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FIGURE 1. A, Cardiac catheterization. Melody valve (Medtronic Inc, Minneapolis, Minn) and stent (descending aorta) are shown. Amplatzer device (yellow arrow) into the APW. B, Displacement of the Amplatzer device (yellow arrow) after implantation of the left PA stent. Ao, Aorta; LPA, left pulmonary artery; PA, pulmonary artery. CLINICAL SUMMARY A 2-month-old baby with a diagnosis of dextrotransposition of the great arteries underwent the ASO (LeCompte maneuver). At the age of 10 years, a covered stent was placed on the main pulmonary artery (PA) for supravalvular pulmonary stenosis, but secondary pulmonary regurgitation developed. The patient was referred for transcatheter pulmonary valve implantation at the age of 11 years. A 22-mm, stent-mounted valved bovine jugular vein graft (Melody valve; Medtronic Inc, Minneapolis, Minn) was implanted, but the patient became hemodynamically unstable (pulmonary-to-systemic ratio 1.96). Transesophageal echocardiography (TEE) showed a traumatic APW in the uppermost portion of the ascending aorta. Hemodynamic stability was achieved after closure using a 10-mm Amplatzer Muscular VSD Occluder (AGA Medical Corp, Golden Valley, Minn) (Figure 1, A), but he remained symptomatic in the subsequent weeks. TEE showed residual left-to-right shunt in the proximal margin, and a covered stent was implanted on the left PA to deal with the residual shunt, but the Amplatzer was dislocated (Figure 1, B) and the patient was referred for emergency surgery. Arterial cannulation was performed through the left femoral artery, and the inferior venae cavae and right atrium were cannulated separately. The patient was cooled to 18 C,

Aortopulmonary window due to transcatheter pulmonary valve implantation after arterial switch operation: Where is the limit?