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Melillo et al. Mini-invasive Surg 2020;4:81 I http://dx.doi.org/10.20517/2574-1225.2020.83 Page 11 of 17

Figure 9. Multiplanar reconstruction analysis of 3D dataset clearly localizing prolapse of the P2 segment and showing preserved leaflet
coaptation in commissural segments

measurement of coaptation depth (distance from the annular plane and the coaptation point, index
of tethering) and coaptation length (index of coaptation reserve) that may be assessed in the potential
grasping zone by MPR or derived from parametric color-coded maps. Moreover, as contemporary trials
have shown, the decision to clip cannot be drawn before a comprehensive evaluation of ventricular
dimension and function. Although a unifying, widely accepted explanation for contrasting results of
MITRA-FR and COAPT trials has not yet been identified, corroborating evidence suggesting a lack of
benefit from the procedure in patients with advanced heart failure is emerging: extreme left ventricular
[40]
dilation and dysfunction [38,39] and right ventricular dysfunction have been identified as predictors of
poor prognosis. The complex interplay between LV geometry and mitral valve function should be taken
into account during evaluation for mitral intervention, and EROA/LV end diastolic volume ratio has
been proposed to translate it into a measurable variable in order to discriminate patients with features of
[41]
proportionate or disproportionate MR, with only the latter having survival benefit from the procedure .
However, concerns on this hypothesis have been raised, relying on accuracy of volume measurements in
[42]
COAPT trial and highlighting the need for further studies with reliable quantitative measurements for
MR and LV volumes by comprehensive multimodality imaging.

PREPROCEDURAL PLANNING FOR MITRAL VALVE ANNULOPLASTY
The rationale of surgical annular ring reduction in secondary MR is to improve leaflet apposition, and
hence the coaptation reserve, and to prevent the further annular dilatation, without disrupting the mobility
of the leaflets. This is achieved through the anterior translation of the posterior annulus, reducing the