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Page 8 of 17 Melillo et al. Mini-invasive Surg 2020;4:81 I http://dx.doi.org/10.20517/2574-1225.2020.83

Figure 6. Spectrum of available transcatheter mitral valve repair options according to functional anatomy of the mitral valve. *Expected
suboptimal result due to residual annular dilatation; † ideal tethering should be limited (coaptation depth < 10 mm)

carefully evaluated to determine the feasibility of percutaneous treatment; to identify the best therapeutic
approach, either leaflet or annulus or combined; and to predict the probability of procedural success that is
crucial for subsequent outcome.

Both primary and secondary MR may be treated with a leaflet approach, while the annular approach is
usually reserved for secondary MR. Functional classification helps to understand pathology and further
guide therapeutic approach [Figure 6]: Carpentier Type I, normal leaflet motion and position (annular
dilation, leaflet perforation, cleft); Type II, excess leaflet motion (prolapse, flail); Type IIIa, restricted leaflet
motion in systole and diastole (rheumatic, fibro-calcification); and Type IIIb, restricted leaflet motion
in systole (tethering secondary to ischemic or non-ischemic cardiomyopathy). In absence of specific
contraindications, a leaflet approach is suitable for treating Types II and IIIb and suboptimal for Type I,
while annular approach is most appropriate for Types I and IIIb if limited leaflet tethering is present.

PREPROCEDURAL PLANNING FOR TRANSCATHETER MITRAL LEAFLET REPAIR
[36]
Transcatheter leaflet repair is based on the surgical technique developed by Alfieri . Two devices
(MitraClip, Abbott, Illinois, USA; and PASCAL, Edwards Lifescience, California, USA) that allow
reproducing the technique into a catheter-based approach are available thus far. The devices are equipped
with two arms to grasp and approximate the free edges of anterior and posterior mitral leaflets.

The site origin of the jet represents the target lesion, so a preprocedural evaluation is firstly aimed at
evaluating leaflet tissue quality, length, and mobility in the area of potential grasping zone. The analysis
of the 3D dataset by MPR represents an added value for this purpose, allowing the evaluation of leaflet