Chordal-Zone Free Externalization of Retrograde Wire to Facilitate BASILICA and Transcatheter Electrosurgical Procedures

While Bioprosthetic or Native Aortic Scallop Intentional Laceration to Prevent Iatrogenic Coronary Artery Obstruction (BASILICA) technique is effective for preventing coronary obstruction, challenges with left ventricular outflow tract (LVOT) snaring of the traversal wire and chordal entrapment risk may occur. We describe the Chordal-zone Free Externalization of Retrograde Wire (CLEAR) technique in three patients undergoing valve-in-valve transcatheter aortic valve replacement with BASILICA. After leaflet traversal, a steerable microcatheter positioned below the aortic valve directed the wire retrogradely from the LVOT to the aortic root for snaring, avoiding deep LVOT penetration. All procedures were successful with no coronary obstruction. In one case, chordal entrapment was detected and corrected without the need for LVOT re-entry. The CLEAR technique simplifies wire externalization, reduces chordal entrapment risk, and allows easier adjustment if snaring fails. This initial experience demonstrates CLEAR technique is feasible and safe when integrated in BASILICA procedure.