There exist 2 contraindications in PTMC: 1) severe (> grade 3+) angiographic mitral regurgitation, and 2) the presence of left atrial thrombus. The treatment for patients with > 3+ mitral regurgitation is clearly that of mitral valve replacement. Patients with left atrial thrombus are subjected to open mitral commissurotomy or valve replacement, depending on the mitral valve status. Those patients with mobile thrombi in the left atrium are at a high-risk of systemic embolism, and require urgent mitral valve surgery.

       However, one may elect to administer long-term (3-12 months) warfarin therapy (to maintain INR 2 to 2.5) in patients with non-mobile thrombi in the left atrial cavity, if their clinical and hemodynamic status does not warrant immediate surgery and the mitral valves are deemed suitable for PTMC. Transesophageal echocardiography is deferred until thrombi resolution is observed by transthoracic echocardiography performed at 3-month intervals [1]. When transesophageal echo confirms the absence of left atrial cavity thrombus, PTMC can then be performed safely [1-3].

       In our centers, the presence of thrombi confined to the left atrial appendage (without protruding into the left atrial cavity) is not a contraindication. PTMC can be performed safely in this setting when performed with extra care using the Inoue-balloon technique [3,4] The risk of cardioembolism is low in this setting when Inoue-balloon PTMC is performed by experts [5].

       Patients with lytic-resistant thrombi after 12 months of warfarin treatment should be considered for open surgical commissurotomy with direct visual clot removal.


References:
  1. Hung JS. Mitral stenosis with left atrial thrombi: Inoue balloon catheter technique. In Cheng TO, editor. Percutaneous Balloon Valvuloplasty. Igaku-Shoin Medical Publishers, Inc.1992, pp 280-293.

  2. Hung JS, Lin FC, Chiang CW. Successful percutaneous transvenous catheter balloon mitral commissurotomy after warfarin therapy and resolution of left atrial thrombus. Am J Cardiol 1989;64:126-128.

  3. Hung JS, Lau KW. Pitfalls and tips in Inoue-balloon mitral commissurotomy. Cathet Cardiovasc Diagn 1996;37:188-199.

  4. Yeh KH, Hung JS, Wu JJ, et al. Safety of Inoue balloon mitral commissurotomy in patients with left atrial appendage thrombi. Am J Cardiol 1995;75:302-304.

  5. Hung JS, Lau KW, Lo PH, et al. Complications of Inoue-balloon mitral commissurotomy - Impact of operator experience and evolving technique. Am Heart J 1999;138:114-121.
 		 
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