Authors

• Andrija Matetić — University Hospital of Split, Split, Croatia — ORCID: 0000-0001-9272-6906
• Frane Runjić — University Hospital of Split, Split, Croatia — ORCID: 0000-0001-6639-5971
• Ivica Kristić — University Hospital of Split, Split, Croatia — ORCID: 0000-0002-9882-9145
• Nikola Crnčević — University Hospital of Split, Split, Croatia — ORCID: 0000-0002-1399-3406
• Darija Baković Kramarić — University Hospital of Split, Split, Croatia — ORCID: 0000-0001-6751-5242

Keywords

transcatheter aortic valve implantation coronary obstruction, leaflet laceration, Croatia

DOI

Full Text

**Introduction**: Transcatheter aortic valve implantation (TAVI) is contraindicated in patients with a high risk of coronary obstruction. The Bioprosthetic or native Aortic Scallop Intentional Laceration to prevent Iatrogenic Coronary Artery obstruction (BASILICA) technique enables TAVI in these high-risk patients by creating intentional and controlled leaflet laceration prior to valve deployment (1). The procedure requires meticulous preprocedural planning and experienced operators to minimize the risks and ensure coronary flow preservation (2, 3). This study presents the first BASILICA procedure in Croatia, successfully performed at the University Hospital of Split for a patient with intermediate-to-high risk of coronary obstruction. **Case report**: 80-year-old female with critical symptomatic aortic stenosis [Vmax 4.7 m/s; MPG 60 mmHg] and high surgical risk was referred for TAVI. Preprocedural assessment revealed an intermediate-to-high risk of left coronary obstruction and sinus sequestration. Calculations revealed a low height of left coronary [9 mm] and sinotubular junction (13 mm), shallow sinuses of Valsalva [SOV-LCC 26.4 mm] and other unfavourable relevant parameters [valve-to-coronary 3.6 mm; valve-to-STJ 1.6 mm; leaflet-STJ mismatch -1.5 mm] (**Figure 1**). The right coronary artery had a higher origin and negligible risk of obstruction. The Structural Heart Team opted for a modified solo LCC-BASILICA technique after detailed preprocedural planning, including 3-dimensional printing simulation. The procedure was performed under echocardiographic and fluoroscopic guidance with operator-led analgosedation. Using an electrified coronary wire, successful and controlled leaflet splay was achieved, followed by TAVI [Edwards Sapien S3 Ultra Resilia 23 mm] with preserved coronary flow and optimal positioning (**Figures 2** and **3**Figure 3). The patient was discharged on postoperative day 4 with uneventful follow-up at 6 months. FIGURE 1. Preprocedural planning and reconstructions from cardiac computed tomography: A. Plain multiplanar reconstructions; B. Valve simulation and calculations; C. 3-dimensional simulation and printing. LCA - left coronary artery; 3D - 3-dimensional. FIGURE 2. Fluoroscopic phases of the procedure: A. Equipment positioning in the left coronary cusp; B. Preparation for electrosurgical crossing; C. Electrosurgical crossing; D. Preparation for controlled leaflet laceration using the ‘flying V’; E. Final successful result. TAVI - transcatheter aortic valve implantation. FIGURE 3. Echocardiographic images: A. Confirmation of catheter position before BASILICA; B. Confirmation of successful left coronary leaflet laceration and splay. BASILICA - Bioprosthetic or native Aortic Scallop Intentional Laceration to prevent Iatrogenic Coronary Artery obstruction. **Conclusion**: The BASILICA technique represents a viable solution for TAVI patients with high risk of coronary obstruction. It can be achieved with favourable outcomes when preceded by detailed preprocedural planning and performed by experienced operators.

Literature

1. Khan JM, Babaliaros VC, Greenbaum AB, Spies C, Daniels D, Depta JP, et al. Preventing Coronary Obstruction During Transcatheter Aortic Valve Replacement: Results From the Multicenter International BASILICA Registry. JACC Cardiovasc Interv. 2021 May 10;14(9):941–8. https://doi.org/10.1016/j.jcin.2021.02.035
2. Khan JM, Greenbaum AB, Babaliaros VC, Rogers T, Eng MH, Paone G, et al. The BASILICA Trial: Prospective Multicenter Investigation of Intentional Leaflet Laceration to Prevent TAVR Coronary Obstruction. JACC Cardiovasc Interv. 2019 July 8;12(13):1240–52. https://doi.org/10.1016/j.jcin.2019.03.035
3. Lederman RJ, Babaliaros VC, Rogers T, Khan JM, Kamioka N, Dvir D, et al. Preventing Coronary Obstruction During Transcatheter Aortic Valve Replacement: From Computed Tomography to BASILICA. JACC Cardiovasc Interv. 2019 July 8;12(13):1197–216. https://doi.org/10.1016/j.jcin.2019.04.052