Valve-in-valve TAVR using BASILICA technique and cerebral protection in a patient with severe dysfunction of the aortic bioprosthesis

Transcatheter aortic valve replacement (TAVR) is recommended for high- and intermediate-risk patients with severe aortic stenosis and a suitable option for degenerated surgical bioprosthetic valves. The feasibility of a complete percutaneous approach in transfemoral TAVR was demonstrated, even in complex scenarios, such as valve-in-valve (ViV) procedures [1]. ViV TAVR is associated both with a higher stroke risk due to biodebris released from the degenerated bioprosthesis and increased risk of coronary occlusion, especially in patients with a short distance between the bioprosthesis and coronary ostia [2]. In such patients, the “chimney technique” or BASILICA technique (Bioprosthetic or Native Aortic Scallop Intentional Laceration to Prevent Iatrogenic Coronary Artery Obstruction) can be used to prevent coronary occlusion [2]. BASILICA is a novel transcatheter electrosurgical technique which increases the safety of ViV TAVR, but also enhances the risk of stroke [3]. Thus, the use of a cerebral protection device (CPD) has been advocated when performing BASILICA prior to TAVR [4].
We present a case of a 66-year-old man after the mini-Bentall procedure with severe dysfunction of the aortic bioprosthesis (Trifecta GT 25 mm), admitted to the cardiology department due to exacerbation of chronic heart failure to NYHA class III. His medical history included percutaneous coronary intervention with stent implantation in the left anterior descending artery and intermediate branch, peripheral artery disease and hypercholesterolemia. Transthoracic echocardiography (TTE) revealed global hypokinesis of the left ventricle (ejection fraction, EF 35%), severe stenosis (Vmax 5.6 m/s, max/mean gradient 125/77 mm Hg, indexed aortic valve area 0.24 cm2/m2) and moderate regurgitation of the aortic bioprosthesis. Computed tomography revealed a virtual transcatheter heart valve-coronary (VTC) distance to the left coronary artery of only 4.6 mm (Figures 1 A–C). Considering the high peri-operative risk (EuroSCORE II 13.2%) and high risk of coronary occlusion [5], the patient was qualified for ViV TAVR using BASILICA and SENTINEL CPD (Boston Scientific, US).
The SENTINEL was delivered via the right radial artery (6-Fr sheath) and the filters were deployed in the brachiocephalic trunk and the left common carotid artery (Figure 1 D). TAVR and BASILICA were performed via the right and left femoral accesses (14-Fr and 7-Fr sheath) under transesophageal echocardiography...


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