En-Face View for Bioprosthetic or Native Aortic Scallop Intentional Laceration to Prevent Coronary Artery Obstruction

An 80-year-old man with a prior surgical aortic valve (SAV) replacement using a 23-mm Sorin Crown (Sorin Group, USA) presented with exertional dyspnea. Echocardiography showed severe transvalvular regurgitation, leading to referral for transcatheter aortic valve implantation in SAV (TAV-in-SAV). Computed tomography (CT) showed a left coronary artery (LCA) height of 4.3 mm and a virtual transcatheter valve-to-sinotubular junction distance of 2.9 mm (Figure A,B), indicating a high risk of coronary obstruction. To mitigate this risk, bioprosthetic or native aortic scallop intentional laceration to prevent coronary artery obstruction (BASILICA) was performed. Both the preprocedural CT and fluoroscopic en face view (Figure C–E; Supplementary Movie) guided the catheter manipulation near the LCA, ensuring accurate leaflet positioning using the fluoroscopic side view (Figure F,G). After successful leaflet traversal and balloon expansion (Figure H), the leaflet was lacerated (Figure I,J), and an Evolut PRO+ (Medtronic, USA) valve was implanted (Figure K).

Figure.

(A,B) Computed tomography (CT) showing low left coronary artery (LCA) and narrow valve-to-sinotubular junction distance. (C,D) CT and fluoroscopic en face view (RAO 50°/cranial 30°, yellow arrow: LCA). (E) Short-axis view on transesophageal echocardiography (TEE) (red arrow: guiding catheter). (F,G) CT and fluoroscopic side view (LAO 20°/caudal 7°). (H) Balloon dilatation. (I) Leaflet laceration. (J) TEE showing the lacerated bioprosthetic valve leaflet (blue arrow). (K) Implanted Evolut PRO+ valve. LAO, left anterior oblique; RAO, right anterior oblique.

The en face (RAO deep cranial) view provides a short-axis perspective of the aortic valve and coronary ostium, facilitating precise catheter manipulation.¹ This view enables more precise manipulation of the guiding catheter’s axis, facilitating easier adjustments to the laceration site. Proper wire positioning is crucial for the success of both BASILICA and the procedural outcome.

Disclosures

D.H. and N.T. are clinical proctors for Edwards Lifesciences, Abbott Medical, and Medtronic. The remaining authors have nothing to disclose.

Supplementary Files

Supplementary Movie. Fluoroscopic videos showing guiding manipulation and guidewire traversal in both side and en face views, with TEE videos.

Please find supplementary file(s);

https://doi.org/10.1253/circj.CJ-24-0670

Reference

• 1.   Hirose S, Enta Y, Ishii K, Inoue A, Nakashima M, Nomura T, et al. En face view of the transcatheter heart valve from deep right-anterior-oblique cranial position for coronary access after transcatheter aortic valve implantation: A case series. Eur Heart J Case Rep 2022; 6: 1–7.