[[100 Welcome to Outlines of Technique in Cardiac Surgery]] # (DRAFT) Technical Outline of Transcatheter Aortic Valve Implantation ## Pre-Operative Steps - Pre-operative Image Analysis and Review - coronary heights - perimeter - diameter - sinus heights - access diameter - calcification of femorals - bifurcation height of femorals - external iliac diameter - horizontality of aorta - Review predicted angles for coplanar and cusp overlap views - Creatinine - Confirm Transthoracic Windows - Check whether pre-existing effusion - Pacing Plan - If Pre-existing pacemaker, or Valve-in-Valve, post-operative pacing will not be necessary and RIJ/Neck Cordis will not be necessary - If Pre-existing pacemaker (except for Micra), have EP team member available to control permanent pacemaker for rapid ventricular pacing - Make sure EP knows case is scheduled in case pacemaker needs to be implanted ## Positioning and Access - RIJ Cordis - RIJ Transvenous Pacemaker - see [[Choice of Transvenous Pacemaker]] - Pannus retraction system - 3 inch cloth tape to expose groins by securing pannus and retracting towards shoulders - BCFA Access - Seldinger technique, 7 fr sheathes - If extremely tortuous or treacherous peripheral arteries, consider very long sheathes - J-wire up Valve Access Arteriotomy - "Pre-Close" Perclose Preparation of Valve Access Arteriotomy - 2 percloses, one 10 O'clock, one 2 O'clock - Replace 7 fr sheath over J wire when finished - If arterial bleeding occuring around 7 fr sheath, upsize to 9 or 10 fr - Amplatz catheter over J-wire - Exchange J-wire for Stiff Wire - Dilation of Valve Access Arteriotomy - Heparin Administration and ACT Check - Place Valve Access Arteriotomy Sheath over Stiff Wire - Sentrant Introducer Sheath preferred - Remove introducer - Amplatz catheter over stiff wire into Aortic root - Exchange stiff wire for Glidewire - Move Image Intensifier to the Chest Position ## Crossing Aortic Valve and Assessment - Cross Aortic Valve - Advance Amplatz Catheter into LV over Guidewire - Stand by in case of Complete Heart Block - Measure LVEDP - Consider Confirmation of Aortic Gradient - Manifold on LV Amplatz catheter - Yellow pressure monitoring line on side port of 7 fr sheath - Consider Pre TAVI Balloon Aortic Valvuloplasty - if LV gradient extremely high, or calcium score very high, or if Amplatz catheter was difficult to advance across valve - Insert Confida wire through LV catheter - Inspect load of Corevalve - Can happen anytime valve is ready - 29 valve most difficult to assemble - Check under fluoro - Exchange sheath for valve delivery system over Lunderquist wire - Guide delivery system over aortic arch under fluoroscopy - Bring up to aortic valve - Pigtail over J wire through utility femoral access into non-coronary sinus - Prepare for valve crossing - Review predicted angles for coplanar and cusp overlap views - Parallax - Cusp overlap view ## Valve Deployment - Standby to pace - Check pacing system will capture - Cross valve - Depth of insertion - Root angiogram - Contrast root shot - Set image intensifier to cusp-overlap angles determined from pre-operative CT scan image analysis with parallax removed from TAVI - Three dots of the Evolut FX should line up and mark 3 mm from the proximal edge of the valve - Because of the interplay between the inflexibility of the TAVI delivery system and the LV guidewire within it as it relates to the variable degree of “horizontality” of the aortic root, the TAVI and the valve may not align perfectly - If they do, things may go more smoothly, though you will still have to deal with the resistance of valve/annular tissues to dilation by the TAVI as it expands, and the position of the annulus relative to the slopes of the contour of the “coca cola glass” shaped Evolut valve. - Beware of the tendency of the resistant annulus to “squirt” or “watermelon seed” the valve in either direction - The TAVI should engage at the shallowest level possible with the non-coronary aspect of the aortic root to avoid conduction system injury. The mitral aspect will often be tilted so that the valve is deeper relative to the annulus than one would otherwise desire. The valve USUALLY has better contact with the non-coronary aspect than the mitral aspect, and when released, it may tilt to establish a better mitral aspect depth of insertion. Though you can influence this a little with pressure on the LV guidewire, there is an inherent loss of control on release from 80 to 100% release. It pays to perform this release very slowly. - If the mitral