TAVI - Sapien 3 (Edwards): Difference between revisions

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==Daniels ==
==Daniels ==
ACIST A1000V SYRINGE USED WITH 50/50 CONTRAST MIX
ACIST A1000V SYRINGE USED WITH 50/50 CONTRAST MIX
===Equipment :===
 
=== **If the patient has an existing RBBB, prep the right chest and no rampart.*** ===
 
===Equipment: ===


*5Fr Micropunture  Kit  
*5Fr Micropunture  Kit  
*6Fr x 10cm sheath
*7Fr Glidesheath (2.5 Verapamil)
*8Fr x 10 cm sheath  
*8Fr x 10 cm sheath


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


=== Unipolar Transvenous pacing supplies (Daniels preference) ===
===Standby Equipment:===
 
* 125cm 5Fr Pigtail
* Alligator Clip Remington Pacing Cables
* 85cm RTP
* TZ Medical Defibrillation Pads - Found in EP pyxis in labs. Large pad utilized as a grounding pad on the patients chest (subxyphoid)
* 200cm Glide Advantage
 
* 8mm x 40mm x 200mm RX MetaCross balloon
{{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.}}
{{Protip|For patients with AI you don't need the Glidewire or AL1. Use second pigtail to cross. }}
 
===Medications on table:===


=== Medications on table: ===
*Lido/Bupivicaine 50/50
*Lido/Bupivicaine 50/50


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==Procedure==
==Procedure==
'''''SEE BELOW FOR STEPS SPECIFIC TO SPIES and AGRAWAL'''''
'''''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.
* Patient on defib pads.  IF PATIENT HAS ICD: DEVICE DISABLED FOR PROCEDURE, COMPANY REP PRESENT IF POSSIBLE.


* Leg strap secured above knees. Wrists restrained.
* 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.  
* 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.  
* Towel off site. Extend Femoral drape all the way to chin.  
* Extension tubing for anesthesia flushed and secured on respecitve sides of the groin .
* Extension tubing for anesthesia flushed and secured on respecitve sides of the groin .


'''FRONT TABLE'''
===FRONT TABLE===


* 50/50 Lido and Bupivacaine mix used for local anesthetic.  Have extra available on front table.
* 50/50 Lido and Bupivacaine mix used for local anesthetic.  Have extra available on front table.
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* 10ml of Rotaglide on table (Attached to E sheath)
* 10ml of Rotaglide on table (Attached to E sheath)
* 10ml syringe of Epi on table.
* 10ml syringe of Epi on table.
* Lido with EPI.
* U/S guidance for groin access
* U/S guidance for groin access


'''BACK TABLE'''- valve prep
===BACK TABLE (Valve)===


* 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%)
* 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)
* 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.  
* 60ml Syringe with contrast mixture for balloon prep.  
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* High pressure stopcock
* High pressure stopcock


'''PROCEDURE STEPS'''
===PROCEDURE STEPS===


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


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


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*'''Pacing : Bipolar pacing - pace 160 with 220 burst , A max output 25ma, set RAP to 220.'''
*'''Pacing : Bipolar pacing - pace 160 with 220 burst , A max output 25ma, set RAP to 220.'''
*Multiple AO grams for positioning
*Multiple AO grams for positioning
*Pace -> AO gram ->  Pigtail pulled back -> Deploy valve
*Pace -> AO gram --> Deploy valve
**Cine length set at 40 seconds or more
**Cine length set at 40 seconds or more
*TTE
*TTE
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**Have second perclose, tools and dilator ready
**Have second perclose, tools and dilator ready
*Protamine given, Preclosures completed, manual pressure for 5ish minutes
*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 advanced to iliac bifurcation and subtracted iliac angio performed (6/18 on Acist)
*Pigtail removed
*Pigtail removed
*Secondary access Perclose
*Secondary access Perclose with Nu-Knit pieces.
*Lido with EPI for fem access.
*TR Band on radial.
*Exofin all access sites, no dressing needed.
*Exofin all access sites, no dressing needed.


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


====Equipment: ====
===Equipment:===


* 5Fr Micropunture  Kit  
* 5Fr Micropunture  Kit  
* 6Fr x 10cm sheath
* 6Fr Glidesheath (2.5 Verapamil)
* 8Fr x 10 cm sheath
* 8Fr x 10 cm sheath
* 8Fr x 35 cm Brite Tip Sheath
* (2) Cordis 150J
* (2) Cordis 150J
* Cordis 260J
* Cordis 260J
* 2 Pigtails
* Straight steel .035 wire (NO straight stiff glide)
* Straight steel .035 wire (NO straight stiff glide)
* Supracore for E Sheath advancement ?
* 1.5mm J Glidewire (BABY J glide ; ADVANCED WITH A CHEATER without catheter loaded)
* Safari  
* Safari  
* 5F Abbott Pacel Balloon Flow Directed Tip Pacing catheter for CS
* Amplatz ES for sheath advancement
*Dual Red/Black Pacing Remington cables
* hand control
*EP Quad Cable
* (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.


====Procedural Differences====
===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  
*E Sheath in right after pre-closure over Supracore  
*AL1 advanced with J wire backloaded.
*AL1 advanced with J wire backloaded.
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*Lido with EPI at end of case  
*Lido with EPI at end of case  


== ''THE GROVES TAVI EXPERIENCE'' ==
== THE GROVES TAVI EXPERIENCE ==


===== Product Substitute =====
=== Product Substitute ===


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


== '''''AGRAWAL SPECIAL''''' ==
== AGRAWAL SPECIAL ==
*All accesses with mircopuncture
*All accesses with mircopuncture
*2 Percloses on primary access site
*2 Percloses on primary access site
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*After valve crossing, EXCHANGE J inserted, AL1 removed and SECOND PIGTAIL advanced. Amplatz ES advanced through pigtail and pigtail removed.
*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 />
*Amplatz ES to exchange 8F for E sheath<br />
===PERIPHERAL BAILOUT EQUIPMENT===
 
 
==PERIPHERAL BAILOUT EQUIPMENT==


* ''Have everything available in the room, but verify items prior to opening.''
* ''Have everything available in the room, but verify items prior to opening.''
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* Viabahn stents <br />
* Viabahn stents <br />


<hr />
Approved: MM/YY
[[Category:Procedures]]
[[Category:Procedures]]

Latest revision as of 18:14, 20 February 2025

Transcatheter Aortic Valve Repair (Wikipedia)

Daniels

ACIST A1000V SYRINGE USED WITH 50/50 CONTRAST MIX

**If the patient has an existing RBBB, prep the right chest and no rampart.***

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

Note 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

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 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
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