Echocardiographic imaging for transcatheter edge-to-edge repair: evaluation, guidance, and follow-up

Transcatheter edge-to-edge repair (TEER) requires precise echocardiographic guidance because the operator cannot directly visualize the mitral valve. Intraprocedural transesophageal echocardiography (TEE) is indispensable for safe and accurate device positioning and manipulation, whereas transthoracic echocardiography (TTE) plays a central role in preprocedural evaluation and serial postprocedural follow-up as part of comprehensive echocardiographic assessment. Before the procedure, echocardiography is essential for assessing the underlying mechanism and severity of mitral regurgitation (MR), determining anatomical suitability for TEER, and estimating procedural difficulty. Measurements such as mitral valve area, transmitral pressure gradient, tethering height, coaptation length, prolapse width and gap, as well as lesion location, leaflet morphology, and calcification distribution are crucial for predicting feasibility and technical complexity. During TEER, TEE must rapidly provide optimal views to guide each procedural step-from transseptal puncture to leaflet grasping and device deployment. Although X-plane imaging and three-dimensional reconstruction are now standard in many centers, live multiplanar reconstruction allows optimal imaging planes to be reconstructed in real time from acoustically favorable probe positions chosen to minimize device-related shadowing, thereby facilitating accurate and efficient intraprocedural guidance. Intraprocedural TEE is also vital for the early detection of complications, including pericardial effusion, leaflet injury, and clinically significant iatrogenic atrial septal defect with right-to-left shunting, as well as for immediate post-deployment hemodynamic assessment. In the postprocedural period, TTE focuses on detection of residual MR, evaluation for iatrogenic mitral stenosis, identification of single-leaflet device attachment or leaflet perforation, and serial assessment of cardiac function. Recent risk scores for patient selection and prognostication underscore the importance of comprehensive, evidence-informed echocardiographic evaluation that integrates both morphological and hemodynamic information.