Melody, Harmony, and Discord: A Complication During Pulmonic Valve Intervention in a Patient With Tetralogy of Fallot.

Patients born with tetralogy of Fallot (ToF) require early corrective surgery, often involving staged procedures and palliative shunts. Interventions may lead to complications as patients reach maturity, which causes them to become candidates for different treatments based on their specific anatomy, physiology, and the evolving structural heart technologies. Especially in advanced percutaneous interventions, each patient's unique physiology coupled with procedure-specific considerations makes perioperative planning a key factor in successful treatment. We present a 17-year-old male with a history of ToF who underwent valve-sparing surgical correction as an infant. Follow-up through his teenage years revealed worsening pulmonic insufficiency and right ventricular (RV) function necessitating pulmonic valve replacement. The recently approved Medtronic Harmony valve provided a well-suited percutaneous option. Pre-operative anesthetic planning included consideration of the impact of his RV function as well as complication contingency planning. Under general anesthesia, the Harmony valve was deployed but soon after embolized into the RV. This required emergent open surgical device retrieval and placement of an RV-pulmonic artery conduit with a homograft. Percutaneous therapies are appealing options, and the available technology is changing rapidly. Though exciting, these treatment options are not without complications. A Harmony valve embolizing to the RV after deployment is one of these very rare complications, but it enforces the salient point that contingency planning is absolutely necessary prior to attempting these interventions. Though the framework for this planning may be well established in some facilities, it becomes much more complicated in lower volume centers.