Management: 
Endovascular pulmonic valve replacement was undertaken by first performing serial balloon dilatation of the stenotic homograft using 16 mm, 18 mm, and 20 mm balloons. Because of the increased risk of coronary compression with transcatheter pulmonic valve interventions, patency of the SVG to LCx and left main coronary arteries was assessed during each balloon inflation using selective angiography.  During inflation of the 20 mm balloon there was partial angiographic compromise of the left main coronary artery noted, indicating that this would be the maximal safe diameter obtainable for transcatheter pulmonic valve implantation(Figure C). Subsequent angiography demonstrated a small area of contained perforation of the homograft. As such, a neoconduit within the homograft was created by implantation of an 18 mm x 28 mm Cheatham Platinum (CP) covered stent followed by deployment of a 10 mm x 29 mm Palmaz stent; post-dilated to 20 mm for additional reinforcement and resistance to elastic recoil (Figure D).   A 20 mm Edwards Sapien S3 valve was then deployed inside the neoconduit. Final pulmonary artery angiography showed no significant pulmonic regurgitation(Figure E). Right ventricular pressure improved to 41/4 mm Hg