Obstruction of the coronary artery, which supplies oxygen-rich blood to the entire heart muscle, is a rare but potentially deadly complication of a minimally invasive procedure to replace the aortic valve, one of four valves that regulate blood flow through the heart.
Miami Cardiac & Vascular Institute has performed a new technique on a 65-year-old heart patient to prevent coronary artery obstruction during her “transcatheter aortic valve replacement” (TAVR). The pre-TAVR procedure, which goes by the acronym, BASILICA, has been performed only about 200 times in the world, and fewer than a dozen have been done in South Florida.
“We are a collaborative organization that is able to do innovative procedures for our patients and get them out of the hospital quickly so they can go back to their lives,” said Phillip Erwin, M.D., Ph.D., interventional cardiologist with the Miami Cardiac & Vascular Institute.
Dr. Erwin performed the first BASILICA procedure at the Institute this month with interventional cardiologist Bernardo Lopez-Sanabria, M.D., and Elliott Elias, M.D., a cardiologist with a focus on interventional echocardiography.
More Options for High-Risk Patients
BASILICA is performed immediately before TAVR to prevent obstruction of the coronary artery. It increases treatment options for high-risk patients who need heart valve procedures. (The BASILICA acronym refers to: Bioprosthetic Aortic Scallop Intentional Laceration to prevent Iatrogenic Coronary Artery obstruction.)
For elderly or frail patients, TAVR offers a less invasive alternative to open heart surgery. However, a small subset of these TAVR candidates may develop coronary artery obstruction during the TAVR procedure. For more than half of these patients, this complication has been fatal.
Many TAVR candidates need to have their aortic valves replaced a second time, after initially having gone through riskier open-heart surgery.
“Based on the CT scans before the procedure, we can predict that obstruction will happen in a subset that qualify for TAVR,” said Dr. Erwin. “And potential cases of coronary artery obstruction will be increasing because the lifespan of a surgical prosthesis (aortic valve replacement, or AVR) is about 10 years. And patients with surgical AVRs are living longer.”
To prevent coronary artery obstruction, the interventional cardiologist performing the BASILICA technique weaves an electrified wire the size of a sewing thread through a catheter and uses it to split the original leaflet in two. This prevents the blocking of the coronary artery once it has been pushed aside by the new transcatheter heart valve during TAVR.
Some patients who benefit from BASILICA have uncommon structures in the heart, such as unusually large aortic valve leaflets, or thin flaps of tissue. The large leaflets block the flow of blood to the coronary arteries as the new valve’s scaffolding opens.
‘A Chance to Live a Full Life’
The 65 year-old woman who successfully underwent the BASILICA procedure, followed by TAVR, had surgical aortic valve replacement about 10 years ago. She is a grandmother and leads and an active life, but she was having difficulty completing her daily activities because of shortness of breath.
“The problem was that her prosthetic valve (surgically implanted 10 years ago) was very close to the openings of her coronary arteries,” explains Dr. Erwin.
There was another unique issue. The patient’s religious belief did not allow for the acceptance of blood products, says Dr. Erwin. Her initial open-heart surgery a decade earlier did not require blood infusions, he added.
The BASILICA procedure and the TAVR performed on the patient were successful and she went home the next day. She was even walking around a couple of hours after procedures, he said.
“You could say that her aortic valve ran out of its warranty, and then we also had to fix the issue that her valve was already too small,” says Dr. Erwin. “This gives a vibrant young woman in her sixties a chance to live a full life and be active with her grandchildren.”