Transcatheter pulmonary valve replacement is the first choice to treat residual or recurrent right ventricular outflow tract dysfunction. Surgery is an effective option when anatomy is not permissive for transcatheter procedures. When surgical risk is too high, hybrid procedures might be considered.

In this paper, we describe the first use of Harmony valve in Europe in a 59 years old patient with a huge right ventricular outflow tract. The procedure was performed by a hybrid approach: before valve deployment, through an anterior mini-thoracotomy, the pulmonary artery was plicated to create a landing zone. The valve was deployed by trans-femoral venous approach. It was secured by putting a suture on the distal stent raw under fluoroscopic guidance. The procedure was uneventful and patient’s New York Heart Association class rapidly improved from III–IV to II.

In conclusion, hybrid strategies might represent an acceptable option for huge right ventricular outflow tract, to be less invasive and to minimise device embolisation risks. When a good match between patient’s anatomy and device can be achieved, a mini-invasive or micro-invasive surgical approach might be considered to minimise bleeding risks and shorten the hospital’s length of stay.