Valve in MAC with Antegrade Lampoon
GENERAL ANESTHESIA AND TEE IMAGING, RADIAL ART LINE BY ANESTHESIA
OVERLAY FOR SENTINEL
PRE PROCEDURE: TYPE AND CROSS, ASPIRIN GIVEN
MAC- Mitral Annular Calcification
https://www.jtcvs.org/article/S0022-5223(18)31545-9/pdf
Per Rosalie:
TAVR/TMVI
- 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 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)
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
Bowl of 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
(1) .035 260cm J wire
(1) .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 utilized 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
