Complications From Transcatheter Pulmonary Valve Replacement With Self-Expanding Prestent

Figure 1. Patient 1 (A) This pulmonary arterial (PA) angiogram in the lateral projection demonstrates severe pulmonary regurgitation and the intended landing zone for the Alterra Adaptive Prestent in patient 1 (the arrow indicates the annulus). (B) This post-implant angiogram in the right ventricle (RV) demonstrates the Alterra Prestent and SAPIEN 3 valve in the supra-annular position. The proximal tines of the Alterra Prestent appear to be extravascular (arrow). (C and D) These (C) axial and (D) coronal cardiac computed tomography images obtained the day after implant demonstrate perforation of the distal tines of the Alterra Adaptive Prestent through the anteroleftward wall of the main PA (arrows), along with a moderate hemopericardium (H). (E) This 4-chamber echocardiographic image the day after implant demonstrates a large hemopericardium (H). (F) This intraoperative photograph reveals that the distal tines of the Alterra Prestent have perforated the left side of the main PA (arrows).

Figure 2. Patient 2 (A) This image from the preoperative computed tomography scan in patient 2 demonstrates the anomalous circumflex coronary artery originating from the right coronary artery and wrapping around the right ventricular outflow tract (RVOT) anteriorly (arrows). (B) This selective right coronary angiogram after placement of the Alterra Adaptive Prestent and SAPIEN 3 valve demonstrates focal compression of the anomalous circumflex artery by a proximal tine of the Prestent (small arrow). (C) This post-catheterization computed tomography image demonstrates a proximal tine of the Alterra Present projecting through the pulmonary artery and coming into contact with the stented anomalous circumflex (arrow). The portion of the coronary artery compressed by the tine now had covered stent material within it and was unobstructed. Ao = aorta.

Figure 3. Patient 3 (A) This pulmonary artery (PA) angiogram obtained after valve implant shows 2 distal tines of the Alterra Adaptive Prestent tines appear to be protruding through the main PA (arrows). (B) This intraoperative photograph demonstrates extravascular protrusion of 3 distal tines (arrows) of the Alterra Adaptive Prestent that have perforated through the anterior wall of the main PA.

Figure 4. Patient 4 (A) This lateral-projection pulmonary artery (PA) angiogram in patient 4 demonstrates severe pulmonary regurgitation and the intended landing zone for the Alterra Adaptive Prestent (the arrow indicates the annulus). (B) This right ventriculogram following post-deployment of Alterra Adaptive Prestent demonstrates a well-seated device in the annular position. Note the interaction of the distal tines with the anterior portion of the main PA (arrow). (C) This intraoperative photograph of the right ventricular outflow tract demonstrates perforation of multiple tines of the Alterra Adaptive Prestent through the PA, with petechiae and hemorrhage of the PA (arrows).

Visual Summary. Self-Expanding Prestent Complications