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 or left femoral vein, 14 Fr Edwards E sheath. Agilis steerable guide
    • Transseptal sheath and Baylis RFA system
  • Catheters
    • 5Fr MPA catheter, 5Fr pigtail catheter, and Brockenbrough needle
  • 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 
  • Initially Left femoral arterial and venous access is obtained. Temporary pacing wire is inserted though L femoral venous access.
  • Right Femoral venous access is then obtained and preclosed with one perclose suture, and 8F sheath is inserted.
  • Transeptal puncture is done under TEE and fluoroscopic guidance (approximately 3.5cm from mitral annulus along the infero-postero margin) and the Mullins sheath is placed in LA. Heparin is then administered.
  • Confida wire is placed in LA through the Baylis sheath.

  • Sheath is then changed to Edwards E sheath over this Confida wire

  • A long Agilis 8.5 Fr steerable guiding catheter is then advanced over the wire into left atrium and the tip is directed towards the mitral valve.
  • Through this catheter mitral valve is crossed with an exchange length Glide wire via a multipurpose catheter
  • The MP catheter is removed, and a long pigtail catheter is then advanced in the LV apex.
  • Now the Confida wire is introduced into the LV apex inside the pigtail.
  • The atrial septum and mitral valve are then dilated with 14 x 40 balloon at 8 atm.
  • Finally, a Sapien-3 valve is delivered over the Confida wire across the atrial septum to the mitral valve and deployed successfully under rapid ventricular pacing.
  • The valve is further post dilated using the same balloon to ensure adequate expansion.
  • An LV to aorta pull back may be done to r/o any LVOT gradient as well.
  • After equipment removal, the Right femoral venous access is closed by tightening the previously laid perclose sutures.