TAVI - CoreValve (Medtronic)

Transcatheter Aortic Valve Repair (Wikipedia) procedures utilize a femoral approach to deliver a stent-based aortic valve to the patients heart. There are two valve types available:

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Loading Instructions

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• CoreValve by Medtronic - This page
• Sapien 3 Ultra by Edwards - Sapien 3 procedure page

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.

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.

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).

Daniels/Spies - Draft

ACIST A1000V SYRINGE USED WITH 50/50 CONTRAST MIX

Sheaths:

• 5Fr Micropunture Kit
• 6Fr x 10cm sheath
• 8Fr x 10 cm sheath
• 8Fr x 35 cm Brite Tip Sheath
• SHEATHLESS INLINE DELIVERY: 18F coons dilator and 14F Cook sheath post.

• 18fr Dryseal if sheath delivery system is used. (Do not open until confirmed during timeout)

Wires

• (2) Cordis 150J
• Cordis 260J
• Amplatz SS 1cm tip
• Terumo Stiff Straight Glidewire 0.035 x 150 cm

Catheters:

• 5Fr AL1 diagnostic
• 5Fr Ang Pigtail
• 5Fr Str Pigtail
• 6Fr JL4/JR4 (when doing coronary angiography)

Medications on table:

• Lido/Bupivicaine 50/50

• Epinephrine 10mcg/ml in red medallion syringe (From anesthesia)

Miscellaneous Supplies

• Acist hand control
• 2L cold saline
• (3) Perclose
• Spies 22G Grey Lido Needle
• 5Fr Josephson Pacing catheter for DD ; 5F Abbott Pacel Balloon Flow Directed Tip Pacing catheter for CS
• Dual Red/Black Pacing Remington cables
• EP Quad Cable

Unipolar Transvenous pacing supplies(Unlikely)

• 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 : If patient is in second degree HB please prep RIJ possible

PROCEDURAL INFO:

• 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
  • Leave micropuncture wire in while venous access is obtained
  • Once venous sheath is in place, dilate tract with 8F dilator
  • Pre-close x 1, sutures secured with hemostat.
  • 8F sheath reconstituted and advanced after pre-closure.

• Venous access- 8F 35cm brite tip over 150cm J wire. (Same side as TAVR sheath)
• Straight Pigtail -> LFA -> AO root injection
  • Standard Injector settings (adjusted based on pt and root size)

5/5 on Acist

• Insert and test pacemaker
  • Rapid pace 160, check for capture, 220 burst
• AL1 advanced through 8F sheath over standard J.
• Standard J removed and crossing wire advanced. Cross valve. Wire removed.
• Measure gradient...maybe
• Safari advanced to LV. AL1 removed.
• 8F sheath removed and 18 F dilator in and out OR 16 F dryseal advanced depending if doing in-line or not.
• Insert valve delivery system
• Multiple AO grams for positioning
• Pace -> AO gram -> Pigtail pulled back -> Deploy valve
  • Cine length set at 40 seconds or more
• TTE
• Pigtail advanced to remove Safari from LV

• Pigtail readvanced to AO for AO gram (15/30 standard injection)
• Temp pacer removed
• Delivery system removed and 14F sheath advanced.
  • 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 (20/20 on Acist)
• Pigtail removed
• Secondary access Perclosed
• Venous sheath removed in lab and manual pressure held until hemostasis achieved.
• Dermabond all access sites, no dressing needed.

** Put stopcock on sideport of delivery system for DD cases **

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Approved: MM/YY