A 54-year-old lady presented to our department with complaints of dyspnea on exertion for the last two years, which increased over the last three months. She also complained of abdomen distension with jaundice for the last three years with intermittent pedal oedema. On examination, she was frail and had an irregularly irregular pulse. She also had a variable S1 with a mid-diastolic murmur localised in the cardiac apex. Electrocardiography showed an atrial fibrillation with a fast ventricular rate. Echocardiography revealed a severe rheumatic mitral stenosis with a dilated left atrium and severe pulmonary hypertension assessed by tricuspid regurgitation gradient. Transesophageal Echocardiography suggested a Type IB LAA clot with no significant MR. After stabilisation of heart failure, she was opined for Mitral valve replacement with LAA clot extraction. However, given the high STS score and after counselling with family, she underwent high-risk Balloon mitral valvotomy with retrievable temporary carotid protection devices kept in the bilateral carotid artery. She became symptomatically better and was discharged. On follow-up, she said she had been rehabilitated to her usual life.
