Leaflet Laceration, an Extreme Measure to Avoid Coronary Occlusion After TAVR

Intentional leaflet laceration before mounting the prosthesis on the release system, so as to reduce the risk of acute coronary occlusion, seems a desperate maneuver to force transcatheter aortic valve replacement (TAVR). Unfortunately, we will always encounter patients without other real choice; in those cases, creativity may start as compassionate treatment and then be upgraded to a valid technique.

This work describes a technique called BASILICA (Bioprosthetic or Native Aortic Scallop Intentional Laceration to Prevent Coronary Artery Obstruction), which consists in laceration of pericardial leaflets in half using electrosurgery, so as to prevent coronary occlusion. The technique was first tested in vitro, and then assessed in horses and pigs, with good results. Consequently, there came a time to try it as a compassionate treatment.

The procedure was carried out in 7 patients, 6 of whom had failed bioprosthetic valves (both stented and stent-less). One patient required laceration of both left and right coronary leaflets.

Read also: EuroPCR 2018 | Meta-Analyzis on Cerebral Protection Devices during TAVR.

Once the laceration was carried out, the bioprosthesis was mounted on the release system and the procedure was carried out in a standard manner (any commercially available valve was admitted).

There was no hemodynamic alteration in relation to the prosthesis in any of these patients, and the procedure was successfully completed in all of them, without coronary obstruction or any other major complication. All patients underwent follow-up up to 30 days.

Conclusion

This new technique will have to stand the test of time. Nowadays, it is only used as compassionate treatment in patients for whom both transcatheter and surgical valve replacement is contraindicated due to extremely low coronary ostiums. However, initial results are promising.

Original title: Transcatheter Laceration of Aortic Leaflets to Prevent Coronary Obstruction During Transcatheter Aortic Valve Replacement.

Reference: Jaffar M. Khan et al. J Am Coll Cardiol Intv 2018;11:677-89.

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