A real-world comparison of two techniques aimed at reducing the risk of coronary obstruction after transcatheter aortic valve implantation (TAVI) has found that both chimney stenting and the BASILICA technique have similar efficacy and comparable one-year outcomes.
Findings of the analysis were presented during a late-breaking trial session at EuroPCR 2023 (16–19 May, Paris, France) by Antonio Mangieri (Humanitas Research Hospital, Milan, Italy) and included data from 168 patients undergoing TAVI with BASILICA or chimney stenting at 20 centres throughout Europe.
BASILICA is a technique performed prior to TAVI in which catheters and guidewires are used to first traverse, then lacerate, the aortic leaflet in front of the threatened coronary artery to preserve coronary perfusion. Chimney stenting, meanwhile, involves the deployment of a coronary stent extending from the proximal portion of a coronary artery cranially, exterior and parallel to the transcatheter valve. Both techniques are aimed at addressing acute coronary obstruction, which Mangieri described as a potentially life-threatening complication of TAVI, occurring in less than 1% of patients, but with an associated rate of mortality of up to 50%.
As part of their analysis, Mangieri and colleagues assessed 11 high-volume centres using the BASILICA technique comparing them to a cohort of consecutive patients using chimney stenting at nine centres. Researchers defined technical success as the successful performance of the chimney or BASILICA technique without clinically relevant ostial coronary obstruction, whilst the study’s primary endpoint was major adverse cardiovascular events (MACE), a composite of death, myocardial infarction (MI), stroke or unplanned target lesion coronary revascularisation at one year.
Of the 168 patients included in the study, 71 (42.3%) underwent chimney stenting and 97 (57.7%) underwent BASILICA. Rates of peri-procedural complications were similar between the two groups, Mangieri reported, and technical success was 98.5% and 96.9% in chimney and BASILICA groups respectively (p=0.48). Bailout stenting of the coronary ostia was performed in eight BASILICA procedures (8.2%), however.
Use of cerebral embolic protection devices was more common across BASILICA patients (1.4% vs. 91.8%, p<0.001), Mangieri detailed, and the rate of residual moderate paravalvular leak (PVL) was significantly higher in the chimney group (9.9% vs. 0%, p=0.002).
At one-year follow-up, the cumulative incidence of MACE was 18.7% (95% CI: 11-30.6%) in the chimney group and 19.9% (95% CI: 12.1-31.5%) in the BASILICA group (log-rank p=0.848), while chimney stenting was associated with a numerically higher cardiovascular mortality than BASILICA (6.7% vs. 1.3%, log-rank p=0.168).
The findings led Mangieri to conclude that both chimney stenting and BASILICA are valid techniques to prevent coronary obstruction in high-risk TAVI, with similar efficacy and comparable one-year outcomes.
BASILICA may reduce some complications related to ostial stenting, without excess stroke risk if performed under cerebral embolic protection, he concluded, adding that the study showed a signal towards higher cardiovascular mortality in patients undergoing chimney stenting, a finding that will need to be further investigated in larger scale clinical trials.