Percutaneous Closure of a Left Ventricular Perforation Post Balloon Mitral Valvotomy Carlos E. Ruiz,* MD, PhD, and Ramesh C. Bansal, MD The risk of left ventricular perforation is a rare but well-recognized complication of percutaneous double balloon mitral valvuloplasty that usually requires surgical bailout. We describe a case of left ventricular perforation with cardiac tamponade, caused by the propulsion of the balloons during balloon mitral valvotomy on an 86-year-old female with previous thoracotomies that was resolved using percutaneous coil embolization of the perforation. This approach to these types of complications, although unlikely to be of extensive use, will serve to expand the horizon of options in the field of interventions. Cathet. Cardiovasc. Intervent. 48:78–83, 1999.  1999 Wiley-Liss, Inc. INTRODUCTION Left ventricular perforation is a rare but well- recognized complication of the percutaneous double balloon mitral valvotomy [1–3]. This type of perforation may be lethal, even when surgical standby is readily available. On the other hand, transcatheter coil emboliza- tion of congenital vascular anomalies is a well-estab- lished procedure and is used for occlusion of PDAs, AVMs, pulmonary sequestrations, etc., as well as postsur- gical systemic pulmonary shunts. Additionally, during percutaneous transhepatic catheterization a coil is de- ployed within the liver parenchyma to prevent further bleeding [4,5]. We describe the successful closure of a left ventricular (LV) apical perforation using Gianturco coil in an 86-year-old female patient after percutaneous double balloon mitral valvotomy and developed signs of cardiac tamponade. Two-dimensional and color flow imaging confirmed a double-chamber pseudoaneurysmal cavity. This echocardiographic information was instrumen- tal in the coil embolization of both chambers. CASE REPORT An 86-year-old female with history of two previous coronary artery bypass graft (CABG), last in 1988, with three-vessel CAD and progressive CHF was reevaluated by her cardiologist. The patient also had a history of insulin-dependent diabetes mellitus, hypothyroidism, iron- deficiency anemia, paroxysmal atrial fibrillation, and rheumatic mitral stenosis. All her underlying medical problems were well controlled and she had no angina. Cardiac catheterization and angiography in April 1998 revealed patency of all coronary bypass grafts and severe mitral stenosis. The patient was then referred to us for a possible balloon valvotomy of her mitral valve, since the risk of surgery was estimated to be prohibitive. On physical examination, cardiac auscultation revealed the absence of an opening snap and no mitral regurgita- tion murmur was auscultated. The CXR was consistent with post-CABG and a very dilated left atrium, moderate pulmonary hypertension, and signs of CHF. The two- dimensional Doppler transthoracic and transesophageal revealed severe mitral stenosis, with severe annular calcification, extending into the posterior leaflet. The mitral valve morphology score was 10/16, with well- documented bilateral symmetric commissural fusion. Mitral valve area by planimetry method was 0.6 cm 2 and by pressure halftime 0.7 cm 2 . There was trivial mitral regurgitation and LV function was normal. The patient underwent percutaneous double balloon mitral valvotomy by the standard technique previously described [6] using the Bonhoeffer-Multitract monorail balloon system (NuMED, Hopkinton, NY). Two balloons of 18-mm diameter by 5-cm length each were used. On the first balloon inflation, the balloons were squeezed forward toward the LV apex by the valve, causing no symptoms or hemodynamic deterioration. The balloons were once more inflated across the valve and this time the Rush University Children’s Hospital Heart Center, Chicago, Illinois *Correspondence to: Dr. Carlos E. Ruiz, Rush University Children’s Hospital Heart Center, 1653 W. Congress Parkway, Chicago, IL 60612-3833. Received 5 October 1998; Revision accepted 2 February 1999 Catheterization and Cardiovascular Interventions 48:78–83 (1999)  1999 Wiley-Liss, Inc.