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Is performing balloon mitral valvotomy really safe without anticoagulation?

I read with interest the article by Ghaffari et al. [1] on performing balloon mitral valvotomy (BMV) with or without anticoagulation. The authors demonstrated the incidence of embolic events to be identical in the two groups. During BMV, most of the catheter exchanges and manipulations occur at the venous side of the circulatory system. This, coupled with the low pressures in the venous system, predisposes to thrombus formation. Though the procedure can be done rapidly with minimum exchange by experienced operators in high volume centres, nevertheless it puts the patient at high risk for pulmonary embolism. Recently, we had a young patient who developed fatal right atrial thrombus with pulmonary embolism during BMV despite adequate anticoagulation. It is necessary to use a computed tomography pulmonary angiogram to assess the pulmonary circulation for possible thrombus in the group that did not receive heparin. Until then, any recommendation to avoid anticoagulation during BMV can be misleading.