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


*5Fr Micropunture  Kit  
*5Fr Micropunture  Kit  
*6Fr x 10cm sheath
*6Fr x 10cm sheath
*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
*Safari Wire (DANIELS & SPIES)
*Amplatz Extra Stiff 1cm tip (GROVES)
*Terumo Stiff Straight Glidewire 0.035 x 150 cm
*Terumo Stiff Straight Glidewire 0.035 x 150 cm
*''CORE VALVE'' - Safari 2 Wire used instead of Amplatz ES
*.035 Standard Straight for Valve-in-Valve crossing, no need for glidewire.
*Acist hand control
*(3) Perclose
*A extension line from anesthesia (Venous extension only if we are doing bipolar pacing)
*5Fr AL1 diagnostic 
*(2) 5Fr Ang Pigtail
**'''Valve-in-valve: Mosaic needs pigtail, all others do not.'''
*6Fr JL4/JR4 (when doing coronary angiography)
*Exofin topical adhesive
*NuKnit for closure


===Catheters:===
=== Unipolar Transvenous pacing supplies (Daniels preference) ===
 
* Alligator Clip Remington Pacing Cables
* TZ Medical Defibrillation Pads - Found in EP pyxis in labs. Large pad utilized as a grounding pad on the patients chest (subxyphoid)
 
{{Protip|For patients with AI you don't need the Glidewire or AL1. Use second pigtail to cross. }}


*5Fr AL1 diagnostic 
*5Fr Ang Pigtail
*5Fr JL4/JR4 (when doing coronary angiography)
*''CORE VALVE'' - 5Fr Str Pigtail in addition to catheters listed above


===Medications on table:===
===Medications on table:===
Line 39: Line 41:


*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


===Miscellaneous Supplies===
===Edwards:===


*Daniel’s TAVR 3-port manifold kit
*Crimper
*Acist hand control
*Indeflator
*25g  1 ½ “ Daniels Lido Needle"
*Appropriate delivery system and valve
*Suture Lock
 
*(4) Sterile Bowls
===Standby ECMO & Pericardial Effusion supplies===
*¾ sterile sheet or back table cover
 
*(2) High Pressure stopcocks
=== Sentinel: ===
*(2) 60ml syringe
* Grandslam 300cm
*20 ml syringe
* 5/6 Slender
*(3) Perclose
* 2.5 Verapamil
*''CORE VALVE'' - 2L cold NS, DO NOT NEED: 4 sterile bowls,  
* 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'''''
 
* Patient on defib pads.  IF PATIENT HAS ICD: DEVICE DISABLED FOR PROCEDURE, COMPANY REP PRESENT IF POSSIBLE.
 
* Leg strap secured above knees. Wrists restrained.
* Patient prepped from naval to mid thigh using chlorahexidine soap followed by chloraprep with 3 minute dry time.
* 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.
* U/S guidance for groin access
 
'''BACK TABLE'''- valve prep
 
* 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%)
* 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'''
 
*Contralateral arterial access - 6fr. Sheath (normally LFA) using 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.
**8F sheath reconstituted and advanced after pre-closure.
 
*Pigtail -> LFA -> 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 ->  Pigtail pulled back -> 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 pulled back to iliac bifurcation and subtracted iliac angio performed (6/18 on Acist)
*Pigtail removed
*Secondary access Perclose
*Exofin all access sites, no dressing needed.
 
== ''THE SPIES TAVR EXPERIENCE'' ==


===Transvenous pacemaker supplies===
====Equipment: ====


*5Fr Josephson Pacing catheter
* 5Fr Micropunture  Kit  
* 6Fr x 10cm sheath
* 8Fr x 10 cm sheath
* 8Fr x 35 cm Brite Tip Sheath
* (2) Cordis 150J
* Cordis 260J
* 2 Perclose
* 2 Pigtails
* Straight steel .035 wire (NO straight stiff glide)
* Amplatz ES for sheath advancement
* Safari
* 5F Abbott Pacel Balloon Flow Directed Tip Pacing catheter for CS
*Dual Red/Black Pacing Remington cables
*Dual Red/Black Pacing Remington cables
*EP Quad Cable
*EP Quad Cable


===Standby ECMO & Pericardial Effusion supplies===
====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
* 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<br />
===PERIPHERAL BAILOUT EQUIPMENT===


===EMERGENT PERICIOCENTESIS===
* ''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 />
<hr/>
Approved: MM/YY
Approved: MM/YY
[[Category:Procedures]]
[[Category:Procedures]]

Latest revision as of 16:49, 1 November 2024

Transcatheter Aortic Valve Repair (Wikipedia)

Daniels

ACIST A1000V SYRINGE USED WITH 50/50 CONTRAST MIX

Equipment :

  • 5Fr Micropunture  Kit  
  • 6Fr x 10cm sheath
  • 8Fr x 10 cm sheath
  • (2) Cordis 150J
  • Cordis 260J
  • Safari Wire (DANIELS & SPIES)
  • Amplatz Extra Stiff 1cm tip (GROVES)
  • Terumo Stiff Straight Glidewire 0.035 x 150 cm
  • .035 Standard Straight for Valve-in-Valve crossing, no need for glidewire.
  • Acist hand control
  • (3) Perclose
  • A extension line from anesthesia (Venous extension only if we are doing bipolar pacing)
  • 5Fr AL1 diagnostic 
  • (2) 5Fr Ang Pigtail
    • Valve-in-valve: Mosaic needs pigtail, all others do not.
  • 6Fr JL4/JR4 (when doing coronary angiography)
  • Exofin topical adhesive
  • NuKnit for closure

Unipolar Transvenous pacing supplies (Daniels preference)

  • Alligator Clip Remington Pacing Cables
  • TZ Medical Defibrillation Pads - Found in EP pyxis in labs. Large pad utilized as a grounding pad on the patients chest (subxyphoid)

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

  • Patient on defib pads. IF PATIENT HAS ICD: DEVICE DISABLED FOR PROCEDURE, COMPANY REP PRESENT IF POSSIBLE.
  • Leg strap secured above knees. Wrists restrained.
  • Patient prepped from naval to mid thigh using chlorahexidine soap followed by chloraprep with 3 minute dry time.
  • 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.
  • U/S guidance for groin access

BACK TABLE- valve prep

  • 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%)
  • 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

  • Contralateral arterial access - 6fr. Sheath (normally LFA) using 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.
    • 8F sheath reconstituted and advanced after pre-closure.
  • Pigtail -> LFA -> 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 -> Pigtail pulled back -> 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 pulled back to iliac bifurcation and subtracted iliac angio performed (6/18 on Acist)
  • Pigtail removed
  • Secondary access Perclose
  • Exofin all access sites, no dressing needed.

THE SPIES TAVR EXPERIENCE

Equipment:

  • 5Fr Micropunture  Kit  
  • 6Fr x 10cm sheath
  • 8Fr x 10 cm sheath
  • 8Fr x 35 cm Brite Tip Sheath
  • (2) Cordis 150J
  • Cordis 260J
  • 2 Perclose
  • 2 Pigtails
  • Straight steel .035 wire (NO straight stiff glide)
  • Amplatz ES for sheath advancement
  • Safari
  • 5F Abbott Pacel Balloon Flow Directed Tip Pacing catheter for CS
  • Dual Red/Black Pacing Remington cables
  • EP Quad Cable

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
  • 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

Approved: MM/YY

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