First-in-Human Mechanical Bilateral Iatrogenic Coronary Leaflet Obstruction Risk Nullification (BICORN) for Transcatheter Aortic Valve-in-Valve Replacement

Q: What is the clinical evidence from this study?

Study design: Case Report. Population: Transcatheter aortic valve-in-valve replacement with extreme bilateral coronary obstruction risk (n=1). Intervention: Mechanical leaflet traversal using the ShortCut device for Bilateral Iatrogenic Coronary Leaflet Obstruction Risk Nullification (BICORN). Primary outcome: Successful deployment of a 20-mm SAPIEN 3 Ultra transcatheter heart valve following mechanical bilateral leaflet traversal and translocation.

Q: What does this research mean for the field?

Mechanical leaflet traversal is a feasible alternative to electrosurgical traversal for bilateral iatrogenic coronary leaflet obstruction risk nullification during valve-in-valve transcatheter aortic valve replacement in patients with unfavorable anatomy. Novelty: ClaimNovelty.METHODOLOGICAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Hussam Al Hennawi; Vernon Mascarenhas; Abdellaziz Dahou; Ahmad Sameed Akram; Tariq Ahmad

doi:10.1016/j.jaccas.2026.111098

November 1, 2026JACC Case ReportsOpen Access

First-in-Human Mechanical Bilateral Iatrogenic Coronary Leaflet Obstruction Risk Nullification (BICORN) for Transcatheter Aortic Valve-in-Valve Replacement

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Key result

Mechanical leaflet traversal using the ShortCut device facilitated BICORN and successful 20-mm SAPIEN 3 Ultra deployment inside a 23-mm SAPIEN 3 valve in 1 patient.

Graphical abstract published by JACC Case Reports — Graphical abstract · Published by JACC Case Reports · CC BY-NC-ND 4.0

Why the study?

Unfavorable cardiac orientation and extreme bilateral coronary obstruction risk can make electrosurgical leaflet traversal challenging during valve-in-valve transcatheter aortic valve replacement, prompting description of mechanical leaflet traversal as an alternative for BICORN.

Key Points

To describe mechanical leaflet traversal as an alternative to electrosurgery for bilateral coronary leaflet modification during valve-in-valve transcatheter aortic valve replacement in high-risk anatomy.
Applied the ShortCut device to mechanically create targeted basal splits in both aortic coronary leaflets in a patient with unfavorable cardiac rotation and extreme obstruction risk.
Traversed the left coronary cusp split using a guidewire, microcatheter, guide catheter, and steerable sheath before balloon dilation and leaflet translocation.
Advanced a 20-mm transcatheter heart valve through the right coronary cusp split and deployed it within the pre-existing 23-mm bioprosthesis.
Successfully achieved mechanical leaflet traversal and bilateral coronary risk nullification with stable valve-in-valve deployment.
Demonstrated that mechanical traversal can overcome procedural barriers presented by cardiac rotation, poor catheter trajectories, and severe leaflet fibrocalcification.

Study Design

Type

Case Report (n=1)

Structured PICO

P

Population

1 patient with a pre-existing 23-mm SAPIEN 3 valve, unfavorable cardiac orientation, and extreme bilateral coronary obstruction risk undergoing valve-in-valve transcatheter aortic valve replacement.

I

Intervention

Mechanical leaflet traversal using the ShortCut device for Bilateral Iatrogenic Coronary Leaflet Obstruction Risk Nullification (BICORN), followed by balloon dilation and left coronary cusp translocation with an 18-mm True Dilatation Balloon, and deployment of a 20-mm SAPIEN 3 Ultra transcatheter heart valve through the right coronary cusp split

First-in-human demonstration that mechanical leaflet traversal using the ShortCut device can facilitate bilateral coronary leaflet obstruction risk nullification (BICORN) during valve-in-valve TAVR when anatomical factors make electrosurgical traversal challenging.

Limitations

Mechanical traversal requires precise targeting
Leaflet translocation may cause embolization, severe aortic insufficiency, or hemodynamic compromise, requiring readiness for immediate valve deployment
Leaflet translocation may cause embolization, severe aortic insufficiency, or hemodynamic compromise

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Implication

May offer a mechanical alternative in complex valve-in-valve TAVR; leaves open the need for prospective validation before clinical adoption.

Abstract

OBJECTIVES: We describe mechanical leaflet traversal as an alternative to electrosurgical traversal for BICORN during valve-in-valve transcatheter aortic valve replacement in a patient with unfavorable cardiac orientation and extreme bilateral coronary obstruction risk. KEY STEPS: The ShortCut device created targeted basal splits in both coronary leaflets. The left coronary cusp split was crossed using a Pilot 100 guidewire (Abbott) and microcatheter with an EBU 3.5 guide catheter (Medtronic) and Agilis steerable introducer (Abbott) support. After balloon dilation, the left coronary cusp was translocated with an 18-mm True Dilatation Balloon (BD). A 20-mm SAPIEN 3 Ultra transcatheter heart valve (Edwards Lifesciences) was then advanced through the right coronary cusp split and deployed within the pre-existing 23-mm SAPIEN 3 valve (Edwards Lifesciences). POTENTIAL PITFALLS: Mechanical traversal requires precise targeting. Leaflet translocation may cause embolization, severe aortic insufficiency, or hemodynamic compromise, requiring readiness for immediate valve deployment. TAKE-HOME MESSAGE: Mechanical traversal may facilitate BICORN when cardiac rotation, unfavorable catheter trajectory, neosinus malalignment, eccentric coronary takeoffs, or leaflet fibrocalcification make electrosurgical traversal challenging.

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Cite This Study

Hennawi et al. (2026) conducted a case report in Transcatheter aortic valve-in-valve replacement with extreme bilateral coronary obstruction risk (n=1). Mechanical leaflet traversal using the ShortCut device for Bilateral Iatrogenic Coronary Leaflet Obstruction Risk Nullification (BICORN) was evaluated on Successful deployment of a 20-mm SAPIEN 3 Ultra transcatheter heart valve following mechanical bilateral leaflet traversal and translocation. Mechanical leaflet traversal using the ShortCut device facilitated BICORN and successful 20-mm SAPIEN 3 Ultra deployment inside a 23-mm SAPIEN 3 valve in 1 patient.

synapsesocial.com/papers/6aefbd5d50d2071ffda4bc7c https://doi.org/10.1016/j.jaccas.2026.111098

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First-in-Human Mechanical Bilateral Iatrogenic Coronary Leaflet Obstruction Risk Nullification (BICORN) for Transcatheter Aortic Valve-in-Valve Replacement

Key Points

Study Design

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

First-in-Human Mechanical Bilateral Iatrogenic Coronary Leaflet Obstruction Risk Nullification (BICORN) for Transcatheter Aortic Valve-in-Valve Replacement

Key Points

Study Design

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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