History and clinical findings: A 68-year-old woman, with a cardiac murmur known since childhood and suffering from increasing dyspnoea for several years, was admitted to hospital after echocardiography had suggested pulmonary valve stenosis and an atrial septal defect. While her general condition was satisfactory, she had marked central cyanosis with clubbed fingers and moderate bilateral oedema of the lower legs. A rough, diamond-shaped systolic murmur was heard, loudest over the left 2nd intercostal space. In addition to a cardiac defect with right to left shunt, primary pulmonary disease with cor pulmonale was considered in the differential diagnosis.
Examinations: Haemoglobin content was 25.1 g/dl, haematocrit 72.4%, red cell count 7.44 x 10(6). Arterial oxygen partial pressure was 40 mm Hg, arterial oxygen saturation 81.8%, Echocardiography further revealed right ventricular enlargement, marked tricuspid regurgitation and a stenosed calcified pulmonary valve. At right heart catheterization a right to left interatrial shunt was calculated at 47% of systemic flow and a systolic pressure gradient between right ventricle and pulmonary artery of 131 mm Hg was measured.
Treatment and course: Haemoglobin content was lowered to 19.4 g/dl after bloodletting. Balloon pulmonary valvuloplasty reduced the transvalvular systolic gradient to 31 mm Hg. The further course was without complication: 4 months later the patient had only grade II (NYHA) dyspnoea, the oxygen saturation was 91.3%.
Conclusion: Severe pulmonary valve stenosis with right to left interatrial shunt can be successfully treated by balloon dilatation even in elderly patients.