During the past 10 years, there has been a trend toward and an interest in the use of catheter-based interventions to perform procedures that were once only approached surgically. The problem with the catheter-based approach has been procedure-related complications. Improved imaging of cardiac structures while undertaking interventional procedures may help to prevent or allow for early identification of these complications. Transesophageal echocardiography has been used during catheter-based procedures as a guide, and has both advantages and disadvantages. Intracardiac echocardiography is a relatively new imaging technique that also provides an enhanced view of cardiac structures and may also allow for the safe and efficient performance of catheter-based procedures. We report the first case of successful percutaneous balloon mitral valvuloplasty done under ultrasound guidance using an intracardiac echocardiography catheter (10F, 5-10 MHz) (Acunav). The strengths and weaknesses of this approach are described and compared with transesophageal echocardiography and older intracardiac echocardiography devices.