After correct transseptal puncture, the mitral clip delivery system is angled down towards the mitral leaflets, aiming for A2P2. Correct positioning can be ascertained from the inter-commissural (550-750) projection demonstrating medial-lateral alignment and the LV outflow (1000-1600) projection demonstrating posterior-anterior alignment. 3D TEE (3D zoom with a large field of view) greatly facilitates this part of the procedure as it provides an enface view of the mitral leaflets and approaching clip (Figure 34).

The optimal position of the clip delivery system is immediately above the regurgitant orifice. The clip should be oriented perpendicular to the commissure, something easily assessed with 3D zoom imaging. However, if 3D is not available, the transgastric short axis view may be used for this purpose. As viewed from the LV outflow tract position (1000-1600) the clip with the arms closed will cross the mitral leaflets and enter the LV. Once the delivery system is in the LV, the clip arms open and the device is pulled back toward the left atrium, simultaneously grasping both leaflets with the device grippers (Figure 35). Using the LV outflow and inter-commissural views (600-700), capture of both leaflets must be verified and the clip closed. Once both leaflets have been satisfactorily clipped, a quick assessment of residual MR with color Doppler is performed.