Same-session percutaneous closure of iatrogenic sinus of Valsalva rupture during transseptal puncture for balloon mitral valvotomy: a case report.

Background: Balloon mitral valvotomy (BMV) is a primary treatment for rheumatic mitral stenosis (MS), although rare procedural complications may occur. Iatrogenic sinus of Valsalva (SoV) rupture related to transseptal puncture is exceptionally uncommon, with limited reports describing immediate transcatheter management. Case summary: A 50-year-old woman with severe rheumatic MS, marked left atrial enlargement, and atrial fibrillation underwent elective BMV following successful anticoagulation therapy and resolution of a left atrial appendage thrombus. During transseptal puncture, she developed a sudden reduction in aortic diastolic pressure. Immediate angiography and transoesophageal echocardiography (TEE) confirmed a focal rupture at the non-coronary cusp region, directly attributable to needle/dilator trauma. The patient remained stable, allowing immediate percutaneous closure via femoral arterial access using a 6-4 mm multi-fenestrated septal occluder device. Successful closure was confirmed intra-procedurally by TEE, demonstrating no residual shunt or worsening of aortic regurgitation. Balloon mitral valvotomy was safely completed in the same session. Serial echocardiographic follow-up at 1, 6, and 12 months demonstrated stable device placement, preserved ventricular function, and moderate residual MS without further complications. Discussion: Same-session percutaneous closure is a feasible and effective strategy for managing transseptal puncture-related SoV rupture during BMV in haemodynamically stable patients. This case highlights the importance of meticulous transseptal technique, multimodality imaging guidance, and procedural adaptability in complex rheumatic interventions.