C 2006, the Authors Journal compilation C 2006, Blackwell Publishing, Inc. CASE REPORTS Bedside Percutaneous Transseptal Mitral Commissurotomy under Sole Transthoracic Echocardiographic Guidance in a Critically Ill Patient Vijay K. Trehan, M.D., D.M., Arima Nigam, M.D., Saibal Mukhopadhyay, M.D., D.M., Jamal Yusuf, M.D., D.M., C.R. UmaMahesh, M.D., D.M., Mohit D. Gupta, M.D., Menahalli Palleda Girish, M.D., and Manish Sharma, M.D. Department of Cardiology, G B Pant Hospital, New Delhi, India Percutaneous transvenous mitral commissurotomy is an effective and safe alternative to surgical treatment, in selected patients of rheumatic mitral stenosis. It is usually performed under fluoroscopic guidance in the catheterization laboratory. We report the successful performance of emergency mitral commissurotomy by the Inoue balloon at bedside under sole transthoracic echocardiographic guidance in a critically ill patient. (ECHOCARDIOGRAPHY, Volume 23, April 2006) mitral stenosis, transthoracic echocardiography, PTMC Percutaneous transseptal mitral commis- surotomy (PTMC), traditionally performed under fluoroscopic guidance is an effective ther- apeutic option in symptomatic patients of mi- tral stenosis (MS).However,it is not uncom- mon to receive critically illpatients of MS at odd hours requiring urgent mechanical relief of their obstruction. We report a case, where due to nonavailability of the catheterization labora- tory,emergency PTMC was performed at bed- side under sole transthoracic echocardiography (TTE) guidance in a critically ill patient as a lifesaving measure. Case Report A 40-year-old female, a known case of rheumatic MS who had undergone closed mi- tral commissurotomy 10 years back, presented at midnight with NYHA class IV dyspnea and hypotension. On physical examination, the patient was drowsy and cyanosed with cold clammy extremities.She was in atrial fibril- lation with a rapid ventricular rate of 150 Address for correspondence and reprint requests: Dr. Saibal Mukhopadhyay,Assistant Professor,Room No.126, Aca- demic Block, Department of Cardiology, G B Pant Hospital, New Delhi-110002,India. E-mail: saibalmukhopadhyay@ yahoo.com beats/min,a systolic BP of 60 mmHg, and a respiratory rate of 44 breaths/min. She was in pulmonary edema with inspiratory crepita- tions audible all over the chest. Arterial blood gas (ABG) analysis revealed type I respiratory failure (oxygen saturation 85%, pO 2 68 mmHg, pCO 2 35 mmHg, pH 7.30) for which she was intubated and put on a mechanical ventilatory support.As the patient was hypotensive with atrial fibrillation and a fast ventricular rate, she was given a loading dose of digoxin, 0.5 mg i.v., which brought down the ventricular rate to around 120/minutes after 10 minutes and the systolic BP rose to 70 mmHg. On TTE, she had critical MS (mitral valve area of 0.6 cm 2 by planimetry and 0.5 cm 2 by pressure half-time, mean transmitral gradient of 24 mmHg) with valve morphology suitable for PTMC (Wilkins score 7/16). There was no mitral regurgitation (MR) or clot seen in the left atrium (LA)/LA appendage. Transesophageal echocardiography (TEE) could not be done as the patient had his- tory of esophageal strictures. The surgeons were reluctant to take the pa- tient up for emergency surgery in lieu of very high risk. As our catheterization laboratory was closed for sterilization purpose, we decided to perform the procedure at bedside under TTE guidance.Since we already have an ongoing 312 ECHOCARDIOGRAPHY: A Jrnl. of CV Ultrasound & Allied Tech. Vol. 23, No. 4, 2006