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DANIELS


Sapien M3
{{Protip|Need Alcohol in lab for this procedure!}}


'''GENERAL ANESTHESIA, TEE, BIPLANE'''
'''TransCatheter Mitral Valve Insertion'''


'''ACCESS 2 FEMORAL VEINS (ESHEATH AND PACER), 1 FEMORAL ARTERY'''
Per Rosalie:


'''TRIPLE LUMEN AND RADIAL ARTERY ACCESS BY ANESTHESIA'''
TMVI


'''STABILIZER PLACEMENT PRIOR TO DRAPING'''
#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 charged separately.  Scan all barcodes (delivery system, loading system and valve).


= SHEATHS: =
MITRAL CLIP (Mitral/Tricuspid):


* (1) 5F MICROPUNCTURE KIT
#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.
* (1) 6F 10CM SHEATH
{| class="wikitable"
* (1) 8F 10CM SHEATH
|+
* (1) 8F 35CM BRITE TIP SHEATH
! colspan="4" |TMVR
* (1) 9F 10CM SHEATH
|-
* (1) 8.5F 63CM SL1 TRANSSEPTAL SHEATH
!Anesthesia
!Imaging
!Access
!Pre-Procedure
|-
|
* General Anesthesia


= WIRES: =
* A-Line Always!
|
* Single Plane Fluoro


== '''Open''' ==
* TEE


* (2) .035 150CM J WIRE
* No Acist
* (1) .035 260CM J WIRE
* Unipolar pacing
* (1) SAFARI 2 WIRE
|
* (1) AMPLATZ SUPER STIFF 1CM TIP


== '''Standby''' ==
* RVF pre-closed x 1
|
* Type and Cross


* Baylis ProTrack wire
* Aspirin Given
|}
==Open:==
===Sheaths:===


= CATHETERS =
*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.


== '''Open''' ==
=== Wires: ===
*150 J wire
*Safari 2


* 6F STRAIGHT PIGTAIL 110CM
===Baylis:===
* 6F ANGLED PIGTAIL 110CM
* VersaCross system
* 5F MPA1
* Grounding pad


== '''Standby''' ==
=== Misc: ===
*Naked 3 Port Manifold
*Alligator pacing cable


* 6F MPA1 125cm
=== Catheters: ===
*6fr. Straight Pig


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


* 5F JOSEPHSON PACING CATHETER
===Edwards valve:===
* EP QUAD CABLE
*Indeflator (Second Indeflator on standby)
* DUAL RED/BLACK REMINGTON PACING CABLE
*Crimper
* (2) PACER BOXES
*E-sheath (Second E-Sheath on standby)
*Delivery system (Second delivery on standby)
*Valve


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


* (5) STERILE BOWLS (2- 0.9% SALINE, 1-HEP SALINE, 1-15% CONTRAST MIX)
* Atrion 38 indeflator
* (1) 90 INCH DRAPE
* Atrion 25 indeflator
* 1L NORMAL SALINE IRRIGATION
* 4-way stopcock
* 500ML HEPARINIZED SALINE
* True Balloon (1mm smaller than intended Sapien implant)
* (2) 60ML SYRINGE
** Fill big indeflator '''all the way''', 20ml in small indeflator
* (1) HIGH PRESSURE STOPCOCK
* (1) 20ML SYRINGE
* 30ML CONTRAST (MIX WITH 170ML HEP SALINE FOR 15% CONCENTRATION)
* 12 INCH EXTENSION
* ROTO TUBING


== '''VALVE- SUPPLIED BY EDWARDS''' ==
===Procedure===


* INDEFLATOR
# Use TAVR mix
* CRIMPER
# De-air and fill both indeflators
* E SHEATH
# Prep balloon similar to Edwards Delivery system prep
* DELIVERY SYSTEM
# Attach both indeflators and open stopcock to be open all ways
* VALVE
# Lock both indeflators


