room setup, access, and closure august 2013 innovating for life. uc201301196a ee
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Room Setup, Access, and Closure
August 2013
Innovating for life.
UC201301196a EE
AcademiaMedical Education
INTERNATIONAL. CAUTION: For distribution only in markets where Engager™ is approved. Medtronic, Inc. 2013. All Rights Reserved.
Objectives
• Discuss room setup
• Understand access steps
• Discuss wound closure
AcademiaMedical Education
INTERNATIONAL. CAUTION: For distribution only in markets where Engager™ is approved. Medtronic, Inc. 2013. All Rights Reserved.
Example Hybrid OR Setup
Anesthesia
Equipment / Valve Preparation Table
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Implanter1st Assist
AcademiaMedical Education
INTERNATIONAL. CAUTION: For distribution only in markets where Engager™ is approved. Medtronic, Inc. 2013. All Rights Reserved.
Pre-case Planning
Determine incision site by using any of the follow modalities:
• Palpating the point of maximum impulse (PMI)• Multi Slice Cat Scan (MSCT)• Transthoracic Echocardiography• By placing a hemostat over the left ventricular
apex under fluoroscopic guidance• Root angiography using implanters view (~AP
projection, typically in the range between RAO 15 and LAO 15 with mild caudal or cranial angulation)
Performed in a surgical environment under sterile technique
AcademiaMedical Education
INTERNATIONAL. CAUTION: For distribution only in markets where Engager™ is approved. Medtronic, Inc. 2013. All Rights Reserved.
• Perform small left anterior thoracotomy at the 5th or 6th intercostal space
• Start incision near the mid-clavicular line and extend toward the nipple approximately 5-6 cm
Surgical Exposure
AcademiaMedical Education
INTERNATIONAL. CAUTION: For distribution only in markets where Engager™ is approved. Medtronic, Inc. 2013. All Rights Reserved.
• Insert soft tissue retractor into the wound, and secure retractor limbs with four sutures
• Insert metal rib retractor within the soft tissue retractor
• Perform pericardiotomy in a linear fashion
• Use pericardial stay sutures to retract the pericardium and facilitate positioning of the heart’s apex into the operative field
• Fix ventricular pacing wires to the right ventricle
• Test rapid pacing at 160-200 bpm with the result of a mean pressure <50 mm Hg or pulse pressure < 10 mm Hg
Apical Exposure
AcademiaMedical Education
INTERNATIONAL. CAUTION: For distribution only in markets where Engager™ is approved. Medtronic, Inc. 2013. All Rights Reserved.
Purse-string Sutures
• Left ventricular purse-string sutures are placed with pledgets - which are large in size (using a clock face paradigm)
• A second set of purse-string sutures should be placed in between the initial set
AcademiaMedical Education
INTERNATIONAL. CAUTION: For distribution only in markets where Engager™ is approved. Medtronic, Inc. 2013. All Rights Reserved.
• Place two 5 Fr sheaths into the femoral artery (radial access can also be used) and vein
• Insert a pigtail guide catheter via the femoral artery over a 0.035 inch (0.89 mm) guidewire into the base of non-coronary cusp under fluoroscopic guidance to mark aortic valve basal plane
• Administer heparin to achieve an ACT > 250 seconds (100 IU/kg, intravenously). ACTs’ should be repeated every 30 minutes
• Perform root aortogram shot using a power injector to demonstrate the location of the aortic valve and the severity of aortic valvular insufficiency
Baseline Aortogram
AcademiaMedical Education
INTERNATIONAL. CAUTION: For distribution only in markets where Engager™ is approved. Medtronic, Inc. 2013. All Rights Reserved.
Apical Puncture
• Puncture with an 18 g needle in the middle of the pre-set purse-string sutures
• Advance an 0.035 inch (0.89 mm) super stiff J-tip wire into the ascending aorta
• Place wire deep into the descending aorta where it will remain for the entire procedure
AcademiaMedical Education
INTERNATIONAL. CAUTION: For distribution only in markets where Engager™ is approved. Medtronic, Inc. 2013. All Rights Reserved.
Apical Closure
• Perform a TEE & angiogram to confirm valve function• Remove delivery system and wire, ensuring control arm
sleeve fully mates with introducer tube prior to withdrawal
• Rapid ventricular pacing may be used to reduce cardiac output and blood pressure during this portion of the procedure
• Stop rapid ventricular pacing and add additional Teflon reinforced sutures if necessary to achieve complete hemostasis
• Take a final root shot with contrast after wire removal to confirm valve function and coronary patency
• Measure transvalvular pressure gradients• Record ECG for potential arrhythmias and/or heart block• Deliver protamine in standard dose• Loosely approximate the pericardium over the apex
AcademiaMedical Education
INTERNATIONAL. CAUTION: For distribution only in markets where Engager™ is approved. Medtronic, Inc. 2013. All Rights Reserved.
Wound Closure
• Insert a chest tube or soft drain into the left pleural space
• Administer a long-acting local anesthetic into the intercostals spaces
• Optional: Pain pump may be inserted (e.g., On-Q)• Pull temporary pacing wires or secure to skin at
closing• Close the chest wall only after the bleeding is
controlled• Close thoracotomy in standard fashion; i.e., PDS
suture for closing intercostals space, vicryl muscular closure and a subcuticular skin closure
• Depending on local practice, some patients may be extubated immediately in the operating room or shortly thereafter in the intensive care or post anesthetic care unit
AcademiaMedical Education
INTERNATIONAL. CAUTION: For distribution only in markets where Engager™ is approved. Medtronic, Inc. 2013. All Rights Reserved.
Summary
• The transapical procedure is a surgical approach performed in a sterile environment
• A small left anterior thoracotomy is performed at the 5th-6th intercostal space
• After apical access is secure the TAVR procedure is completed
• Apical and wound closure is completed at the end of the procedure
Engager is a registered trademark of Medtronic, Inc.
For more information and a complete list of adverse events, warning and contraindications reference Engager IFU.
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