We thank Ms. Dorothea Scheurlen for technical video support.

The protocol follows the guidelines of our&#39;s institution&#39;s human research ethics committee.
1. Evaluation before intervention
<ol>
	<li>Exclude pericardial effusion before transseptal puncture. If a small pericardial effusion is present, measure the maximal end-diastolic echolucent space in a four-chamber (4Ch) view with a focus on the right ventricle (RV), a mid-oesophageal right ventricular inflow-outflow view, and a long-axis (LAX) view.</li>
	<li>Evaluate the pulmonary venous flo...

Echo-guidance for the PMVR is a safe method. Complications due to echocardiography may occur but rarely lead to significant damage. Nevertheless, esophageal lesions are possible after performing transesophageal echocardiography. This incidence is reduced with a shorter duration of the intervention34. On the contrary, several complications associated with the transcatheter edge-to-edge mitral valve repair are described35,36. Major bleeding ...

Mitral regurgitation (MR) is the second-most frequent indication for valve surgery in Europe1. Untreated, it may lead to severe heart failure and reduced quality of life2,3,4. The percutaneous mitral valve repair (PMVR) is a catheter-based technique, which mimics the Alfieri stitch surgical method to mitral repair by connecting the A2 and P2 scallops5. For patients with high surgical risk, this technique offers a minimally invasive approach for the treatment of severe MR. Data from several registries and trials has shown that the MitraClip procedure, a transcatheter mitral valve repair therapy, is an effective and safe method6,7,8,9. In 2019, a similar device, the PASCAL transcatheter valve repair system, was introduced to the market. It has shown feasibility and acceptable safety in the treatment of patients with severe MR10. The duration and success of the PMVR are dependent on the individual operator&#39;s skill and experience11. In contrast to other percutaneous techniques, like the percutaneous transvalvular replacement (TAVR), which can be done with fluoroscopy only, PMVR requires echocardiographic guidance12,13.
This article describes step by step the echocardiographic approach during PMVR, including measurements, suggestions for intraprocedural quantification of the MR and important views to prevent periprocedural complications.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>EPIQ 7 Ultrasound System</td>
			<td>Philips</td>
			<td>US218B0542</td>
			<td>Cardiac Ultrasound Machine</td>
		</tr>
		<tr>
			<td>X8-2t xMATRIX 3D-TEE probe</td>
			<td>Philips</td>
			<td>B34YYK</td>
			<td>TEE-probe</td>
		</tr>
		<tr>
			<td>Sheath 6F 25 cm</td>
			<td>Merit Medical</td>
			<td>B60N25AQ</td>
			<td>Sheath</td>
		</tr>
		<tr>
			<td>Dilator 16 F</td>
			<td>Abbott</td>
			<td>405544</td>
			<td>Dilator</td>
		</tr>
		<tr>
			<td>BRK-1 transseptal needle 71 cm</td>
			<td>St. Jude Medical</td>
			<td>ABVA407201</td>
			<td>Transseptal Needle</td>
		</tr>
		<tr>
			<td>Swartz Lamp 90&#176;</td>
			<td>St. Jude Medical</td>
			<td>407356</td>
			<td>Transseptal Guiding Introducer Sheath</td>
		</tr>
		<tr>
			<td>Amplatz super stiff</td>
			<td>Kook Medical</td>
			<td>46509</td>
			<td>Wire</td>
		</tr>
		<tr>
			<td>Steerable Guide Catheter</td>
			<td>Abbott</td>
			<td>SGC0302</td>
			<td>Steerable Guide Catheter</td>
		</tr>
		<tr>
			<td>MitraClip NTR Delivery System</td>
			<td>Abbott</td>
			<td>CDS0602-NTR</td>
			<td>Clip Delivery System</td>
		</tr>
		<tr>
			<td>MitraClip NTR Bundle</td>
			<td>Abbott</td>
			<td>MSK0602-NTR</td>
			<td>Device</td>
		</tr>
	</tbody>
</table>

a simplified stepwise approach to echo guidance during percutaneous mitral valve repair

Percutaneous transcatheter edge-to-edge reconstruction of the mitral valve is a safe and well-established therapy for severe symptomatic mitral regurgitation in patients with high surgical risk. Echocardiographic guidance in addition to fluoroscopy is the gold standard and should be performed using a standardized technique.
This article lays out our reproducible step by step echocardiographic guide including views, measurements as well as highlighting possible difficulties that may arise during the procedure.
This article provides detailed and chronological echocardiographic views for each step of the procedure, especially preferences between 2D and 3D imaging. If needed, pulse wave, continuous wave and color doppler measurements are described. Furthermore, as there are no official recommendations for the quantification of mitral regurgitation during the percutaneous edge-to-edge-repair procedure, advice is also included for echocardiographic quantification after grasping the mitral leaflets and after device deployment. In addition, the article deals with important echocardiographic views to prevent and deal with possible complications during the procedure.
Echocardiographic guidance during transcatheter mitral valve repair is mandatory. A structured approach improves the collaboration between interventionist and imager and is indispensable for a safe and effective procedure.

Percutaneous edge-to-edge valve repair is an alternative to surgical valve repair or replacement in patients not eligible for surgery with symptomatic severe MR. The first clinical application of the MitraClip was investigated in the Endovascular Valve Edge-to-Edge Repair Study I (EVEREST I)14 trial. Many other trials have proven the effectiveness of the procedure with an improvement of symptoms as well as low rates of hospital mortality and adverse events (ACCESS EU, TRAMI, EVEREST II)<sup class=...

Watch this Scientific Journal Video about A Simplified Stepwise Approach to Echo Guidance during Percutaneous Mitral Valve Repair at JoVE.com

A Simplified Stepwise Approach to Echo Guidance during Percutaneous Mitral Valve Repair

This protocol presents in detail how to perform real-time echocardiographic guidance during transcatheter mitral valve repair. The fundamental views and the necessary measurements are described for each stage of the procedure.