Figure 4.

Modification of techniques to advance the valve delivery system. The large profile delivery system of Venus P-valve could be advanced to the outflow tract only with some manipulations by creating a large right atrial loop (a) that was slowly unwound (b) resulting in advance of the valve assembly. An inflated balloon (c) reduced the friction in the distal outflow. When a long 26F braided sheath was available (d), it allowed unhindered passage of the delivery system (e) and valve deployment was preceded by withdrawing the long sheath (f). Extreme tortuous left pulmonary artery was managed by right pulmonary artery deployment (g) where an inflated balloon (h) reduced the friction and allowed progressive advance (i) of the delivery system