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