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. 2019 Jul 8;12(13):1229-1237.
doi: 10.1016/j.jcin.2019.04.013.

Impact of Leaflet Laceration on Transcatheter Aortic Valve-in-Valve Washout: BASILICA to Solve Neosinus and Sinus Stasis

Hoda Hatoum  1 , Pablo Maureira  2 , Scott Lilly  3 , Lakshmi Prasad Dasi  4
Affiliations

Impact of Leaflet Laceration on Transcatheter Aortic Valve-in-Valve Washout: BASILICA to Solve Neosinus and Sinus Stasis

Hoda Hatoum et al. JACC Cardiovasc Interv. .

Abstract

Objectives: The aim of this study was to evaluate any potential leaflet washout benefits after bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction during TAVR (BASILICA) in transcatheter valve-in-valve (ViV) in the context of leaflet thrombosis.

Background: Leaflet thrombosis after transcatheter aortic valve replacement is secondary to flow stasis in both the sinus and neosinus. Strategies to improve washout and ameliorate neosinus and sinus flow velocities may have the potential to mitigate the occurrence of clinical and subclinical leaflet thrombosis.

Methods: A 23-mm Edwards SAPIEN 3 and a 26-mm Medtronic Evolut were deployed in a 23-mm transparent surgical aortic valve model before and after leaflet laceration. The valves were placed in the aortic position of a pulse duplicator flow loop. Particle image velocimetry was performed to quantify sinus flow hemodynamic status. A tracing fluorescent dye was injected to evaluate the number of cycles to washout in both regions of interest.

Results: The leaflet laceration procedure led to an increase in the velocities in the sinus and the neosinus by 50% for Evolut ViV and 61.9% for SAPIEN 3 ViV. In addition, leaflet laceration led to a reduction in overall cycles to washout in the neosinus by at least 56% with the Evolut and 54.5% with the SAPIEN 3 and in the sinus by at least 16.7% with the Evolut and 60.8% with the SAPIEN.

Conclusions: Leaflet laceration using a BASILICA-type approach may hold the potential to mitigate neosinus and sinus flow stasis. Controlled in vivo trials are necessary to establish the potential benefit of BASILICA to reduce the occurrence of leaflet thrombosis.

Keywords: BASILICA; TAVR; laceration; leaflet thrombosis; valve-in-valve; washout.

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Figures

Figure 1:
Figure 1:
Valve-in-Valve combination with Evolut and SAPIEN 3 TAVs. Valve-in-valve deployment in a transparent surgical valve model with (a) Evolut and (b) SAPIEN 3 pre-leaflet laceration and (c) Evolut and (d) SAPIEN 3 post-laceration.
Figure 2:
Figure 2:
Sinus and Neo-sinus washout curves obtained through integrating dye concentration throughout a number of cardiac cycles with Evolut and SAPIEN 3 before and after leaflet laceration. (a) Neo-sinus washout curves with dye injected from the neo-sinus; (b) sinus washout curves with dye injected from the neo-sinus; and (c) sinus washout curves with dye injected from the sinus. Bars in the figure correspond to standard deviations obtained over five different takes.
Figure 3:
Figure 3:
Number of cardiac cycles to washout in the sinus and the neo-sinus with Evolut and SAPIEN 3 TAVs before and after leaflet laceration. (a) Number of cycles to washout in the neo-sinus with dye injected from the neo-sinus; (b) number of cycles to washout in the sinus with dye injected from the neo-sinus; and (c) number of cycles to washout in the sinus with dye injected from the sinus. Bars in the figure correspond to standard deviations obtained over five different takes.
Figure 4:
Figure 4:
Sinus and neo-sinus hemodynamics shown in-vitro using particle image velocimetry. Flow velocity field for the Evolut ViV and the SAPIEN 3 ViV pre and post-laceration as indicated.
Figure 5:
Figure 5:
Improvement of the velocity in the neo-sinus after leaflet laceration. Probability distribution of the velocity magnitude in the neo-sinus with Evolut and SAPIEN 3 pre- and post-leaflet laceration.
See this image and copyright information in PMC

Comment in

  • Transcatheter Valves Get More Complicated.
    Webb JG, Hensey M. Webb JG, et al. JACC Cardiovasc Interv. 2019 Jul 8;12(13):1238-1239. doi: 10.1016/j.jcin.2019.05.007. JACC Cardiovasc Interv. 2019. PMID: 31272670 No abstract available.

References

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