TEER with MitraClip

Anesthesia	Imaging	Access
General	Fluoro, TEE	4F Femoral Vein for drawing ACT's **If functional MR/low EF Anesthesia to obtain A line and femoral vein sheath not necessary.
Pre Procedure Watchouts
** Tidal volume during time-out!

Protip: When using the PDOII plug In MitraClip setting use TorqView 180 (smaller cable needed)

Charges: MITRAL CLIP (Mitral/Tricuspid):

1. Use the device set "CL ITEMS NOT SCANNING"– Mitraclip Bundle G4

Big Equipment:

• Cath pack
• Lift / Footstool / Support base
• Clear Plexiglass base support
• Sterile System Stabilizer
• Baylis generator

Baylis Transseptal:

• SL1 TransSeptal sheath
• Large curve Baylis needle
• Baylis cable
• Grounding pad

Wires:

• .032 X 260 “J” wire
• Amplatz SuperStiff 1cm Tip 260cm

Catheters:

• 5F MPA2

Misc supplies:

• 4fr. Pinnacle sheath for ACT (not needed if anesthesia has an A line.)
• Micropuncture
• 8F Sheath for dilator only
• 20F Dilator
• (2) 108cm High pressure IV Lines
• (5) Stopcocks
• (1)Perclose (If Spies is primary, NO perclose if Daniles is primary.)
• 0-prolene Suture for woggle
• (2) 60cc syringe
• (2) 12” extension (Keep stickers to label flush tubing)
• Sterile towel pack for back table
• Naked 3-port manifold to measure LA pressure only
• Fluoro cover to anesthesia IV pole or moving xray shield
• U/S probe cover

Standby:

• 20fr. DrySeal for recovering wire to LUPV
• Additional Perclose
• Pericardiocentesis supplies
• 8x40 135cm Mustang balloon
• 12fr. Short Cook sheath
• Presto indeflator

Non-Sterile Supplies:

• (2) Liter bags of heparinized saline
• (2) Liter sized pressure bags

Procedure

• Anesthesia will obtain radial art line prior to draping.
• Pre procedure TEE imaging performed

• Prior to prepping patient, place MitraClip Plate (plexiglass board – hinge side up) under patient’s leg off center to the right. Place MitralClip Lift (step stool) over patients right leg, angled down towards the head. Measure 75cm from subxyphoid to leading edge of stool. Make sure there is direct contact between stool and plate.

• Prep patient and drape per usual. Drape anesthesia pole and/or xray shield.
• Obtain RFV access, dilate with 8F, preclose. .032 wire inserted into perclose.
• SL1 introduced over .032 wire.
• Baylis needle inserted and echo imaging performed. Transseptal puncture performed.
• Baylis needle removed. .032wire inserted. Dilator removed
• MPA advanced over the wire to pulmonary vein. LA pressure measured. Give MD Amplatz SuperStiff to shape.
• Amplatz SuperStiff advanced.
• MPA removed.
• SL1 removed
• 20F dilator inserted and removed
• MitraClip Guide inserted.
• Setup stabilizer and silicone sheet. Hand MD 60ml syringe with short extension tubing for aspiration.
• Amplatz wire and dilator removed. Clip inserted.
• Drips should be maintained at 1 drip every 3 seconds. If bubbles are seen on echo, turn drips down.
• When clip is being deployed turn room lights up and drips up. Place bowl below to catch drips while deploying.
• Hand MD 60ml syringe with extension tubing for aspiration while delivery system is removed.
• LA pressure measured. Set up for subsequent clips if needed.
• Vicryl used for groin closure.

BACK TABLE SETUP

• 108" Tubing spikes handed off to circulator, keep rollers on sterile field.

• Follow Rep instructions for device prep.

Prep instructions;

• Guide Prep: -Remover both protective covers from the end of the guide. -Place a stop cock on the dilator flush port and ensure the tuohy is closed. -Attach a syringe to the dilator stop cock, flush side port then flush forward with the tip underwater until bubbles stop. With your finger over the end of the dilator, open up the tuohy and flush back. Close the tuohy. Remove your finger from the tip of the dilator and flush forward since more, ensuring no bubbles. Place your finger back over the tip of the dilator and turn off the stopcock to the device. -Insert the dilator into the back of the guide ~10cm to break the seal. Then take out and place to the side. -Place a stopcock on the back of the guide and attach a 50-60cc syringe with a short extension tubing attached. Flush side port, then flush forward with the tip of the guide in the air. Once water comes out the end, place finger over the end and turn the stop cock off. Now with your finger still over the end, invert the guide so that the blue handle is in the air and the tip is submerged underwater. Remove your finger. Confirm there are no large bubbles in the guide flush port. -With the tip of the guide still submerged in the water, insert the dilator into the back of the guide until the dilator comes out the back end with a smooth transition. -Add half a turn of negative to the guide. Clip Prep: -Orient the handles so that the black fin faces the ground and the black fastener faces the ceiling. -Replace the red cap with a stop cock and set the red cap aside. Flush the side port, flush forward, turn stop cock off to the device. -Secure the clip over a bowl of saline. -Attach both of your lines to the device. First one goes in the middle facing away from you. Second goes on the bottom of the handle. Turn your middle line on. Flush side port, flush forward. Loosen the black fastener and advance and retract your handle ten times. Leave handle fully advanced. Secure the black fastener. Turn on your second line. Flush the side port, flush forward. Once the clear handle cavity is full attach the red cap. -Retract and advance the lock line 3 times back and forth to the blue line. Leave it in the locked position. -Burp the lock line cap. Close it to finger tight. -Raise grippers. -Unlock the clip. -Lower grippers. -Close the clip to 60 degrees. -Lock the clip. -Close the clip fully. -Open the clip to neutral. -One full revolution in the open direction. -Confirm the clip did not open. -Close the clip to neutral. -Raise grippers. -Unlock clip. -Invert the clip. -Lock the clip. -Close the clip fully. -Lower grippers. -Torque and translate the handle. Leave handle fully retracted. -Load the clip into the blue introducer. -Return the handle to neutral. -Cut off the bag enclosing the clip.