Coronary ostial eccentricity in severe aortic stenosis: Guidance for BASILICA transcatheter leaflet laceration

Background: Eccentricity of coronary ostial positions in relation to the aortic valve cusp may influence the target laceration location in BASILICA (Bioprosthetic or native Aortic Scallop Intentional Laceration to prevent Coronary Artery obstruction). Eccentricity of the coronary ostia in relation to coronary cusps of native and valve in-valve transcatheter aortic valve replacement (TAVR) was not well described before. Methods: A total of 121 pre-TAVR patients' CT data (72 native valves TAVR and 49 bioprosthetic surgical valves TAVR) was included and coronary ostial eccentricity angles were measured and compared. Coronary ostial angles were measured between mid-cusp line to coronary ostium in CT perpendicular images. Results: In the overall cohort, the right coronary artery (RCA) had an eccentric origin in the majority of cases, favoring the commissure between the right and the non coronary cusp (17.0 degrees, IQR; 10-25). On the other hand, the left coronary artery (LCA) originated most commonly near center of the cusp position (0 degrees, IQR;-8-7.5) In comparison of native and bioprosthetic valves, RCA ostial angles were more eccentric in native valves (19.0 degrees, IQR; 12-26) than in bioprosthetic valves (14.0 degrees, IQR; 3-20) (p = 0.004). Whereas, LCA ostial angle has no significant differences between native valves (-2.0 degrees, IQR;-7.75-5.75) and bioprosthetic valves (1 degrees, IQR;-8-13), (p = 0.6). Conclusion: RCA ostia often have an eccentric origin towards the non-coronary cusp, especially in native aortic valves, while LCA ostia commonly originate near the center of the cusp. This finding may contribute to better performance of BASILICA procedures.