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Background Transapical beating-heart neochord implantation (Neochord) to repair mitral valve regurgitation has been demonstrated to be a safe and effective minimally invasive alternative to open surgical repair in selected patients with mitral leaflet prolapse. Successful neochordae implantation depends on accurate localization of the site of regurgitation and careful assessment of MV morphology. The objective of this study is to demonstrate that 3D-transesophageal echocardiography (3D-TEE) has become a fundamental tool, essential in both the preoperative study and to guide the procedure and for follow-up. Methods All consecutive patients with severe symptomatic DMR due to prolapse or flail of one or both mitral leaflets that underwent the NeoChord procedure between March 2017-Jan 2021 were included. Patients were categorized according to MV anatomy by 3D-TEE; Type A isolated central posterior leaflet prolapse and/or flail, Type B posterior multi-segment prolapse and/or flail, Type C anterior and/or bi-leaflet prolapse or flail, Type D paracommissural prolapse and/or flail and/or significant leaflet and/or annular calcifications. Results 43 patients were included. Median age was 67.7±13.4 y. Median EuroSCOREII 2.7%±1.91. There were 35 Type A patients (81.4%), 4 Type B (9.3%), 1 Type C (2.3%), and 3 Type D (7%). Type A was considered the more favorable morphology. 2D/3D TEE were employed for guiding the device from the apex of the left ventricle across the mitral annulus (Figure 1, A–C), orientation of the tip of the device with regards to the prolapsing segment of the leaflet positioning and leaflet grasping (Figure 1, D, E) and evaluation of the final length and tension of the neochordae to obtain a satisfactory mitral valve competence. (Figure 1, F). Procedural success was achieved in 38 patients (88,4%). 5 patients, 2 type A and 3 type D, underwent conversion to open surgery for immediate failure. 1 high-risk patient considered inoperable died before discharge. At 19 (IQR 13–23) months median follow-up, MR ≤II was present in 29 (76.3%). Overall 2 year survival was 100%. Freedom from reintervention was 89% for overall population. Conclusions TEE-Guided Transapical beating-heart neochord implantation is a feasible, low-risk technique. 2D and 3D TEE are the fundamental and essential diagnostic tools for the correct selection and monitoring of the procedure, as well as its possible complications. Funding Acknowledgement Type of funding sources: None. Figure 1

Usefullness of 2D/3D-TEE for guiding transapical beating heart neochordae implantation in mitral regurgitation