So let's move right ahead to the cases. So we'll have a case of each of the valves that we've discussed. So the first case is gonna be Dr. Samantha Gilk, who's did a lot of her training in Children's Nebraska and Omaha is currently a fourth year in pediatric critical care at Baylor. And then she's going back to Omaha next year to do a pediatric interventional cardiology training. Thank you to the SCI team and Constant for inviting me to present this case and thank you to the team in Omaha and my mentors there for allowing me to present this. So we had a case of a 64 year old female with non ischemic cardiomyopathy. She had an LVEF in the high teens to low 20s. She also had pulmonary hypertension and paroxysmal atrial fibrillation and had an ICD in place. She underwent a HeartMate 3 LVAD placement one month prior to our procedure. Her post-op course was complicated by severely depressed RV function that initially required dual inotropic support as well as inhaled valetri. But she was failing medical management and decision was made to undergo percutaneous RVAD placement with a ProTec Duo. Unfortunately, at the time of ProTec Duo placement, she had development of a flail pulmonary valve leaflets and in the setting of that developed severe pulmonary valve insufficiency. The severe PI ultimately rendered the RVAD ineffective and she was failing maximal medical management. So she was presented to the multidisciplinary team and the decision was to proceed with percutaneous pulmonary valve placement as she was not a surgical candidate. Her CT scan was done a week prior at the time or before her RVAD was placed. So that CT was sent for Altera screening and these are just a couple images from the Altera screening reports and she was a favorable candidate for Altera placement. So she was taken to the cath lab. Her RVAD was removed from her right IJ venous access and at that time, a 26 French Gore dry seal was placed to maintain access in case the RVAD was needed to be replaced. Her baseline hemodynamics, she had an RA mean pressure of 19. Her RV pressure was 34 over 19. PA means were 25 with a wedge pressure of 15. By thermodilution, her cardiac output was 4.3 indexed to 2.5 and her PBR was 0.92. Here's her baseline angiogram in the cath lab. You can see there's no branch pulmonary artery stenosis. There's minimal septum at the top of the branch PAs. There's a large dilated main pulmonary artery and the thought for placement was a supervalvular annular implant. A couple angiograms during placement of the Altera pre-stent. You can see here, repeat angiogram deployment was through the, or via the right pulmonary artery and then pulled back into the desired landing zone and here with valve deployment, you can see that we're deploying in a supervalvular annular position with the valve or the pre-stent well seated there. A 29 millimeter Sapiens S3 was then deployed and you can see it's not quite fully attached to the Altera pre-stent, so a second balloon inflation with three CCs of additional contrast or additional volume in the balloon was utilized following this. After completion of the valve implant, there is no residual pulmonary insufficiency. The valve is well positioned. There's no paravalve or leak. By echocardiogram, the leaflets are moving well and there's no pulmonary valve insufficiency by TEE. A repeat hemodynamics following valve implant, her thermodilution cardiac output was at 90. Her RAD output was higher now at five liters per minute indexed to three. Her RA mean remained elevated at 18 with an RBEDP of 18. Her PA pressures remained with a mean of 25 and her wedge pressure was 18. She did not require going back on RVAD support following the procedure. She had evidence of better LV filling and improved septal position, so a decision was made to not put her RVAD back in. As far as follow-up, following transcatheter pulmonary valve placement, she remained on durable LVAD support and home Milrinone therapy. She continues to have severely depressed RV function but has not required reinitiation of RVAD support or increased inotropic support. Her most recent echocardiogram just a month ago, which is about 11 months after valve implant, her peak velocity across the pulmonary valve was just one meter per second and she had just trivial insufficiency.

64-year-old female

non-ischemic cardiomyopathy

HeartMate 3 LVAD placement

severe pulmonary valve insufficiency

percutaneous pulmonary valve placement