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Ancona et al. Mini-invasive Surg 2020;4:79 I http://dx.doi.org/10.20517/2574-1225.2020.80 Page 3 of 23

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Table 1. Mitraclip : Imaging modality for each procedural step
Imaging modality
Procedural step TIPS and TRICKS
Echocardiography Fluoroscopy
1. Tailored Trans-septal Biplane views: bicaval and SAX AP projection => sharp tenting should be seen
puncture views LAO projection => superior and posterior location in the fossa
3D lateral perspective of IAS with a height of 4-4.5 cm to the annulus (see text
ME 4-chamber view with for details)
retroflexion (height) => avoid PFO
2. Steerable guiding 2D SAX AP projection => dilator is removed when the SGC is at least 2
catheter into LA 2D LAX cm across the IAS
4-chamber view
3D overhead of LA
3D lateral view
3. Clip delivery system 3D overhead of LA AP projection
into LA 2D ME views
4. Steering and Biplane views: commissural and RAO CRA
Positioning LAX views with and without
color Doppler
3D overhead of LA
5. Axial alignment Biplane views: commissural and RAO CRA => check perpendicularity (3D) and the path of
LAX views clip (biplane) towards the target lesion
6. Alignment of the Clip 3D en face view RAO CRA => clip should be clearly visualized in the LAX
arms Biplane views: commissural and view
LAX
views
MV SAX transgastric view
7. Advancement into Biplane views: commissural and RAO CRA => re-assess perpendicularity
LV LAX views
8. Grasping Biplane views: commissural and RAO CRA => LAX view is of utmost importance
LAX views => adenosine and breath-hold may be necessary
LAX view (sometimes) in some cases
9. Assessment of leaflet Biplane views from commissure RAO CRA => multiple two-dimensional views!
Insertion to commissure
2D LAX
2D 4-chamber view
SAX transgastric view
3D en face view
MPR
10. Procedural Result 2D color-Doppler RAO CRA => it could be challenging!! REMEMBER: (semi)-
(pre and post clip 3D color-Doppler quantitative methods (VC and PISA EROA) have
deployment) MPR Color-Doppler not been validated in the presence of split MR jets
Pressure gradient => pulmonary vein pattern is a good indicator
MPR valve area => 3D TEE color Doppler could have a role in
quantification
=> increase in arterial pressure and LV stroke
volume may also be helpful indicators
=> check trans-mitral gradient and residual MV
area
=> careful evaluation of complications (e.g.,
significant IAS shunt, pericardial effusion)
11. Clip Deployment Biplane views RAO CRA
12. System Removal Multiple 2D ME views RAO CRA
3D overhead view

SAX: short axis; AP: antero-posterior; LAO: left anterior oblique; RAO: right anterior oblique; IAS: interatrial septum; PFO: patent
foramen ovalis; LAX: long axis; LA: left atrium; SGC: steerable guide catheter; CRA: cranial; ME: mid esophageal; MV: mitral valve; MPR:
multiplanar reconstruction; VC: vena contracta; EROA PISA: effective regurgitant orifice area with proximal isovelocity hemispheric
surface area; MR: mitral regurgitation; TEE: transesophageal echocardiography

could be acceptable (~3.5-4.0 cm above the annular plane) as coaptation is dislocated deeper in the left
ventricle. Moreover, slight differences in height above the annulus could be determined by the planned
positioning of the device in terms of a lateral vs. medial regurgitant lesion. A lower TSP site is required for
a lateral defect, while higher TSP site is required for a medial defect as a low TSP will move the clip below
the mitral annulus when deflecting the system toward the mitral annular plane from lateral to medial.