THE M-TEER WORKBOOK
Draw  ·  Sketch  ·  Colour  ·  Learn  ·  Master
The Creative Companion to M-TEER Simplified
Designed during TEER Fellowship with
Prof. Francesco Maisano
CANDIDATE NAME:
TRAINING CENTRE:
San Raffaele University Hospital, Milan
Workbook Philosophy

--- TABLE 1 (1 rows) ---
“The hand that draws understands what the eye merely sees.”
--- END TABLE 1 ---

This workbook is built on a single conviction: you learn the mitral valve best when you recreate it yourself. Every sketch you draw, every segment you colour, every diagram you annotate becomes a memory anchor no lecture can replicate.
This is not a colouring book for children — it is a deliberate learning tool for serious clinicians.
Workbook Structure at a Glance

--- TABLE 2 (9 rows) ---
Section | Theme | Activity Type
A | Know It | Anatomy drawing & labelling
B | See It | Echo tracing & interpretation
C | Map It | Pathology classification sketches
D | Plan It | Patient case planning pages
E | Do It | Procedural step visualisation
F | Fix It | Complication scenario mapping
G | Colour It | Full artistic colouring studio
H | Own It | Personal reflection & notes
--- END TABLE 2 ---

How to Use This Workbook
Work through sections in order during your fellowship, or jump to the module relevant to your current rotation.
Keep a set of coloured pencils or fine-tip markers with you — colour coding is used throughout.
Pair each module with the corresponding chapter in M-TEER Simplified for full context.
Use the reflection boxes honestly — they are for you, not for assessment.
Revisit completed pages after 3, 6 and 12 months — you will be surprised how your understanding deepens.
Table of Contents
SECTION A
KNOW IT
Anatomy Drawing Modules
Understand the mitral valve as a connected system, one structure at a time.
MODULE A1 — The Mitral Valve Apparatus: Build It from Scratch
Learning Goal: Understand all six components of the mitral apparatus as a connected system.
Drawing Exercise — “The 6-Layer Build”
Draw the annulus (saddle shape — hint: not flat!)
Add the anterior leaflet (large, sail-like, A1–A2–A3)
Add the posterior leaflet (smaller, 3 scallops: P1–P2–P3)
Draw the commissures (AC and PC — the forgotten landmarks)
Add primary, secondary, tertiary chordae tendineae
Place the papillary muscles (anterolateral + posteromedial)
Drawing Canvas

--- TABLE 3 (1 rows) ---
Sketch the heart cross-section and build your 6-layer mitral apparatus here.
--- END TABLE 3 ---

Colouring Key — apply these colours to your drawing above

--- TABLE 4 (7 rows) ---
 | Anterior leaflet
 | Posterior leaflet
 | Annulus
 | Chordae tendineae
 | Papillary muscles
 | Commissures
MAISANO MOMENT “The annulus is saddle-shaped for a reason. When you flatten it, you create disease. Nature’s geometry is the best teacher.”
--- END TABLE 4 ---

MODULE A2 — Scallop Segmentation Map
The Carpentier Segmentation System: Colour & Label.
Surgeon’s view (from left atrium looking down)

--- TABLE 5 (3 rows) ---
Anterior Leaflet |  |  | Commissures
A1 | A2 | A3 | AC (anterolateral)
P1 | P2 | P3 | PC (posteromedial)
--- END TABLE 5 ---

Candidate Tasks
Colour each scallop a different shade in the drawing canvas below
Mark the primary TEER target zone (A2–P2)
Draw a MitraClip device at A2–P2
Label the typical DMR prolapse location
Label the typical SMR tethering pattern

--- TABLE 6 (1 rows) ---
Draw the en-face mitral valve and complete the tasks above.
--- END TABLE 6 ---

MODULE A3 — The Subvalvular World
Full-page blank cross-section for candidate to draw and label:
Primary chordae (to leaflet edges)
Secondary chordae (to leaflet bodies)
Tertiary chordae (to posterior leaflet base)
Anterolateral papillary muscle (dual blood supply)
Posteromedial papillary muscle (single supply — why it ruptures in MI)

