TAVR stands for  Transcatheter Aortic Valve Repair, in this procedure a catheter is inserted into the leg that holds a new Aortic Valve to be deployed with the existing native valve. This is an alternative to open heart surgery to replace a stenotic Aortic Valve. The steps for and supplies for this procedure are long and the procedure and go in multiple ways depending on the situation. I will be discussing the most basic and simple aspects of the procedure below.

Supplies

• Surgical Cath Pack
• 6Fr Femoral Sheath x2
• 6Fr Radial Sheath
• 8Fr Sheath
• Angled Pigtail Catheter x2
• JR 4 Catheter
• Baby J Wire
• 150cm J Wire
• Exchange Wire
• Safari Wire
• Perclose x2
• Temporary Pacemaker
• Amplatz Extra Stiff Wire
• TR Band
• TAVR Sheath
• TAVR Delivery System

Procedural Steps

1. Prepare patient with sterilized solution, drape the patient leaving assess to areas you will perform on.
2. Gain Radial access and insert 6Fr Radial Sheath, insert Radial Cocktail to prevent vasospasm.
3. Locate the Femoral Vein and insert your first 6Fr Sheath.
4. Locate the Femoral Artery and insert your second 6Fr Sheath.
5. Pass Temporary Pacemaker through your Femoral Vein Sheath until the tip reaches the Right Ventricle.
6. Test the function of the Pacemaker but rapidly pacing patients heart to 180bpm the reduce to ensure capture. Set back up settings to 40bpm at a sensitivity of 2mV.
7. Insert the Baby J wire into the first Angled Pigtail Catheter and advance wire until it reaches the Aortic Valve.
8. Insert the Angled Pigtail Catheter until it reaches the Aortic Valve and remove the Baby J Wire.
9. Connect the Angled Pigtail to the ACIST Machine. When ready record with CIN and inject contrast into the Aortic Root to confirm location and reference points.
10.  Move back to the Femoral Artery Sheath, remove the 6Fr Sheath and insert the 8Fr Sheath Dilator.
11. Remove Dilator and insert your first Perclose.
12. Deploy but do not close the suture.
13. Remove first Perclose and insert second Perclose.
14. Deploy but do not close the suture.
15. Remove second Perclose and insert 8Fr Sheath.
16. Insert the JR 4 Catheter with the 150cm J Wire.
17. Pass both up into the Aortic Arch and remove the J Wire.
18. Insert the Amplatz Extra Stiff Wire.
19. Remove both the JR 4 Catheter and 8Fr Sheath together over the Amplatz Wire leaving it in place.
20. Insert the TAVR Sheath.
21. Insert JR 4 Catheter over Amplatz Wire and through TAVR Sheath.
22. Remove the Amplatz wire and insert Exchange Wire.
23. Cross the stenotic native Aortic Valve with the Exchange Wire.
24. Remove the JR 4 Catheter over the wire leaving the tip within the Left Ventricle.
25. Advance the second Angled Pigtail Catheter over the Exchange Wire.
26. Remover the Exchange wire and insert the Safari Wire into the Left Ventricle.
27. Remove the Angled Pigtail Catheter over the wire leaving the tip within the Left Ventricle.
28. Advance the TAVR Delivery System over the Safari Wire.
29. Cross the Native Aortic Valve with the TAVR Delivery System.
30. Confirm location of the new valve with a CIN recording while injecting through the first Angled Pigtail Catheter located in the wrist.
31. Rapid pace the patients heart to 180bpm to ensure limited blood flow through the native valve during deployment.
32. Inflate the balloon on the TAVR Delivery System until full expansion.
33. Decrease rapid passing back to backup settings of 40bpm at a sensitivity of 2mV.
34. Remove Delivery System and advance first Angled Pigtail. When ready inject contrast to ensure proper function and full expansion.
35. Remove Delivery System and suture down both Perclose.
36. Remove Temporary Pacemaker and hold manual pressure until bleeding stops.
37. Remove Angled Pigtail Catheter and place TR Band over radial artery to hold pressure until bleeding stops.