Echocardiographic Guidance of Intentional Leaflet Laceration prior to Transcatheter Aortic Valve Replacement: A Structured Approach to the Bioprosthetic or Native Aortic Scallop Intentional Laceration to Prevent Iatrogenic Coronary Artery Obstruction Procedure

Abstract

•Echocardiography complements fluoroscopy in guiding the BASILICA procedure.•Simultaneous multiplane TEE facilitates accurate positioning of catheters.•Even with calcified bioprostheses, TEE displays valve anatomy and detects complications. Bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction (BASILICA) is a recently developed technique to reduce the risk of ostial coronary obstruction during transcatheter aortic valve replacement. Intraprocedural fluoroscopy and transesophageal echocardiography imaging are used complimentarily to guide the procedure. So far, no structured echocardiographic imaging protocol has been described for this intervention. Based on an experience of more than 50 BASILICA procedures at two different institutions, we present a step-by-step approach for transesophageal echocardiography guidance during BASILICA and highlight anatomical and procedural characteristics from an echocardiographic perspective. Bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction (BASILICA) is a recently developed technique to reduce the risk of ostial coronary obstruction during transcatheter aortic valve replacement. Intraprocedural fluoroscopy and transesophageal echocardiography imaging are used complimentarily to guide the procedure. So far, no structured echocardiographic imaging protocol has been described for this intervention. Based on an experience of more than 50 BASILICA procedures at two different institutions, we present a step-by-step approach for transesophageal echocardiography guidance during BASILICA and highlight anatomical and procedural characteristics from an echocardiographic perspective. Bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction (BASILICA) is a recently developed technique to reduce the risk of ostial coronary obstruction in the setting of transcatheter aortic valve (AV) replacement (TAVR).1Khan J.M. Dvir D. Greenbaum A.B. Babaliaros V.C. Rogers T. Aldea G. et al.Transcatheter laceration of aortic leaflets to prevent coronary obstruction during transcatheter aortic valve replacement: concept to first-in-human.JACC Cardiovasc Interv. 2018; 11: 677-689Crossref PubMed Scopus (124) Google Scholar Although the reported incidence of coronary obstruction during TAVR is approximately 0.7% for native AV and 2.3% for bioprosthetic valve-in-valve (VIV) procedures,2Ribeiro H.B. Webb J.G. Makkar R.R. Cohen M.G. Kapadia S.R. Kodali S. et al.Predictive factors, management, and clinical outcomes of coronary obstruction following transcatheter aortic valve implantation: insights from a large multicenter registry.J Am Coll Cardiol. 2013; 62: 1552-1562Crossref PubMed Scopus (341) Google Scholar,3Ribeiro H.B. Rodés-Cabau J. Blanke P. Leipsic J. Kwan Park J. Bapat V. et al.Incidence, predictors, and clinical outcomes of coronary obstruction following transcatheter aortic valve replacement for degenerative bioprosthetic surgical valves: insights from the VIVID registry.Eur Heart J. 2017; 39: 687-695Crossref Scopus (148) Google Scholar it has been associated with a mortality of more than 50% at 30 days. Ostial coronary obstruction most commonly occurs as a result of outward displacement of the preexisting AV leaflets by the implantation of a transcatheter heart valve (THV). With the BASILICA procedure, one or both aortic or prosthetic coronary leaflets are split in half from their base to the tip before proceeding to TAVR, allowing them to splay away from the coronary ostia after TAVR. Its feasibility and safety have been shown in small clinical studies.4Khan J.M. Greenbaum A.B. Babaliaros V.C. Rogers T. Eng M.H. Paone G. et al.The BASILICA trial: prospective multicenter investigation of intentional leaflet laceration to prevent tavr coronary obstruction.JACC Cardiovasc Interv. 2019; 12: 1240-1252Crossref PubMed Scopus (98) Google Scholar,5Kitamura M. Majunke N. Holzhey D. Desch S. Bani Hani A. Krieghoff C. et al.Systematic use of intentional leaflet laceration to prevent TAVI-induced coronary obstruction: feasibility and early clinical outcomes of the BASILICA technique.EuroIntervention. 2020; 16: 682-690Crossref PubMed Scopus (7) Google Scholar Patient selection and preprocedural planning for BASILICA are largely based on computed tomography (CT) imaging with multiplanar reconstruction, including measurements using a virtual THV model and identification of fluoroscopic projections with commissural alignment.6Komatsu I. Leipsic J. Webb J.B. Blanke P. Mackensen G.B. Don C.W. et al.Imaging of aortic valve cusps using commissural alignment: guidance for transcatheter leaflet laceration with BASILICA.JACC Cardiovasc Imaging. 