Inoue versus double-balloon mitral commissurotomy        PTMC is performed in many skilled centers with a very low incidence of cardiac perforation and a high success rate [1-8] (Table I). Both the Inoue and double-balloon techniques appear to yield the same degree of valve enlargement. However, the Inoue method is more extensively applied for several reasons (Table II). First, it is technically less demanding and simpler to perform than the double-balloon approach, thereby engendering a shorter procedural and irradiation time [5, 9]. This advantage is vital in pregnant patients where the hazards of irradiation to the fetus is of paramount importance, and for patients in pulmonary edema in whom swift and expeditious procedure is clearly desirable.        Second, the Inoue-balloon system has a short balloon, a flexible catheter tip and does not require the placement of guide wires within the left ventricle, as opposed to the longer, stiffer Mansfield balloon which mandates left ventricular wiring. These differences in procedural characteristics may account for the extremely low risk of left ventricular perforation in Inoue PTMC procedures [10]. In contrast, left ventricular perforation with or without tamponade, especially in the presence of a small left ventricle, has been reported in up to 8% of double-balloon procedures [9].        Third, the ability for control of the catheter balloon, afforded by the Inoue-balloon assembly, enables the operator to prevent entrapment of the balloon within the chordae. Thus, rupturing of the chordae during full balloon inflation and creation of severe mitral regurgitation can be avoided. It also allows the catheter tip to be steered away from the left atrial appendage, hence preventing systemic embolization in patients with left atrial appendage thrombus undergoing the Inoue-PTMC [11]. Thrombus confined within the left atrial appendage is not considered a contraindication in our institutions.        Lastly, the Inoue-balloon system is designed for stepwise dilation and left atrial hemodynamic assessment after each inflation-deflation cycle. Thus, the procedure can be terminated immediately whenever there is a suggestion of increasing mitral regurgitation [13]. This salutary feature is crucial during PTMC in high-risk situations such as grossly distorted mitral valves and/or coexisting baseline moderate (grade 2+) mitral regurgitation, where the risk of incurring severe mitral regurgitation is enhanced [6, 8, 11-14]. Having said that, the Inoue-balloon system, nonetheless, suffers from one major drawback; it is substantially more expensive than the double-balloon system.
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