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354 | The Surgical Technologist | APRIL 2015 table cover will be placed lengthwise at the end of the bed in order to accommodate the length of the vascular table. A large antimicrobial incise drape will be placed across the patients’ chest to the groin, followed by a cardiac split drape. At this point, sterile light handles will be placed, and suc- tion and the cautery pencil will be thrown off the field to the circulating nurse and plugged in. In some cases, the right arm from the elbow to the hand will be circumferentially prepped and draped in order to leave access to the right radial artery for the cardiologist in the event that coronary stenting becomes necessary. PROCEDUR A L S T EP S FOR T HE T R ANSF EMOR A L A PPROACH After the time out is performed, the cardiothoracic surgeon will make a skin incision using a 15 blade on a #7 handle. The surgical technologist will hand the surgeon Debakey forceps and the cautery pencil. A medium Weitlaner will be placed and the assistant will use an Army/Navy retractor to help with visualization. Metzenbaum scissors will replace the cautery pencil while the surgeon dissects the tissue to expose the femoral artery. Medium and small hemoclips may be used to ligate vessels as the tissue is dissected. The femoral artery will be isolated using a right angle fol- lowed by Dacron tapes and tourniquets or vessel loops. Access will be gained into the femoral artery using an introducer kit (21 gauge needle, .018-inch wire, 5 French sheath). The introducer wire will be replaced with a larger .035-inch exchange wire and a 6 French sheath is inserted into the vessel. Once this is done, the cardiologist and the interventional technologist will take over by placing an extra stiff .035-inch wire over the aortic arch and across the aortic valve. A pigtail catheter will be placed into the ascending aorta through a second 6 French sheath in order to perform an angiogram. A third 6 French sheath will be utilized for an internal pacing wire, which will remain throughout the operation. A super stiff .035-inch wire will be placed into UGUST 2015 the external iliac vein through the fourth and final 6 French sheath for the potential of a cardiopulmonary bypass. A diagnostic angiogram will be performed using a con- trast power injector while the surgical technologist and the valve rep inspect the valve, valve equipment and prepare the valve for insertion. Once the valve has been prepped, the surgical technologist will present the dilators for intro- duction of the valve sheath. The valvuloplasty balloon will be de-aired and the insufflator will be filled with the pre- measured amount of contrast medium/NaCl, ensuring it is in locked position. The surgical technologist will hand the balloon and the insufflator to the interventional technolo- gist communicating the size of the balloon, the pre-mea- sured amount of contrast medium/ NaCl in the insufflator and its locked position. The interventional technologist or surgical technologist will assist the cardiologist/cardiotho- racic surgeon by placing and removing the increasing sizes of dilators on the extra stiff wire to dilate the femoral artery and the valve sheath, and prepare to advance the valvuloplasty balloon. Once the balloon is advanced and in place within the aortic valve another time out will be performed and the balloon will be inflated under rapid heart pacing. While the valvuloplasty is per- formed, the surgical technologist and the valve rep will finalize the prepara- tion and position of the new valve on the delivery catheter. The primary cardiothoracic surgeon or cardiologist will check the position and orientation of the valve on the delivery catheter. Once the placement is confirmed, the valve will be crimped the rest of the way into its final position. The valvuloplasty then will be complete and the cardi- ologist will be ready for the valve. The surgical technolo- gist will bring the prepared delivery catheter containing the valve and the insufflator to the operative field and it will be given to the interventional technologist. The surgi- cal technologist will communicate the size of the valve, the amount of contrast medium/NaCl in the insufflator and its locked position. The cardiologist will advance the delivery catheter into the aortic arch and delicately advance it into place within the aortic valve. Before deploying the valve, rapid pacing is induced so that aortic valve will be in the open position and the native leaflets will be out of the way. If the placement of the prosthetic valve is agreed upon by There are several advantages to transcatheter aortic valve replacement, the foremost being recovery time. Patients typically are discharged from the hospital within a few days of their procedure. 4 TAVR procedures preclude the need for a sternotomy, which is necessary for traditional aortic valve replacement surgery.