Bilateral Modified Self-Expanding Valve Implantation in Branch Pulmonary Arteries

BACKGROUND: Transcatheter pulmonary valve implantation (TPVI) in repaired tetralogy of Fallot is challenging due to right ventricular (RV) outflow tract complexity. Severe main pulmonary artery (PA) dilation can preclude TPVI, a platform limitation. CASE SUMMARY: A 67-year-old man with repaired tetralogy of Fallot, severe pulmonary regurgitation, and RV dysfunction presented with right heart failure. Prior institutions deemed him unsuitable for surgical or transcatheter intervention. After multidisciplinary discussion, Harmony valves (Medtronic) were modified by removing distal polyester fabric (rows 1 and 2) to prevent segmental branch PA obstruction, and implanted sequentially in bilateral PAs. RV remodeling and symptom improvement were noted at 3-month follow-up. DISCUSSION: This first reported modified Harmony valve case demonstrates feasibility of bilateral PA implantation without branch obstruction, expanding TPVI options in severely dilated PAs. TAKE-HOME MESSAGE: Modifying the Harmony valve by distal fabric removal preserves segmental PA flow and maintains radial force and valve function in branch PA TPVI.