Barts TAVI procedure

Transcatheter Aortic Valve Implantation (TAVI) is a means of replacing a

diseased aortic valve in the heart through a catheter-based approach rather than the

conventional approach of open heart surgery. Surgical aortic valve replacement

(AVR) is a major operation that requires that patients have a reasonable level of

fitness to survive, and benefit from, the procedure.

The TAVI procedure is an elective one that requires detailed assessment of the

patient and agreement from a multidisciplinary team (MDT) in a cardiac centre that a

patient is appropriate for TAVI.

BARTS TAVI

SCRUB TROLLEY kits:

4F, 10F Femoral Sheath

6F Radial Sheath

5F Pigtail Catheter (125cm length)

6F Pigtail Catheter (100cm length)

5F AL1 Catheter (100cm length)

Safari Wire

1 Proglide

1 8F Angioseal

2 5ml Syringe

1 10ml Syringe

FOR JENAVALVE (bifemoral access) + RIJV (for temporary pacing):

18Fr COOK Sheath 30cm

6Fr femoral sheath

6Fr MPA1 diagnostic catheter

Big Trolley:

Frozen saline bag x 2

Extra big bowl for valve rinsing

Heparinised saline (500ml) on pressure (IV pole) (like mitraclip setup)

Y-connector (hemostasis valve) + extension

Sterile drip set (like mitraclip setup)

20ml 1% Lidocaine

10ml Heparin

1:1000 Adrenaline

VALVE PREP TROLLEY:

3-way tap

60mL luerlock syringe (for de-airing)

30mL luerlock syringe (for flushing)

Contrast 15mL/Saline 85mL

A pair of Scissor and forceps (borrow from small trolley)

2 Bowls of Saline for soaking valve (minimum of 1 minute each bowl)

PROCEDURAL STEPS:

(If narrow QRS, pacing through Safari wire. If broad QRS, [high risk of complete heart block post procedure] anaesthetist will insert 5Fr sheath via RIJV for temporary pacing).

4Fr femoral sheath to Right Femoral Artery (RFA)

6Fr radial sheath to Right Radial Artery (RRA)

Femoral shots to check : of sheaths

RRA (right radial artery access):

Insert 5F pigtail (with 260cm wire) through 6Fr RRA sheath and position in the aortic root (will be used for Aortogram shots and hemodynamic monitoring)

RFA (right femoral artery access):

In RFA, Insert 150cm guidewire then remove 4Fr sheath and insert 8F angioseal to measure the depth, then remove

Insert the proglide and preclose

Insert 10Fr sheath and give heparin

Introduce 6F pigtail catheter through 10Fr sheath and position in the aorta

Remove guidewire and replace with SAFARI wire (stiffness of safari provides support for the insertion of 14fr E-sheath)

Remove pigtail catheter as well as 10Fr sheath but leave safari wire in place

Insert 14Fr Edwards E-Sheath to the RFA

Introduce 5Fr AL1 catheter to the E-sheath and remove Safari wire, and replace with...

150cm guidewire (straight end first)

Once across the aortic valve, Remove the 150cm guidewire and replace with long exchange wire (260cm)

Remove 5Fr AL1 and replace with 6Fr pigtail catheter

Remove long exchange wire (260cm) and replace with Safari wire

Remove 6Fr pigtail catheter but leave safari wire in LV

Introduce Valve delivery system via 14Fr E-Sheath (RFA)

Aortogram (from pigtail in the RRA) to position valve

Pace to 150->180 (to drop pressure) then deploy valve

Remove delivery system

Close RFA using proglide and angioseal

Iliac shot (DSA) from pigtail in the RRA to confirm status of RFA (post proglide closure)

Close 6Fr RRA with Helix or TR band

End of case

Mike Mullen’s ACIST settings:

Flow 6ml/s / volume 6ml - for checking femoral puncture LFA/RFA

Flow 25ml/s / volume 25ml - for aortogram

Flow 10ml/s / volume 10ml - for DSA post proglide/angioseal

Alternative closure device:

PerQseal:

S (14-16Fr), L (18-24Fr). Note: use L for all valves except Portico (use small)

0.0014” Angioplasty wire

Introducer (re-use 6Fr femoral sheath introducer, to aid insertion of angioplasty wire)

https://www.Heart-Valve-Surgery.com - See how the Edwards SAPIEN 3 transcatheter aortic valve replacement (TAVR) is implanted.

Shaped and sized for safety, this guidewire is designed to facilitate placement of interventional devices in the chambers of the heart during transcatheter aortic valve procedures. To learn more about the SAFARI2 TAVI / TAVR Guidewire visit: http://www.bostonscientific.com/en-US/products/guidewires/safari2-preshaped-guidewire.html

MAR2018 L01_BSH375017_

STEPS: (Dr Simon Kennon, Prof Anthony Mathur)

4Fr to RFA

6Fr to RRA

Femoral shots to check patency of sheaths

RRA:

Insert 5F pigtail (with 260cm wire) through 6Fr RRA sheath and position in the aortic root

RFA:

In RFA, Insert 150cm guidewire then remove 4Fr sheath and insert 8F Angioseal to measure depth then remove

Insert 1 proglide and preclose

Insert 10Fr sheath

Insert 5F AL1 and cross the valve with 150cm guidewire (straight end first)

Once crossed, introduce AL1 catheter inside the LV, and remove the guidewire and replace with Safari wire (stiff wire)

Remove the AL1 catheter as well the 10Fr femoral sheath and replace with valve sheath (Edwards E-sheath, Abbott Ultimum, Boston i-Sleeve or Lotus)

Introduce Valve delivery system via 14Fr E-Sheath (RFA)

Aortogram (from pigtail in the LFA) to position valve

Pace to 150->180 (to drop pressure) then deploy valve

Remove delivery system

Close RFA using proglide

Iliac shot (DSA) from pigtail in the LFA to confirm status of RFA (post proglide closure)

Close 6Fr RRA with Helix or TR band

End of case

Additional supplies for JenaValve case:

Ice cold normal saline (500ml bags; 4 per case) *kindly use Lab 10 fridge if possible*

Warm saline on standby (taken from Theatres)

Tuohy-Borst valve with Y-connector (Abbott Co-pilot preferred)

Pressurized heparinised saline bag with sterile extension tubing (1 giving set + 2 wide-bore ext. tubes)

14Fr Boston Scientific sheath

18Fr 30cm Cook sheath (back-up)

6Fr MPA diagnostic catheter

LV high-pressure injector lines

5 rinse basins (use Tavi Pack + Angiopack)