On-line transesophageal echocardiography in balloon mitral commissurotomy

Balloon mitral commissurotomy (BMC) has been widely applied in treating mitral stenosis. In most centers, it is guided by fluoroscopy. In view of the better visualization of the interatrial septum and the mitral apparatus by transesophageal echocardiography (TEE), we employed on-line multiplane TEE to supplement fluoroscopy for BMC. Consecutive 150 patients with mitral valve area <1.5 cm², no thrombus in the left atrial cavity, and mitral regurgitation less than grade 3, were enrolled in the study. Seventy (47%) of them had thrombus in the left atrial appendage inspite of adequate anticoagulation before BMC. We used Inoue balloon catheter and stepwise dilatation with on-line TEE guidance. Immediately after BMC, the mitral orifice area increased from 1.0±0.3 to 1.8±0.6 cm² (p = 0.000), the mean pressure gradient dropped from 10.9±4.6 to 5.1±2.5 mmHg (p = 0.000), and the left atrial endsystolic diameter decreased from 48±10 to 43±9 mm (p = 0.000). There was no procedure-related mortality, stroke, or emergency valvular operation. Septal puncture became easy and safe. On-line assessment became very effective and radiation hazards were greatly reduced.