So, last case today will be Alexandra Erdmann, who's going to be presenting a Harmony case. She just recently completed training in Pittsburgh and has now just joined the University of Wisconsin and the American Family Children's Hospital as a new interventional cardiologist. Okay, thanks for sticking around, everyone. Last case. So, first, thank you to Sky and the organizers of the webinar for inviting me to present. I was asked to present a Harmony TPB case. With this, I'm really hoping to highlight how we approach the screening reports, as well as strategies and techniques that I picked up during my time at Pittsburgh. I have no disclosures. Our case was a 20-year-old male with congenital pulmonary valve stenosis who underwent a balloon valvuloplasty at day one. He also had a secundum ASD, which was closed with a 15-millimeter ampli-traceptal occluder at eight years of age. Overall, had been doing well, but did eventually develop symptomatic severe pulmonary insufficiency with moderate to severe RV dilation. So, given his anatomy, we felt like he would be a good candidate for a self-expanding valve technology and obtain a CT, and received the following screening report from Medtronic. So, the first part of the screening report, you'll get still of a CT image of the pulmonary arteries and the RVOT, and here you see his dilated RVOT and pulmonary arteries, as well as the suggested landing zone, which for him was about four millimeters in length. If you look at the perimeter plot on the right of the screen, you'll see that the suggested landing zone really would land us more in an annular implant, which is fine, but our strategy over time was really to aim for supravalvular implants whenever possible. And so, looking at this perimeter plot, we felt like this patient could be a candidate for supravalvular implant. If you look at the inflow zigs here, we felt like there would be enough oversizing within the pulmonary valve sinuses in order to have stability of the valve complex, knowing that we wouldn't have a lot of oversizing, potentially, of the outflow zigs, but we did have the length of the pulmonary artery to allow for a higher implant. This was further corroborated by this animation. You see the TPV25 animation on the right of the screen, and those inflow zigs remain green throughout most of that pulmonary valve sinus. You even have some yellow, which is oversizing of the outflow zigs, but not quite enough to make them green. Additionally, we used the min-max diameter plots to support our decision. This, as Dr. Armstrong described earlier, shows and suggests that we have more of an oval anatomy, and that we have a lot of oversizing, especially of this minimum diameter plot, so we decided to proceed, again, with the plan of trying to be supravalvular. You have the 3D reconstructions, and these are showing that we have sufficient length of our pulmonary artery, as well as camera angles in the screening report. These are the angles we decided to use for this particular case. We like them because you see the pulmonary artery bifurcation really well, as well as the RPA. We almost universally adopted a RPA wire position for the harmony valve cases, and often started our unsheathing of zigs 1 and 2 within the RPA in order to have the most distal implant that we could. So, here's our case. Baseline angiography, similar to the CT, shows severe pulmonary insufficiency, and this is similar to the CT, shows severe pulmonary insufficiency with the dilate RBOT in pulmonary arteries. There's no branched pulmonary stenosis. Our landmarks, we were going to use kind of the midspine to get our delivery system out to that point in the proximal RPA, and then our bifurcation is really just left of the spine. On the lateral, to get a sense of where the pulmonary valve annulus was, about here, so kind of that shadowing of the sternum, but we'll take angios to verify that as we go. So, this is after we've sent the delivery system out. Again, we're in the proximal RPA. We've already launched our carrots, married the valve to the radiopaque marker there, and so we're ready to unsheathe zigs 1 and 2. In this, this was kind of a fluid motion of unsheathing while also pulling back towards the MPA. At the end of this, you see they nicely flower into the PA. Angiography showed that we're as distal as we can in the pulmonary artery, sitting on the back wall of bifurcation, and on lateral, you get the sense that the coil is really sitting around the annulus, so we're really happy with that positioning and decided to unsheathe the remainder of the valve. So, you see us doing that here. And again, this is nice fluid motion once you're happy with the position to then deploy that. We then take some angiography to make sure, again, we like our position. Even with the valve as distal as we can, you have good flow into the branch pulmonary arteries. You do also see there's a little kink in the center of the valve complex. That will go away once you no longer have the forward tension from the delivery system and the nitinol is allowed to really adapt the anatomy of the pulmonary artery. So, we then uncoiled and released the valve. and then get our ending angiography. Starting with the RV angiogram, there's no RVOT obstruction, there's good flow into the branch pulmonary arteries, and our valve is sitting nicely within the pulmonary valve sinuses, staying out of the myocardium as much as possible. Because we didn't have a lot of apposition, or really any apposition of ZIGs one and two, worry about parabolic leak, and on AP, you could see the contrast does come back towards one and two, but we didn't see any contrast coming all the way through to the RV, and we also do ice on all of these valves, and did not see any parabolic leak with that. So ultimately, this young man did really well. In the hospital, we do post TTEs, which showed mild pulmonary valve insufficiency, and again, no parabolic leak. He was having frequent palpitations the night of the procedure, with PVCs and a bigeminy-trigeminy pattern, so we did ultimately send him home on a TENOLOL, which was continued for about a month, and in all of these self-expanding valves, we obtained Holter's on discharge, and his showed just rare, uniform, isolated PVCs. One month later, he was doing wonderfully, with significantly increased exercise tolerance. He was having occasional palpitations, but his Holter at that point showed only rare PVCs, and this was actually while he was off of beta-blocker therapy, and ECHO already showed significant RV remodeling and good valve function. So again, I'm hoping that this case really highlights how we approach the screening reports, using them really as a stepping stone in our pre-procedural planning, with experience learned to use those screening reports to get a supravalvular implant in as many patients as we can, as the anatomy is allowed, but ultimately knowing that the nitinol will decide where the valve ends up sitting, and how we adapt these strategies, such as the RPA wire position and RPA deployment, in order to get the distal implants that we desired. So with that, thank you, and I'll take any questions.

interventional cardiologist

Harmony TPB

pulmonary valve stenosis

secundum ASD

self-expanding valve technology