The BASILICA procedure for valve-in-valve transcatheter aortic valve replacement

Cardiologists at Penn Medicine Doylestown Health and the Hospital of the University of Pennsylvania are performing the Bioprosthetic or native Aortic Scallop Intentional Laceration to prevent Iatrogenic Coronary Artery obstruction (BASILICA) procedure to prevent blockage of the coronary arteries that may occur in a subset of patients undergoing transcatheter aortic valve replacement (TAVR).

TAVR is a minimally invasive percutaneous procedure that places a new prosthetic valve inside a damaged or diseased aortic valve. The procedure is a life-saving intervention that allows valve replacement without open-heart surgery, often with few complications. However, in a subset of patients without sufficient space between the diseased valve and the nearby coronary arteries, the diseased leaflets may obstruct the coronary arteries when the new valve is placed. This coronary obstruction can be fatal in up to half of patients affected.

Efforts to address this issue have included the placement of a pre-positioned stent to deflect the occluding leaflet, known as “snorkel stenting,” a procedure that may be accompanied by poor durability of coronary flow due to early stent failure.

Developed by the National Institutes of Health, the BASILICA procedure uses percutaneous electrocautery immediately prior to TAVR to lacerate the diseased leaflet at risk for causing coronary obstruction, enabling blood to flow into the coronary artery after the new TAVR valve is placed. This technique has allowed for safe TAVR valve placement in patients who would otherwise require open heart surgery.

Thus far, BASILICA has been used in approximately 1,000 patients worldwide. The procedure was recently introduced at Penn Medicine Doylestown Health by interventional cardiologists Zachary Rodgers, MD, PhD and Hetal Haresh Metha, MD, alongside cardiothoracic surgeon Matthew Paulus Thomas, MD.

Case report

Mrs. O, an 84-year-old female with a history of prior surgical aortic valve replacement, was referred to Dr. Zachary Rodgers at Penn Medicine Doylestown Health for consultation following several weeks of progressive heart failure symptoms. At this time, she was found on echocardiogram to have severe stenosis of her prior surgical aortic valve replacement.

At 84 years of age, Mrs. O was at high risk for redo surgical aortic valve replacement (AVR). Placement of a TAVR valve within the prior surgical valve (“TAVR-in-SAVR”), offered a much lower risk alternative. Unfortunately, her cardiac CT scan demonstrated that her left main coronary artery would be at high risk for obstruction when the old bioprosthetic valve was displaced by the new TAVR valve.

To avoid this complication, Dr. Rodgers and the Heart Team at Penn Medicine Doylestown Health concluded that BASILICA leaflet modification offered the best option to safely perform TAVR. Mrs. O's surgery would be proctored by Ashwin Senthil Nathan, MD, an experienced TAVR surgeon at the Hospital of the University of Pennsylvania, and early adopter of the BASILICA technique.

The BASILICA procedure involves precise laceration of the aortic valve leaflet at risk for obstruction. This is accomplished by using an electrified wire to puncture the base of the leaflet and subsequently lacerate the leaflet from base to tip. When the new TAVR valve is deployed, this laceration becomes a “V” shaped opening, providing a pathway for blood flow into the coronary artery which would otherwise be obstructed.

Mrs. O was intubated and sedated, and a TEE probe was placed for procedural guidance. Via femoral vein access, a temporary venous pacemaker was placed in the right ventricle to allow for rapid cardiac pacing during eventual TAVR valve placement. Fluoroscopy was used to identify the ideal angles to visualize the left coronary leaflet of the prior surgical valve. To reduce the risk of stroke during procedure, a Sentinel cerebral embolic protection device was advanced via right radial artery access and deployed in the aortic arch.

Access was obtained in the right femoral artery using an 18F sheath. Via this access, the stenosed valve was crossed and a looped snare deposited in the left ventricular outflow tract just below the aortic valve.

Attention then turned to the leaflet puncture, the crux of the BASILICA procedure. Puncture requires precise positioning of a catheter centered at the base of the target leaflet. In Mrs. O’s case, this positioning proved challenging with conventional catheter shapes. A 5 French JR4 catheter with the tip manually shortened was placed within a larger 8 French EBU4 catheter (“mother-daughter technique”) to achieve ideal positioning, and confirmed on TEE and fluoroscopy.

A stiff Astato XS 20 coronary wire, electrically insulated by a microcatheter, was advanced via the JR4 catheter to the leaflet base. After attaching a Bovie pencil to the external end of the Astato wire, leaflet puncture was achieved by advancing the wire through the diseased leaflet during brief electrocautery application. The wire was then captured by the previously placed LVOT snare and externalized back out the same femoral access from which it was advanced. The long wire now created a loop through the base of the leaflet, with both ends externalized through the femoral sheath.

The externalized wire was then modified so that it could be used to lacerate the leaflet. To accomplish this, a 5 mm segment of externalized wire was denuded on one side with a scalpel and kinked over the back of the Scalpel blade to create a V with the denuded wire on the inside. This “flying V” was then re-advanced toward the valve until positioned at the base of the leaflet. Catheters were advanced along both ends of the wire all the way to the leaflet tip to provide insulation of the wire. With tension applied to both ends of wire during continuous electrocautery application, the flying V was used to lacerate the leaflet from base to tip. Subsequent TEE imaging demonstrated successful leaflet laceration with wide-open aortic regurgitation.

Now, with leaflet obstruction no longer a concern, TAVR was performed in the standard manner. The wire and attached catheters used for BASILICA were removed. Via the same access sheath, the valve was recrossed, and a wire deposited in the LV apex over which a 23 mm self-expanding Medtronic Evolut FX+ TAVR valve was advanced and deployed. Aortography demonstrated excellent valve positioning and function and no obstruction of flow into the left coronary artery. Post-dilation of the valve was performed to optimize expansion and eliminate a mild residual paravalvular leak.

At the completion of this procedure, all equipment was removed and the large bore access site closed percutaneously. Mrs. O was extubated in the operating room and after an uneventful recovery was discharged on postoperative day one. She experienced immediate and significant improvement in her heart failure symptoms and continues to do well today.

Clinical consult and patient referral

To refer a patient to Penn Medicine Doylestown Health Cardiology, please call the provider-only line at 215-345-1900 or submit via the secure online referral form.