UNICORN TAVR in Native Complex Congenital Aortic Stenosis at High Risk of Coronary Obstruction

Figures

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  Visual Summary. Diagram Demonstrating the UNICORN Technique In UNICORN, monopolar electrosurgery is used to traverse one of the coronary leaflets (in this case, the left). The fenestration is serially dilated before intraleaflet deployment of the THV, which lacerates the cusp as it expands and splays the cusp remnants away from the threatened coronary artery, thus preventing obstruction. THV = transcatheter heart valve; UNICORN = undermining iatrogenic coronary obstruction.

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  Figure 1. Preprocedure Transesophageal Echocardiography and CT (A) TEE at presentation, showing severe aortic stenosis with a maximum velocity of 4.2 m/s and mean and peak aortic gradients of 45 and 70 mm Hg, respectively. (B and C) Short- and long-axis TEE views of the aortic valve showing thickened and dysplastic aortic leaflets and severe native aortic regurgitation. (D) Electrocardiogram-gated CT coronary angiogram performed to plan TAVR, demonstrating a very small annulus (area 296 mm2 with perimeter 64.3 mm), with anatomical risk factors for coronary obstruction including shall sinuses of Valsalva (E), low coronary ostia with relatively long leaflets (F), and a low virtual valve-to-coronary distance of 3.5 mm (G). Virtual valve-to-sinotubular junction distance was zero. CT = computed tomography; TAVR = transcatheter aortic valve replacement; TEE = transesophageal echocardiography.

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  Figure 2. Left Coronary Cusp Traversal Fluoroscopy (A) and TEE (B) before electrosurgical traversal of the coronary cusp, showing the Astato wire in the nadir of the coronary cusp. (C) Fluoroscopy post-cusp traversal. (D) TEE confirms that the wire is free within the left ventricle and not within the septum. LA = left atrium; LCC = left coronary cusp; LV = left ventricle; LVOT = left ventricular outflow tract; TEE = transesophageal echocardiography.

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  Figure 3. Progressive Dilatation of the Fenestration in the Left Coronary Cusp Fluoroscopy of the 3-mm (A) and 6-mm (C) noncompliant (NC) balloons within the left coronary cusp (LCC). (B) TEE appearance of the 3-mm balloon with the LCC. (D) Fluoroscopy of the inflated 12-mm balloon over the Sion blue wire before THV deployment. LV = left ventricle; TEE = transesophageal echocardiography; THV = transcatheter heart valve.

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  Figure 4. THV Deployment Fluoroscopy pre-deployment (A) and post-deployment (B) of the THV under rapid pacing, showing bailout stent positioned in the left coronary artery in the event that obstruction developed. Angiography post-deployment (B) shows an unobstructed left coronary artery. IVC = inferior vena cava; LAD = left anterior descending artery; NCC = noncoronary cusp; THV = transcatheter heart valve.

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  Figure 5. TEE Post-deployment (A) Post-deployment TEE showing a well-positioned and well-expanded THV. (B) Post-THV decrease in transaortic velocity to a Vmax of 3.1 m/s and mean and peak aortic gradients of 22 and 38 mm Hg, respectively. LVOT = left ventricular outflow tract; TAVR = transcatheter aortic valve replacement; TEE = transesophageal echocardiogram; THV = transcatheter heart valve.