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
2021; Elsevier BV; Volume: 34; Issue: 6 Linguagem: Inglês
10.1016/j.echo.2021.01.015
ISSN1097-6795
AutoresVolodymyr Protsyk, Massimiliano Meineri, Mitsunobu Kitamura, Anna Flo Forner, David Holzhey, Hölger Thiele, G. Burkhard Mackensen, Danny Dvir, Mohamed Abdel‐Wahab, Jöerg Ender,
Tópico(s)Cardiac Structural Anomalies and Repair
Resumo•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 gradients, effective orifice area, and paravalvular regurgitation check. Check MV for regurgitation. Exclusion of aortic dissection or hematoma.Ao, Aorta; AR, aortic regurgitation; asc/desc, ascending/descending; CH, chamber; CWD, continuous-wave Doppler; LVEF, LV ejection fraction; MV, mitral valve; PWD, pulsed-wave Doppler; RV, right ventricle; TG, transgastric; TV, tricuspid valve. Open table in a new tab Ao, Aorta; AR, aortic regurgitation; asc/desc, ascending/descending; CH, chamber; CWD, continuous-wave Doppler; LVEF, LV ejection fraction; MV, mitral valve; PWD, pulsed-wave Doppler; RV, right ventricle; TG, transgastric; TV, tricuspid valve. Two perpendicular fluoroscopic projections (side and front cusp view) are usually predetermined based on preprocedural CT to guide correct catheter placement. The side view allows positioning of the catheter in the correct coronary cusp and choosing its proper direction toward the aortic leaflet/LVOT (attack angle). The front view allows the alignment of the catheter in the center of the leaflet. These projections are not always easily obtainable and could be impossible in certain anatomies due to extreme fluoroscopic angulations, particularly the front view of the left cusp and the side view of the right cusp.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 Navigation of valve anatomy can be even more challenging on fluoroscopy in the presence of native, stentless, or transcatheter valves,10Abdel-Wahab M. Kitamura M. Krieghoff C. Lauten P. Komatsu I. Thiele H. et al.BASILICA for a degenerated self-expanding transcatheter heart valve: structural considerations for supra-annular prosthetic leaflets.JACC Cardiovasc Interv. 2020; 13: 778-781Crossref PubMed Scopus (3) Google Scholar as commissural markers are absent, and TEE is particularly beneficial in these situations. Multiplanar TEE allows simultaneous display of the precise traversal catheter's position, its attack angle, and coronary ostium alignment. This permits the operator to reduce the number of changes among various fluoroscopic projections. In a case where the coronary ostium is not aligned with the center of the leaflet (ostial eccentricity) combined with a deficient sinus of Valsalva (VIVID classification Type IIB and IIIB),11Tang G.H.L. Komatsu I. Tzemach L. Simonato M. Wolak A. Blanke P. et al.Assessing the risk for coronary obstruction after transcatheter aortic valve implantation and the need to perform BASILICA: the VIVID classification.EuroIntervention. 2020; https://doi.org/10.4244/EIJ-D-20-00067Crossref Google Scholar leaflet laceration might be performed opposite to the ostium location instead of along the leaflet center.12Komatsu I. Wijeysandera H. Radharkrisnan S. Whisenant B. Simonato M. Chen A. et al.Technical considerations and pitfalls of BASILICA: bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction.Structural Heart. 2020; : 1-10Google Scholar This could be a major challenge for fluoroscopic guidance given the two fixed perpendicular planes, while TEE allows easier continuous imaging for catheter guidance independent of the location and alignment of coronary ostia. Ostial eccentricity is more common for the right coronary cusp, especially in native AVs.13Komatsu I. Leipsic J. Webb J.G. Blanke P. Mackensen G.B. Don C.W. et al.Coronary ostial eccentricity in severe aortic stenosis: guidance for BASILICA transcatheter leaflet laceration.J Cardiovasc Comput Tomogr. 2020; 14: 516-519Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar Due to restrictions in achievable fluoroscopic projection angles, TEE is even more valuable in cases of BASILICA for the right coronary cusp. Visualization of the snaring system positioned through the valve is feasible in the midesophageal (ME) AV long-axis (LAX) view using multiplane imaging simultaneously displaying two orthogonal imaging planes on the screen (Figure 2A, Video 2). Slight deviations from the classic views by minute left or right turning of the TEE probe or by adjustments of the rotation angle may be needed to obtain the LAX view of the catheter and wire on the left image. The orthogonal cutting plane is set at the level of the AV to show the position of the MP catheter inside the valve in the resulting short-axis (SAX) view on the right side of the screen. This SAX view represents a mirror image of the standard ME AV SAX view and can be optionally corrected on the machine