Table 3.

Role of echocardiography for planning and guiding transcatheter edge-to-edge leaflet repair in mitral valve prolapse.

Pre-procedural evaluation
3D assessment of MV anatomy and identification of leaflet abnormalities
Measurement of 3D VCA, location of the regurgitant orifice and identification of multiple MR jets
Favorable echocardiographic features
A2/P2 prolapse
Flail gap <10 mm and flail width <15 mm
Non-tethered leaflets with leaflet length ≥10 mm
MV area >4 cm2 and baseline MV mean gradient <3 mmHg
Single central jet or jet has a dominant central location
Transseptal crossing height to MA plane >4 cm
Challenging echocardiographic features
Barlow's disease
Commissural or anterior leaflet prolapse
Multisegmented prolapse/flail
Significant cleft; leaflet or chordal calcification within the grasping zone;
leaflet perforation
Severe MA calcification, with <5 mm of leaflet available for grasp
Posterior mitral leaflet length <7 mm
MV area <4 cm2 and baseline MV mean gradient 4–5 mmHg
Small LA size
Intraprocedural guidance
Safe and optimal site of transseptal puncture
Introduction of the steerable guide catheter into the LA and advancement of the clip delivery system
Safe steering of the clip delivery system and its alignment perpendicular to the MV coaptation plane
Adequate grasping of the leaflets
Assessment of MR reduction (3D VCA), device release and exclusion of significant mitral stenosis (3D TEE MV area)

3D, three-dimensional; LA, left atrium; MA, mitral annulus; MR, mitral regurgitation; MV, mitral valve; VCA, vena contracta area.