--- TABLE 7 (2 rows) ---
Sketch the LV cross-section with the full subvalvular apparatus.
CLINICAL INSIGHT — Answer After Drawing Why does the posteromedial papillary muscle rupture more often in inferior myocardial infarction?
--- END TABLE 7 ---

MODULE A4 — The Mitral Valve in 3D Space
Perspective drawing exercise. For each view below, trace the valve as it would appear and note the corresponding probe angle.
1. En face (“surgical”) view from above

--- TABLE 8 (1 rows) ---
Trace the en-face view here.
--- END TABLE 8 ---

2. Long-axis (parasternal echo) view

--- TABLE 9 (1 rows) ---
Trace the long-axis view here.
--- END TABLE 9 ---

3. Bicommissural (TEE) view

--- TABLE 10 (1 rows) ---
Trace the bicommissural view here.
--- END TABLE 10 ---

Match each view to its probe angle

--- TABLE 11 (4 rows) ---
View | Probe Angle (°) | Key Structures Seen
En face / surgical view | 3D reconstruction | 
Long-axis | 120–135° | 
Bicommissural | 60° | 
--- END TABLE 11 ---

SECTION B
SEE IT
Echo Tracing & Interpretation Pages
You treat what you see — train your eye through your hand.
MODULE B1 — TEE View Tracing Library
For each of the 8 essential TEER TEE views, trace the key structures, label them, note the probe angle and depth, and write what you are specifically looking for in TEER planning.
View 1: Midesophageal 4-chamber (0°)

--- TABLE 12 (2 rows) ---
Probe Angle / Depth | Key Structures to Label | TEER Planning Purpose
Trace the echo image and label structures here.
--- END TABLE 12 ---

View 2: Midesophageal commissural (60°)

--- TABLE 13 (2 rows) ---
Probe Angle / Depth | Key Structures to Label | TEER Planning Purpose
Trace the echo image and label structures here.
--- END TABLE 13 ---

View 3: Midesophageal long-axis (120°–135°)

--- TABLE 14 (2 rows) ---
Probe Angle / Depth | Key Structures to Label | TEER Planning Purpose
Trace the echo image and label structures here.
--- END TABLE 14 ---

View 4: Transgastric basal short-axis (“fish-mouth view”)

--- TABLE 15 (2 rows) ---
Probe Angle / Depth | Key Structures to Label | TEER Planning Purpose
Trace the echo image and label structures here.
--- END TABLE 15 ---

View 5: Biplane imaging of A2–P2

--- TABLE 16 (2 rows) ---
Probe Angle / Depth | Key Structures to Label | TEER Planning Purpose
Trace the echo image and label structures here.
--- END TABLE 16 ---

View 6: 3D en-face “surgeon’s view”

--- TABLE 17 (2 rows) ---
Probe Angle / Depth | Key Structures to Label | TEER Planning Purpose
Trace the echo image and label structures here.
--- END TABLE 17 ---

View 7: Colour Doppler jet mapping

--- TABLE 18 (2 rows) ---
Probe Angle / Depth | Key Structures to Label | TEER Planning Purpose
Trace the echo image and label structures here.
--- END TABLE 18 ---

View 8: Post-clip assessment view

--- TABLE 19 (2 rows) ---
Probe Angle / Depth | Key Structures to Label | TEER Planning Purpose
Trace the echo image and label structures here.
--- END TABLE 19 ---

MODULE B2 — Measure It Yourself
Practice measurement worksheet — complete using a live case or recorded loop.

--- TABLE 20 (12 rows) ---
TEER Planning Measurement | Value | Unit
Coaptation gap |  | mm
Anterior leaflet length |  | mm
Posterior leaflet length |  | mm
Mitral valve area |  | cm²
EROA |  | cm²
Vena contracta |  | mm
Annular diameter (AP) |  | mm
Annular diameter (IC) |  | mm
Mean gradient (baseline) |  | mmHg
Post-clip gradient |  | mmHg
REPEAT THIS PAGE Photocopy or redraw this table for at least 5 different cases during your fellowship — trend your own measurement accuracy over time.
--- END TABLE 20 ---

MODULE B3 — Jet Location Map
For each case encountered in fellowship, draw the MR jet location and direction on the blank en-face template, classify the jet, note the likely mechanism, and record the date and a brief case description.

