View source for TAVI - Sapien 3 (Edwards)

'''Transcatheter Aortic Valve Repair''' ([[wikipedia:Percutaneous_aortic_valve_replacement|Wikipedia]]) 

*[https://www.medtronic.com/us-en/healthcare-professionals/therapies-procedures/cardiovascular/transcatheter-aortic-valve-replacement.html CoreValve by Medtronic] - [[TAVR - CoreValve (Medtronic)|CoreValve Procedure Page]]
*[https://www.edwards.com/gb/devices/heart-valves/transcatheter-SAPIEN-3-Ultra Sapien 3 Ultra by Edwards] 

==Daniels ==
ACIST A1000V SYRINGE USED WITH 50/50 CONTRAST MIX
===Equipment :===

*5Fr Micropunture  Kit  
*6Fr x 10cm sheath
*8Fr x 10 cm sheath 

*(2) Cordis 150J
*Cordis 260J
*Safari Wire (DANIELS & SPIES)
*Amplatz Extra Stiff 1cm tip (GROVES)
*Terumo Stiff Straight Glidewire 0.035 x 150 cm
*.035 Standard Straight for Valve-in-Valve crossing, no need for glidewire.
*Acist hand control
*(3) Perclose
*A extension line from anesthesia (Venous extension only if we are doing bipolar pacing)
*5Fr AL1 diagnostic 
*5Fr Ang Pigtail x 2
**'''Valve-in-valve: Mosaic needs pigtail, all others do not.'''
*6Fr JL4/JR4 (when doing coronary angiography)
*Exofin topical adhesive
*NuKnit for closure

=== Unipolar Transvenous pacing supplies (Daniels preference) ===

* Alligator Clip Remington Pacing Cables
* TZ Medical Defibrillation Pads - Found in EP pyxis in labs. Large pad utilized as a grounding pad on the patients chest (subxyphoid)

{{Protip|</BR>For cases where patient has an LVAD you'll need a Safari II instead of an ES</BR>
For patients with AI you don't need the Glidewire.}}

{{Protip|For AI cases you'll need a second pigtail and no AL1.}}

===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

===Standby ECMO & Pericardial Effusion supplies===

=== 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'''''

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

* Leg strap secured above knees. Wrists restrained.
* Patient prepped from naval to mid thigh using chlorahexidine soap followed by chloraprep with 3 minute dry time. 
* 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.
* U/S guidance for groin access

'''BACK TABLE'''- valve prep

* 3 Bowls: (1) Normal Saline (500ml in each bowl)  (1) Hep Saline (500ml) (1) 30ml contrast (170ml 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'''

*Contralateral arterial access - 6fr. Sheath (normally LFA) using micropuncture. Verify wire position with fluoro and save an image.
*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.

*Pigtail -> LFA -> 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 ->  Pigtail pulled back -> 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 pulled back to iliac bifurcation and subtracted iliac angio performed (6/18 on Acist)
*Pigtail removed
*Secondary access Perclose
*Exofin all access sites, no dressing needed.

== ''THE SPIES TAVR EXPERIENCE'' ==

====Equipment: ====

* 5Fr Micropunture  Kit  
* 6Fr x 10cm sheath
* 8Fr x 10 cm sheath
* 8Fr x 35 cm Brite Tip Sheath
* (2) Cordis 150J
* Cordis 260J
* 2 Pigtails
* Straight steel .035 wire (NO straight stiff glide)
* Supracore for E Sheath advancement ?
* Safari 
* 5F Abbott Pacel Balloon Flow Directed Tip Pacing catheter for CS
*Dual Red/Black Pacing Remington cables
*EP Quad Cable

====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
* 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<br />
===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 <br />

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Approved: MM/YY
[[Category:Procedures]]