TTVR

Sheaths:[edit | edit source]

8Fr x 10 cm sheath (Dilator used only)

Wires[edit | edit source] Cordis 260J 1 cm Tip Amplatz Extra Stiff 260cm

Catheters:[edit | edit source] 6Fr Ang Pigtail

Medications on table:[edit | edit source] Lido/Bupivicaine 50/50 Epinephrine 10mcg/ml in red medallion syringe (From anesthesia) 10 ml Rotaglide

Miscellaneous Supplies[edit | edit source] (4) Sterile Bowls Back table cover High Pressure stopcock 60ml syringe 20 ml syringe (1) Perclose Fluoro cover

Transvenous pacemaker supplies[edit | edit source] 5Fr Josephson Pacing catheter Dual Red/Black Pacing Remington cables EP Quad Cable

Standby ECMO & Pericardial Effusion supplies[edit | edit source]

Procedure[edit | edit source]

SEE BELOW FOR STEPS SPECIFIC TO SPIES

Patient on defib pads. IF PATIENT HAS ICD: DEVICE DISABLED FOR PROCEDURE, COMPANY REP PRESENT IF POSSIBLE. 

Leg strap secured above knees. Wrists restrained.

Patient prepped from naval to mid thigh using chlorahexidine soap followed by chloraprep with 3 minute dry time.

Towel off site. Extend Femoral drape all the way to chin.

Fluoro cover used to drape anesthesia's IV pole/x-ray shield.

Extension tubing for anesthesia flushed and secured on respecitve sides of the groin .

Dual pressure lines primed and zeroed prior to case start.

FRONT TABLE

50/50 Lido and Bupivicaine mix used for local anesthetic. Have extra available on front table.

100% contrast available on table. (May need for hand injection or for peripheral balloon prep)

10ml of Rotoglide on table (for E sheath just prior to valve insertion)

10ml syringe of 10mcg/ml taped on table.

U/S guidance for groin access

BACK TABLE- valve prep

4 Bowls: (2) Normal Saline (1) Hep Saline (1) 30ml contrast, 170ml Hep Saline mix (15%) 

60ml Syringe with contrast mixture for balloon prep

20ml Syringe for flushing delivery system

Indelator: volume dependent upon valve size

Crimper

Hemostats and scissors for valve opening

PROCEDURE STEPS Contrlateral 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 Double preclose. Each perclose suture secured with hemostat. After second perclose Amplatz ES is inserted using micropuncture sheath as a cheater

Venous access- 8F 35cm brite tip over 150cm J wire. (Same side as TAVR sheath) Esheath sutured with 0-Ethibond Pigtail -> LFA -> AO root injection Standard Injector settings (adjusted based on pt and root size) 10/10 20mm valve

15/15 23mm and 26mm valve

20/20 29mm valve 

Insert and test pacemaker Rapid pace 160, check for capture, 220 burst

AL1 advanced through E sheath over Amplatz ES Amplatz ES removed and crossing wire advanced. Cross valve. Wire removed. Measure gradient Amplatz ES shaped by MD and advanced to LV. AL1 removed. 8fr. Dilator or micropuncture sheath on Amplatz ES as a cheater

Rotoglide in sheath. 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

if post dilation is needed...

Rep will come up and re-prep valve, adding desired amount of additional volume

If Amplatz ES was pulled back, recross wire will be needed (260cm straight stiff glide) Pigtail readvanced to AO for AO gram (15/30 standard injection) Amplatz ES exchanged for 260 J Temp paver removed Delivery system removed Have 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 Pigtail removed Secondary access Perclosed Venous sheath exchanged for 9fr. Sheath 10cm sheath -> suture-locked

EMERGENT PERICARDIOCENTESIS[edit | edit source]

Call Echo

Supplies:[edit source]

Emergency Kit located in each lab containing the following items: Eye drape Chiba biopsy needle 10cm 18g Skater introducer set Bard locking pigtail (6f or 8f) (3) 60ml luer lock syringe Standard .035 150cm j wire Amplatz super stiff .035 180cm wire Probe cover Stopcock Accordion drainage bag