= TRANS SEPTAL =
==Standby:==


* BAYLIS NEEDLE LARGE CURVE C1
===Septal procedure:===
* BAYLIS MACHINE
*9X4X75 Mustang
* BAYLIS CABLE
*14, 16 XXL Balloons
* GROUNDING PAD
*Torqueview 45° delivery system (9fr. or 10fr.)
*10mm, 14mm, 18mm septal occluder


= SEPTAL DILATION =
===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


* 14X4 ATLAS GOLD- 135 CM SHAFT PREFERRED


* PRESTO INDEFLATOR
==Medications for table==


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


* TORQUEVUE 45DEGREE DELIVERY SYSTEM (9F OR 10F)
==Procedure:==
* 10MM, 14MM, 18MM SEPTAL OCCLUDER


= ADDITIONAL SUPPLIES =
*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.


== '''Open''' ==


* (2) PERCLOSE
==ECMO Standby:==
* 3 PORT MANIFOLD  
*16fr. vented arterial cannula
* ACIST- 70/30 MIX
*21fr. venous cannula
* PROBE COVER
*Perclose x 2
* DUMP BAG
*ECMO instrument tray
* 25g 1½ INCH NEEDLE
*180 Amplatz Super Stiff wire
* STAT LOCK WITH STRING SECUREMENT
* PROLENE 2-0
* TAVR INSTRUMENT TRAY
* CHLORAPREP AND PREP TRAY
* DERMABOND
* (2) FLUORO DRAPES (FOR LATERAL BASE AND ANESTHESIA POLE)
* 36X36 BANDBAG (FOR LATERAL DETECTOR)
* 1L HEP SALINE ON PRESSURE BAG HUNG FROM IVY POLE


= MEDICATIONS =
==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


* BUPIVACAINE/LIDOCAINE MIX
* EPINEPHRINE 10MCG/ML IN RED SYRINGE ON BACK TABLE
* ROTAGLIDE 10ML (PRE VALVE)


= STANDBY EMERGENCY ECMO SUPPLIES =
[[Category:Procedures]]


* 16F ARTERIAL CANNULA
<HR />
* 21F VENOUS CANNULA
APPROVED: MD initials MM/YY
* (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
 
= STANDBY PARAVALVULAR LEAK REPAIR SUPPLIES =
'''SEE MITRAL PARAVALVULAR LEAK REPAIR'''
 
* AMPLATZER VASCULAR PLUG 2 SIZE 8-18 AVAILABLE
 
= PROCEDURE: =
 
* Patient prepped from '''navel to knees''' in sterile fashion.  
* ISOCENTER XRAY
* Access obtained with u/s
 
Typical sites:
 
*** 6F LFA for Pigtail
*** 8F 35cm LFV for transcutaneous pacing
*** 20F RFV E-sheath for valve delivery
**** Dilate with 8F
**** Preclose
* Pigtail advanced through 6F sheath and LVgram performed
* Mitral annulus denoted on live monitor screen in A plane
* SL1 inserted over .032 kit wire
* Baylis needle inserted through SL1 and atrial septum puncture performed.
* Needle removed
* 5F MPA and standard J wire advanced to pulmonary vein
* 1cm Amplatz Super Stiff advanced and MPA and SL1 removed
* Edwards Guide Sheath (GS) advanced
* Dock Delivery System (DDS) advanced through GS
* Dock deployed in a timely fashion ;)
* DDS removed and MPA inserted over exchange  J for valve crossing
* J wire exchanged for Safari 2 and MPA removed
* 14mm balloon advanced for septostomy
* Balloon and GS removed
* Valve delivery system advanced
* When valve is in place, temp pacer inserted and tested.
* Valve deployed. Septum evaluated with echo for shunting and PVL.
* Delivery system removed and MPA inserted for LA pressure measurement.
* All equipment removed
* Preclosure closed and stitch to RFV
* Perclose LFA
* 8F vein exchanged for 9F 10cm sheath
* Secure sheath with Statlock. Tegaderm both sides.
 
Did you notice we wrote IVY pole instead of IV? Delirious.
 
The End.

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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