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Moderate or severe mitral regurgitation is the most common valve disease in the USA. Without treatment, severe mitral regurgitation has a 5-year survival rate of approximately 40%. Surgery plays a pivotal role in the treatment of these patients. However, close to 50% of patients can be denied surgery due to being deemed to be high risk. The pioneering work of St Goar led to the development of a catheter-based system, the MitraClip™, that percutaneously accomplishes the Alfieri's method. With this percutaneous technique, rather than sutures, one or two clips are placed under transesophageal guidance attaching the midportions of the anterior and posterior leaflets, creating a double mitral orifice. The procedure requires seven basic steps with strong collaboration between the interventional cardiologist and echocardiologist. This paper focuses on the role of echocardiography for patient selection and procedural guidance for the MitraClip insertion.