a 56-year - old gentleman previously known to have rheumatic mitral stenosis , presented with a recent increase of dyspnea ( new york heart association class iii ) , now associated with orthopnea and paroxysmal nocturnal dyspnea . on examination , he had rapid atrial fibrillation with a pulse rate of 130/min .
after control of the pulse rate with digoxin and beta blockers , echocardiography revealed a mitral valve area of 1.1  cm by pressure half - time method , a mean diastolic pressure gradient of 18  mm hg across the mitral valve , a total mitral valve score of 9/16 , and no mitral regurgitation .
moderate calcification of the mitral valve was noted ; however , since no commissural calcium was found , percutaneous mitral valvuloplasty was planned .
trans - esophageal echocardiography showed no thrombi in the left atrial appendage , a mitral valve annulus diameter of 38  mm , and a thin inter - atrial septum ( 2  mm ) .
the procedure was performed through a right femoral vein puncture , employing the multi - track technique , using 2 balloons ( 20 and 18  mm in diameter ) . following a smooth trans - septal puncture ,
the mitral valve was crossed with a judkins right catheter , and 2 wires were secured in the left ventricular apex with a double coil clearly seen in both .
the 2 balloons were advanced along the wires and inflated ; yet , surprisingly , no clear waist was seen ( figure 1 ) .
skeptic about the balloon position , the operator decided to redo the inflation more proximally , wherein a clear waist was seen that ultimately yielded to balloon inflation .
suddenly , blood pressure collapsed to 80/60  mm hg , with a slow  though still irregular 
bedside echocardiography confirmed the presence of moderate pericardial effusion so that pericardiocentesis was immediately performed ( figure 2 ) .
roughly , 250  ml of frank red oxygenated blood were drained out of the pericardial sac . in the mean time , heparin was counteracted by protamine sulphate administration , and dopamine infusion started at a rate of 10 g / kg / min .
blood pressure returned back to 100/60  mm hg , and the pulse rate rose to 100  bpm .
the pigtail catheter in the pericardial sac stopped to drain any more blood ; however , once again , blood pressure started to drop progressively down to 60/40  mm hg , and the pulse rate surged  now to 110  bpm .
amazingly , bedside echocardiography unveiled an echo - dense mass posterior to the left ventricle .
unfortunately , however , during transfer to the operating room , the patient was arrested in asystole .
resuscitation started straight away and continued for 15  min , well inside the operating room .
following median thoracotomy , the surgeon was confronted with a large blood clot filling the posterior pericardial sac .
the clot was removed at once ; the heart restarted to beat at 70  bpm and blood pressure was restored to 100/70  mm hg .
a 1.5  cm tear was discovered in the left ventricular apex , which was sutured with teflon sutures . eventually , the patient was hemodynamically stable but was discharged to the intensive care unit in deep coma , wherein he was supported with mechanical ventilation .
his consciousness level improved the next day , so that his glasgow coma score was 6 ; the day after , it reached 9 .
thereafter , he became fully conscious , and was disconnected off mechanical ventilation ; however , he suffered some memory deficit , and mild motor dysphasia .
three days later , he regained an almost normal neurological state and was discharged from the intensive care unit .
post - procedural echocardiography revealed a mitral valve area of 1.9  cm , with no mitral regurgitation , and confirmed the absence of further accumulation in the pericardium .
over the past two decades , percutaneous mitral valvuloplasty has emerged as the procedure of choice in 
the procedure is associated with mortality rates that range from 0 to 3% , chiefly due to cardiac tamponade , severe mitral regurgitation , or deterioration of the patient 's general condition . 
 
the incidence of hemopericardium following percutaneous mitral valvuloplasty is reported at 1 - 3% , being related to either trans - septal puncture or left ventricular perforation with guide wires or balloons . 
 
the site of perforation is crucial for both the immediate and long - term outcome .
frequently self - limited perforation of the right atrial appendage often responds well to pericardiocentesis , and spontaneous closure is the rule . on the other hand ,
left ventricular apical perforations can be swiftly fatal due to the high left ventricular pressure , especially if induced by the rigid balloon catheters rather than the guide wires , and therefore frequently need emergency surgical repair . 
 
pick up cases which need life - saving immediate pericardiocentesis , aided by reversal of anticoagulation by protamine sulphate , even before hemodynamic deterioration .
bedside echocardiography is the standard of care for prompt diagnosis , and should be an indispensable  workhorse in any cath lab that performs percutaneous mitral valvuloplasty procedures . during pericardiocentesis , one should always ensure a proper position of the pigtail catheter inside the pericardial sac , guided by fluoroscopy and bedside echocardiography .
however , if the clinical condition deteriorates despite the absence of effluent from the pericardium , emergency surgical exploration would be mandatory .
moreover , it is widely acknowledged that blood in the pericardial sac does not clot due to the defibrination effect by cardiac motion . in the current case , however , rapid accumulation of a large amount of blood over a brief period of time might have been the cause of blood clotting in the posterior pericardial sac , further augmented by protamine sulphate injection .
it would be wise to inflate the balloons extremely cautiously , so that if no waist is seen , inflation should be immediately halted and the balloon catheters pulled back to a more proximal position , in order to avoid injury of the left ventricular apex . 

 the incidence of hemopericardium following percutaneous mitral valvuloplasty is reported at 13% , being related to either trans - septal puncture , or left ventricular perforation with guide wires or balloons . 
 we report a case of percutaneous mitral valvuloplasty for a middle - aged man with moderately severe rheumatic mitral stenosis . 
 the procedure was performed through a right femoral vein approach , employing the multitrack technique , utilizing 2 balloons ( 20 and 18  mm ) . 
 inadvertently , the procedure was complicated by cardiac tamponade . despite immediate diagnosis and 
 prompt pericardiocentesis , hemodynamic stability was not maintained . 
 echocardiography revealed a mass in the posterior pericardial sac . 
 the patient was arrested in asystole , and rigorously resuscitated during transfer to the operating room . 
 exploration revealed a tear in the left ventricular apex that was adequately sutured . 
 in a few days , the patient gradually regained adequate consciousness , and was ultimately discharged . 
 post - procedural echocardiography revealed a mitral valve area of 1.9  cm2 , with no mitral regurgitation . 