ASD occlusion and BAV or BPV Figure 9. Completely endothelised occluder device viewed from the left atrium with no residual shunt Figure 10. Completely endothelised occluder device viewed from the right atrium With the pulmonic valve peak-to-peak pressure gradient being only 5 mmHg above the cut-off value for interventional treatment of pulmonic stenosis in symptomatic patients (30 mmHg), we decided to correct the ASD first. The Qp/Qs ratio (1.45 : 1) was slightly below the 1.5 : 1 value. The ASD itself, however, was large (19 mm in diameter) and we expected the left-to-right shunt ratio to be diminished by the elevated pressures in the right- sided chambers. Treating the ASD first allowed us to reassess the pulmonic stenosis, with the peak- to-peak pressure gradient remaining above the 30 mmHg threshold, and thus we decided to proceed with the pulmonic balloon valvuloplasty. Our patient with pulmonary valvular stenosis and ASD was older than patients in previously published reports. She remained asymptomatic up to the age of 63 years probably due to only borderline Qp/Qs ratio and only mildly elevated pulmonary valve pressure gradient. The late pulmonary artery dilatation in our patient demonstrates a need for a thorough follow-up examination. The percutaneous treatment of ASD and calcific aortic stenosis has not been previously reported. At present, with TAVI being an alternative form of treatment of patients with calcific aortic stenosis not eligible for surgical valve replacement, aortic balloon valvuloplasty is being used in fewer cases or has been abandoned completely [6]. The reasons for it falling out of favour are mainly a high rate of restenosis and a small haemodynamic effect. However, in everyday clinical practice in the setting of an expanding elderly population there are patients who could benefit from this procedure [7]. We encountered an older, high-risk patient with severe comorbidities and in critical condition, who was eligible for neither surgical treatment, nor TAVI. Therefore, we decided to perform an aortic balloon valvuloplasty as a palliative treatment combined with ASD closure of a large defect with significant left-to-right shunt. Before the actual occlusion of the ASD we carefully monitored the PA and PCW pressure during balloon occlusion of the defect, in case the elimination of the shunt worsened the situation in the pulmonary bed. Our case reports show that secundum type ASD combined with pulmonic or aortic valve stenosis can be treated by a one-stage percutaneous procedure. In the case of ASD and pulmonic stenosis, there is no clear agreement as to which defect should be treated first. Before the ASD closure in a patient with aortic stenosis, a careful haemodynamic assessment is essential. Acknowledgment Supported by the Czech Ministry of Health MZOFNM2005. R e f e r e n c e s 1. Kan JS, White RI Jr, Mitchell SE, Gardner TJ. Percutaneous balloon valvuloplasty: A new method for treating congenital pulmonary-valve stenosis. N Engl J Med 1982; 307: 540-2. 2. Bonow RO, Carabello BA, Chatterjee K, et al. ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing Committee to Revise the 1998 guidelines for the management of patients with valvular heart disease) developed in collaboration with the Society of Cardiovascular Anesthesiologists endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons. J Am Coll Cardiol 2006; 48:e1–e148. 3. Wahl A, Windecker S, Misteli M, Meier B. Combined percutaneous pulmonary valvuloplasty and atrial septal defect closure for pulmonary valvular stenosis and associated secundum atrial septal defect in an adult. Catheter Cardiovasc Interv 2001; 53: 68-70. 4. Vera JA, Nounou M, Kern M. Staged Percutaneous Atrial Septal Defect Closure and Pulmonic Balloon Valvuloplasty in an Adult with Congenital Heart Disease. Catheter Cardiovasc Interv 2008; 72: 416-23. Arch Med Sci 6, December / 2010 979