Early multicenter experience of Melody valve implantation in India

Figures

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  Figure 1. Coronary artery relation to conduit. Multiplanar reformatted computed tomographic image (a) demonstrates the distal part of the calcified conduit (C) overlying the right coronary artery origin from aorta. Another patient after Ross surgery (b) with a calcified conduit (c) which is in close relation to both the coronary artery origins (black arrows) from a dilated aortic root. PA: Pulmonary artery, LPA: Left pulmonary artery, RVOT: Right ventricular outflow tract, SVC: Superior vena cava, RPA: Right pulmonary artery

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  Figure 2. Distal branch pulmonary artery stenosis. Axial computed tomographic image of a patient with a degenerated bioprosthetic valve (a) implanted for pulmonary regurgitation after truncus repair with absent left pulmonary artery shows stenosis between the pulmonary trunk and the lone right pulmonary artery. A second patient (b) after initial left modified Blalock–Taussig shunt followed by conduit repair for tetralogy has stenosis of origin of left pulmonary artery near the shunt insertion. PA: Pulmonary artery, LPA: Left pulmonary artery, SVC: Superior vena cava, RPA: Right pulmonary artery

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  Figure 3. Strategy in densely calcified conduit. Calcified conduits at risk of rupture are initially interrogated with compliant sizing balloons during coronary injection (a) before prestenting of the conduit with a covered stent. This covered stent is later expanded to larger diameter of 20 mm (b) with high-pressure balloons. Once the conduit gradient is eliminated, Melody valve is positioned in the landing zone present (c) and expanded. A competent pulmonary valve is shown in pulmonary arteriogram recorded in lateral view (d). PA: Pulmonary artery, LPA: Left pulmonary artery, LCA: Left coronary artery

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  Figure 4. Balloon interrogation of coronary arteries. Left coronary artery origin and its left anterior descending and circumflex (Cx) branches are demonstrated in caudal projection (a) before balloon interrogation of the conduit. Inflation of a 20 mm balloon (b) in the conduit does not cause any compression of the left coronary artery. Even though a left coronary angiogram in a lateral projection (c) after inflation of a larger 22 mm balloon fails to show the coronary ostium, the caudal projection (d) shows that the shift of calcium in the postero-inferior wall of the conduit causes extrinsic left coronary artery compression

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  Figure 5. Valve-in-valve implantation within bioprosthetic valves. Left coronary artery injection in lateral view (a) shows its relation to the bioprosthetic valve before its interrogation using a high pressure 22 mm balloon (b) across the valve. A Melody valve is expanded within the bioprosthetic valve, which acts as the landing zone (c). Final pulmonary arteriogram in cranial projection (d) shows absence of regurgitation

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  Figure 6. Left pulmonary artery stent followed by Melody valve. Pulmonary angiogram in caudal projection (a) demonstrates narrowing of the origin of the left pulmonary artery shown in arrow and large right pulmonary artery. After stent angioplasty of the left pulmonary artery, interrogation of the left coronary artery after inflating an 18 mm balloon in the conduit (b) demonstrates normal coronary flows. The conduit is prestented with a Cheatham platinum stent (c) followed by implantation of Melody valve (d) within the prestented landing zone

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  Figure 7. One-step combined prestenting and implantation of Melody valve. Right ventriculogram (a) shows a narrow dysfunctional conduit and dilated left (left pulmonary artery) and right (right pulmonary artery) pulmonary arteries after repair of tetralogy of Fallot with absent pulmonary valve syndrome. Left coronary artery interrogation with a 22 mm balloon in the conduit (b) shows unobstructed flows. A 42 mm AndraStent XL is crimped around the Melody valve within the 22 mm Ensemble delivery system (c) as an one-step procedure and positioned across the narrowed conduit. Pulmonary arteriogram after expansion of the Melody valve (d) shows absence of pulmonary regurgitation