Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

Users Online : 5781

AbstractCase ReportDiscussionConclusionReferencesDOI and Others
Article in PDF How to Cite Citation Manager Readers' Comments (0) Audio Visual Article Statistics Link to PUBMED Print this Article Send to a Friend
Advertisers Access Statistics Resources

Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"

Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018

Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."

Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018

Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."

Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018

Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."

Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
On Sep 2018

Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."

Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata

Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
On Aug 2018

Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".

Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
On Aug 2018

Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".

Dr. Mamta Gupta
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018

Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.

Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."

Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
On May 11,2011

Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."

Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
On April 2011

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.

Dr. Anuradha
On Jan 2020

Important Notice

Case Series
Year : 2022 | Month : December | Volume : 16 | Issue : 12 | Page : OR05 - OR08 Full Version

Unusual Findings and Outcomes of Balloon Mitral Valvotomy

Published: December 1, 2022 | DOI:
Ravindranath K Shankarappa, Yeriswamy M Channabasappa, Abdul Rehaman, Arun B Shivashankarappa, Raghavendra Murthy

1. Professor, Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India. 2. Associate Professor, Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India. 3. Assistant Professor, Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India. 4. Assistant Professor, Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India. 5. Associate Professor, Department of CTVS, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India.

Correspondence Address :
Dr. Arun B Shivashankarappa,
Shree Mallikarjuna, #K41, Upkar Meadows Layout, Kyalasanahalli, Jigani Anekal Taluk, Bengaluru, Karnataka, India.


Balloon mitral valvotomy is a common procedure done for rheumatic mitral stenosis. However, certain cases may pose challenges and rarely may be life-threatening. Here, three unusual cases of balloon mitral valvotomy are presented. Case 1, a 42-year-old male, had procedural challenge in terms of Interatrial Septal (IAS) fibrotic thickening and calcification, posing difficulty in trans-septal puncture and crossing IAS with valvotomy balloon. Case 2, a 38-year-old female, had bidirectional Ventricular Tachycardia (VT) with a single dose of intravenous digoxin, and stress cardiomyopathy. Case 3, a 49-year-old male, had difficulty in negotiating valvotomy balloon towards apex and in the process, there was left ventricular free wall perforation.


Bidirectional ventricular tachycardia, Interatrial septum, Left ventricular perforation, Stress cardiomyopathy

Balloon Mitral Valvotomy (BMV) has evolved over a period, since its introduction by Inoue in 1984 (1). BMV is commonly performed interventional procedure for Rheumatic Mitral Stenosis (MS). BMV improves the valve orifice by splitting the fused commissures. In addition, it results in fracture of nodular calcium within leaflet structure. BMV has almost replaced surgical Closed Mitral Valvotomy (CMV) for pliable MS. It is associated with challenging steps like trans-septal puncture and rarely, life-threatening complications like cardiac tamponade due to left atrial, left ventricular perforation (2). Here, three challenging cases of BMV have been presented.

Case Report

Case 1

A 42-year-old male presented with dyspnoea for six months. He had Rheumatic Heart Disease (RHD), and had undergone Closed Mitral Valvotomy (CMV) 25 years back. On clinical evaluation, he was diagnosed with severe mitral restenosis, moderate Pulmonary Hypertension (PH) with Atrial Fibrillation (AF). Echocardiography showed severe Mitral Stenosis (MS) with Mitral Valve Orifice Area (MVOA) of 0.8 cm2 and mild submitral fusion. Mean gradient across mitral valve was 16 mmHg. There was severe Tricuspid Regurgitation (TR) with Pulmonary Artery Systolic Pressure (PASP) of 50 mmHg. He was considered for BMV.

