The Chordal-Zone Free Externalization of Retrograde Wire (CLEAR) Procedure to Facilitate BASILICA and Transcatheter Electrosurgical Procedures

BACKGROUND: While the BASILICA (bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction) 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. CASE SUMMARY: We describe a novel technique, chordal-zone free externalization of retrograde wire (CLEAR), in 3 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 1 patient, chordal entrapment was detected and corrected without the need for LVOT re-entry. TAKE-HOME MESSAGES: The CLEAR technique simplifies wire externalization, reduces chordal entrapment risk, and allows easier adjustment if snaring fails. It is a feasible and safe technique when integrated with the BASILICA procedure.