Aortopulmonary window due to transcatheter pulmonary valve implantation after arterial switch operation

Method A 12-year old boy (d-transposition of the great arteries and ASO (LeCompte maneuver) in the neonatal period) was referred for transcatheter pulmonary valve implantation due to pulmonary regurgitation. A 22-mm stentmounted valved bovine jugular vein graft (Melody valve, Medtronic, Minneapolis) was implanted, but the patient became hemodynamically unstable (pulmonary-tosystemic ratio 1.96). Transesophageal echocardiography (TEE) showed a traumatic APW in the uppermost portion of the ascending aorta. Haemodynamic stability was achieved following closure using a 10-mm AmplatzerMuscular-VSD-Occluder but he remained symptomatic in the subsequent weeks. TEE showed residual left-toright shunt in the proximal margin and a covered stent was implanted on the left pulmonary artery (LPA) to deal with the residual shunt, but the Amplatzer was dislocated. He was referred for emergent surgery. He was cooled to 18°C and ventricular fibrillation was achieved. Carbon dioxide field flooding was employed throughout. The circulation was arrested and the right PA was incised and extended toward the LPA. Both percutaneous devices were removed and the APW was closed (Gore-Tex patch). The PA and branches were reconstructed (bypass time 150 and arrest time 23 minutes). TEE showed no residual shunts.