-wet introducer to activate hydrophilic coating
-use 35 cc syring to flush introducer and dilator
-introduce over super stiff 0.035 guidewire
-standard guidewire exchange method
-access vein with 6 Fr sheath
-predilate with 1 to 2 progressive size dilators
-make cut in skin that is wide
-insert introducer while rotating slightly up to RA
-aspirate and fludh introducer using 35-50 cc syringe
-attach heparinized saline drip
-do not repeatedly retract device by pushing deployment button forward
-numerous deployments can negatively affect tine performance
-Ensure the tether lock is in the locked position and the tether pin is inserted in the handle
-advance device cup completely over device
-flush delivery system again
-ensure distal cup is filled with saline (do not flick device to remove air bubbles)
-flush system with micra in deployed position until no further bubbles are seen coming from
device cup
-device cup si advanced over device until the device is completely inside cup and 4 tines are
-system is flushed until a continous flow of saline is seen at distal tip of delivery system
-length of delivery system from distal end to black outer layer is same as length of introducer
-Device cup becomes visible just past tip of introducer sheath when the black portion of the
delivery catheter is reached
-Insert delivery system into introducer by holding it right behind the device cup in order to
prevent any kinking of the delivery system
-Fluoro when you reach the black outer layer of the delivery system
-Ensure top of delivery system is not contacting roof of RA
-while keeping delivery system at bottom 1/3 of RA Retract delivery system into the IVC to
enable delivery system to be deflected
-preshaped curve to assist in navigating apical septal location
-distal curve to assist in crossing the TV when sliding the deflection button
-cross TV in RAO 30
-once TV is crossed release deflection button and navigate by advancing and gently rotating
the delivery system as needed towards the apex
-Consider a 30-40 degree clockwise rotation LAO 40 to obtain a more septal position
-Confirm septal position using RAO 30 and LAO 40
-Use contrast to ensure not on free wall, to ensure good contact with endocardium
-High risk patients: chronic steroid, elderly, females, HTN, cancer patients...
-Risk of perforation is similar to current PPM (0.6% in post trial data) contrast use can reduce

Cross TV in RAO 30 and advance delivery tool 3/4 towards apex
crank handle 180 degree CW and hold
Change LAO to 45-60 ddegree view
articulate catheter and move cup towards valve and back towards septum until good septal
bend is visualized
inject 5-7 cc of contrast in LAO 45-60 adn RAO 30 to verify septal
if free wall reposition
free wall septal groove ok
heavily trabeculated area ok
-To reduce chance of tether sticking, flush delivery tool with saline after each contrast injection
-LAO: if contrast flows below cup indicates septal position
RAO: note cup tissue contact, this is septal free wall groove
-Nitinol tines
-It is critical to achieve adequate tip pressure at distal end of delivery system to help ensure
fixation adn good contact
device cup should be against RV septum.v
During deployent delivery system retracts from device, limiting pressure on myocardium
-Goose neck: delivery system will buckle or bend just proximal to the device cup when
adequate tip pressure is achieved
remove tether pin from handle
unlock tether button
at delivery site apply further pressure by advancing delivery tool further into the introducer
push down and retract the deployment button halfway to partially retract the device cup
pull back the delivery system to relieve pressure
fully deploy device by fully retracting deployment button
lastly pull the delivery system back from device so it wont interfere during the pull and hold test
-Inadequate tip pressure: shallow curve and lack of reverse curve

-Delivery catheter pulled away from device and not touching it
-zoom in on device
-gently pull on tether and hold for 3-4 heart cycles while recording cine until the heartbeat is
felt and then a bit more and record on cine > 15 fps
-Record cine by pulling on tether
-release tether, review cine frame by frame determine number of tines engaged in tissue by
reviewing cine recording frame by frame
-Use multiple views if needed (RAP, AP, LAO)
-If at least two tines are engaged proceed to electrical testing (2 tines can hold 13 times weight
of device)
-If tines slay open during pull and hold they are engaged in the myocardium

R > 5 mV
400-1500 ohms
threshold < 1 V

-Gently pull on tether and then advance the delivery system over tether down to device
-Make sure device is programmed to off mode
-recapture cone should be fully extended and there should be tension on the tether
-gently pull on tether to assist in guiding delivery system to device
-Do not deflect during recapturing
-Ensure recapture cone is fully mated to proximal feature on device
-Confirm recapture cone and device are fully aligned confirming in multiple views
-Lock tether button
-Gently advance device cup over device by pressing down deployment button adn sliding it
-Verify on fluoro that device tines are fully inside device cup

-Flush delivery system
-Clean visible part of tether ensuring it is not tangled
-with recapture cone extended advance delivery system near device
-Confirm free movement of tether by gently pulling first one end then the other. Too much
resistance could cause the device to dislodge when removing tether
-If resistance is felt, flush delivery system
-Assess stability on fluoro
-Cut tether at the side where higher resistance is felt  near the pin
-While watching device under fluoro gently and continuously pull on tether to completely
remove it from delivery system
-need closure method

Crossing TV distal curve
gooseneck adequate tip pressure before deployment
LAO contrast flow below cup indicates septal
LAO Septal
RAO Septal free wall contat