Introduction: Atrial septal defects are the most com-mon a-cyanotic cardiac malformations, with an inci-dence of 1 in 1500 live births, accounting for 30-40% of intracardiac shunts in adults. Ostium primum atrial septal defect (ASD) is a rare type of interatrial commu-nication, almost always associated with anomalies of the atrioventricular valves, thus determining a severe cardiac pathology.

Methods: A 76-year-old patient is admitted for NYHA class IV heart failure and new-onset atrial fibrillation. Echocardiography shows mild left ventricular systolic dysfunction, biatrial and right ventricular dilatation, severe mitral insufficiency, moderate aortic insufficien-cy, moderate-severe tricuspid insufficiency, moderate pulmonary hypertension and an interatrial communi-cation with left-to-right shunt, probably ASD ostium primum type. Transesophageal ultrasound confirms the severity of valvular damage and the type and di-mension of the of the ASD (approximately 1.8 cm).

Results: T he association of moderate-severe valvulo-pathies with a type of ASD that cannot benefit from interventional treatment due to its anatomical features, leads to open heart surgery. Preoperative coronarogra-phy describes three vessel atherosclerotic disease. EU-ROSCORE II 5.9%. Surgery consists of double CABG, aortic valvuloplasty, De Vega tricuspid valve annu-loplasty, biological mitral valve prosthesis no. 29 and ASD closure, with optimal result. Postoperative evo-lution is favorable, 30 days after surgery the patient is in sinus rhythm and with minimal heart failure symp-toms. Echocardiography shows a normofunctional mi-tral prosthesis, no intracardiac pathological communi-cation and no pulmonary hypertension.

Conclusions: Ostium primum ASD is a rare cardiac pathology, with severe hemodynamic consequences. Due to frequent concomitant atrioventricular valve damage and to the impossibility of minimally invasi-ve treatment, it can be a cardiac surgery challenge. The peculiarity of the present case consists in the old age of symptom onset and diagnosis, as well as in the asso-ciation with significant coronary disease, leading to a complex surgical solution with optimal outcome.