Do Not BASILICA the New Valve

Bioprosthetic or native Aortic Scallop Intentional Laceration to prevent Iatrogenic Coronary Artery obstruction (BASILICA) is currently the standard technique for leaflet modification in transcatheter aortic valve replacement to overcome coronary obstruction. The technique involves traversal of the coronary cusp with a 0.014-inch coronary wire, snaring the wire, and then lacerating the leaflet with a denuded portion of the wire known as the flying V. The procedure requires careful planning and technical expertise. We report a new complication of BASILICA where prepositioning of a transcatheter heart valve (THV) before laceration accidentally damaged the THV.

This complication originates from the inadvertent crossing of the straight-tip wire between the flying V and the aortic cusp when the flying V was not well apposed to the cusp. Prepositioning of the THV has become a variation of the procedure for patients with a high perceived risk of hemodynamic instability after BASILICA. This backfired, resulting in a complicated procedure.

The exact position of the 0.014-inch wire and flying V might be difficult to visualize in patients with a large body habitus. Operators should check that the flying V is at the cusp level before crossing the aortic valve with a wire. During the initial delivery of the flying V to the cusp, care should be taken to avoid losing the wire in the guide. Multicenter data of BASILICA show that hemodynamic instability is uncommon in single-leaflet lacerations. Therefore, prepositioning of a THV before leaflet laceration is usually unnecessary and requires strong clinical justification if pursued TAKE-HOME MESSAGES: BASILICA is a complex procedure. Operator familiarity with potential pitfalls and appropriate bailout methods are necessary. Operators should ensure that the flying V is well apposed to the leaflet before crossing into the left ventricle with a wire to prepare for valve deployment.