worsening shortness of breath. She was found to have severe aortic stenosis and underwent TAVR CT in which she was found to have a left coronary height of 8.2 mm and a right coronary height of 7.45 mm. We opted to performed double leaflet BASILICA.

Methods
and

Results:
A 16F sheath was placed in the right common femoral artery. A 14F sheath was placed in the left femoral artery. A 20 Gooseneck snare was placed in the LV through a 6F MP. A 7F AL 3 guide was position at the base of the left coronary leaflet. An 0.014 Astato 20 wire inside a Piggyback catheter was electrified which penetrated the leaflet. This wire was snared creating a rail. A second 6F MP guide was placed in the LV followed by placement of a 20 Gooseneck snare. A 7F MP guide was used to reach the base of the right coronary leaflet. A 0.014 Astato wire inside a Piggback catheter was position at the base of the right coronary leaflet, electrified and snared in the LVOT and a rail was created. Left and right coronary leaflet laceration was performed. A 26 Evolut R valve was deployed without coronary obstruction.

Conclusions:
BASILICA is novel alternative to coronary artery protection prior to TAVR valve implantation. Acute and delayed coronary obstruction is associated with high morbidity and mortality. Low-lying coronary arteries in relation with aortic leaflets are more prevalent in patients with bioprosthetic valves as these valves are often implanted in a supra-annular position with effaced sinuses. Bioprostheses with externally mounted leaflets further increase this risk.