TAVI - Sapien 3 (Edwards)

Transcatheter Aortic Valve Repair (Wikipedia)

• CoreValve by Medtronic - CoreValve Procedure Page
• Sapien 3 Ultra by Edwards

Daniels

ACIST A1000V SYRINGE USED WITH 50/50 CONTRAST MIX

Equipment:

• 5Fr Micropunture  Kit  
• 7Fr Glidesheath (2.5 Verapamil)
• 8Fr x 10 cm sheath

• (2) Cordis 150J
• Cordis 260J
• 1.5mm J Glidewire (BABY J glide ; ADVANCED WITH A CHEATER without catheter loaded)
• Terumo Stiff Straight Glidewire 0.035 x 150 cm
• Safari
• .035 Standard Straight for Valve-in-Valve crossing, no need for glidewire.
• Acist hand control
• (2) Perclose
• TR Band
• A extension line from anesthesia (Venous extension only if we are doing bipolar pacing)
• 5Fr AL1 diagnostic 
• (1) 5Fr Ang Pigtail
• (1) 5Fr St. Pigtail for root angio from radial
  • Valve-in-valve: Mosaic needs pigtail, all others do not.
• 6Fr JL4/JR4 (when doing coronary angiography)
• Exofin topical adhesive
• NuKnit for closure
• Alligator Clip Remington Pacing Cables
• TZ Medical Defibrillation Pads - Large pad utilized as a grounding pad on the patients left ribs.

Standby Equipment:

• 125cm 5Fr Pigtail
• 85cm RTP
• 200cm Glide Advantage
• 8mm x 40mm x 200mm RX MetaCross balloon

Protip: For patients with AI you don't need the Glidewire or AL1. Use second pigtail to cross.

Medications on table:

• Lido/Bupivicaine 50/50

• Epinephrine 10mcg/ml in red medallion syringe (From anesthesia)
• 10 ml Rotaglide yellow syringe

Edwards:

• Crimper
• Indeflator
• Appropriate delivery system and valve

Sentinel:

• Grandslam 300cm
• 5/6 Slender
• 2.5 Verapamil
• DSA at 6fps of aortic arch with contralateral pigtail
• Don't open sentinel until we see the Grandslam advanced to the arch
• Prep instructions in lab 1 on the wall next to the light switches

For coronary protection:

• Radial access OR 12F dryseal in LFA if using sentinel
• 6F JL4
• Runthrough
• coronary balloon on md request

• 22G Grey Lido needle for Spies

Procedure

SEE BELOW FOR STEPS SPECIFIC TO SPIES and AGRAWAL and GROVES

• Patient on defib pads. IF PATIENT HAS ICD: DEVICE DISABLED FOR PROCEDURE, COMPANY REP PRESENT IF POSSIBLE.

• Leg strap secured above knees. Left wrist.
• Patient prepped from naval to mid thigh using chlorahexidine soap followed by chloraprep with 3 minute dry time.
• Right radial prepped.
• Towel off site. Extend Femoral drape all the way to chin.
• Extension tubing for anesthesia flushed and secured on respecitve sides of the groin .

FRONT TABLE

• 50/50 Lido and Bupivacaine mix used for local anesthetic. Have extra available on front table.
• 1-1.5 L of Hep Saline in large bowl
• 10ml of Rotaglide on table (Attached to E sheath)
• 10ml syringe of Epi on table.
• Lido with EPI.
• U/S guidance for groin access

BACK TABLE (Valve)

• 3 Bowls: (1) Normal Saline (500ml in each bowl) (1) Hep Saline (500ml) (1) 15ml contrast (85ml Hep Saline added to by scrub person to make it 15%)
• 20 ml of contrast in cup (100% contrast available on table. May need for hand injection or for peripheral balloon prep)
• 60ml Syringe with contrast mixture for balloon prep.
• 20ml Syringe for flushing delivery system
• Indeflator: volume dependent upon valve size
• Crimper
• High pressure stopcock

PROCEDURE STEPS

• Right radial access for 6Fr slender. 2.5 of verapamil.
• Primary access - with micropuncture. Verify wire position with fluoro and save an image
  • Pre-close x 1, sutures secured with hemostat.
  • 8F sheath reconstituted and advanced after pre-closure.
• 1.5mm Baby J glidewire with cheater advanced from the radial. DO NOT preload pigtail.

