SAN FRANCISCO—Both 2D echocardiography and 3D are essential for intraprocedural guidance (ACC) scientific session.

Sanger reviewed the six steps of the percutaneous mitral valve repair and where each echo approach assisted the physician. “We were doing clips before 3D, so it is doable. But the advent of 3D has added value,” he said. Knowledge of spatial relationships and the temporal domain are essential for the procedure, he continued. The six steps and preferred modes are:

1. Case selection: 3D is important and facilitates knowledge transfer from the echo lab to the surgeon.
2. Clip delivery system placement: 2D views suffice and provide the spatial resolution to visualize small angulations.
3. Checking arm angles: 3D helps the surgeon visualize clip arm alignment.
4. Assess clip trajectory: To make sure the clip is going to stay where it is supposed to transgastric views help.
5. Ready to grasp: Multiple views are done to make sure both leaflets are inserted. 3D can help show clip placement and also provide visualization if clip regrasping or redeployment is necessary.
6. Release clip: Rose cautioned when the clip is in place, the surgeon may see more regurgitation. “Some patients may need another clip,” he cautioned.

Rose concluded, “3D allows one to see the forest for the trees, 2D better enables one to examine each tree and both perspectives are essential for optimal MitraClip deployment.”