--- TABLE 21 (1 rows) ---
REMEMBER “Ten cases drawn by hand = ten cases never forgotten.”
--- END TABLE 21 ---

Jet Map — Case 1

--- TABLE 22 (2 rows) ---
Date | Brief Case Description | Classification (Central / Commissural / Eccentric) | Likely Mechanism (Carpentier)
Draw the en-face mitral valve and mark the jet location and direction.
--- END TABLE 22 ---

Jet Map — Case 2

--- TABLE 23 (2 rows) ---
Date | Brief Case Description | Classification (Central / Commissural / Eccentric) | Likely Mechanism (Carpentier)
Draw the en-face mitral valve and mark the jet location and direction.
--- END TABLE 23 ---

Jet Map — Case 3

--- TABLE 24 (2 rows) ---
Date | Brief Case Description | Classification (Central / Commissural / Eccentric) | Likely Mechanism (Carpentier)
Draw the en-face mitral valve and mark the jet location and direction.
--- END TABLE 24 ---

Jet Map — Case 4

--- TABLE 25 (2 rows) ---
Date | Brief Case Description | Classification (Central / Commissural / Eccentric) | Likely Mechanism (Carpentier)
Draw the en-face mitral valve and mark the jet location and direction.
--- END TABLE 25 ---

Jet Map — Case 5

--- TABLE 26 (2 rows) ---
Date | Brief Case Description | Classification (Central / Commissural / Eccentric) | Likely Mechanism (Carpentier)
Draw the en-face mitral valve and mark the jet location and direction.
--- END TABLE 26 ---

Jet Map — Case 6

--- TABLE 27 (2 rows) ---
Date | Brief Case Description | Classification (Central / Commissural / Eccentric) | Likely Mechanism (Carpentier)
Draw the en-face mitral valve and mark the jet location and direction.
--- END TABLE 27 ---

Jet Map — Case 7

--- TABLE 28 (2 rows) ---
Date | Brief Case Description | Classification (Central / Commissural / Eccentric) | Likely Mechanism (Carpentier)
Draw the en-face mitral valve and mark the jet location and direction.
--- END TABLE 28 ---

Jet Map — Case 8

--- TABLE 29 (2 rows) ---
Date | Brief Case Description | Classification (Central / Commissural / Eccentric) | Likely Mechanism (Carpentier)
Draw the en-face mitral valve and mark the jet location and direction.
--- END TABLE 29 ---

Jet Map — Case 9

--- TABLE 30 (2 rows) ---
Date | Brief Case Description | Classification (Central / Commissural / Eccentric) | Likely Mechanism (Carpentier)
Draw the en-face mitral valve and mark the jet location and direction.
--- END TABLE 30 ---

Jet Map — Case 10

--- TABLE 31 (2 rows) ---
Date | Brief Case Description | Classification (Central / Commissural / Eccentric) | Likely Mechanism (Carpentier)
Draw the en-face mitral valve and mark the jet location and direction.
--- END TABLE 31 ---

SECTION C
MAP IT
Pathology Classification Sketches
Draw the mechanism, and the diagnosis follows.
MODULE C1 — Carpentier Classification Drawing Pages
For each type, draw the mitral leaflet motion and annotate the mechanism.
TYPE I — Normal leaflet motion
Sketch the MR mechanism (e.g., annular dilation, leaflet perforation).

--- TABLE 32 (1 rows) ---
Draw Type I mechanism here.
--- END TABLE 32 ---

TYPE II — Excessive leaflet motion
Draw prolapse, flail, or chordal rupture. Mark which scallop is involved — A1? P2? A commissure?

--- TABLE 33 (1 rows) ---
Draw Type II mechanism here.
--- END TABLE 33 ---

TYPE IIIa — Restricted motion (diastole AND systole)
Draw rheumatic thickening or calcification causing restriction.

--- TABLE 34 (1 rows) ---
Draw Type IIIa mechanism here.
--- END TABLE 34 ---

TYPE IIIb — Restricted motion (systole only)
Draw tethered leaflets with papillary muscle displacement. Note: this is the SMR hallmark.

