Percutaneous Balloon Mitral Valvuloplasty in Patients with Left Atrial Thrombi

Tsung O. Cheng, MD, Professor of Medicine, George Washington University, Washington, D.C. (USA) I read with interest the article on the use of transesophageal echo-cardiography (TEE) in monitoring emergency percutaneous balloon mitral valvuloplasty (PBMV) in a patient with massive left atrial thrombosis by Chirillo et al. [1]. Although I agree that TEE was of great value in monitoring each step of PBMV to avoid systemic embo-lization in their patient, I disagree with the author’s statement of the ‘Inoue balloon ... having a larger profile’. The trefoil balloon that they used has a far larger profile than the Inoue balloon [2]. The Inoue balloon catheter technique is best suited for patients with mitral stenosis and left atrial or/and left auricular thrombi. For their detection biplane TEE is far superior to uniplane TEE [3]. Hung [4] using biplane TEE to monitor PBMV with the Inoue balloon catheter technique found that there was no contact between the guide-wire/catheter and the left atrial appendage area and thrombi within the appendage. The ability to ‘steer’ the Inoue catheter device is a critical advantage of its use when atrial appendage thrombi are present [5]. In general patients with mitral stenosis and a history of systemic embolism should receive warfarin for 4-6 weeks prior to PBMV [4]. Of course, in this case this was not an issue because PBMV was done as an emergency procedure due to patient’s deteriorating condition. References Chirillo F, Ramondo A, Dan M, Rampazzo C, Chioin R: Successful emergency percutaneous balloon mitral valvotomy in a patient with massive left atrial thrombosis: Utility of transesophageal echocardio-graphic monitoring. Cardiology 1991;79:161-164. Cheng TO: Percutaneous Balloon Valvuloplasty. New York, Igaku-Shoin Medical Publishers, in press. Wang XF, Li ZA, Cheng TO, Deng YB, Wang JE, Yang Y: Biplane transesophageal echocardiography: An anatomic-ultrasonic-clinical correlative study. Am Heart J, in press. Hung JS: Mitral stenosis with left atrial thrombi: Inoue balloon catheter technique; in Cheng TO: Percutaneous Balloon Valvuloplasty. New York: Igaku-Shoin Medical Publishers, in press. Nishimura RA, Holmes DR Jr, Reeder GS: Efficacy of percutaneous mitral balloon valvuloplasty with the Inoue balloon. Mayo Clin Proc 1991;66:276-282.