by inverting left to right. The MP catheter is straight, and its double outline pattern disappears as an anchor wire is advanced through the catheter. The hyperechoic anchor wire reaches the LV cavity with its curved end. The position of the anchor wire in the LV can be controlled in the ME LAX view (Figure 2B, Video 2). Clear visualization of the snare below the AV is usually not easy from the ME probe position but can be achieved when device orientation and anatomic conditions are favorable (Figure 2C). The correctly placed traversal catheter should be located with its tip at the nadir of the leaflet right in front of the coronary ostium. The alignment with the coronary ostium is crucial in case of ostial eccentricity and a very small sinus of Valsalva. This part of the BASILICA procedure appears to be the rate-limiting step. We recommend TEE imaging of traversal catheter placement again using ME AV LAX and multiplane mode with optional inversion of the right-sided image. As the catheter advances in the target sinus, it should be displayed in its LAX on the main left view of the multiplane mode. Alignment with the catheter is easily achieved with slight turning of the probe and adjustment of rotation angle. The traversal catheter has a curved shape, and hence it is rarely possible to get its entire course visualized in the same plane, especially when left cusp laceration is planned. Therefore, the distal portion of the catheter pointing to the AV leaflet should certainly be seen (Figure 3A, Video 3). The position of the catheter's tip is then identified on the right SAX view of the multiplane mode (using an inverted image) by setting the tilt plane cutting through the tip on the LAX view. In the SAX view, the catheter tip should be positioned in front of and proximal to the coronary ostium (Figure 3B, Video 3). If the catheter is repositioned, it can be easily displayed again through slight turning of the TEE probe in the needed direction. Malposition of the catheter can be revealed with TEE also using multiplane imaging (Figure 4).Figure 4Malposition of the traversal catheter. Malposition of the traversal catheter (A) between the aortic wall and the Mitroflow valve ring, (B) in the left/right commissure of the Trifecta valve and (C) outside of the Corevalve stent frame.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Control of the catheter's tip attack angle (direction toward the aortic leaflet/LVOT) in the LAX view is important to prevent catheter deviations and incidental penetration into adjacent structures such as the left atrium, right ventricle, and so on. The traversal vector must be directed toward the LVOT and aligned with its axis (Figure 5). After confirmation of the correct placement of the traversal system in the ME AV LAX multiplane view, the leaflet is punctured using guide wire electrification. While applying current to the wire, the aortic root instantly fills with "bubbles" caused by heat-induced evaporation, and the moment of traversal may not be clearly displayed with TEE (Figure 6, Video 4). Importantly, leaflet traversal can be visually confirmed only by TEE by displaying the target leaflet pierced with the traversal wire in the ME AV LAX view with optional zoom. In contrast to the anchor wire that lies in the LV apex, the traversal wire tip remains in the LVOT (Figure 7A and B, Video 5).Figure 7Control of leaflet traversal. (A) Correct traversal at the nadir of the left coronary cusp (see also Video 5). (B) Correct traversal at the nadir of the right coronary cusp. (C) Incorrect traversal of the left coronary cusp into the left atrium through the aortomitral curtain (see also Video 6). AML, Anterior mitral leaflet; Ao, aorta; LA, left atrium; LCC, left coronary cusp; RV, right ventricle.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Transesophageal echocardiography provides essential information on the precise location of the traversal wire, and unintended penetration into adjacent cardiac structures such as the left atrium or the interventricular septum (that cannot be easily detected on fluoroscopic imaging) should be excluded before snaring is attempted (Figure 7C, Video 6). This may potentially avoid serious complications. In addition, failed wire traversal can result in aortic root injury if the electrified wire buckles inside the aortic root, and this rare but serious complication should also be excluded by TEE if wire traversal is not successful (Figure 8). Importantly, snaring of the traversal wire is difficult to detect by TEE due to the large amount of reverberation artifacts arising from the adjacent catheters and wires. After the traversal wire is snared (Figure 9) and retrieved into the MP catheter, the mitral valve must be assessed in the ME LAX view for regurgitation secondary to accidental chordal entrapment. Chordal entrapment may happen when the traversal wire is snared too low in the LVOT or LV.12Komatsu I. Wijeysandera H. Radharkrisnan S. Whisenant B. Simonato M. Chen A. et al.Technical considerations and pitfalls of BASILICA: bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction.Structural Heart. 