Percutaneous transvenous mitral commissurotomy (PTMC) is the preferred treatment for symptomatic patients with moderate-severe mitral stenosis (MS). PTMC is usually performed using dumbbell (hour glass) shaped balloons (Inoue balloon, Accura balloon). Both balloons have been shown to be similar with respect to safety and efficacy1 , 2. The Accura balloon is less expensive and more cost-effective1 , 2. The technique of PTMC has a steep learning curve. Even after having acquired expertise in the technique, difficulties may be encountered at various steps. This chapter will deal with techniques that can be used to overcome difficulties during PTMC. At the authors’ institution, more than 1000 PTMCs are being performed every year. Difficulties in PTMC may be encountered at various anatomical levels as well as in certain special subset of patients.