--- TABLE 35 (1 rows) ---
Draw Type IIIb mechanism here.
--- END TABLE 35 ---

MODULE C2 — DMR vs. SMR Side-by-Side Sketch
Full double-page spread — draw both etiologies and compare directly.

--- TABLE 36 (5 rows) ---
DMR — Degenerative | SMR — Secondary/Functional
Draw the prolapsing or flail segment | Draw the tethered leaflets
Mark the chordal rupture if present | Mark the papillary muscle displacement
Sketch the LV: normal size/function | Sketch the dilated cardiomyopathy LV
Colour the jet direction (usually eccentric) | Colour the central or posterior jet
--- END TABLE 36 ---

DMR — Drawing Canvas

--- TABLE 37 (1 rows) ---
Draw the DMR valve and LV here.
--- END TABLE 37 ---

SMR — Drawing Canvas

--- TABLE 38 (1 rows) ---
Draw the SMR valve and LV here.
--- END TABLE 38 ---

MODULE C3 — Barlow's Disease Anatomy Map
The complex anatomy challenge — map the following features:
Bileaflet prolapse pattern
Excess leaflet tissue (“billowing”)
Annular dilation
Multiple jet locations

--- TABLE 39 (2 rows) ---
Draw the Barlow's valve with all features above.
REFLECTION Why does this anatomy make TEER technically demanding? What would Prof. Maisano weigh when comparing TEER vs. surgical repair here?
--- END TABLE 39 ---

SECTION D
PLAN IT
Pre-Procedural Case Planning Templates
Every successful procedure begins on paper.
MODULE D1 — The TEER Case Planning Sheet
Use one copy per case during your fellowship. 20 copies are provided below.
M-TEER Case Planning Sheet — Copy 1

--- TABLE 40 (7 rows) ---
Field | Detail
Patient code | 
Age / Sex | 
MR etiology (DMR / SMR / Mixed) | 
NYHA class (I–IV) | 
EF (%) | 
STS score | 
--- END TABLE 40 ---

Anatomy Sketch

--- TABLE 41 (8 rows) ---
Draw the valve anatomy here.
Field | Detail
Target zone | 
Clip strategy (Single / Double / Triple) | 
Clip size (NT / NTW / XT / XTW) | 
Transseptal height (target 3.5–4 cm) | 
Key challenges | 
Heart team decision | 
--- END TABLE 41 ---

M-TEER Case Planning Sheet — Copy 2

--- TABLE 42 (7 rows) ---
Field | Detail
Patient code | 
Age / Sex | 
MR etiology (DMR / SMR / Mixed) | 
NYHA class (I–IV) | 
EF (%) | 
STS score | 
--- END TABLE 42 ---

Anatomy Sketch

--- TABLE 43 (8 rows) ---
Draw the valve anatomy here.
Field | Detail
Target zone | 
Clip strategy (Single / Double / Triple) | 
Clip size (NT / NTW / XT / XTW) | 
Transseptal height (target 3.5–4 cm) | 
Key challenges | 
Heart team decision | 
--- END TABLE 43 ---

M-TEER Case Planning Sheet — Copy 3

--- TABLE 44 (7 rows) ---
Field | Detail
Patient code | 
Age / Sex | 
MR etiology (DMR / SMR / Mixed) | 
NYHA class (I–IV) | 
EF (%) | 
STS score | 
--- END TABLE 44 ---

Anatomy Sketch

--- TABLE 45 (8 rows) ---
Draw the valve anatomy here.
Field | Detail
Target zone | 
Clip strategy (Single / Double / Triple) | 
Clip size (NT / NTW / XT / XTW) | 
Transseptal height (target 3.5–4 cm) | 
Key challenges | 
Heart team decision | 
--- END TABLE 45 ---

M-TEER Case Planning Sheet — Copy 4

--- TABLE 46 (7 rows) ---
Field | Detail
Patient code | 
Age / Sex | 
MR etiology (DMR / SMR / Mixed) | 
NYHA class (I–IV) | 
EF (%) | 
STS score | 
--- END TABLE 46 ---

