Surgical Proof of Concept: The BASILICA Technique

In this case, an 88-year-old woman with a history of 23 mm mitroflow aortic valve replacement (AVR) presented with symptomatic aortic stenosis. Due to a concern over coronary artery obstruction with valve-in-valve transcatheter aortic valve replacement (TAVR), surgical AVR is pursued.

In this video, the stenotic prosthetic valve is seen with interrogation of the valve, revealing severely calcified leaflets. Patent flow is seen via retrograde cardioplegia. The right coronary leaflet is opened, while the left coronary leaflet is more severely calcified and is immobile. A balloon catheter is passed across the valve. Retrograde cardioplegia is once again administered to demonstrate patent flow from both the left and right coronary arteries. The balloon is dilated and retrograde delivery is once again attempted. With the balloon dilated, one can see diminished flow from both coronaries, corroborating the preoperative concern for coronary artery obstruction.

The bioprosthetic aortic scallop intentional laceration to prevent Iatrogenic coronary artery obstruction (BASILICA) technique is a transcatheter strategy to deal with potential coronary obstruction, which involves the laceration of valve leaflets, so that upon dilation, the lacerated leaflets will splay outward and away from the coronary ostia. The balloon is removed from across the valve. The right and left leaflets are incised to mimic the laceration that is performed in the BASILICA technique. The right coronary leaflet is incised, and then the calcified left coronary leaflet is incised. The balloon dilator is once again passed across the valve. With the leaflets lacerated, the valve is dilated and retrograde cardioplegia is delivered once again. The lacerated leaflets splay outward and away from the coronary ostia. There is improved flow through the left coronary after the leaflet incision, however the right coronary ostia remains obstructed by the dilated valve leaflets. The balloon is then removed. Patent coronary flow is confirmed once again by delivery of retrograde carioplegia. Open surgical aortic valve replacement is then performed.

This patient had an uncomplicated postoperative course and was discharged from the hospital on postoperative day seven.

Reference

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 Jul 8;12(13):1240-1252.