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'''TransCatheter Mitral Valve Repair/Replacement'''
 
{{Protip|Need Alcohol in lab for this procedure!}}
 
'''TransCatheter Mitral Valve Insertion'''


Per Rosalie:
Per Rosalie:


TAVR/TMVI
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).
#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).
#Medtronic Core Valve – all items are charged separately.  Scan all barcodes (delivery system, loading system and valve).


MITRAL CLIP (Mitral/Tricuspid):
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.
#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.
{| class="wikitable"
|+
! colspan="4" |TMVR
|-
!Anesthesia
!Imaging
!Access
!Pre-Procedure
|-
|
* General Anesthesia


* A-Line Always!
|
* Single Plane Fluoro


'''GENERAL ANESTHESIA AND TEE IMAGING, RADIAL ART LINE BY ANESTHESIA'''
* TEE


'''ACCESS 2 FEMORAL VEINS (TAVR AND PACER)'''
* No Acist
* Unipolar pacing
|


'''PRE PROCEDURE: TYPE AND CROSS, ASPIRIN GIVEN'''
* RVF pre-closed x 1
|
* Type and Cross


==SHEATHS:==
* Aspirin Given
|}
==Open:==
===Sheaths:===


*Micropuncture
*Micropuncture
*8fr Pinnacle for Perclose
*8fr Pinnacle for Perclose
*8x35 Brite tip
*Perclose (If Spies is primary, NO perclose if Daniels is primary.)
*8.5 SL1
*8.5F Agilis
*8.5 Small Curl Agilis
*16F E sheath, '''always''', regardless of valve size.
==WIRES:==
 
===Open===


=== Wires: ===
*150 J wire
*150 J wire
*.'''032''' x 260 J-wire
*Safari 2
*Safari 2
*Amplatz Super Stiff 1cm tip


===Standby===
===Baylis:===
* VersaCross system
* Grounding pad


*.035 260CM J WIRE
=== Misc: ===
*SUPRACORE 190CM
*Naked 3 Port Manifold
 
*Alligator pacing cable
==CATHETERS==
 
===Open===


=== Catheters: ===
*6fr. Straight Pig
*6fr. Straight Pig
*5fr. MPB2
===Standby===
*6F LANGSTON
*5.2F ANGLED PIGTAIL
*5F MPA
*5F JL4 AND JR4 (FOR CORONARIES)
==PACING==
*5F JOSEPHSON PACING CATHETER
*EP QUAD CABLE
*DUAL RED/BLACK REMINGTON PACING CABLE
*(2) PACER BOXES


==VALVE TABLE==
=== Septal dilation: ===
*'''12X4X75 Mustang for 23mm and 26mm Sapien or 14mm Armada for 29mm Sapien'''
*Presto indeflator


*(4) STERILE BOWLS (2- 0.9% SALINE, 1-HEP SALINE, 1-15% CONTRAST MIX)
===Edwards valve:===
*(1) 90 INCH DRAPE (OR)
*Indeflator (Second Indeflator on standby)
*1L NORMAL SALINE IRRIGATION
*Crimper
*500ML HEPARINIZED SALINE
*E-sheath (Second E-Sheath on standby)
*(1) 60ML SYRINGE
*Delivery system (Second delivery on standby)
*(1) HIGH PRESSURE STOPCOCK
*Valve
*(1) 20ML SYRINGE
*30ML CONTRAST (MIX WITH 170ML HEP SALINE FOR 15% CONCENTRATION)


==FOR EDWARDS VALVE==
== Balloon Valve Fracture ==
[[File:Valve_Cracker.jpg|thumb|150px|right|Valve Cracker Setup|link={{filepath:Valve_Cracker.jpg}}]]
[[Double Pump Valve Cracker]]
===Equipment===


*INDEFLATOR
* Atrion 38 indeflator
*CRIMPER
* Atrion 25 indeflator
*E SHEATH
* 4-way stopcock
*DELIVERY SYSTEM
* True Balloon (1mm smaller than intended Sapien implant)
*VALVE
** Fill big indeflator '''all the way''', 20ml in small indeflator


==TRANS SEPTAL==
===Procedure===


*BAYLIS NEEDLE LARGE CURVE C1
# Use TAVR mix
*BAYLIS MACHINE
# De-air and fill both indeflators
*BAYLIS CABLE
# Prep balloon similar to Edwards Delivery system prep
*GROUNDING PAD
# Attach both indeflators and open stopcock to be open all ways
# Lock both indeflators


==SEPTAL DILATION==
==Standby:==


===Open===
===Septal procedure:===
 
*9X4X75 Mustang
*12X4X75 MUSTANG '''OR''' 14X4 XXL (Ask before opening)
*PRESTO INDEFLATOR
 
