Restrictive perimembranous ventricular septal defect with left to right Shunt post urgent aortic balloon valvuloplasty and transcatheter aortic valve replacement

An 86-year-old male patient was admitted in our cardiology ward with signs of congestive biventricular heart failure. The patient presented with deteriorating dyspnea on mild exertion and at rest the last days, compatible with class NYHA III-IV heart failure, bilateral peripheral oedema, increased NT-proBNP (9198 pg/mL), mildly elevated Troponin (TnT 64 pg/mL), interstitial pulmonary oedema and bilateral pleural effusions in chest X ray. Permanent atrial fibrillation, known left branch bundle block (QRS = 170 ms), hypertension, and chronic renal failure were referred as co-morbidities. The transthoracic echocardiogram (TTE) revealed severely impaired left ventricle (LV) function [ejection fraction (EF) = 25%–30%] with diffuse wall hypokinesia, a high-grade aortic stenosis with mean trans valvular pressure gradient of 44 mmHg, despite the low ejection fraction, accompanied with mild-moderate aortic regurgitation in the context of a severe degenerative tricuspid aortic valve disease, an ascending aorta aneurysm with 5.4 cm diameter, as well as severe pulmonary hypertension (85 mmHg). The patient demonstrated mild clinical improvement with intravenous diuretic therapy and given the very high surgical risk (estimated logistic Euroscore II = 41%) for aortic valve replacement, retrograde aortic balloon valvuloplasty as a bridge to transcatheter aortic valve replacement (TAVR) was decided.  The patient clinical status deteriorated significantly in the following days, presenting signs of cardiogenic shock. Emergency retrograde aortic balloon valvuloplasty was performed under general anesthesia and transoesophageal echo guidance. Due the urgent procedure, two-dimensional and three-