Discussion 
Although the patient met class I indications for aortic and pulmonic valve replacement, we instead proceeded with an endovascular approach to address both valvular pathologies given his high risk for repeat traditional surgery given his multiple previous sternotomies and surgical complications. We elected to proceed with intervention for pulmonic stenosis first given that right ventricular dysfunction is typically more recalcitrant to reversal than is left ventricular dysfunction due to limited medical therapies; and due to concern for potential worsening of left sided output due to inadequate preload should right ventricular dysfunction develop.
Ideal transcatheter pulmonic intervention involves implanting a valve large enough to eliminate the hemodynamic stress placed on the right ventricle while simultaneously avoiding catastrophic rupture of the stenotic pulmonic conduit and/or coronary artery compression. In this case, we were unable to obtain surgical records confirming the original pulmonic conduit size. Therefore, we proceeded with serial balloon dilation to determine the maximal feasible neoconduit size. Because of the risk of coronary compression, it is critical to perform coronary angiography during each balloon inflation to assure that coronary compression is not occurring. The maximal allowable size of the neoconduit is therefore typically limited by the largest diameter balloon used that does not lead to coronary compression.
In this case, balloon dilatation lead to a small contained perforation of the surgical pulmonic conduit, and thus a CP covered stent was deployed to seal the contained perforation. Although the CP stent sealed the perforation, it does not have adequate structural radial support to resist elastic recoil. Therefore, the addition of the Palmaz stent was necessary to add structural integrity to the neoconduit. With the proper scaffolding in place, the Edwards valve could then be deployed.
The Aortic valve intervention presented the challenge of treating bioprosthetic valve stenosis with concomitant moderate to severe PVL. After valve deployment, post-dilation bioprosthetic valve fracture (BVF) and enlargement of the surgical valve lead to sealing of the PVL and improvement in overall hemodynamics. Given the patient’s young age, we prioritized treatment of PVL at the LVOT level by placing a Sapien Ultra valve slightly more ventricular than would be typical, followed by BVF. This strategy avoided placement of a vascular plug which can increase the risk of complications with future TAVR in TAVR procedures by deforming during valve expansion leading to ostial right coronary artery (RCA) obstruction or migration.