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Daniels


Transcather Mitral Valve Replacement
{{Protip|Need Alcohol in lab for this procedure!}}


'''GENERAL ANESTHESIA AND TEE IMAGING'''
'''TransCatheter Mitral Valve Insertion'''


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


'''PRE PROCEDURE: TYPE AND CROSS, ASPIRIN GIVEN'''
TMVI


= SHEATHS: =
#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).


* (1) 5F MICROPUNCTURE KIT
MITRAL CLIP (Mitral/Tricuspid):
* (1) 5F 10CM SHEATH
*** '''OR''' 6F IF CORONARY IMAGING NECESSARY
* (1) 8F 10CM SHEATH
* (1) 8F 35CM BRITE TIP SHEATH
* (1) 9F 10CM SHEATH
* (1) 8.5F 63CM SL1 TRANSSEPTAL SHEATH
* (1) 8.5F AGILIS SMALL CURL


= WIRES: =
#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


== '''Open''' ==
* A-Line Always!
|
* Single Plane Fluoro


* (2) .035 150CM J WIRE
* TEE
* (1) SAFARI 2 WIRE


== '''Standby''' ==
* No Acist
* Unipolar pacing
|


* .035 260CM J WIRE
* RVF pre-closed x 1
* AMPLATZ SUPER STIFF 1CM TIP
|
* SUPRACORE 190CM
* Type and Cross


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


== '''Open''' ==
*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.


* 6F STRAIGHT PIGTAIL 110CM
=== Wires: ===
*150 J wire
*Safari 2


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


* 6F LANGSTON
=== Misc: ===
* 5.2F ANGLED PIGTAIL
*Naked 3 Port Manifold
* 5F MPA
*Alligator pacing cable
* 5F JL4 AND JR4 (FOR CORONARIES)


= PACING =
=== Catheters: ===
*6fr. Straight Pig


* 5F JOSEPHSON PACING CATHETER
=== Septal dilation: ===
* EP QUAD CABLE
*12X4X75 Mustang ''' for 23mm and 26mm Sapien''' or 14mm Armada '''for 29mm Sapien'''
* DUAL RED/BLACK REMINGTON PACING CABLE
*Presto indeflator
* (2) PACER BOXES


= VALVE TABLE =
===Edwards valve:===
*Indeflator (Second Indeflator on standby)
*Crimper
*E-sheath (Second E-Sheath on standby)
*Delivery system (Second delivery on standby)
*Valve


* (4) STERILE BOWLS (2- 0.9% SALINE, 1-HEP SALINE, 1-15% CONTRAST MIX)
==Standby==
* (1) 90 INCH DRAPE (OR)
* 1L NORMAL SALINE IRRIGATION
* 500ML HEPARINIZED SALINE
* (1) 60ML SYRINGE
* (1) HIGH PRESSURE STOPCOCK
* (1) 20ML SYRINGE
* 30ML CONTRAST (MIX WITH 170ML HEP SALINE FOR 15% CONCENTRATION)


== '''FOR EDWARDS VALVE''' ==
===Septal procedure:===
*9X4X75 Mustang
*14, 16 XXL Balloons
*Torqueview 45° delivery system (9fr. or 10fr.)
*10mm, 14mm, 18mm septal occluder


* INDEFLATOR
===Baylis Standby===
* CRIMPER
*SL1 sheath
* E SHEATH
*Large curve Baylis needle
* DELIVERY SYSTEM
*Baylis cable
* VALVE
*0.32 x 260 J-wire


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


* BAYLIS NEEDLE LARGE CURVE C1
* BAYLIS MACHINE
* BAYLIS CABLE
* GROUNDING PAD


= SEPTAL DILATION =
==Medications for table==


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


* 12X4X75 MUSTANG '''OR''' 14X4 XXL BALLOON (FROM IR)
==Procedure:==


''SIZE DEPENDENT ON VALVE- CHECK WITH DANIELS BEFORE OPENING''
*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.


* PRESTO INDEFLATOR


== '''Standby''' ==
==ECMO Standby:==
*16fr. vented arterial cannula
*21fr. venous cannula
*Perclose x 2
*ECMO instrument tray
*180 Amplatz Super Stiff wire


* 9X4X135 MUSTANG
==Pericardiocentesis standby==
* TORQUEVUE 45DEGREE DELIVERY SYSTEM (9F OR 10F)
*Eye drape
* 10MM, 14MM, 18MM SEPTAL OCCLUDER
*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


= ADDITIONAL SUPPLIES =


== '''Open''' ==
[[Category:Procedures]]


* (2) PERCLOSE
<HR />
* 3 PORT MANIFOLD  
APPROVED: MD initials MM/YY
* ACIST- FULL STRENGTH CONTRAST OK
* PROBE COVER
* DUMP BAG
* 25g 1½ INCH NEEDLE
* STAT LOCK WITH STRING SECUREMENT
* PROLENE 2-0
* TAVR INSTRUMENT TRAY
* CHLORAPREP AND PREP TRAY
* A LINE TUBING AND VENOUS EXTENSION FOR ANESTHESIA
* DERMABOND
 
== '''Standby''' ==
 
* 150ML CONTRAST (FOR CORONARIES)
* BIOPATCH
* FLUORO DRAPE
* 8F ANGIOSEAL
* 0 SILK SUTURE
* EXTRA PERCLOSE
 
= MEDICATIONS =
 
* 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.  
* Access obtained with u/s
 
Typical sites:  
 
*** 5F LFA for anesthesia monitoring
*** 8F 35cm LFV for transcutaneous pacing
*** 14F OR 16F RFV E-sheath for valve delivery
**** Dilate with 8F
**** Preclose
* SL1 inserted over .032 kit wire
* Baylis needle inserted through SL1 and atrial septum puncture performed.
* Needle removed, .032 wire advanced to pulmonary vein
* 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
* Balloon removed, valve delivery system advanced.
* When valve is in place, temp pacer inserted and tested.
* Valve deployed. Septum evaluated with echo for shunting.
* Pacer removed. Delivery system removed.
* Preclosure closed and stitch to RFV
* Perclose LFA
* 8F vein exchanged for 9F 10cm sheath
* Secure sheath with Statlock. Tegaderm both sides.

Latest revision as of 16:05, 7 January 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

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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