Preparation

• Labs: CBC, BMP and coagulation profile

• Trans-esophageal echocardiography

 

Equipment

• Sheaths

  • 5Fr sheath for left arterial access, 6 Fr sheath for temporary venous pacemaker through right IJ vein, 16 Fr sheath for right femoral vein. Agilis steerable guide

• Catheters

  • 5Fr MPA catheter, 5Fr pigtail catheter, and 6Fr Swan-Ganz catheter

• Wires

  • 035” standard J wire, 0.035” Confida wire,

• Balloon

  • 14 x 40 mm balloon

• Contrast

  • 50 cc (1:3 dilution)

• Manifolds

  • Three manifolds

• Heparin

  • 5,000 IU

 

Procedural Steps

• Obtain Right femoral venous access and an optional left femoral arterial access for hemodynamic monitoring

• Preclose right femoral vein access with one perclose suture and insert the E-sheath. Mattress sutures are placed around the E-sheath

• Full dose heparin is then administered

• Obtain the co-planar angles aligning the stent posts to remove any parallax on the bioprosthetic valve

• Use a 6F Swan Ganz catheter to cross the bioprosthetic valve from RA to RV and record the gradients

• Put a 0.035 inch long exchange J-wire through the Swan Ganz catheter and swap it for a 135cm pigtail

• Now the Confida wire is introduced into the RV apex inside the pigtail.

• Move the C-arm to the co-planar angle

• Finally, a Sapien-3 valve is delivered over the Confida wire across the bioprosthetic tricuspid valve

• The Sapien valve is deployed 10% higher than the atrial end of the fluoroscopic marker of the stent to achieve a conical shape

• The valve can be further postdilated using the same balloon by adding extra volume to ensure adequate expansion.

• After equipment removal, the right femoral venous access is closed by tightening the previously placed perclose sutures