aspect depth of insertion endangers the free movement of the anterior leaflet, a shallower non-coronary aspect depth of insertion is necessary and the TAVI must be repositioned. - If you anticipate the need for post TAVI balloon aortic valvuloplasty, you may wish to intentionally plan for a deeper depth of insertion - If the procedure is valve in valve, where injury to conduction system is unlikely, or in the context of pre-existing permanent pacemaker, where injury to the conduction is not an issue, deeper insertion is tolerable if desired. - This is the paradox of the balloon expandable TAVI versus the self expanding TAVI. The self expanding TAVI must be released from an external sheath and requires a certain space occupying volume of the nitinol alloy to exert sufficient force on the stenotic valve, along with the animal tissue. To the current date, that has limited the flexibility of the delivery system, and interferes with perfect alignment with the native root. The design makes the valve re-capturable, and a good thing too, as the flexibility interferes with control. Meanwhile, the abiity to manipulate the relative positions of the balloon and the cobalt-chromium valve of the balloon expandable TAVI at different points of insertion and deployment allow control wires to be used within the delivery system to fine tune alignment of TAVI and aortic root. This is a good thing too, as you only get one shot, and you best not miss, as it cannot be recaptured. - Begin deployment - Rapid ventricular pacing - Wait until release of the valve begins to allow the proximal edge to start flaring - 80% Deployment - Check with root shot - Check with echo - Dealing with a tilted valve - Rapid ventricular pacing - 100% Deployment - Stand by in case of Complete Heart Block - Pull back Confida wire to allow nose cone to "center" within the TAVR so that it will not make contact with edges of the valve and accidentally dislodge the TAVR - Use slight "vibration/oscillation" of the nose cone to prevent engagement with either proximal or distal edges of the TAVR - Re-insert Confida wire into LV - Withdrawal of delivery system into descending aorta - Re-assembly of delivery system - Slide catch back and push handle back to the roller, then unwind handle two twists to make sure nose cone is not jammed into delivery system, possibly raising a lip - Exchange of delivery system for sheath/introducer over Confida wire ## Assessment of TAV and Treatment of Paravalvular Leak - J-wire to remove noncoronary sinus pigtail and reposition within outflow of TAVR above leaflets - Pigtail over Confida wire into LV, withdraw confida - Hook up pigtails to manifold and yellow pressure lines - Check post valve gradient - Check LVEDP for possible PVL - Check with root shot - If confident, withdraw Confida wire and pigtail prior to confirmation - Check with echo - Decide on post TAVI BAV - Post TAVI BAV - Consult valve sheet for annular diameter - Choose balloon for BAV - True balloon for valve in valve or for slight undersizing in particularly calcified valve - Z-med balloon for slight oversizing - Re-insert Confida wire into LV - BAV catheter over Confida wire into valve - Attach Presto insufflator - Test rapid ventricular pacing - Agreement from all team members - Hold ventilation - Begin rapid ventricular pacing - When pressure has dropped on A-line, quickly deploy BAV balloon - Observe expansion of valve - Gauge resistance of tissues and limits of the balloon through combination of tactile sense and observation of fluoroscopy - Quick deflation of BAV ballon to complete emptiness - Pacing off - Stand by in case of Complete Heart Block ## Arteriotomy Closure - Prepare for dry seal closure - Size of external iliac for size of endovascular balloon to be advanced from utility femoral access - J wire up the Sentrant sheath as bailout - Alternative options for endovascular balloon "rail" creation/delivery - Guidewire via utility femoral access pushed into Sentrant sheath through LIMA catheter - Guidewire via utility femoral access pulled into Sentrant sheath by snare - Guidewire via utility femoral access delivered into Superficial Femoral over iliac bifurcation, utility femoral access exchanged over guidewire for a Balkin sheath - Dry seal closure of valve access arteriotomy - Completion angiogram - Perclose/Angioseal closure of utility access [[TAVR Op Note Template]] [[Guidewire Pacing for TAVI]] [[20220802 If a TAVR Slips up above the annulus]] [[Notes on Transapical Sapien 3 Implantation]] [[Rescue Plan for TAVR Disaster]]