2019; 12: 2262-2265Crossref PubMed Scopus (3) Google Scholar, 7Komatsu I. Mackensen G.B. Aldea G.S. Reisman M. Dvir D. Bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction. Part 1: How to evaluate patients for BASILICA.EuroIntervention. 2019; 15: 47-54Crossref PubMed Scopus (14) Google Scholar, 8Lederman R.J. Babaliaros V.C. Rogers T. Khan J.M. Kamioka N. Dvir D. et al.Preventing coronary obstruction during transcatheter aortic valve replacement: from computed tomography to BASILICA.JACC Cardiovasc Interv. 2019; 12: 1197-1216Crossref PubMed Scopus (58) Google Scholar The procedure is considered when one or both coronary arteries originate below the projected tip of the deflected native or prosthetic aortic leaflet on CT in several anatomical conditions, including a narrow sinus of Valsalva, or if the deflected leaflets would reach a narrow sinotubular junction. The additional role of echocardiography in the assessment of coronary obstruction risk remains to be defined. The BASILICA procedure is typically performed in a hybrid operating room under fluoroscopic guidance, with or without transesophageal echocardiography (TEE) guidance.4Khan J.M. Greenbaum A.B. Babaliaros V.C. Rogers T. Eng M.H. Paone G. et al.The BASILICA trial: prospective multicenter investigation of intentional leaflet laceration to prevent tavr coronary obstruction.JACC Cardiovasc Interv. 2019; 12: 1240-1252Crossref PubMed Scopus (98) Google Scholar,8Lederman R.J. Babaliaros V.C. Rogers T. Khan J.M. Kamioka N. Dvir D. et al.Preventing coronary obstruction during transcatheter aortic valve replacement: from computed tomography to BASILICA.JACC Cardiovasc Interv. 2019; 12: 1197-1216Crossref PubMed Scopus (58) Google Scholar The role of periprocedural TEE during BASILICA is still to be fully studied, and specific imaging protocols and management of possible challenges have not been reported to date. Based on more than 50 BASILICA procedures, this article aims at highlighting anatomical and procedural characteristics from an echocardiographic perspective and providing echocardiographers involved in BASILICA procedures with a step-by-step guide through this intervention. Details of the BASILICA procedure have been previously published.8Lederman R.J. Babaliaros V.C. Rogers T. Khan J.M. Kamioka N. Dvir D. et al.Preventing coronary obstruction during transcatheter aortic valve replacement: from computed tomography to BASILICA.JACC Cardiovasc Interv. 2019; 12: 1197-1216Crossref PubMed Scopus (58) Google Scholar,9Komatsu I. Mackensen G.B. Aldea G.S. Reisman M. Dvir D. Bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction. Part 2: How to perform BASILICA.EuroIntervention. 2019; 15: 55-66Crossref PubMed Scopus (14) Google Scholar Using an electrified guide wire, the target AV leaflet is first traversed at its base and then lacerated. Understanding of the procedural steps and equipment is necessary to allow effective communication with the interventional team based on the echocardiographic findings (Figure 1, Table 1). The procedure requires precise maneuvering of catheters and snares in the target leaflet, the left ventricular outflow tract (LVOT), and the left ventricle (LV). BASILICA consists of the following steps, as shown in Figure 1 and Video 1:Table 1BASILICA equipment relevant for TEEDeviceUseTEE appearanceSnare system: MP guiding catheterGuiding the snareStraight echodense catheter Single-loop snareCapturing the traversal guide wireThin hyperechoic wire ending with a loop, usually only partially visualized Anchor guide wireStabilizing the MP catheterThick hyperechoic wire, with curved endTraversal system: Curved guiding catheterDelivering the traversal guide wire to the leafletCurved echodense catheter with double outline pattern Traversal guide wire (Astato XS 20)Leaflet traversal and lacerationThin straight hyperechoic wire Piggyback microcatheterInsulating jacket mounted over traversal guide wireCannot be displayed Open table in a new tab This commonly consists of a multipurpose (MP) guiding catheter with a stabilizing anchor wire and a snaring loop. The AV is crossed by the guiding catheter, and a curved anchor guide wire is delivered through it to the LV apex. A single-loop snare is then advanced through the MP catheter and placed in the LVOT below the AV annulus alongside the anchor wire. This consists of a traversal catheter with a special electrifiable guide wire inside. The traversal catheter is positioned in the target coronary sinus. The catheter has a curved shape (either assembled in a telescopic way out of two catheters or out of a single one specifically developed for BASILICA) adjusted to the anatomy to achieve the desired alignment with the valve cusp and the aorta. The special electrifiable traversal guide wire (Astato XS 20, Asahi Intecc, Aichi, Japan) is insulated in a wire converter (Piggyback, Teleflex, Morrisville, NC) and advanced through the traversal