**4. Modifications**

The use of a long sheath as described by Quandt et al. [13] is mainly performed to minimise the tricuspid valve apparatus injury and to achieve a stable stent position by repeated test angiograms. However, the use of a long delivery sheath may be associated with haemodynamic instability, particularly in smaller and sicker patients due to tricuspid valve splinting open leading to compromised cardiac output and extreme cyanosis.

Linnane et al. have used periventricular approach in 4 patients weighing ≤2 kg through a small subxiphoid incision [14]. This approach provided a more direct route to the RVOT and the stent was deployed under Trans Thoracic Echocardiography (TTE) guidance.

Linnane et al. [15] also described a method for avoiding long delivery sheath during the stent deployment by crossing the tricuspid valve and RVOT with an angled glide catheter to facilitate placement of the guidewire in the branch pulmonary arteries and doing 3–4 clockwise rotations to create some backwards tension on the wire during stent advancement. The authors utilised TTE to guide the stent placement rather than angiography.
