Feasibility of 35-mm Balloon-Expandable Transcatheter Pulmonary Valve Implantation in Extra-Large Native Right Ventricular Outflow Tracts

BACKGROUND: Transcatheter pulmonary valve implantation is established for right ventricular outflow tract dysfunction but remains limited in extra-large native outflow tracts because of device size constraints. CASE SUMMARY: This case series describes implantation of a custom 35-mm balloon-expandable Myval valve in 4 patients with severe pulmonary regurgitation and right ventricular dilation who were unsuitable for conventional transcatheter therapy. Multimodality imaging and balloon interrogation consistently identified a functional landing zone of approximately 32 mm, guiding valve selection. Prestenting was applied in aneurysmal outflow tracts, while direct implantation was feasible in the presence of focal narrowing. Procedural success was achieved in all cases, with elimination of pulmonary regurgitation, low gradients, and no major complications. These findings demonstrate feasibility and reproducibility of this approach and support dynamic sizing to expand transcatheter options in extra-large native outflow tracts. TAKE-HOME MESSAGE: Implantation of a custom 35-mm balloon-expandable valve in extra-large native right ventricular outflow tracts is feasible and reproducible, demonstrating that dynamic sizing and tailored procedural strategy can safely expand transcatheter pulmonary valve implantation to patients previously excluded by device size limitations.