catheter toward the base of the leaflet. The leaflet is punctured with the traversal guide wire while applying electric current to its distal end. The traversal guide wire is snared in the LVOT and retrieved through the AV in the MP catheter. In that way, a loop is formed between the two guiding catheters with the traversal guide wire crossing through the aortic leaflet between them. The anchor wire is removed from LV. A kinked V-shape part of the wire (“flying V”) is prepared outside the patient's body and is then delivered through the traversal catheter to the place of laceration at the leaflet to act as a “percutaneous knife.” The leaflet is split by pulling both MP and traversal catheters while applying electricity to the distal end of the traversal wire. Before that, a pigtail catheter is usually placed in the LV to facilitate immediate TAVR. For bileaflet BASILICA, the right and left coronary leaflets are first consecutively traversed and then lacerated immediately before TAVR. Defining a standardized, AV-focused preprocedural TEE protocol is highly recommended. It allows definition of the valve pathology at baseline for postprocedural comparisons, excludes vegetations or valve thrombosis, and identifies the patient-specific standard views required for intraprocedural guidance. Special attention is required to identify partial or complete tears of the target coronary leaflet(s) in patients with regurgitant bioprosthetic valves, as these may interfere with or even prohibit leaflet laceration. The baseline focused examination consists of up to eight two-dimensional (2D) views (Table 2). The use of a matrix array probe is essential. It allows simultaneous multiplane imaging mode for cross-sectional visualization of the catheters’ positions during the procedure. Three-dimensional (3D) imaging displaying anatomical views may further define leaflet anatomy and pathology and can be used to clarify some specific clinical questions (e.g., understanding of spatial relationships, evaluation of ostial eccentricity, etc.).Table 2Periprocedural TEE examination and guidanceStageTEE view/modalityCommentPreprocedural focused AV examination1.Deep TG or TG LAX (2D, CFD, CWD, PWD)2.TG SAX/2 CH (2D multiplane)3.ME 4 CH/2 CH (2D multiplane, CFD)4.ME LV LAX (2D, CFD)5.ME AV LAX (2D, CFD)6.ME AV SAX (2D, CFD)7.ME asc/desc Ao SAX/LAX (2D)Confirmation of pathology. Verify indications for BASILICA. Baseline for pressure gradients. Exclusion of relevant paravalvular AR. Baseline LV/RV function assessment. Exclusion of pericardial effusion, MV/TV pathology. Relationship of MV apparatus to LVOT. Evaluation of aortic root anatomy. Exclusion of calcifications that might interfere with procedure. Exclusion of leaflet tears. Position of both coronary ostia, relation/(ex-)centricity to struts of stented prosthetic valve. Blood flow in coronary arteries. Exclusion of aortic dissection.Positioning the snareME AV LAX multiplane with inversion of the right image (Figure 2A and C)Displaying the snare system positioned through the AV. Displaying the snare loop in the LVOT. Slight corrections to classic display possibly needed (turning the probe to left/right and/or adjustment of rotation angle) to display the catheter in LAX.ME LV LAX (Figure 2B)Control of the position of the anchor wire in the LV.Positioning the traversal systemME AV LAX multiplane with inversion of the right image (Figure 3)Displaying the traversal catheter with its tip at the aortic leaflet. Control of catheter's attack angle. Control of the alignment with the coronary ostium. Slight corrections to classic display possibly needed (turning the probe to left/right, adjustment of rotation angle and upper/lower position of probe to better demonstrate coronary cusp in the presence of prosthetic valve or calcification).Leaflet traversalME AV LAX (+zoom)(Figures 6 and 7)Displaying the traversal wire piercing through the leaflet. Control of proper location of the wire after traversal and before snaring.Snaring and V positioningME AV SAX multiplane (Figures 9 and 10)Assuring of the radial position of the V.Leaflet lacerationME AV LAX CFD (Figure 11)Quick assessment of the AR after laceration.ME AV SAX, +CFD (Figure 12)Confirmation and evaluation of the laceration.Postprocedural examination1.ME AV SAX (2D, CFD)2.ME AV LAX (2D, CFD)3.ME 4 CH multiplane (2D, CFD)4.Deep TG or TG LAX (2D, CFD, CWD, PWD)5.TG SAX/2 CH (2D multiplane)6.ME asc/desc Ao SAX/LAX (2D)Patency and flow in coronary artery after TAVR. Global LV/RV function and exclusion of new wall motion abnormalities. THV pressure effective and paravalvular MV for Exclusion of aortic or aortic CWD, LV right valve. Open table in a new tab aortic CWD, LV right valve. fluoroscopic projections and cusp are usually based on preprocedural CT to guide catheter The allows positioning of the catheter in the coronary cusp and its proper toward the aortic The allows the alignment of the catheter in the of the leaflet. projections are not and be in to fluoroscopic the of the left cusp and the of the right I. Mackensen G.B. Aldea G.S. Reisman M. Dvir D. Bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction. Part 1: How to evaluate patients for BASILICA.EuroIntervention. 