===Standby===
 
*9X4X75 MUSTANG
*14, 16 XXL Balloons
*14, 16 XXL Balloons
*TORQUEVUE 45DEGREE DELIVERY SYSTEM (9F OR 10F)
*Torqueview 45° delivery system (9fr. or 10fr.)
*10MM, 14MM, 18MM SEPTAL OCCLUDER
*10mm, 14mm, 18mm septal occluder


==ADDITIONAL SUPPLIES==
===Baylis Standby===
*SL1 sheath
*Large curve Baylis needle
*Baylis cable
*0.32 x 260 J-wire


===Open===
===Bipolar pacing standby:===
*8x35 Brite tip
*5F Josephson Pacing Cable
*EP Quad Cable
*Remington Pacing Cable
*(2) Pacer Boxes


*2xPERCLOSE
*3 PORT MANIFOLD - No contrast
*PROBE COVER
*PROLENE 2-0
*FLUORO DRAPE
*CHLORAPREP AND PREP TRAY


===Standby===
==Medications for table==


*150ML CONTRAST (FOR CORONARIES)
*Bupivacaine/Lidocaine
*BIOPATCH
*Epinephrine 10mcg/ml in red syringe on back table secured with steri-strip
*8F ANGIOSEAL
*Rotaglide 10 ml (Edwards valve only!)
*0 SILK SUTURE
*EXTRA PERCLOSE


==MEDICATIONS==
==Procedure:==
 
*BUPIVACAINE
*EPINEPHRINE 10MCG/ML IN RED SYRINGE ON BACK TABLE
*ROTAGLIDE 10ML (EDWARDS VALVE)
 
==STANDBY EMERGENCY ECMO SUPPLIES==
 
*16F ARTERIAL CANNULA
*21F VENOUS CANNULA
*(2) PERCLOSE
*ECMO INSTRUMENT TRAY
*AMPLATZ SUPER STIFF
 
==STANDBY PERICARDIOCENTESIS SUPPLIES==
 
*EYE DRAPE
*CHIBA NEEDLE 10CM 18G
*SKATER INTRODUCER SET
*BARD LOCKING PIGTAIL 6F OR 8F
*(3) 60ML SYRINGES
*STOPCOCK
*AMPLATZ SUPER STIFF 180CM
 
==PROCEDURE:==


*Patient prepped from '''navel to knees''' in sterile fashion.  
*Patient prepped from '''navel to knees''' in sterile fashion.  
*Access obtained with u/s
*Access obtained with u/s
 
*Dilate with 8F dilator
Typical sites:
*Pre-close, Versacross pigtail wire advanced through Perclose
 
*Versacross sheath inserted
***14F OR 16F RFV E-sheath for valve delivery
*Transeptal puncture, then pigtail wire advanced
****Dilate with 8F
*Versacross sheath removed
****Preclose
*Agilis advanced and directed to mitral valve.
*SL1 inserted over .032 260cm J
*Pigtail and Safari2 inserted through Agilis for valve crossing.
*Baylis needle inserted through SL1 and atrial septum puncture performed.
*Safari2 wire inserted to ventricle. Simultaneous LA/LV pressure recorded.
*Needle removed, .032 wire advanced to pulmonary vein
*Pigtail and Agilis removed.
*Agilis advanced and directed to mitral valve
*Pigtail inserted through agilis for valve crossing.
*Safari2 wire inserted to ventricle.
*Pigtail and agilis removed.
*12mm/14mm balloon advanced for septostomy and possible BAV
*12mm/14mm balloon advanced for septostomy and possible BAV
*Balloon removed, valve delivery system advanced.
*Balloon removed, valve delivery system advanced.
*When valve is in place, temp pacer inserted and tested.
*When valve is in place, black alligator cable attached and pacing tested.
*Valve deployed. Septum evaluated with echo for shunting.
*Valve deployed. Septum evaluated with echo for shunting.
*Pacer removed. Delivery system removed.
*Delivery removed and SL1 re-advanced.
*Preclosure closed and stitch to RFV
*Pigtail advanced to LV, wire removed and simultaneous LA/LV pressures recorded (maybe).
*8F vein pulled and manual pressure applied
*Pigtail and SL1 removed.
*Tegaderm both sides.
*Pacer removed.  
*Perclose completed and stitch to RFV
*Dermabond access site, no dressings needed.
 
 
==ECMO Standby:==
*16fr. vented arterial cannula
*21fr. venous cannula
*Perclose x 2
*ECMO instrument tray
*180 Amplatz Super Stiff wire
 
==Pericardiocentesis standby==
*Eye drape
*18g. x 10 cm. Chiba needle
*Skater introducer set
*Bard locking pigtail 6fr. or 8fr.
*60ml syringe x 3
*Stopcock
*180 Amplatz Super Stiff wire
 


<br>
[[Category:Procedures]]
[[Category:Procedures]]
<HR />
<HR />
APPROVED: MD initials MM/YY
APPROVED: MD initials MM/YY

Latest revision as of 18:26, 12 March 2025

Note Protip: Need Alcohol in lab for this procedure!

