Challenges in balloon pulmonary valvotomy for severe pulmonary stenosis presenting with cyanosis and ventricular dysfunction

Valvular pulmonary stenosis (PS) can present with cyanosis and right heart failure in older children and adults. Transcatheter balloon pulmonary valvuloplasty is a standard intervention for severe valvular PS in all age groups. Balloon dilatation in critical PS like presentation in older age groups has unique challenges in management. These cases are associated with right ventricular dysfunction, cyanosis, pulmonary edema, injury to right ventricular structure, and arrhythmia. Imaging is an essential component for diagnosis and management. We present two such cases of older children who presented with cyanosis and right ventricular dysfunction. Detailed imaging and team approach of care helped in managing the challenges of balloon pulmonary valvuloplasty in older sick substrates.