Valve in MAC with Antegrade Lampoon

Valve in MAC with Antegrade Lampoon
Anesthesia	Imaging	Access	ACIST/manifold
General L Radial art line	Fluoro and TEE	26F RFV (For transeptal equipment) (No need for E-Sheath) 8F LFA(For IABP and Pigtial for arch shot) 6F RRA (For Sentinel)	One manifold with contrast
Pre-Procedure Watchouts
PRE PROCEDURE: TYPE AND CROSS, ASPIRIN GIVEN

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 LFA(For IABP and pigtail for arch shot)
• 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
• Sentinel- opened after grandslam wire across great vessel

FROM ROOM SUPPLIES

• 6F PA Catheter
• (2) .032 260cm J wire
• .035 260cm J wire
• .035 150cm J wire
• 300cm Grandslam
• 300 cm Runthrough wire
• Safari
• Amplatz SS 1cm
• (2) 8F Sheath
• 5/6 Slender Sheath
• (2) 6F JR4 Guide
• 6F JL3.5 Guide
• 5F MPA1
• 6F Straight Pigtail
• 25mm Gooseneck snare
• Preclose x 2
• 0-Ethibond
• 0-Prolene on a Ct-1 Needle for Woggle
• TR-Band

Standby:

• 12F Flexcath
• 6F MP Guide
• 8F 90cm Shuttle sheath and 125cm Pigtail for measuring gradient post valve placement Standby Items FROM STORE ROOM
  • 8F 35cm Brite Tip Sheath
  • Josephson Pacing Wire
  • Remington Cable
  • Blue Pacing Cable

Rough Procedural Plan:

1. Obtain access as listed above.
2. After radial access Grandslam advanced to determine if Sentinal can be utilized. Grandslam removed until all access are obtain.
3. Preclose LFA x 1 and 8F sheath inserted for IABP
4. Preclose RFV and dryseal inserted over super stiff wire
5. 6F Pigtail advanced for arch shot (hand injection with manifold, NO DSA) for sentinel.
6. Grandslam and Sentinal advanced. Pigtail removed after sentinel in position.
7. SL1- transeptal puncture
8. Exchange SL1 for two .032 wires
9. Agilis x 2 inserted
10. 6F PA floated through one of the Agilis over runthrough
11. 6F JR4 with ensnare inserted through LFA. Runthrough snared in LV.
12. PA catheter removed and 6F JL3.5 advanced over snared runthrough
13. 6F JR4 through other agilis.
14. Lampoon equipment advanced through 6F JR4
15. 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)
16. Anterior leaflet traversed.-- Test bovie at 30 cut. Increase to 70 cut for traversal and laceration.
17. After leaflet traversal and system snared- guide and Runthrough removed.
18. Balloon pump advanced.
19. Leaflet lacerated.
20. Lampoon system deconstructed. (May need SL1, 032 wire and agilis to regain transeptal access; so quickly reprep one agilis)
21. Pigtail advanced with Safari
22. Pigtail out. Unipolar pacing tested.
23. Septostomy.
24. Valve inserted and deployed.
25. Pigtail for wire exchange
26. 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