Limited-Access Zero-Contrast BASILICA Transcatheter Aortic Valve Replacement

Abstract

Objective: Severe anaphylactic reactions to intra-arterial contrast agents, access site limitations, and high-risk coronary artery occlusion may all possibly prohibit the success of a transcatheter aortic valve replacement (TAVR). We describe a case including all 3 of these components and demonstrate the importance of multimodality imaging, including computed tomography (CT), fluoroscopy, and trans-esophageal echocardiography (TEE).

Key steps: 1) Obtain orthogonal BASILICA angle from CT. 2) Set up a single femoral access for BASILICA and subsequent TAVR. 3) Place a coronary wire with the radial opaque part at the noncoronary cusp (NCC) from an ulnar artery. 4) Perform TEE with fluoroscopic guidance on BASILICA without intra-arterial contrast agent. 5) Use coronary wire as a marker at the NCC to facilitate TAVR deployment.

Potential pitfalls: A single wire at cusp level minimizes the need to use a multiple pigtail technique. In general, cerebral protection devices are commonly used in leaflet modification procedures such as BASILICA to reduce stroke risk. In view of limited access, it was not feasible in this case to use them. Despite no intra-arterial contrast being used, pre-TAVR CT still requires an intravenous contrast agent for CT planning.

Take-home message: In a case of limited access, high coronary occlusive risk, and anaphylactic reaction to contrast agents, a limited-access zero-contrast agent BASILICA TAVR is a feasible approach with the use of multimodality imaging.

Keywords: BASILICA; noncoronary cusp; single access; transcatheter aortic valve replacement; transesophageal echocardiogram.