Risk of leaflet avulsion after UNICORN leaflet modification

Multiple coronary protection strategies have been described to reduce the risk of coronary obstruction during redo-transcatheter aortic valve implantation (redo-TAVI). However, their effectiveness can be limited by anatomical or valve-related factors12. The Undermining Iatrogenic Coronary Obstruction with Radiofrequency Needle (UNICORN) leaflet modification technique offers a potentially attractive approach during redo-TAVI, as it allows for greater clearance of the obstructing leaflet3. Nonetheless, we highlight an important consideration regarding the safety and efficacy of the UNICORN technique in this context.

A 78-year-old male was planned for redo-TAVI to address a severely regurgitant and degenerated ACURATE neo2 valve (ACn2; Boston Scientific). Preprocedural computed tomography (CT) revealed the left coronary artery (LCA) to be at high risk for coronary obstruction, with the neoskirt plane for a SAPIEN 3 (S3; Edwards Lifesciences) extending above the coronary risk plane and a valve-to-aorta distance of less than 2 mm. Given the good commissural alignment of the index ACn2, leaflet modification with UNICORN was planned to mitigate the risk of coronary obstruction.

The procedure involved using a 7 Fr Amplatz left (AL) 3 guide catheter, a FineCross...