2020; : 1-10Google Scholar If snaring attempts repeatedly fail, the correct position of the traversal wire needs to be rechecked on TEE. After successful snaring, the lacerating part of the wire ("flying V") is delivered through the traversal catheter to the place of laceration. The V should ideally be positioned radially to assure proper laceration from base to tip of the leaflet: one part of the V (coming from the traversal catheter) is oriented along the aortic side of the leaflet, and the other part (coming from the MP catheter) is oriented along the ventricular side as centrally as possible, avoiding enclosed commissures (Figure 10). Otherwise, the laceration may be performed asymmetrically with residual risk of ostial coronary obstruction.Figure 10Optimal position of the flying V before laceration. (A) ME AV SAX view showing the MP and traversal catheters after delivery of the flying V. Catheters are positioned radially in relation to the AV orifice and can be displayed orthogonally only with two different tilt planes 1 and 2. (B) Suboptimally placed flying V with the MP catheter situated in the left/right commissure, which carries a risk of asymmetrical laceration. The orthogonal tilt plane displays two catheters forming a V shape simultaneously. LCA, Left coronary artery; MP, MP catheter; TC, traversal catheter.View Large Image Figure ViewerDownload Hi-res image Download (PPT) In the moment of laceration, the aorta fills again with bubbles on TEE. As both catheters are retracted, they disappear from the image, while the LV pigtail catheter can still be seen. Accidental dislodgment of the pigtail catheter (which is placed before the laceration to allow quick THV deployment) should be immediately communicated to the interventionalist. In cases with relevant preexisting aortic insufficiency, the new acute severe regurgitation is usually well tolerated. Patients without preexisting aortic regurgitation and a low heart rate can become unstable after leaflet laceration, but overpacing with the temporary pacemaker in addition to inotropic and/or vasopressor support is usually sufficient to maintain arterial pressure in this relatively short phase preceding THV implantation. Color flow Doppler (CFD) analysis of the AV in the ME AV LAX view allows estimation of the degree of acute aortic insufficiency (Figure 11, Video 7). The laceration is then further displayed by switching to the ME AV SAX view with optional activation of image zoom (Figure 12A and B, Videos 8 and 9). Ideally, laceration should be oriented radially and reach the bottom of the leaflet. Asymmetrical laceration (Figure 12C–E, Video 10) may still contribute to obstruction of the coronary ostia after TAVR and should therefore be communicated to potentially allow for other preventive maneuvers, such as provisional placement of a coronary stent.Figure 12Assessment of the lacerated bioprosthetic leaflet. Midesophageal SAX view showing (A) properly positioned leaflet defect in front of left coronary ostium (see also Video 8); (B) regurgitation jet originating from the defect (see also Video 9); (C-E) laceration becomes distinctly asymmetric when displayed from base of the leaflet (C) to its tip (E) (see also Video 10).View Large Image Figure ViewerDownload Hi-res image Download (PPT) Transcatheter aortic valve replacement is performed immediately after leaflet laceration. The post-TAVR examination should start by demonstrating maintained perfusion in both coronary arteries in the ME AV SAX view with CFD and reduced Nyquist limit (25-30 cm/sec). New left and right ventricular wall motion abnormalities should be ruled out in the ME four-chamber, two-chamber, and transgastric SAX views. Ostial coronary obstruction can still occur in case of suboptimal leaflet laceration and/or if a THV commissure aligns with the laceration line after implantation. Obstruction of a coronary ostium not targeted by BASILICA can also unexpectedly happen in case of suboptimal axial THV canting in the aortic root.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 In addition, partial leaflet prolapse into the coronary ostium may occur without causing immediate clinical or hemodynamic consequences (Figure 13, Video 11).14Kitamura M. Pighi M. Ribichini F. Abdel-Wahab M. Leaflet prolapse after BASILICA and transcatheter aortic valve replacement.JACC Cardiovasc Interv. 