During BMV, there was resistance offered during puncturing of Interatrial Septum (IAS) with Brockenbrough needle. Fluoroscopy showed circumferential calcification of Left Atrium (LA). With difficulty, IAS was punctured, and LA coiled guidewire was introduced and dilated with septal dilator. But again, there was difficulty in crossing IAS with 24 mm Accura balloon. IAS was dilated with septal dilator repeatedly, even after which we could not cross the IAS with Accura balloon. Next, it was decided to dilate the IAS with peripheral balloon. A 0.035” exchange length wire was passed though the puncture made in IAS. Through the Cook’s sheath, an 8×40 mm Indigo peripheral balloon was passed over the 0.035 wire and positioned across the IAS and dilated till the disappearance of the waist [Video-1]. 0.035’ wire was exchanged with LA-coiled guidewire. Now, the authors could easily pass the Accura balloon across IAS and complete the procedure (Table/Fig 1),[Video-1].

Post-BMV, MVOA was 1.6 cm2, mean MV gradient decreased to 8 mmHg. Medial commissure was fully split, and lateral commissure was partially split. PASP reduced from 50 mmHg to 30 mmHg. Patient improved symptomatically. Later to assess the LA anatomy, cardiac Computed Tomography (CT) was performed. Circumferential mural calcification was noted in LA, predominantly involving free wall. There was calcification and asymmetrical fibrotic thickening (6-8.5 mm) of IAS (Table/Fig 2),[Video-2]. It is unusual to have such marked fibrotic thickening of IAS and calcification, which posed procedural challenge in the form of difficulty in trans-septal puncture and taking valvotomy balloon across the IAS. A peripheral balloon was used to overcome this challenge and completed BMV successfully.

Case 2

A 38-year-old female presented with dyspnoea for two months, increased since last one week. She was in AF with fast ventricular rate, pulmonary oedema, and cardiogenic shock. She was started on invasive ventilation in view of respiratory failure. Echocardiogram showed dilated LA, right atrium, and Right Ventricle (RV). IAS was thin and bulging towards right atrium. There was thickening of mitral leaflets, restricted mobility of posterior mitral leaflets and dooming of anterior mitral leaflets suggesting rheumatic mitral stenosis. MVOA of 0.8 cm2. Mean gradient across mitral valve was 13 mmHg. Both the commissures were fused. The leaflets were pliable. There was mild mitral regurgitation (MR) and moderate TR. PASP was suprasystemic measuring 124 mmHg. RV dysfunction was present. There was LA appendage clot protruding into body (type IIB clot) measuring 2.7×1.2 cm. Left ventricular (LV) Ejection Fraction (EF) was 60%.

In view of unstable haemodynamics, she was considered for emergency BMV. Mean LA pressure was 40 mmHg. Mean gradient across mitral valve was 14 mmHg. Mitral valve was dilated with 26 mm Accura balloon, with two inflations done at 22 mm and 23 mm. There was a drop in mean gradient to 7 mmHg and increase in MVOA to 1.4 cm2 following BMV. PASP reduced to 64 mmHg. There was mild MR, medial commissure was completely split, and lateral commissure partially split. AF with fast ventricular rate still persisted, despite intravenous amiodarone. Intravenous digoxin 0.25 mg was given to control the ventricular rate. But, she developed bidirectional Ventricular Tachycardia (VT) (Table/Fig 3). She was treated with intravenous potassium chloride. Amiodarone infusion was continued.

Case 3

A 49-year-old male presented with dyspnoea and effort intolerance from six months. He was diagnosed with RHD with severe MS about two months back and was advised mitral valve replacement, for which the patient was not willing. On Echocardiography, MVOA was 0.6 cm2 with mean gradient of 10 mmHg. Both mitral leaflets were calcified at the tip, extending into chordae. There was severe submitral fusion and mild MR. Wilkin’s Echo score was 12. There was trivial TR with PASP of 33 mmHg. As he was not willing for surgery, BMV was considered.

