Modified Guide Anchoring “UNICORN” Technique for Valve-in-Valve TAVI

Figures

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  Visual Summary. Stepwise Procedural Workflow of the Modified Guide Anchoring “UNICORN” Technique

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  Figure 1. Preprocedural Planning and Anatomic Constraints (A) Multiplanar cardiac computed tomography (CT) reconstruction demonstrating a critical valve-to-coronary (VTC) distance of 1.8 mm to the right coronary artery. (B) Multiplanar cardiac CT reconstruction demonstrating VTC distance to the left main of 4 mm. (C) Multiplanar cardiac CT reconstruction in the coronal plane featuring a virtual valve overlay. The simulation highlights the anticipated position of a transcatheter heart valve within the existing sutureless bioprosthesis.

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  Figure 2. Modified UNICORN Maneuver and Leaflet Modification (A) Fluoroscopic image showing the 6-F MPA1 guide catheter and microcatheter successfully traversing the right coronary cusp. The Modified UNICORN guide anchoring maneuver: immediately post-traversal, the MPA1 guide is advanced directly across the bioprosthetic frame into the left ventricle to secure position. (B) Mechanical leaflet laceration using a 10.0- × 20-mm high-pressure peripheral balloon inflated to disrupt the obstructive leaflet tissue.

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  Figure 3. Procedural Completion (A) Deployment of the 23-mm balloon-expandable transcatheter heart valve under rapid ventricular pacing. (B-C) Final aortic root angiogram demonstrating brisk TIMI flow grade flow in the right coronary artery and left main coronary artery without the need for chimney stenting.

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  Figure 4. Final Hemodynamics and Follow-Up Echocardiography (Left) Postprocedural transesophageal echocardiography confirmed the absence of paravalvular leak and a significant reduction in the peak transvalvular gradient (9 mm Hg). (Right) At 6-month follow-up, transthoracic echocardiography showing well-seated valve with mean gradient of 13.