Hybrid case ( Theatre team + Cath Lab team)

Location: Hybrid Theatre 9

under General Anaesthetic

TOE guidance

Temporary pacing via RFV

Arterial line

Cell saver

Kits:

Barts TAVI pack

4Fr Micropuncture kit

9Fr sheath (for carotid)

6Fr Femoral sheath (RFA)

6Fr Femoral sheath (RFV) - temporary pacing wire

5Fr AL1 catheter

5Fr JR4 catheter

Safari wire

Prostyle

8Fr Angioseal

MyVal Crimping kits:

5 rinsing bowls

1liter saline bag

500ml heparinised saline bag

Procedural Steps:

Secure arterial line via right or left radial artery prior to GA induction.

Theatre scrub nurse to drape exposing right neck (RICA), chest and both femoral groin.

 

Femoral access:

6Fr sheath to right femoral artery or right radial artery for secondary access.

6Fr sheath to right femoral vein – insert 4frBalloon flotation pacing wire (if pacing via TPW)

Aortagram using pigtail

 

Carotid access:

Surgical cut-down to common carotid artery (diathermy, dissection, through muscle, fascia and onto the artery). In the absence of other anatomical considerations, the left carotid is generally preferred to the right.

Facial vein tied off,  common carotid artery isolated.

Assess cerebral circulation –clamp carotid artery and observe cerebral oxygen saturations

Heparin- 6,000iu initial dose

Once carotid artery is isolated and secured, access using micro puncture needle and exchange to 9Fr sheath.

5Fr AL1 and straight tip Soft tip of standard 0.35 wire to cross aortic valve.  6FJR4 and 6Fr MPA1  used as an alternative catheters.

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

Attach pacing leads if pacing via Safari

BAV performed with appropriately sized VACS balloon under rapid pacing via the Safari wire. Pre-dilate with balloon size of aortic annular diameter minus 1-2mm.

9Fr exchanged for 14Fr python sheath over a 0.35 wire

Appropriately sized MyVal implanted in aortic position with rapid pacing at 180bpm through Safari wire.

Remove delivery system

Sheath removed and haemostasis achieved using clamp

Surgical closure of carotid artery.

Right femoral Artery closure:

Close RFA using proglide and 6Fr Angioseal

Post procedural care:

Admit to HDU or ITU bed

Echo

Bloods

As per post TAVI and surgical care