During BMV, there was difficulty in crossing mitral valve and negotiating the 24 mm Accura balloon to LV apex, as there was severe submitral disease. Each time it was getting entangled in submitral apparatus. Repeat attempts were made to take the balloon to LV apex. Patient suddenly became dyspnoeic and developed hypotension. Echocardiography showed large pericardial effusion with tamponade, suggesting cardiac perforation. Immediately, pericardiocentesis and auto-transfusions were done. But there was rapid reaccumulation of haemopericardium. Immediately, cardiothoracic surgical team was consulted and taken for emergency surgery. Intraoperatively, 3 mm rent in posterior wall of LV was noted, with jet of blood (Table/Fig 5),[Video-4]. The defect was repaired with felt. Mitral valve was replaced with 27 mm St. Jude’s mechanical prosthetic valve. However, patient succumbed to disseminated intravascular coagulation on day five.

Key findings and outcomes of all the cases are summarised in (Table/Fig 6).


Case 1 was associated with difficulty in obtaining trans-septal puncture. The present case had rare finding of LA calcification, which is a relatively uncommon complication of long-standing RHD (3). Calcification commonly involves LA appendage, LA free wall and mitral valve apparatus and is called porcelain atrium or coconut atrium (2). IAS is rarely involved in calcification, which was seen in the present case. Thick fibrotic IAS, measuring 6-8.5 mm was another rare finding noted in this case, which posed difficulty in trans-septal puncture. In these cases, application of surgical electrocautery at the hub of Brokenbrough needle or the use of radiofrequency needle can be used to facilitate trans-septal puncture (4),(5). Despite a tremendous surge in interventional procedures utilising trans-septal puncture, IAS thickness assessment has not received much attention and is a less studied entity. Interatrial septum anatomy can be evaluated with transthoracic and trans-oesophageal Echocardiography (6), cardiac CT (7), magnetic resonance imaging (8) and intracardiac Echocardiography (9). Pre-BMV assessment of IAS thickness helps in better planning of the procedure.

Emergency BMV in patient with very severe MS, like case 2 is challenging. Presence of AF with fast ventricular rate, cardiogenic shock and LA clot (Type IB) were the challenges (10). Following BMV, the haemodynamics improved. To control ventricular rate, digoxin was used. But she developed bidirectional VT, which is unusual with a single dose. Probably, due to low body weight, decreased renal clearance, as the patient was in cardiogenic shock and relatively low serum potassium (serum potassium=3.5 mEq/L), she might have developed digitalis toxicity at lower dose. She also developed stress cardiomyopathy, following BMV. There are case reports of Takotsubo cardiomyopathy following elective mitral valve surgeries (11),(12). But, its occurrence following BMV has not been reported in literature. Apart from this, patient also had iatrogenic ASD. However, it was not haemodynamically significant.

Case 3 had severe rheumatic MS with severe submitral disease and calcified leaflets. Hence, it was not an ideal case for BMV. During BMV, while crossing the mitral valve with Accura balloon, LV posterior wall perforation happened. The most frequent cause of BMV-related death has been LV perforation. This was previously associated with the double balloon technique, which requires insertion of LV guidewires (13). LV perforation was also reported with metallic commissurotome (14). Its incidence has come down substantially with the introduction of Inoue and Accura balloon. LV perforation with Accura balloon is not reported in literature. In the present case, because of severe submitral disease, possibly balloon might had been entangled in between the chordae and balloon tip might had been forced towards LV posterior wall causing perforation.


The BMV is a very useful and life-saving procedure in emergency situations. However, appropriate case selection, by preprocedural Echocardiography is important to improve the success rate and to avoid inadvertent complications. Rarely, one can encounter unusual findings during BMV, which need to be addressed appropriately.


