A Novel Technique to Reduce Branch Pulmonary Artery Diameter During Transcatheter Pulmonary Valve Replacement Utilizing Side-by-Side Transcatheter Valves in a Superior-Inferior Orientation.

Introduction: Transcatheter pulmonary valve replacement (TPVR) is increasingly used to treat complications related to dysfunctional right ventricular outflow tracts (RVOT). Candidacy is limited by RVOT diameter and coronary artery anatomy. We present the case of a branch pulmonary artery (BPA) that was too large to accommodate a single TPVR and underwent placement of 2 TPVR. Clinical case: The patient is a 54-year-old with a history of pulmonary valve stenosis who underwent a Brock procedure at 8 years-old. He presented due to NYHA class 3 heart failure symptoms. He underwent an extensive work up and he was recommended to undergo TPVR because he was a poor surgical candidate due to comorbidities.Coronary compression testing showed distortion of the right coronary cusp preventing traditional TPVR. He had a dilated, dynamic right pulmonary artery (RPA). Based on balloon sizing he underwent deployment of 2 stents simultaneously in a superior-inferior manner in the RPA. A 22 mm Melody valve was deployed in both stents. He returned to the cath lab 5 weeks later. At that time an angiogram showed good function of the valves with trivial insufficiency. A 26 mm Edwards Sapien 3 valve was then deployed into the left pulmonary artery. Discussion: This case demonstrates that a "double valve" strategy is feasible when the native vessel is too large for current TPVR. Satisfactory valve function is present at early follow up.