First patient treated with BASILICA before valve-in-valve TAVR in a mechanically-expanded valve
A heart team has made a bit of history, performing BASILICA before valve-in-valve transcatheter aortic valve replacement (TAVR) in a mechanically-expanded Lotus transcatheter heart valve (THV) for what is believed to be the very first time.
The group shared its first-in-human analysis in JACC: Case Reports, an American College of Cardiology journal.[1]
During BASILICA procedures, catheters and guidewires are used to intentionally lacerate the aortic leaflet in a way that preserves coronary perfusion. BASILICA is already known to be safe and effective when performed immediately before TAVR, helping the care team limit the risk of obstruction, but less was known its use before valve-in-valve TAVR due to a degenerated Lotus valve.
“Valve-in-valve TAVR inside a degenerated Lotus THV has previously been successful using both self-expanding and balloon-expandable THVs,” wrote first author Ahmed Ghoneem, MD, with the department of cardiovascular medicine at the University of Pittsburgh Medical Center in Harrisburg, and colleagues. “However, BASILICA to modify the Lotus leaflets has only been reported in benchtop models. To the best of our knowledge, this is the first reported experience of successful BASILICA to prevent coronary obstruction before valve-in-valve TAVR inside a Lotus valve.”
Because Boston Scientific’s Lotus THVs are mechanically-expanded devices as opposed to self-expanding or balloon-expandable devices, the authors added, it made the case even more complex than it would have been otherwise.
Ghoneem et al. shared the story of a 79-year-old female patient with a degenerated 23 mm Lotus THV. The valve was not properly aligned, resulting in a high risk of sinus sequestration. Valve-in-valve was seen as the only therapeutic option, and the group performed BASILICA to lacerate the leaflet and allow more blood flow. Balloon inflation could have potentially interfered with the Lotus valve, so the group implanted a self-expanding Evolut FX THV from Medtronic into the patient’s failed valve.
The BASILICA procedure was complex, in part due to the fact that the fluoroscopic projections required were “unattainable” due to the Lotus valve’s frame. The group settled for “compromise” or “near” angles in addition to transesophageal echocardiogram (TEE) guidance.
Another early challenge involved the “complex angles and position of the right coronary artery ostium near the post of the Lotus,” but the group used a series of catheters and wires to complete the BASILICA with no complications. The results of the procedure were confirmed using TEE images, and then they were able to proceed with the valve-in-valve TAVR.
“The patient was seen in follow-up at two and six weeks after her procedure,” the authors wrote. “She reported significant improvement in her level of activity, with minimal shortness of breath. A repeat echocardiogram revealed an improved ejection fraction to 40% and a mean gradient of 10 mmHg across the TAVR valve.”
A sign of things to come?
The group concluded by noting the Lotus THV has been a bit of an “orphan valve” since being discontinued. Through this case, however, they believe they have shown that BASILICA is feasible.
“With more patients outliving their TAVR valves and valve-in-valve TAVR becoming more required, leaflet modification procedures will need to be performed at more structural programs,” they wrote. “Dedicated leaflet modification devices (currently in development) may help overcome some of the challenges highlighted in this case and democratize leaflet modification in the future.”
Michael has more than 19 years of experience as a professional writer and editor. He has written at length about cardiology, radiology, artificial intelligence and other key healthcare topics.