TransCatheter Mitral Valve Insertion

Per Rosalie:

TMVI

  1. 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).
  2. Medtronic Core Valve – all items are charged separately.  Scan all barcodes (delivery system, loading system and valve).

MITRAL CLIP (Mitral/Tricuspid):

  1. 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.
TMVR
Anesthesia Imaging Access Pre-Procedure
  • General Anesthesia
  • A-Line Always!
  • Single Plane Fluoro
  • TEE
  • No Acist
  • Unipolar pacing
  • RVF pre-closed x 1
  • Type and Cross
  • Aspirin Given

Open:

Sheaths:

  • Micropuncture
  • 8fr Pinnacle for Perclose
  • Perclose (If Spies is primary, NO perclose if Daniels is primary.)
  • 8.5F Agilis
  • 16F E sheath, always, regardless of valve size.

Wires:

  • 150 J wire
  • Safari 2

Baylis:

  • VersaCross system
  • Grounding pad

Misc:

  • Naked 3 Port Manifold
  • Alligator pacing cable

Catheters:

  • 6fr. Straight Pig

Septal dilation:

  • 12X4X75 Mustang for 23mm and 26mm Sapien or 14mm Armada for 29mm Sapien
  • Presto indeflator

Edwards valve:

  • Indeflator (Second Indeflator on standby)
  • Crimper
  • E-sheath (Second E-Sheath on standby)
  • Delivery system (Second delivery on standby)
  • Valve

Balloon Valve Fracture

Valve Cracker Setup

Double Pump Valve Cracker

Equipment

  • Atrion 38 indeflator
  • Atrion 25 indeflator
  • 4-way stopcock
  • True Balloon (1mm smaller than intended Sapien implant)
    • Fill big indeflator all the way, 20ml in small indeflator

Procedure

  1. Use TAVR mix
  2. De-air and fill both indeflators
  3. Prep balloon similar to Edwards Delivery system prep
  4. Attach both indeflators and open stopcock to be open all ways
  5. Lock both indeflators

Standby:

Septal procedure:

  • 9X4X75 Mustang
  • 14, 16 XXL Balloons
  • Torqueview 45° delivery system (9fr. or 10fr.)
  • 10mm, 14mm, 18mm septal occluder

Baylis Standby

  • SL1 sheath
  • Large curve Baylis needle
  • Baylis cable
  • 0.32 x 260 J-wire

Bipolar pacing standby:

  • 8x35 Brite tip
  • 5F Josephson Pacing Cable
  • EP Quad Cable
  • Remington Pacing Cable
  • (2) Pacer Boxes


Medications for table

  • Bupivacaine/Lidocaine
  • Epinephrine 10mcg/ml in red syringe on back table secured with steri-strip
  • Rotaglide 10 ml (Edwards valve only!)

Procedure:

  • Patient prepped from navel to knees in sterile fashion.  
  • Access obtained with u/s
  • Dilate with 8F dilator
  • Pre-close, Versacross pigtail wire advanced through Perclose
  • Versacross sheath inserted
  • Transeptal puncture, then pigtail wire advanced
  • Versacross sheath removed
  • Agilis advanced and directed to mitral valve.
  • Pigtail and Safari2 inserted through Agilis for valve crossing.
  • Safari2 wire inserted to ventricle. Simultaneous LA/LV pressure recorded.
  • Pigtail and Agilis removed.
  • 12mm/14mm balloon advanced for septostomy and possible BAV
  • Balloon removed, valve delivery system advanced.
  • When valve is in place, black alligator cable attached and pacing tested.
  • Valve deployed. Septum evaluated with echo for shunting.
  • Delivery removed and SL1 re-advanced.
  • Pigtail advanced to LV, wire removed and simultaneous LA/LV pressures recorded (maybe).
  • Pigtail and SL1 removed.
  • Pacer removed.
  • Perclose completed and stitch to RFV
  • Dermabond access site, no dressings needed.


ECMO Standby:

  • 16fr. vented arterial cannula
  • 21fr. venous cannula
  • Perclose x 2
  • ECMO instrument tray
  • 180 Amplatz Super Stiff wire

Pericardiocentesis standby

  • Eye drape
  • 18g. x 10 cm. Chiba needle
  • Skater introducer set
  • Bard locking pigtail 6fr. or 8fr.
  • 60ml syringe x 3
  • Stopcock
  • 180 Amplatz Super Stiff wire

APPROVED: MD initials MM/YY

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