femoral vein. The left-to-right shunt ratio of pulmonary blood flow (Qp) to systemic blood flow (Qs) was assessed to be 1.45 : 1. The peak-to-peak pressure gradient across the pulmonary valve was 35 mmHg. First, the ASD was closed using a 21 mm Figulla Occluder device (Occlutech GmbH, Jena, Germany) under transoesophageal echocardiographic guidance (Figure 2). The peak-to-peak pressure gradient across the valve was measured again and showed 33 mmHg. Therefore, pulmonary balloon valvulo- plasty was performed with a NuCLEUSTM 25 × 30 mm percutaneous transluminal valvuloplasty catheter (NuMED, Inc., Hopkinton, NY, Figure 3). The resulting peak-to-peak pressure gradient was 10 mmHg. The patient was started on dual antiplatelet therapy (aspirin 100 mg daily and clopidogrel 75 mg daily for 6 months). Follow-up echocardiogram 2 months after the procedure showed no residual shunt and a maximal pressure gradient across the pulmonary valve of 38 mmHg and the patient reported an improvement in the functional class (NYHA I). Six months after the procedure, the maximal pressure gradient declined to 25 mmHg and a recent one-year follow-up showed a further decline to 16 mm Hg as well as a new dilatation of the pulmonary artery to a diameter of 50 mm. Patient 2 A 78-year-old woman was admitted to the hospital due to heart failure symptoms (dyspnoea, fatigue, peripheral oedema). Shortly after admission, respiratory distress occurred due to pulmonary oedema and the patient had to be artificially ventilated. Transoesophageal echo- cardiogram showed a severe calcific aortic stenosis with 102 mmHg maximal and 56 mmHg mean pressure gradient and a large secundum type ASD (17 mm in diameter) with left-to-right shunt (Figure 4). She was referred for combined percutaneous aortic balloon valvuloplasty and ASD closure. Right heart catheterization was performed via the right jugular vein. Temporary pacing was introduced into the right ventricle via the right Figure 1. Transoesophageal echocardiogram of a secundum type ASD with a Multipurpose catheter (Cordis, Miami Lakes, FL) crossing the defect from right to left atrium Figure 3. Balloon valvuloplasty of pulmonary valvular stenosis following ASD closure Figure 2. Transoesophageal echocardiogram after ASD closure Figure 4. Transoesophageal echocardiogram of a secundum type ASD Arch Med Sci 6, December / 2010 977