So then we'll move to our second case by Dr. Sebastian Goresny. He's a pediatric interventional cardiologist and the head of pediatric cardiology at, I'm going to mispronounce this, Jagiellonian University in Krakow, Poland, and the cath lab director at the University Children's Hospital there in Krakow as well. Go ahead, Sebastian. Thank you very much for the introduction. Yeah, it is past 2 a.m., but thank you very much for inviting me and giving me this opportunity to present one of the cases we performed recently. I have no disclosures, however, I need to say that the patient that I'll discuss was referred to me by my previous boss. That's the team of doctors where I worked previously, and my previous boss said that perhaps I would like to treat this one with a big self-expandable valve, and he even offered to come and scrub with me for that case. This is the history and imaging of that patient, 15-year-old boy with tetralogeal fallot who underwent transannular patch repair and presented with significant PR, with significantly dilated right ventricle, with low pressure in the right ventricle, and NPA of around 26 millimeters on echo. However, CT imaging revealed that the right ventricle outflow tract and NPA was larger than that at some levels, even above 30 millimeters, 37 by 24 millimeters, as you can see here, and the anatomy of that outflow tract was not as straightforward with dilation above the annulus and slight narrowing just at the level of pulmonary artery bifurcation. These are images from a screening report pointing out some measurements and information and suggestions of approach for that case, and here you can see right ventricle outflow tract dimensions. You can see that at the vulval level, diameter was 28 to around 30, 30 maybe 2, and then in the supra-vulval level, the dimension was significantly larger, up to 36 millimeters, and there are some more comments regarding implantation of venous valve in this patient. It was stated that the anatomy is challenging, that there was also proximity of the aortic root, and careful balloon interrogation was suggested to assess compliance of that NPA and that patch in the outflow tract, and also to assess impact on the aortic root. However, the summary of that, of these comments was more optimistic and that there was sufficient length for the P valve and that this case was categorized as AMBER 2, which actually means that there was either borderline anatomy or unusual manures were anticipated. And I used ultrasound for axis, and on both sides I could see very nice primal arteries. However, on the right side, I can advance wire, and this is image of right iliac arteries, and this is how it looked on the left side. Well, you can see that there is passage this way, but I didn't decide to go this way, and I didn't think that that collateral here would be also a good way to introduce a large delivery system. So it took me a moment to puncture that right internal jugular vein, 45 kilogram patient. Usually we use that approach for single ventricle patients, and it's not a big deal. However, here, having in mind that large sheets would be required for delivery of that valve, I did it more meticulously. And here you can see angiogravity, AP, and lateral to assess the aortic roots, and there is a trivial aortic regurgitation. Here, MPA or LPA injection, and we can see there is a significant regurgitation, and on the lateral, we can better appreciate level of the annulus here, and this we thought would be our landing zone for the valve. So we wanted to be always at this level and go further towards pulmonary arteries. Values here are somewhere between 26 to 30 millimeters, but as mentioned before, with this valve, it is suggested to use balloon sizing, and this injection shows us that this is a 34 millimeter sizing balloon. There's no contrast flow to pulmonary arteries, both on AP or cranial and on the lateral. And one more angiography here to assess coronary arteries and the aortic root. There is some flattening here, but we cannot see any significant aortic regurgitation, and a similar image on the lateral for coronaries far away. And in terms of measurements, we can see that our X3 here is around 33 millimeters, X2 32 millimeters, and our lateral X1 is 30.2, so we were considering either 36 or 34, and the length of the valve, we decided to use 25. Initially we did use a 36 in diameter, and this is introduction of 26 dry seal over a Lunderquist wire placed in the RPA. And I must say that it was easier introduction of that dry seal as it was in the first case we did that day, which was done from cranial arteries. So with a little bit of patience, it tracked this, this sheath tracked well through the right ventricle and then up through the outflow tract and to the right pulmonary artery. It was suggested in the screening report perhaps to use the left pulmonary artery. I think that's from the beginning of the utilization of venous P-valve, and more centers and operators would use that. However, after two cases we did with the LPA, more recently I've used RPA from the remaining patients. And you can see here on the lateral, perhaps that kink looks more scary, but when you look in the AP, this bend here, this curve isn't that scary anymore. And now it's introduction of the venous P-valve. It is around six to almost seven centimeters long when in the capsule. But again, there was no difficulty in advancing that and the patient remained stable. And now opening of the valve, the distal flare. So you can see this is the end of the dry seal. And below that you can see that there is marker indicating the end of the capsule. And there are at least two techniques of deploying the distal flare. Some deploy the entire flare, which means that they go more open the valve more before pulling it back to the MPA. The other technique is actually to have the small flare and then gradually pull back on the entire system so that it falls into the desired position. So the distal flare is still in the RPA and now the dry seal is being pulled a little bit and the entire system is being pulled with a gentle push on the wire. And in a moment, that distal flare will pop into orifice of the left pulmonary artery. Let's move to the next one, please. And now please play the one on the left side. And now we see the distal flare open and please play the other one. So we see that the distal flare is at the bifurcation. It's actually above the distal bifurcation. And we can see that now the capsule is at the middle of the valve. And in the next slide, please go to the next slide. I will remove the, pull back the dry seal more. And let's play this one. Okay, so dry seal is coming back. And after that, let's go to the next one. There will be one more NGO. Just to confirm the position, let's play the other one as well. Yes, so we have the flare at the bifurcation and we want to be with the proximal markers just above the level of the annulus there. On the lateral, you can appreciate that better. You can see that leaflet nicely at the posterior wall of the outflow trap. Let's go to the next one. And this is going to be the final deployment. Now at this stage, you have to be quick. There's no coming back and you have to do it quickly. And after that is done, you would have to make sure that those clasps, so it's proximal ears, two ears are loose before we replace the delivery system. Let's move to the next one. And it was a little bit exciting to remove it. Real challenge, but I think this wire, it wasn't so easy to keep the wire in the middle of the valve. So at this moment was a little bit emotional, but you can see that then this parrot went back to the right ventricle and the valve remained stable. And let's move on. Next please. Next I'm going to wrap up, okay? Sorry. Final angio and next one please. And the lateral as well. Okay. And there's going to be on the next slide, we can see echo, pre-discharge echo, just trivial regurgitation. And the patient came two months later for outpatient visit and as well. And there's still that trivial regurgitation. Let's go to the next slide. Thank you very much to Professor Gevillic and Matt Jones and Shaq Qureshi for supporting me clinically and for the PNAS team for being there and providing a lot of valuable advices. Thank you very much.

Dr. Sebastian Goresny

pediatric interventional cardiologist

tetralogy of Fallot

pulmonary regurgitation

self-expandable valve