2019; 15: 47-54Crossref PubMed Scopus (14) Google Scholar of valve anatomy can be even more on fluoroscopy in the presence of or transcatheter M. M. Krieghoff C. P. I. et for a transcatheter heart for prosthetic Cardiovasc Interv. 2020; PubMed Scopus (3) Google Scholar as commissural are and TEE is in these TEE allows simultaneous display of the precise traversal catheter's its attack and coronary This the to reduce the of fluoroscopic In a the coronary is not with the of the leaflet with a sinus of and I. M. A. Blanke P. et the risk for coronary obstruction after transcatheter aortic valve implantation and the to perform the VIVID 2020; Google Scholar leaflet laceration might be performed to the location of the leaflet I. S. M. A. et and of bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery 2020; Scholar This be a for fluoroscopic guidance the two while TEE allows imaging for catheter guidance of the location and alignment of coronary Ostial is more for the right coronary in native I. Leipsic J. Webb J.G. Blanke P. Mackensen G.B. Don C.W. et ostial in aortic guidance for BASILICA transcatheter leaflet Cardiovasc 2020; PubMed Scopus (7) Google Scholar to in fluoroscopic TEE is even more in of BASILICA for the right coronary of the snaring system positioned through the valve is in the AV using multiplane imaging displaying two imaging on the (Figure Video 2). Slight from the classic views by left or right of the TEE probe or by of the rotation angle may be needed to the LAX of the catheter and wire on the left The is at the of the AV to the position of the MP catheter the valve in the on the right of the This SAX a image of the standard AV SAX and can be on the by left to The MP catheter is and its double outline pattern as an anchor wire is advanced through the catheter. The hyperechoic anchor wire the LV with its curved end. The position of the anchor wire in the LV can be in the LAX (Figure Video 2). visualization of the snare below the AV is usually not from the probe position can be when and are (Figure The placed traversal catheter be with its tip at the of the leaflet right in of the coronary ostium. The alignment with the coronary is in of ostial and a small sinus of This part of the BASILICA procedure to be the TEE imaging of traversal catheter using AV LAX and multiplane mode with inversion of the the catheter in the target it be displayed in its LAX on the left of the multiplane with the catheter is with of the probe and adjustment of rotation angle. The traversal catheter has a curved and it is possible to its visualized in the when left cusp laceration is the distal of the catheter to the AV leaflet be (Figure Video The position of the catheter's tip is then on the right SAX of the multiplane mode an by setting the through the tip on the LAX In the SAX the catheter tip be positioned in of and to the coronary (Figure Video the catheter is it can be displayed through of the TEE probe in the needed of the catheter can be with TEE using multiplane imaging (Figure of the traversal catheter. of the traversal catheter between the aortic wall and the valve in the left/right of the valve and outside of the Figure image Control of the catheter's tip attack angle toward the aortic in the LAX is to prevent catheter and as the left right and The traversal be toward the LVOT and with its (Figure of the of the traversal system in the AV LAX multiplane the leaflet is punctured using guide wire applying current to the wire, the aortic root with by and the of traversal may not be displayed with TEE (Figure Video leaflet traversal can be only by TEE by displaying the target leaflet with the traversal wire in the AV LAX with In to the anchor wire that in the LV the traversal wire tip remains in the LVOT (Figure and Video of leaflet traversal at the of the left coronary cusp Video traversal at the of the right coronary traversal of the left coronary cusp the left through the Video left left coronary right Figure image echocardiography on the precise location of the traversal wire, and as the left or the be on fluoroscopic be before snaring is (Figure Video This may complications. In wire traversal can result in aortic root if the electrified wire the aortic and this be by TEE if wire traversal is not (Figure snaring of the traversal wire is to by TEE to the large of from the catheters and the traversal wire is snared (Figure and retrieved the MP catheter, the valve be in the LAX for to may when the traversal wire is snared in the LVOT or I. S. M. A. et and of bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery 2020; Scholar snaring