40 years female presented with h/o Dyspnea NYHA class III2 D echo was done suggestive of severe mitral stenosis with mild Mitral regurgitation with MVA-0.6 sq.cmWilkins score was favorable with score of 8/16 Echo & CT was suggestive of giant LA size measuring 13cm in diameter

2D echo & Cardiac CT

The septal puncture point was chosen more caudal than usual & the distal curve of the puncture needle was made sharper.Once the Inoue balloon was introduced into LA, the stylet was rotated in a clockwise fashion to create a reverse loop.The balloon was gradually pushed further to bring it close to MV. 0.014´´ coronary wire was introduced into the left ventricle (LV) and advanced as deep as into the aorta through the aortic valve.It was snared to make a veno-arterial loop over which Inoue balloon was tracked. Once into LV, the distal part was inflated and gradually withdrawn to lock it against MV and straighten the loop. The balloon was gradually advanced over the wire into LV across stenosed MV

 Patients with giant LA present a challenging anatomic substrate for PTMC.The septal puncture should be done more caudal with TEE guidance whenever feasible.Among patients with giant LA, reverse loop with wire-assisted tracking and snare-assisted delivery is quite a useful, effective, and safe technique.Alternatively, an arteriovenous loop may be created using a 0.035" Terumo glide wire to assist the PTMC balloon to track across Mitral valve