Pavol Tomasov, Katerina Linhartova, Petra Antonova, Radka Adlova, David Alan, Josef Veselka femoral vein. Coronary angiography and left heart catheterization were performed via the right femoral artery. No significant coronary stenosis was found and the left-to-right shunt ratio of Qp to Qs was 1.5 : 1. Peak-to-peak pressure gradient across the aortic valve was 50 mmHg. Aortic balloon valvuloplasty with a NuCLEUSTM 22 × 40 mm percutaneous transluminal valvuloplasty catheter (NuMED, Inc., Hopkinton, NY) was accomplished. The resulting peak-to-peak pressure gradient was 10 mmHg. Next, under transoesophageal echocardiographic guidance, sizing of the ASD using a 17 mm balloon while measuring the pulmonary artery (PA) and pulmonary capillary wedge (PCW) pressures was achieved (Figures 5, 6). After ruling out elevation in PA pressures during the sizing balloon inflation, the ASD was successfully closed with an 18 mm Figulla Occluder device (Occlutech GmbH, Jena, Germany, Figures 7, 8). The patient was started on a dual antiplatelet therapy (aspirin 100 mg daily and clopidogrel 75 mg daily for 2 months). Shortly after the procedure the heart failure symptoms subsided. The patient died 18 months later of a sudden cardiac death. The autopsy showed a completely endothelised Figulla occluder device with no residual shunt (Figures 9, 10). Discussion In adult patients, combined occurrence of secundum type ASD and pulmonic stenosis is an uncommon condition. When isolated, both conditions can be treated percutaneously. Several reports describing a transcatheter approach for the treatment of combined secundum type ASD and pulmonic stenosis vary in answering the question which defect should be treated first and whether the procedures should be staged or combined [3-4]. Treating the ASD first should eliminate the left- to-right shunt and thus also the right ventricle volume overload and possibly lower the pressure gradient across the pulmonic valve, enabling one to reassess the pulmonic stenosis severity. On the other hand, addressing the pulmonic stenosis first lowers the peri-procedural risk of ASD occluder device dislodgement. Figure 5. Pulmonary artery pressure measurement before ASD occlusion Figure 7. ASD closure Figure 6. Pulmonary artery pressure measurement immediately after ASD occlusion Figure 8. Transoesophageal echocardiogram after ASD closure 978 Arch Med Sci 6, December / 2010