From Transseptal Puncture to Mitral Commissurotomy: A Zero-Wire-Exchange Approach Using Inoue Balloon

Percutaneous mitral commissurotomy (PMC) remains the standard therapy for rheumatic mitral stenosis, although decreasing disease prevalence in developed countries has reduced operator familiarity. Advancing the Inoue balloon across the mitral valve continues to pose a technically demanding step that may extend procedures or result in unsuccessful attempts. We describe 2 cases of severe mitral stenosis successfully treated with PMC using a zero-exchange-wire technique. Transseptal puncture was performed under transesophageal echocardiography guidance using the VersaCross radiofrequency system. The same preshaped 0.035-inch radiofrequency wire was advanced across the mitral valve into the left ventricle, guided by the steerable sheath. The Inoue balloon was then slenderized and delivered over the wire after septal dilatation. Sequential inflations were performed over the wire, achieving optimal results. In summary, we describe a modified over-the-wire technique for PMC that most structuralists are familiar with, using dedicated Inoue balloons, obviating the need for wire exchange, with shorter procedural time and no safety concerns.