2020; 13: e143-e145Crossref PubMed Scopus (3) Google Scholar The latter information is of particular relevance as it is often missed on aortic root angiography and would need a selective coronary angiogram. The aortic prosthesis should then be checked for gradients and paravalvular regurgitation as usual. Finally, the ascending and descending aorta should be rechecked to exclude dissection or hematoma formation. The possible BASILICA-related complications that can be detected with TEE are listed in Table 3.Table 3Possible BASILICA-related complications detectable in TEEComplicationEtiologyPreventionPericardial effusionPenetration of cardiac chambers/aortic wall with stiff wires.Control of wire position.Penetration of cardiac chambers/aortic wall with electrified guide wire.Assure the position of traversal catheter at the aortic leaflet and its proper attack angle before traversal.Intracardiac shuntsTraversal into adjacent chambers/structures with electrified guide wire.Assure the position of traversal catheter at the aortic leaflet and its proper attack angle before traversal.Aortic dissectionInjury of aortic wall with buckled electrified guide wire during failed traversal (applying current too long combined with too much pressure on the wire).Partially: Confirm proper position of traversal catheter at the aortic leaflet and absence of heavy calcifications.Mitral regurgitationTear of chordae of mitral valve during snaring/laceration.Assure the position of the snare not too low in LVOT. Check for mitral regurgitation after wire snaring/before laceration.Acute heart failureOstial coronary obstruction with a part of lacerated leaflet.Assure alignment of the tip of the traversal catheter with the coronary ostium before traversal.Confirm symmetrical or ostially aligned lacerationAlignment of THV commissure with the laceration line.Not possible, not directly detectable.Partial leaflet prolapse into the coronary ostiumAsymmetrical or not ostially aligned laceration. Incidence may be higher in native and stentless valves.Assure alignment of the tip of the traversal catheter with the coronary ostium before traversal. Confirm symmetrical or ostially aligned laceration. Open table in a new tab Three-dimensional echocardiography showed its utility in guiding BASILICA for a native AV15Tang G.H.L. Lerakis S. Kini A. Khan J.M. Kovacic J.C. 4-Dimensional transesophageal echocardiographic guidance during TAVR with BASILICA.JACC Cardiovasc Imaging. 2020; 13: 1601-1614Crossref PubMed Scopus (1) Google Scholar; however, it remains of limited value in cases where overall 2D image quality is compromised by acoustic shadowing or other artifacts (e.g., prosthetic or heavily calcified valves). In our opinion, BASILICA cannot be generally guided by live 3D (as the mitral valve edge-to-edge procedure, for example) because of unfavorable imaging quality in most of the patients. Often, only a narrow ultrasound window is available to sufficiently visualize the aortic cusps in two dimensions, which limits the possibility of continuous maintenance of that window while operating the live 3D image. The precise location of the traversal catheter's tip (which is probably the most needed information during BASILICA) can be, in our opinion, more easily obtained with 2D simultaneous multiplane imaging as described previously rather than with live 3D imaging. Nevertheless, when the imaging conditions are favorable (absence of calcium, presence of native/stentless/transcatheter valve), 3D imaging could be valuable for different diagnostic questions, such as the evaluation of sinus anatomy and ostial eccentricity, catheter alignment with the coronary ostium, confirmation of proper leaflet traversal, and confirmation of successful laceration (Figure 14). When displaying an aortic root in SAX in live 3D, the image detail can be increased by adapting an elevation width of the 3D volume to the required minimum. This allows uncovering the origin of the coronary artery while still focusing on desired objects. Available image-fusion technologies might be further considered for evaluation in BASILICA procedures.16Brouwer J. ten Berg J.M. Rensing B.J.W.M. Swaans M.J. First use of futuristic image fusion technology during transcatheter aortic valve replacement.JACC Cardiovasc Interv. 2019; 12: 2223-2224Crossref PubMed Scopus (3) Google Scholar During BASILICA, TEE provides valuable real-time imaging information that facilitates accurate and fast positioning of devices. In combination with fluoroscopy, possible complications might be quickly identified and prevented. Understanding the procedural steps is key for the echocardiographer to effectively communicate with all heart team members. Two-dimensional and simultaneous multiplane echocardiography seem to be reliable and effective in guiding BASILICA even in calcified or stented prosthetic AVs when acoustic shadowing limits the quality of leaflet imaging. Fusion imaging may further enhance the benefits of combining TEE and fluoroscopy for BASILICA guidance.
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