Inoue K, Owaki T, Nakamura T, Kitamura F, Miyamoto N. Clinical application of transvenous mitral commissurotomy by a new balloon catheter. J Thorac Cardiovasc Surg. 1984;87(3):394-02. [crossref] [PubMed]
Harikrishnan S. Percutaneous mitral valvotomy- Indications, Contraindications and Mechanisms. In: Harikrishnan S. Percutaneous mitral valvotomy. 2017:60-66. [crossref] [PubMed]
Lee WJ, Son CW, Yoon JC, JO HS, Son JW, Park KH, et al. Massive left atrial calcification associated with mitral valve replacement. J Cardiovasc Ultrasound. 2010;18(4):151-53. [crossref] [PubMed]>[PubMed]
Gowda ST, Qureshi AM, Turner D, Madan N, Weigand J, Lorber R, et al. Transseptal puncture using surgical electrocautery in children and adults with and without complex congenital heart disease. Catheter Cardiovasc Interv. 2017;90(3):E46-E54. [crossref] [PubMed]
Tokuda M, Yamashita S, Matsuo S, Kato M, Sato H, Oseto H, et al. Radiofrequency needle for transseptal puncture is associated with lower incidence of thromboembolism during catheter ablation of atrial fibrillation: Propensity score-matched analysis. Heart Vessels. 2018;33(10):1238-44. [crossref] [PubMed]
Agmon Y, Meissner I, Tajik AJ, Seward JB, Petterson TM, Christianson TSH, et al. Clinical, laboratory, and transesophageal echocardiographic correlates of interatrial septal thickness: A population-based transesophageal echocardiographic study. J Am Soc Echocardiogr. 2005;18(2):175-82. [crossref] [PubMed]
Yasunaga D, Hamon M. MDCT of interatrial septum, DiagnInterv Imaging. 2015;96(9):891-99. [crossref] [PubMed]
Teo KS, Disney PJ, Dundon BK, Worthely MI, Brown MA, Sanders P, et al. Assessment of atrial septal defects in adults comparing cardiovascular magnetic resonance with transoesophageal echocardiography. J Cardiovasc Magn Reson. 2010;12 (1):44. [crossref] [PubMed]
Hijazi ZM, Shivkumar K, Sahn DJ. Intracardiac echocardiography during interventional electrophysiological cardiac catheterisation. Circulation. 2009;119(4)587-96. [crossref] [PubMed]
Manjunath CN, Srinivasa KH, Ravindranath KS, Manohar JS, Prabhavathi B, Dattatreya PV, et al. Balloon mitral valvotomy in patients with mitral stenosis and left atrial thrombus. Catheter Cardiovasc Interv. 2009;74:653-61. [crossref] [PubMed]
Devesa A, Hernández-Estefanía R, Tuñón J, Aceña A. Takotsubo syndrome after mitral valve surgery: A case report. European Heart Journal-Case Reports. 2020;4(6):01-05. [crossref] [PubMed]
Blázquez JA, González JM, Dalmau MJ, López J. Takotsubo cardiomyopathy after elective mitral valve replacement. Interact Cardiovasc Thorac Surg. 2010;11(1):117-19. [crossref]

DOI and Others

DOI: 10.7860/JCDR/2022/59418.17376

Date of Submission: Jul 31, 2022
Date of Peer Review: Sep 15, 2022
Date of Acceptance: Oct 18, 2022
Date of Publishing: Dec 01, 2022

• Financial or Other Competing Interests: None
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes

• Plagiarism X-checker: Aug 08, 2022
• Manual Googling: Oct 14, 2022
• iThenticate Software: Oct 15, 2022 (5%)

ETYMOLOGY: Author Origin

JCDR is now Monthly and more widely Indexed .
  • Emerging Sources Citation Index (Web of Science, thomsonreuters)
  • Index Copernicus ICV 2017: 134.54
  • Academic Search Complete Database
  • Directory of Open Access Journals (DOAJ)
  • Embase
  • EBSCOhost
  • Google Scholar
  • HINARI Access to Research in Health Programme
  • Indian Science Abstracts (ISA)
  • Journal seek Database
  • Google
  • Popline (reproductive health literature)