Clinical Images

Reverse-Loop Technique for Percutaneous Transvenous Mitral Commissurotomy in a Patient With Huge Left Atrium

Rajesh Vijayvergiya, MD;  Sudhanshu Budhakoty, MD;  Ganesh Kasinadhuni, MD;  Kewal Kanabar, MD

Rajesh Vijayvergiya, MD;  Sudhanshu Budhakoty, MD;  Ganesh Kasinadhuni, MD;  Kewal Kanabar, MD

J INVASIVE CARDIOL 2019;31(12):E397.

Key words: cardiac imaging, large atrium, new technique


A 34-year-old man with chronic rheumatic heart disease, severe mitral stenosis, atrial fibrillation, and New York Heart Association class III was referred for percutaneous transvenous mitral commissurotomy (PTMC) in January 2016. In the past 5 years, he underwent 2 PTMC attempts at another institute; both attempts failed because the operator was unable to cross the mitral valve with the balloon. Two-dimensional echocardiography revealed mitral valve area of 0.8 cm2, transmitral diastolic gradient of 26/14 mm Hg, and no mitral regurgitation. The left atrium (LA) was hugely enlarged,  with dimensions of 10.9 x 13.3 cm, area of 89.7 cm2, and volume of 502 mL in apical 4-chamber view (Figure 1A).

Following standard transseptal puncture, an Inoue balloon was positioned in the LA. A marked distance between the tip of a Mullen’s sheath at the interatrial septum and a pigtail catheter in the ascending aorta, as well as a large loop of Inoue wire outlining the LA boundary, were suggestive of huge LA (Figure 1B). The conventional method of direct vertical balloon entry across the mitral valve was not successful despite repeated attempts. Later, a reverse-loop (or double-loop) balloon was made by pushing the extra shaft length in the LA (Figure 1C). As the balloon tip reached near the mitral valve, the stylet was withdrawn 1-2 cm within the assembly and the balloon catheter was pushed into the left ventricle. Then, the distal half of the balloon was inflated and the entire assembly was pulled back until it got stuck at mitral valve. At this point, the remaining half of the balloon was inflated for mitral valve dilation (Figure 1D; Video 1). Post PTMC, the mitral valve area was 1.6 cm2. The patient remained relatively asymptomatic over 3 years of follow-up. 

Reverse-loop technique is an alternative to conventional direct-entry technique during PTMC in patients with large LA.

View the Accompanying Video here.


From the Department of Cardiology, Post Graduate Institute of Medical Education & Research, Chandigarh, India.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein. 

The authors report that patient consent was provided for publication of the images used herein.

Manuscript accepted March 4, 2019.

Address for correspondence: Prof (Dr) Rajesh Vijayvergiya, MD, DM, FSCAI, FISES, FACC, Department of Cardiology, Advanced Cardiac Centre, Post Graduate Institute of Medical Education & Research, Sector 12, Chandigarh – 160 012, India. Email: rajeshvijay999@hotmail.com 

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