TAVI - Sapien 3 (Edwards): Difference between revisions

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'''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:
'''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.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] - This page
*[https://www.edwards.com/gb/devices/heart-valves/transcatheter-SAPIEN-3-Ultra Sapien 3 Ultra by Edwards]  


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.
==Daniels ==
ACIST A1000V SYRINGE USED WITH 50/50 CONTRAST MIX


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


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


*5Fr Micropunture  Kit  
*5Fr Micropunture  Kit  
*6Fr x 10cm sheath
*7Fr Glidesheath (2.5 Verapamil)  
*8Fr x 10 cm sheath (Dilator used only)
*8Fr x 10 cm sheath
*8Fr x 35 cm Brite Tip Sheath
*9Fr x 10cm sheath
 
===Wires===


*(2) Cordis 150J
*(2) Cordis 150J
*Cordis 260J
*Cordis 260J
*Amplatz Extra Stiff 260cm
*1.5mm J Glidewire (BABY J glide ; ADVANCED WITH A CHEATER without catheter loaded)
*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.
*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.


===Catheters:===
===Standby Equipment:===
 
* 125cm 5Fr Pigtail
*5Fr AL1 diagnostic 
* 85cm RTP
*5Fr Ang Pigtail
* 200cm Glide Advantage
*5Fr JL4/JR4 (when doing coronary angiography)
* 8mm x 40mm x 200mm RX MetaCross balloon


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


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


===Miscellaneous Supplies===
''if post dilation is needed...''


*Daniel’s TAVR 3-port manifold kit
Rep will come up and re-prep valve, adding desired amount of additional volume
*Acist hand control
 
*25g  1 ½ “ Daniels Lido Needle"
If Safari was pulled back, recross wire will be needed (260cm angled stiff glide)
*Suture Lock
 
*(4) Sterile Bowls
*Pigtail readvanced to AO for AO gram (15/30 standard injection)
*¾ sterile sheet or back table cover
*Safari exchanged for 260 J
*(2) High Pressure stopcocks
*Delivery system removed
*(2) 60ml syringe
**Have second perclose, tools and dilator ready
*20 ml syringe
*Protamine given, Preclosures completed, manual pressure for 5ish minutes
*(3) Perclose
*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


===Transvenous pacemaker supplies===
== 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 />


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


===Standby ECMO & Pericardial Effusion supplies===
==PERIPHERAL BAILOUT EQUIPMENT==


===EMERGENT PERICARDIOCENTESIS===
* ''Have everything available in the room, but verify items prior to opening.''
{{Pericardiocentesis}}
* 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 />


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

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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