• Straight Pigtail -> AO root injection
  • Standard Injector settings 10/10 20mm valve, 15/15 23mm and 26mm valve, 20/20 29mm valve

• AL1 advanced through 8F sheath over standard J.
• Standard J removed and crossing wire advanced. Cross valve. Wire removed.
• Measure EDP and gradient.
• 8F sheath removed and E Sheath advanced.
• Insert valve delivery system
• Test pacer, black alligator clip on back of wire.
• Pacing : Unipolar Pacing - pace 120 - 180 , V max output 20ma. "Dial up to 180, dial down to 120, per MD request"
• Pacing : Bipolar pacing - pace 160 with 220 burst , A max output 25ma, set RAP to 220.
• Multiple AO grams for positioning
• Pace -> AO gram --> Deploy valve
  • Cine length set at 40 seconds or more
• TTE

if post dilation is needed...

Rep will come up and re-prep valve, adding desired amount of additional volume

If Safari was pulled back, recross wire will be needed (260cm angled stiff glide)

• Pigtail readvanced to AO for AO gram (15/30 standard injection)
• Safari exchanged for 260 J
• Delivery system removed
  • Have second perclose, tools and dilator ready
• Protamine given, Preclosures completed, manual pressure for 5ish minutes
• Pigtail advanced to iliac bifurcation and subtracted iliac angio performed (6/18 on Acist)
• Pigtail removed
• Secondary access Perclose with Nu-Knit pieces.
• Lido with EPI for fem access.
• TR Band on radial.
• Exofin all access sites, no dressing needed.

THE SPIES TAVR EXPERIENCE

Equipment:

• 5Fr Micropunture  Kit  
• 6Fr Glidesheath (2.5 Verapamil)
• 8Fr x 10 cm sheath
• (2) Cordis 150J
• Cordis 260J
• Straight steel .035 wire (NO straight stiff glide)
• 1.5mm J Glidewire (BABY J glide ; ADVANCED WITH A CHEATER without catheter loaded)
• Safari
• Amplatz ES for sheath advancement
• hand control
• (2) Perclose
• TR Band
• A-extension line from anesthesia
• 5Fr AL1 diagnostic 
• (1) 5Fr Ang Pigtail
• (1) 5Fr St. Pigtail for root angio from radial
• 6Fr JL4/JR4 (when doing coronary angiography)
• Exofin topical adhesive
• Alligator Clip Remington Pacing Cables
• TZ Medical Defibrillation Pads - Large pad utilized as a grounding pad on the patients left ribs.

Standby Equipment:

• 125cm 5Fr Pigtail
• 85cm RTP
• 200cm Glide Advantage
• 8mm x 40mm x 200mm RX MetaCross balloon

Procedural Differences

• E Sheath in right after pre-closure over Supracore
• AL1 advanced with J wire backloaded.
• After valve crossing, EXCHANGE J inserted, AL1 removed and SECOND PIGTAIL advanced.
• Safari advanced through pigtail and pigtail removed.
• Iliac angio 6/18ml
• Lido with EPI at end of case

THE GROVES TAVI EXPERIENCE

Product Substitute

• 2 pigtails
• Amplatz ES 1CM tip for sheath advancement
• Balloon-tipped Abbott Pacer

AGRAWAL SPECIAL

• All accesses with mircopuncture
• 2 Percloses on primary access site
• .035 Standard Straight wire for valve crossing
• After valve crossing, EXCHANGE J inserted, AL1 removed and SECOND PIGTAIL advanced. Amplatz ES advanced through pigtail and pigtail removed.
• Amplatz ES to exchange 8F for E sheath
  

PERIPHERAL BAILOUT EQUIPMENT

• Have everything available in the room, but verify items prior to opening.
• 5F Rim Catheter
• 6F or 7F Destination RDC
• Exchange length Glidewire advantage
• Exchange length angled glidewire
• Supracore wire
• Mustang balloons on 75cm shaft (6mm to 10mm x 40mm)
• Viabahn stents