View source for TAVR - Lotus (Boston Scientific)

'''Transcatheter Aortic Valve Repair''' ([[wikipedia:Percutaneous_aortic_valve_replacement|Wikipedia]]) procedures utilize a femoral approach to deliver a stent-based aortic valve to the patients heart. There are two valve types available:

*[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] - [[TAVR - Sapien 3 (Edwards)]]
*[https://www.bostonscientific.com/content/gwc/en-US/products/transcatheter-heart-valve/tavr-valve-system.html] - This Page

This procedure is usually done in Room 1, and requires a 5 person team: Front table scrub, Back table scrub (device prep), Circulator, Pacer/Circulator, and Recorder. The rep for the respective company will be present to assist with device prep except in the case of an emergency valve placement.

In rare cases, the [[BASILICA]] procedure will be necessary to split the existing valve leaflets to prevent blockage of the coronary arteries. In that situation, the equipment on the [[BASILICA]] page will be needed in addition to the equipment listed below.

Per Rosalie:

TAVR/TMVI

#Edwards Sapien 3 Ultra (20, 23 & 26mm) and Sapien 3 (29mm) – scan the valve barcode (box) in McKesson for documentation and charges.  Bundle includes valve, delivery system, crimper, e sheath intro set, balloon cath & locking syringe.  With the new inventory system (POU) space is limited in entering item full description.   If pre dilatation Edwards balloon is necessary free text the balloon used in procedure notes (McKesson).
#Medtronic Core Valve – all items are charge separately.  Scan all barcodes (delivery system, loading system and valve).

MITRAL CLIP (Mitral/Tricuspid):

#Use the barcode on Mckesson screen in Lab 1 – Mitraclip (Abbott) bundle consists of (1) Steerable Guide Catheter, (2) NTR Clip Delivery System & (1) XTR Clip Delivery System.

==Daniels/Spies - Draft==
ACIST A1000V SYRINGE USED WITH 50/50 CONTRAST MIX
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===Sheaths:===

*5Fr Micropunture  Kit  
*6Fr x 10cm sheath
*8Fr x 10 cm sheath (Dilator used only)
*8Fr x 35 cm Brite Tip Sheath

===Wires===

*(2) Cordis 150J
*Cordis 260J
*Amplatz Extra Stiff 260cm
*Terumo Stiff Straight Glidewire 0.035 x 150 cm

===Catheters:===

*5Fr AL1 diagnostic 
*5Fr Straight Pigtail (2 for Spies)
*5Fr JL4/JR4 (when doing coronary angiography)

===Medications on table:===

*Lido/Bupivicaine 50/50
*Epinephrine 10mcg/ml in red medallion syringe (From anesthesia)


===Miscellaneous Supplies===

*3-port manifold kit
*Acist hand control
*Back table cover
*High Pressure stopcock
*60ml syringe
*20 ml syringe
*(3) Perclose
*Fluoro cover
*A & V extension line from anesthesia
*2-0 Prolene
*(3) hemostats
*Needle drivers
*[[:File:Bowlset.jpg|Bowl set from SPD]]

===Transvenous pacemaker supplies===

*5Fr Josephson Pacing catheter
*Dual Red/Black Pacing Remington cables
*EP Quad Cable

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

==Procedure==
''SEE BELOW FOR STEPS SPECIFIC TO SPIES''


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. 

Fluoro cover used to drape anesthesia's IV pole/x-ray shield.

Extension tubing for anesthesia flushed and secured on respecitve sides of the groin .

Dual pressure lines primed and zeroed prior to case start.


'''FRONT TABLE'''

50/50 Lido and Bupivicaine mix used for local anesthetic.  Have extra available on front table.

100% contrast available on table.  (May need for hand injection or for peripheral balloon prep)

10ml syringe of Epi taped on table.

U/S guidance for groin access


'''BACK TABLE'''- valve prep
Fill big bowl from bowl set with ~2-3 liters of NS so it is 2-3” deep.
Fill smaller round bowl 3/4 full with NS
Fill kidney basin 3/4 full Hep. Saline


Boston Scientific Reps prep valve

'''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
**Leave micropuncture wire in while venous access is obtained
**Once venous sheath is in place, dilate tract with 8F dilator
**Double preclose. Each perclose suture secured with hemostat.
**After second perclose Amplatz ES is inserted using micropuncture sheath as a cheater
**Lotus sheath inserted

*Venous access- 8F 35cm brite tip over 150cm J wire. (Same side as TAVR sheath)

*Pigtail -> LFA -> AO root injection
**Standard Injector settings (adjusted based on pt and root size)

10/10 20mm valve, 15/15 23mm and 26mm valve, 20/20 29mm valve

*Insert and test pacemaker
**Rapid pace 160, check for capture, 220 burst
*AL1 advanced through sheath over Amplatz ES
*Amplatz ES removed and crossing wire advanced. Cross valve. Wire removed.
*Measure gradient
*Safari wire inserted
*Insert valve delivery system
*Multiple AO grams for positioning
*Deploy valve
**Cine length set at 40 seconds or more
*TTE


*Pigtail readvanced to AO for AO gram (15/30 standard injection)
*Temp pacer removed
*Delivery system removed
**Have 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
*Pigtail removed
*Secondary access Perclosed
*Venous sheath exchanged for 9fr. Sheath 10cm sheath -> suture-locked


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

*All accesses obtained with micropuncture
*50/50 contrast for groin shot at both arterial access sites
*Amplatz ES removed after E sheath insertion. AL1 advanced with J wire backloaded.
*After valve crossing, EXCHANGE J inserted, AL1 removed and SECOND PIGTAIL advanced. Amplatz ES advanced through pigtail and pigtail removed.
*NO ROTOGLIDE
*Have IM available for iliac angiogram.




===PERIPHERAL BAILOUT EQUIPMENT===
''Have everything available in the room, but verify items prior to opening.''

5F Rim Catheter

6F or 7F Balkin 

Exchange length Glidewire advantage

Exchange length angled glidewire 

Supracore wire

Mustang balloons on 75cm shaft (6mm to 10mm x 40mm)

Viabahn stents
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===EMERGENT PERICARDIOCENTESIS===
{{Pericardiocentesis}}

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Approved: MM/YY