Prevention of coronary obstruction in patients at risk undergoing transcatheter aortic valve implantation: the Hamburg BASILICA experience

Figures

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  Fig. 1. Study flowchart. AR aortic regurgitation, AS aortic stenosis, BASILICA bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction, CO coronary obstruction, SAVR surgical aortic valve replacement, SHV surgical heart valve, TAVI transcatheter aortic valve implantation, THV transcatheter heart valve, ViV valve-in-valve

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  Fig. 2. Deficient Sinus. 3mensio Structural Heart V9.1, Pie Medical Imaging, Maastricht, Netherlands. A Deficient Sinus (pre-procedural CT). Deficient Sinus is defined by low coronary height and narrow sinus of Valsalva. Measurement (3.1 mm) indicates low left coronary artery height. Surgical valve leaflets have been drawn retrospectively. B Coronary obstruction in a patient with Deficient Sinus [pre-procedural CT with a virtually implanted THV (Evolut R, Medtronic)]. Following THV implantation, the surgical valve leaflet directly obstructs the complete sinus of Valsalva, including the LCA, inhibiting coronary blood flow. C Valve-to-coronary (VTC) distance (3D CT reconstruction). CT computed tomography, LCA left coronary artery, THV transcatheter heart valve, VTC valve-to-coronary distance

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  Fig. 3. Sequestered Sinus. A Sequestered Sinus (pre-procedural CT). Sequestered Sinus is defined by low STJ height (indicated measurement, 10.5 mm) and narrow STJ diameter. Surgical valve leaflets have been drawn in retrospectively. B Coronary obstruction in a patient with Sequestered Sinus [pre-procedural CT with a virtually implanted THV (Evolut R, Medtronic)]. Following THV implantation the surgical valve leaflet indirectly inhibits blood flow to SOV and LCA by obstruction at the STJ. C Valve-to-sinotubular junction (VTSTJ) distance (3D CT reconstruction). CT computed tomography, LCA left coronary artery, SOV sinus of Valsalva, STJ sinotubular junction, THV transcatheter heart valve, VTSTJ valve-to-sinotubular junction

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  Fig. 4. BASILICA (fluoroscopic images). A Catheter and wire setup before BASILICA. B Leaflet traversal into the snare. C Flying V configuration. D Result after successful leaflet laceration and THV implantation. BASILICA bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction, THV transcatheter heart valve

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  Fig. 5. BASILICA failure. A Impenetrable calcified leaflet (Sorin Mitroflow surgical valve). B Wire-interference with a THV in mitral position (Sapien-in-MAC), Sorin Mitroflow aortic valve, pre-TAVI three-dimensional CT reconstruction. C pre-TAVI CT (see B). BASILICA bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction, CT computed tomography, MAC mitral annulus calcification, TAVI transcatheter aortic valve implantation, THV transcatheter heart valve

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  Fig. 6. Chimney stenting. A Chimney stent implantation in left coronary artery after BASILICA failure (CoreValve Evolut R in Sorin Mitroflow), post-TAVI CT. B post-TAVI three-dimensional CT reconstruction (see A). BASILICA bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction, CT computed tomography, TAVI transcatheter aortic valve implantation

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  Fig. 7. Successful BASILICA. A Confirmation of successful leaflet laceration by peri-procedural transesophageal echocardiography. B Lacerated leaflet (x) in a patient with Sequestered Sinus, post-TAVI CT. C Confirmation of lacerated leaflet (dashed line), post-TAVI three-dimensional CT reconstruction. D Post-TAVI CT in a patient with Sequestered Sinus (CoreValve Evolut R in Sorin Mitroflow) after BASILICA. BASILICA bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction, CT computed tomography, TAVI transcatheter aortic valve implantation