Aortic Valve Leaflet Modification: A Working Group Position Statement on Best Practices and Step-by-Step Guide.

Coronary artery obstruction is a potential life-threatening complication of transcatheter aortic valve replacement (TAVR) in all settings including native, valve-in-valve, and redo-TAVR. Risk of obstruction can be identified on preprocedural computed tomography. BASILICA (bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction) effectively prevents TAVR-induced coronary obstruction. Perceived technical complexity, limited availability of purpose-built devices, and scarce training opportunities have hindered the adoption of BASILICA and related techniques. This document synthesizes international experience to provide contemporary best-practice guidance for BASILICA and related leaflet modification strategies. This state-of-the-art review details transcatheter electrosurgery principles; how to determine risk and computed tomographic risk analysis and plan the procedures; a step-by-step guide to electrosurgical BASILICA; tips and tricks for uncommon challenges; scenarios in which BASILICA is unlikely to succeed; and variant techniques such as intraleaflet valve deployment, alternative measures, and dedicated devices. These contemporary best practices can help operators gain or maintain proficiency.