Modified Guide Anchoring "UNICORN" Technique for Valve-in-Valve TAVI: Navigating Hostile Anatomy With Leaflet Laceration.

BACKGROUND

Sutureless bioprostheses present unique challenges for valve-in-valve (ViV) transcatheter aortic valve implantation due to their frame architecture and proximity to coronary ostia.

CASE SUMMARY: A 71-year-old woman with a failing Perceval valve with high-risk coronary anatomy precluding chimney stenting and Bioprosthetic Aortic Scallop Intentional Laceration to prevent Iatrogenic Coronary Artery obstruction. Leaflet traversal of the right coronary cusp was achieved through an MPA1 guide. The guide was advanced across the bioprosthetic frame into the left ventricle immediately post-traversal to secure position. This facilitated wire exchange and leaflet laceration. A balloon-expandable valve was then successfully implanted.

DISCUSSION: Unlike stented valves, the sutureless valve crown creates a mechanical trap. Its 1-mm clearance precluded chimney stenting due to sandwich compression risk, whereas effaced sinuses prevented Bioprosthetic Aortic Scallop Intentional Laceration to prevent Iatrogenic Coronary Artery obstruction leaflet splaying. The modified UNICORN guide anchoring maneuver bypassed these hurdles, securing the ventricle to facilitate stable, efficient mechanical modification in no-option anatomy.

TAKE-HOME MESSAGE: Guide anchoring provides a shorter blueprint for complex scenarios by securing ventricular access and enabling mechanical laceration.