Valve in MAC with Antegrade Lampoon

GENERAL ANESTHESIA AND TEE IMAGING, RADIAL ART LINE BY ANESTHESIA

PRE PROCEDURE: TYPE AND CROSS, ASPIRIN GIVEN

MAC- Mitral Annular Calcification

[1]

Per Rosalie:

TAVR/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 charge separately.  Scan all barcodes (delivery system, loading system and valve).

Access sites:

• 26F RFV (For transeptal equipment) (No need for E-Sheath)
• 8F LFV (For pacer)
• 8F LFA(For IABP)
• 6F RFA (For JR4 Guide)
• 6F RRA (For Sentinel)

Supplies:

Open:

FROM STRUCTURAL HEART CART

• .014 Astato xs 20 guidewire 180cm for ALEGRA; 300cm for standard
• Piggyback wire converter 4fr x 145 (or finecross, confirm)
• 26F Dryseal
• 14mm Armada Balloon
• SL1
• Baylis Needle
• Bovie pen
• Grounding Pad

MISC SUPPLIES

• (3) Watchdog devices
• (3) Stopcocks
• 4 hemostats
• (3) 60ml syringes
• (2) 12 inch extension tubing
• Extra bowl for D5
• (2) Agilis SM Curl
• Priority Pack
• Balloon Pump

FROM STORE ROOM

• 8F 35cm Brite Tip Sheath
• Josephson Pacing Wire
• Remington Cable
• Blue Pacing Cable
• Sentinel- opened after grandslam wire across great vessels

FROM ROOM SUPPLIES

• 6F PA Catheter
• 260cm Angled Glidewire
• (2) .032 260cm J wire
• .035 260cm J wire
• .035 150cm J wire
• 300cm Grandslam
• 300 cm Runthrough wire
• Safari
• Amplatz SS 1cm
• 8F Sheath
• (2) 6F JR4 Guide
• 6F JL3.5 Guide
• 5F MPA1
• 6F Straight Pigtail
• 5/6 Slender Sheath
• 25mm Gooseneck snare (Able to utilize this snare for both wire grasps)
• Preclose x 4
• 0-Ethibond
• 0-Prolene
• TR-Band

Standby:

• 12F Flexcath
• 6F MP Guide
• 8F 90cm Shuttle sheath and 125cm Pigtail for measuring gradient post valve placement
  

Rough Procedural Plan:

Obtain access as listed above.

After radial access Grandslam advanced to determine if Sentinal can be utilized. Grandslam removed until all access are obtain.

Preclose LFA x 1 and 8F sheath inserted for IABP

Preclose RFV x 2 and dryseal inserted over super stiff wire

6F Pigtail advanced for arch shot (20 for 20) for sentinel.

Grandslam and Sentinal advanced. Pigtail removed after sentinel in position.

Balloon pump advanced.

SL1- transeptal puncture

Exchange SL1 for two .032 wires

Agilis x 2 inserted

6F PA floated through one of the Agilis over runthrough

6F JR4 with ensnare inserted through LFA. Runthrough snared in LV.

PA catheter removed and 6F JL3.5 advanced over snared runthrough

6F JR4 through other agilis.

Lampoon equipment advanced through 6F JR4

25mm Gooseneck snare through JL3.5 next to runthrough

(if ballooning leaflet for LVOT obstruction make sure "flying-V" isn't added to wire until after 5.0 x 20 compliant balloon is utilized)

Anterior leaflet traversed.-- Test bovie at 30 cut. Increase to 70 cut for traversal and laceration.

After leaflet traversal and system snared- 7F guide and Runthrough removed.

Pacer inserted.

Leaflet lacerated.

Lampoon system deconstructed. (May need SL1, 032 wire and agilis to regain transeptal access; so quickly reprep one agilis)

Pigtail advanced with Safari

Pigtail out.

Septostomy

Valve inserted and deployed.

Pigtail for wire exchange

If a post deployment gradient is needed, balloon pump will be removed and short 8F sheath exchanged for 8F 90cm shuttle sheath. 125cm pigtail inserted to LV. 2nd manifold needed.

*ECMO??

*Possible ASD Closure