Practical Approach to Transcatheter Aortic Valve Implantation and Bioprosthetic Valve Fracture in a Failed Bioprosthetic Surgical Valve

Figure 5

Coronary protection using chimney stenting (a–c) or BASILICA (d, e). (a) An 83-year-old male patient underwent transfemoral ViV-TAVI because of severe aortic regurgitation in a bioprosthetic valve of unknown type. Because of low coronary height, shallow sinuses, VTC 1 mm, and advanced age, coronary protection was obtained with a wire, 6 F GuideLiner, and unexpanded stent in the LAD (red arrowhead). Device malposition of a 25 mm Navitor valve occurred, resulting in severe aortic regurgitation (yellow arrowhead). (b) A second Navitor 25 mm valve was implanted with a good result (double layer of markers of the Navitor valve, yellow arrowhead). (c) Chimney stenting was performed using a Synergy Megatron 4.0 × 20 mm DES with kissing balloon inflation with 6.0 × 20 mm Emerge NC (yellow arrowhead) and 22 mm True balloon (red arrowhead). (d) A 63-year-old female patient underwent transfemoral ViV-TAVI in a 21 mm Trifecta valve. Because of low right coronary ostium (10 mm), VTC of 3 mm, shallow sinuses, and externally mounted leaflets, the right coronary was protected with a wire (yellow arrowhead) and 6 F GuideLiner (temporarily retracted in the 6 F guiding catheter). Because of the young age, a BASILICA procedure was performed upfront (red arrowhead, set up before leaflet laceration with an 8 F traversal MP1 guiding catheter with Astato XS 20 wire inside the PiggyBack wire converter and snared Astato wire inside a 6 F MP guiding catheter). (e) Haziness at the right coronary ostium after successful implantation of a Navitor 23 mm valve 4 mm below the fluoroscopic ring. (f) IVUS showing a nice opening at the level of the right coronary ostium towards the aorta (yellow arrowheads) BASILICA: bioprosthetic aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction; IVUS: intracoronary vascular ultrasound; DES: drug-eluting stent; VTC: virtual transcatheter to coronary distance.

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