Balloon-assisted bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction with en face view for patients exhibiting severe calcified leaflet: a case report.

Background: Balloon-assisted bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction (BA-BASILICA) enables valve-in-valve transcatheter aortic valve implantation (ViV-TAVI) in patients at risk of coronary artery obstruction. However, its efficacy in patients with severely calcified leaflets remains unclear.

Case summary: We report a 78-year-old woman with a deteriorated 21 mm Carpentier-Edwards PERIMOUNT Magna valve. Computed tomography showed severe calcification in the left coronary leaflet, extending above the left coronary artery (LCA) ostium, with a virtual transcatheter heart valve to coronary ostium distance of 3.7 mm, indicating a high risk of coronary obstruction after ViV-TAVI. We performed ViV-TAVI using the BA-BASILICA because of the patient's high surgical risks. Traversal of the calcified leaflet was successfully achieved using both en face and side views to visualize the traversal system's position in an area without calcification and in front of the LCA. After traversal, the leaflet was dilated with a balloon and accidentally split into two. A 20 mm SAPIEN 3 Ultra RESILIA valve was deployed. Despite initial procedural success, severe LCA stenosis developed due to leaflet compression. This was resolved by orthotopic stenting using an en face view to identify cells not covered by the bioprosthetic leaflet generated by BA-BASILICA.

Discussion: To our knowledge, this is the first report of ViV-TAVI using the BA-BASILICA with an en face view of severely calcified leaflets. This case suggests that BA-BASILICA with an en face view could be effective for patients at high risk of coronary obstruction with severely calcified leaflets.