Transcatheter Electrosurgery in the Asia-Pacific

Figures

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  Figure 1. Complex Anatomical Features in Patients From the Asia-Pacific Regions High-risk features such as a small aortic root among the Asian-Pacific population may increase the risk of transcatheter heart valve implantation and warrants the use of leaflet modification techniques. AMVL = anterior mitral valve leaflet; AVR = aortic valve replacement; BASILICA = Bioprosthetic or Native Aortic Scallop Intentional Laceration to Prevent Coronary Artery Obstruction; BATMAN = Balloon Assisted Translocation of the Mitral Anterior Leaflet to Prevent Left Ventricular Outflow Obstruction; LAMPOON = Laceration of the Anterior Mitral Leaflet to Prevent Outflow Obstruction; LV = left ventricle; LVOT = left ventricular outflow tract; STJ = sino-tubular junction; TAVR = transcatheter aortic valve replacement; TAV-in-SAV = transcatheter aortic valve replacement in surgical aortic valve; TAV-in-TAV = transcatheter aortic valve replacement in transcatheter aortic valve; TMVR = transcatheter mitral valve replacement; UNICORN = Undermining Iatrogenic Coronary Obstruction With Radiofrequency Needle.

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  Central Illustration. Transcatheter Electrosurgery in the Asia-Pacific Transcatheter electrosurgical techniques such as BASILICA (Bioprosthetic or Native Aortic Scallop Intentional Laceration to Prevent Coronary Artery Obstruction), LAMPOON (Laceration of the Anterior Mitral Leaflet to Prevent Outflow Obstruction), and BATMAN (Balloon Assisted Translocation of the Mitral Anterior Leaflet to Prevent Left Ventricular Outflow Obstruction) were pioneered in North America and Europe since 2017. At present, there are relatively fewer operations with experience in electrosurgery in the Asia-Pacific region. Nevertheless, case volume has been steadily growing and innovative techniques such as UNICORN (Undermining Iatrogenic Coronary Obstruction With Radiofrequency Needle) have emerged from the region.

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  Figure 2. BASILICA Technique (A) Astato guidewire directed toward the base of the target leaflet. Gooseneck snare in the LVOT. Safety wire in the LV apex. (B) After traversal of the target leaflet, Astato guidewire is snared in the LVOT. (C) A "flying V" configuration is created in the Astato wire by denuding and kinking a segment near the end of a wire converter, such as PiggyBack wire converter (Teleflex) or 0.035-inch microcatheter. (D) Echocardiography showing linear laceration at the target leaflet. Abbreviations as in Figure 1.

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  Figure 3. UNICORN Technique With Balloon-Expandable Valve (A) VersaCross RF wire is used to traverse the base of the target leaflet. (B) First balloon dilatation with coronary balloon. (C) Second dilatation with peripheral balloon. Target leaflet is not lacerated after this step. (D) Balloon-expandable valve is deployed within the newly created fenestration. RF = radiofrequency; other abbreviation as in Figure 1.

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  Figure 4. Antegrade Base-to-Tip LAMPOON Technique (A) Two transseptal steerable sheaths are placed in the left atrium, one for delivering Astato wire for traversing the A2 segment of the anterior mitral valve leaflet; and another one for positioning the EN Snare in the LVOT. (B) After leaflet traversal, the Astato is snared and externalized. (C) Astato wire in “flying V” configuration is used to lacerate the anterior mitral valve leaflet. (D) “Flying V” shown on transesophageal echocardiography. Abbreviations as in Figure 1.

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  Figure 5. Transcaval TAVR (A) Preoperative computed tomography for evaluating feasibility and locating the traversal site. (B) Simultaneous aortogram and venogram to confirm the target puncture site. (C) Astato guidewire in the IVC and gooseneck snare in the aorta. (D) Orthogonal project to confirm the traversal site. (E) Astato wire traversal from the IVC to the aorta. (F) Astato wire snared in the aorta. (G) Delivery of TAVR sheath through the cavo-aortic access. (H) Closure of the cavo-aortic tract. (I) Aortogram to confirm satisfactory sealing of the cavo-aortic tract. ADO10/8 = amplatzer duct occluder 10/8; BMW = balance middleweight; IVC = inferior vena cava; JR4 = Judkins right 4; RDC1 = renal double-curve 1; other abbreviations as in Figure 1.