Anatomy Sketch

--- TABLE 47 (8 rows) ---
Draw the valve anatomy here.
Field | Detail
Target zone | 
Clip strategy (Single / Double / Triple) | 
Clip size (NT / NTW / XT / XTW) | 
Transseptal height (target 3.5–4 cm) | 
Key challenges | 
Heart team decision | 
--- END TABLE 47 ---

M-TEER Case Planning Sheet — Copy 5

--- TABLE 48 (7 rows) ---
Field | Detail
Patient code | 
Age / Sex | 
MR etiology (DMR / SMR / Mixed) | 
NYHA class (I–IV) | 
EF (%) | 
STS score | 
--- END TABLE 48 ---

Anatomy Sketch

--- TABLE 49 (8 rows) ---
Draw the valve anatomy here.
Field | Detail
Target zone | 
Clip strategy (Single / Double / Triple) | 
Clip size (NT / NTW / XT / XTW) | 
Transseptal height (target 3.5–4 cm) | 
Key challenges | 
Heart team decision | 
--- END TABLE 49 ---

M-TEER Case Planning Sheet — Copy 6

--- TABLE 50 (7 rows) ---
Field | Detail
Patient code | 
Age / Sex | 
MR etiology (DMR / SMR / Mixed) | 
NYHA class (I–IV) | 
EF (%) | 
STS score | 
--- END TABLE 50 ---

Anatomy Sketch

--- TABLE 51 (8 rows) ---
Draw the valve anatomy here.
Field | Detail
Target zone | 
Clip strategy (Single / Double / Triple) | 
Clip size (NT / NTW / XT / XTW) | 
Transseptal height (target 3.5–4 cm) | 
Key challenges | 
Heart team decision | 
--- END TABLE 51 ---

M-TEER Case Planning Sheet — Copy 7

--- TABLE 52 (7 rows) ---
Field | Detail
Patient code | 
Age / Sex | 
MR etiology (DMR / SMR / Mixed) | 
NYHA class (I–IV) | 
EF (%) | 
STS score | 
--- END TABLE 52 ---

Anatomy Sketch

--- TABLE 53 (8 rows) ---
Draw the valve anatomy here.
Field | Detail
Target zone | 
Clip strategy (Single / Double / Triple) | 
Clip size (NT / NTW / XT / XTW) | 
Transseptal height (target 3.5–4 cm) | 
Key challenges | 
Heart team decision | 
--- END TABLE 53 ---

M-TEER Case Planning Sheet — Copy 8

--- TABLE 54 (7 rows) ---
Field | Detail
Patient code | 
Age / Sex | 
MR etiology (DMR / SMR / Mixed) | 
NYHA class (I–IV) | 
EF (%) | 
STS score | 
--- END TABLE 54 ---

Anatomy Sketch

--- TABLE 55 (8 rows) ---
Draw the valve anatomy here.
Field | Detail
Target zone | 
Clip strategy (Single / Double / Triple) | 
Clip size (NT / NTW / XT / XTW) | 
Transseptal height (target 3.5–4 cm) | 
Key challenges | 
Heart team decision | 
--- END TABLE 55 ---

M-TEER Case Planning Sheet — Copy 9

--- TABLE 56 (7 rows) ---
Field | Detail
Patient code | 
Age / Sex | 
MR etiology (DMR / SMR / Mixed) | 
NYHA class (I–IV) | 
EF (%) | 
STS score | 
--- END TABLE 56 ---

Anatomy Sketch

--- TABLE 57 (8 rows) ---
Draw the valve anatomy here.
Field | Detail
Target zone | 
Clip strategy (Single / Double / Triple) | 
Clip size (NT / NTW / XT / XTW) | 
Transseptal height (target 3.5–4 cm) | 
Key challenges | 
Heart team decision | 
--- END TABLE 57 ---

M-TEER Case Planning Sheet — Copy 10

--- TABLE 58 (7 rows) ---
Field | Detail
Patient code | 
Age / Sex | 
MR etiology (DMR / SMR / Mixed) | 
NYHA class (I–IV) | 
EF (%) | 
STS score | 
--- END TABLE 58 ---

