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Preparation
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Labs: CBC, BMP and coagulation profile
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Trans-esophageal echocardiography
Equipment
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Sheaths
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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
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Transseptal sheath and Baylis RFA system
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Catheters
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5Fr MPA catheter, 5Fr pigtail catheter, and Brockenbrough needle
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Wires
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035” standard J wire, 0.035” Confida wire,
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Balloon
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Contrast
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Manifolds
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Heparin
Procedural Steps
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Initially Left femoral arterial and venous access is obtained. Temporary pacing wire is inserted though L femoral venous access.
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Right Femoral venous access is then obtained and preclosed with one perclose suture, and 8F sheath is inserted.
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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.
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Confida wire is placed in LA through the Baylis sheath.
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Sheath is then changed to Edwards E sheath over this Confida wire
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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.
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Through this catheter mitral valve is crossed with an exchange length Glide wire via a multipurpose catheter
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The MP catheter is removed, and a long pigtail catheter is then advanced in the LV apex.
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Now the Confida wire is introduced into the LV apex inside the pigtail.
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The atrial septum and mitral valve are then dilated with 14 x 40 balloon at 8 atm.
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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.
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The valve is further post dilated using the same balloon to ensure adequate expansion.
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An LV to aorta pull back may be done to r/o any LVOT gradient as well.
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After equipment removal, the Right femoral venous access is closed by tightening the previously laid perclose sutures.