Preventing Coronary Obstruction During Transcatheter Aortic Valve Replacement From Computed Tomography to BASILICA

• Type of Material: Article
• Authors: Robert Lederman, Emory University; Vasilis Babaliaros, Emory University; Toby Rogers, National Heart, Lung, and Blood Institute; Jaffar Khan, Emory University; Norihiko Kamioka, Emory University; Danny Dvir, University of Washington; Adam Greenbaum, Emory University
• Language: English
• Date: 2019-07-08
• Publisher: Elsevier: 12 months
• Publication Version: Author Accepted Manuscript (After Peer Review)
• Copyright Statement: Published by Elsevier on behalf of the American College of Cardiology Foundation
• License: Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International
• Final Published Version (URL): http://dx.doi.org/10.1016/j.jcin.2019.04.052
• Title of Journal or Parent Work: JACC: Cardiovascular Interventions
• ISSN: 1936-8798
• Volume: 12
• Issue: 13
• Start Page: 1197
• End Page: 1216
• Grant/Funding Information: This work was supported by grant Z01-HL006040 from the National Heart, Lung, and Blood Institute Division of Intramural Research (to Dr. Lederman).
• Keywords: virtual valve; cardiac computed tomography; valve-in-valve; Life Sciences & Biomedicine; INSIGHTS; RISK; Cardiac & Cardiovascular Systems; LEAFLET; transcatheter aortic valve replacement; Cardiovascular System & Cardiology; TRANSCAVAL ACCESS; coronary artery obstruction; Science & Technology; CLOSURE; virtual valve-to-coronary distance; PROTECTION; LACERATION; IMPLANTATION; CLINICAL-OUTCOMES; transcatheter electrosurgery
• Research Categories: Health Sciences, Medicine and Surgery

Abstract

Coronary artery obstruction is an uncommon but devastating complication of transcatheter aortic valve replacement (TAVR). Computed tomography appears to be a sensitive but nonspecific predictor of coronary artery obstruction. Transcatheter approaches to prevent and treat coronary artery obstruction, such as “snorkel” stenting, are unsatisfactory because of serious early and late ischemic complications. Bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction during TAVR (BASILICA) is an early-stage transcatheter procedure to prevent coronary artery obstruction. It works by splitting the native or bioprosthetic leaflets so that they splay after TAVR and preserve coronary artery inflow. Because of the paucity of suitable alternatives, there is interest in the BASILICA technique despite its infancy. This tutorial review summarizes current thinking about how to predict and prevent coronary artery obstruction using BASILICA. First, the authors depict the main pathophysiological mechanisms of TAVR-associated coronary artery obstruction, along with the factors thought to contribute to coronary obstruction. Next, the authors provide a step-by-step guide to analyzing pre-procedural computed tomographic findings to assess obstruction risk and, if desirable, to plan BASILICA. Next, the authors describe the mechanisms underlying transcatheter electrosurgery. Finally, they provide step-by-step guidance on how to perform the procedure, along with a required equipment list.