the position of the traversal wire to be on the part of the wire (“flying V”) is delivered through the traversal catheter to the place of laceration. The V be positioned to proper laceration from base to tip of the one part of the V from the traversal is the aortic of the leaflet, and the part from the MP is the ventricular as as (Figure the laceration may be performed with risk of ostial coronary position of the V before laceration. AV SAX the MP and traversal catheters after of the V. are positioned in to the AV and can be displayed only with two different 1 and placed V with the MP catheter in the left/right a risk of laceration. The displays two catheters a V shape coronary MP traversal Figure image In the of the with on both catheters are from the while the LV pigtail catheter can still be of the pigtail catheter is placed before the laceration to allow THV be immediately to the In with relevant preexisting aortic the new is usually without preexisting aortic and a heart can after leaflet with the in to and/or is usually to pressure in this THV flow of the AV in the AV LAX allows of the of aortic (Figure Video The laceration is then further displayed by to the AV SAX with of image (Figure and and laceration be and reach the of the leaflet. laceration (Figure Video may still to obstruction of the coronary ostia after TAVR and be to allow for as of a coronary of the lacerated bioprosthetic leaflet. SAX positioned leaflet in of left coronary Video from the Video laceration when displayed from base of the leaflet to its tip Video Figure image aortic valve replacement is performed immediately after leaflet laceration. The examination by in both coronary arteries in the AV SAX with CFD and left and right ventricular wall motion be out in the and SAX Ostial coronary obstruction can still in of leaflet laceration and/or if a THV with the laceration after of a coronary not by BASILICA can in of THV in the aortic R.J. Babaliaros V.C. Rogers T. Khan J.M. Kamioka N. Dvir D. et al.Preventing coronary obstruction during transcatheter aortic valve replacement: from computed tomography to BASILICA.JACC Cardiovasc Interv. 2019; 12: 1197-1216Crossref PubMed Scopus (58) Google Scholar In partial leaflet the coronary may without immediate clinical or (Figure Video M. M. M. after BASILICA and transcatheter aortic valve Cardiovasc Interv. 2020; PubMed Scopus (3) Google Scholar The is of as it is on aortic root and would a coronary The aortic then be for and paravalvular as the and be to or The possible that can be with TEE are in Table in of wall with of wire of wall with electrified guide the position of traversal catheter at the aortic leaflet and its proper attack angle before with electrified guide the position of traversal catheter at the aortic leaflet and its proper attack angle before of aortic wall with electrified guide wire during traversal current with pressure on the proper position of traversal catheter at the aortic leaflet and of of of valve during the position of the snare not in LVOT. for after wire heart coronary obstruction with a part of lacerated alignment of the tip of the traversal catheter with the coronary before or of THV with the laceration not leaflet the coronary or not laceration. may be in native and alignment of the tip of the traversal catheter with the coronary before or laceration. Open table in a new tab Three-dimensional echocardiography its in guiding BASILICA for a native S. A. Khan J.M. transesophageal echocardiographic guidance during TAVR with BASILICA.JACC Cardiovasc Imaging. 2020; PubMed Scopus Google it remains of in image is by or (e.g., prosthetic or calcified In BASILICA be by the valve procedure, for of imaging in most of the only a narrow is to the aortic cusps in two the of of that while operating the The precise location of the traversal catheter's tip is the most needed during BASILICA) can in more with simultaneous multiplane imaging as described previously than with when the imaging are of presence of imaging be for different as the evaluation of sinus anatomy and ostial eccentricity, catheter alignment with the coronary of proper leaflet and of laceration (Figure displaying an aortic root in SAX in the image can be by an of the to the required This allows the of the coronary artery while still on desired might be further considered for evaluation in BASILICA J. J.M. use of image during transcatheter aortic valve Cardiovasc Interv. 2019; 12: PubMed Scopus (3) Google Scholar BASILICA, TEE imaging that facilitates accurate and positioning of In with possible might be and Understanding the procedural steps is for the to with heart team and simultaneous multiplane echocardiography to be and effective in guiding BASILICA even in calcified or stented prosthetic when the of leaflet imaging may further the of TEE and fluoroscopy for BASILICA guidance.

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