Temple Health team reports complex structural heart case utilizing BASILICA technique and mechanical circulatory support

Physicians at the Temple Heart & Vascular Institute recently reported a highly complex structural heart case demonstrating advanced procedural planning, multi-leaflet BASILICA technique, and rapid escalation to mechanical circulatory support in a patient with prohibitive coronary obstruction risk undergoing transcatheter aortic valve replacement (TAVR).

The case was led by Temple cardiovascular surgeon Suyog Mokashi, MD, MBA, Temple cardiologists Timothy Cashman, MD, PhD, Pravin Patil, MD, and Brian O’Murchu, MD, as well as Nishant Sethi, MD, of Commonwealth Health Physicians Network. It describes the use of a multi-leaflet BASILICA (Bioprosthetic or Native Aortic Scallop Intentional Laceration) technique to mitigate the risk of coronary obstruction in a patient with a small aortic annulus and high-risk anatomy.

Managing Coronary Obstruction Risk in TAVR

An 86-year-old patient with prior surgical aortic valve replacement, severe aortic insufficiency, and critically short valve-to-coronary distances was referred to Temple Health after being declined for intervention at two high-volume centers.

Given the patient’s anatomy and comorbidities, the Temple team pursued a double BASILICA approach, intentionally lacerating both the left and right prosthetic valve leaflets prior to deployment of a transcatheter valve. This strategy was selected to preserve coronary flow in the setting of high obstruction risk.

Despite these precautions, the patient developed acute left coronary artery obstruction immediately following valve deployment, resulting in cardiac arrest.

Rapid Escalation to Advanced Mechanical Circulatory Support

The team initiated venoarterial extracorporeal membrane oxygenation (ECMO) emergently and performed coronary intervention to restore flow. For ongoing hemodynamic support and left ventricular unloading, an Impella CP device was subsequently placed, establishing an ECPELLA strategy.

With immediate multidisciplinary coordination across structural heart intervention, cardiac surgery, advanced heart failure, perfusion, critical care, and imaging teams:

• Coronary flow was restored
• Ventricular function improved
• Mechanical support was successfully weaned

The patient ultimately recovered and was discharged to rehabilitation, later returning to independent living.

Technical Insights: Valve Positioning and Coronary Flow

Post-procedural analysis suggested that high valve deployment may have contributed to coronary obstruction, with the prosthetic valve skirt positioned in front of the splayed leaflet despite BASILICA.

This case reinforces several key considerations for physicians:

• Coronary height and valve-to-coronary distance remain critical determinants of risk
• Even with BASILICA, valve positioning is essential to preserve coronary perfusion
• Complex anatomy may require immediate access to mechanical circulatory support

This case at Temple Health demonstrates how advanced structural heart expertise, multidisciplinary procedural planning, and immediate access to complex hemodynamic support strategies can expand treatment options for patients previously considered inoperable or declined elsewhere.

Read the publication in JACC: Cardiovascular Intervention.