Anatomy Sketch

--- TABLE 59 (8 rows) ---
Draw the valve anatomy here.
Field | Detail
Target zone | 
Clip strategy (Single / Double / Triple) | 
Clip size (NT / NTW / XT / XTW) | 
Transseptal height (target 3.5–4 cm) | 
Key challenges | 
Heart team decision | 
--- END TABLE 59 ---

M-TEER Case Planning Sheet — Copy 11

--- TABLE 60 (7 rows) ---
Field | Detail
Patient code | 
Age / Sex | 
MR etiology (DMR / SMR / Mixed) | 
NYHA class (I–IV) | 
EF (%) | 
STS score | 
--- END TABLE 60 ---

Anatomy Sketch

--- TABLE 61 (8 rows) ---
Draw the valve anatomy here.
Field | Detail
Target zone | 
Clip strategy (Single / Double / Triple) | 
Clip size (NT / NTW / XT / XTW) | 
Transseptal height (target 3.5–4 cm) | 
Key challenges | 
Heart team decision | 
--- END TABLE 61 ---

M-TEER Case Planning Sheet — Copy 12

--- TABLE 62 (7 rows) ---
Field | Detail
Patient code | 
Age / Sex | 
MR etiology (DMR / SMR / Mixed) | 
NYHA class (I–IV) | 
EF (%) | 
STS score | 
--- END TABLE 62 ---

Anatomy Sketch

--- TABLE 63 (8 rows) ---
Draw the valve anatomy here.
Field | Detail
Target zone | 
Clip strategy (Single / Double / Triple) | 
Clip size (NT / NTW / XT / XTW) | 
Transseptal height (target 3.5–4 cm) | 
Key challenges | 
Heart team decision | 
--- END TABLE 63 ---

M-TEER Case Planning Sheet — Copy 13

--- TABLE 64 (7 rows) ---
Field | Detail
Patient code | 
Age / Sex | 
MR etiology (DMR / SMR / Mixed) | 
NYHA class (I–IV) | 
EF (%) | 
STS score | 
--- END TABLE 64 ---

Anatomy Sketch

--- TABLE 65 (8 rows) ---
Draw the valve anatomy here.
Field | Detail
Target zone | 
Clip strategy (Single / Double / Triple) | 
Clip size (NT / NTW / XT / XTW) | 
Transseptal height (target 3.5–4 cm) | 
Key challenges | 
Heart team decision | 
--- END TABLE 65 ---

M-TEER Case Planning Sheet — Copy 14

--- TABLE 66 (7 rows) ---
Field | Detail
Patient code | 
Age / Sex | 
MR etiology (DMR / SMR / Mixed) | 
NYHA class (I–IV) | 
EF (%) | 
STS score | 
--- END TABLE 66 ---

Anatomy Sketch

--- TABLE 67 (8 rows) ---
Draw the valve anatomy here.
Field | Detail
Target zone | 
Clip strategy (Single / Double / Triple) | 
Clip size (NT / NTW / XT / XTW) | 
Transseptal height (target 3.5–4 cm) | 
Key challenges | 
Heart team decision | 
--- END TABLE 67 ---

M-TEER Case Planning Sheet — Copy 15

--- TABLE 68 (7 rows) ---
Field | Detail
Patient code | 
Age / Sex | 
MR etiology (DMR / SMR / Mixed) | 
NYHA class (I–IV) | 
EF (%) | 
STS score | 
--- END TABLE 68 ---

Anatomy Sketch

--- TABLE 69 (8 rows) ---
Draw the valve anatomy here.
Field | Detail
Target zone | 
Clip strategy (Single / Double / Triple) | 
Clip size (NT / NTW / XT / XTW) | 
Transseptal height (target 3.5–4 cm) | 
Key challenges | 
Heart team decision | 
--- END TABLE 69 ---

MODULE D2 — The “TEER-able or Not?” Decision Tree Sketchpad
Build your own decision flowchart using the prompts below, then compare with the “Maisano Model” in M-TEER Simplified.
Start: “Patient referred for M-TEER”
Is anatomy suitable? — What makes it unsuitable?
Is the MR severe? — How do you confirm severity?
Is the patient symptomatic? — NYHA / 6MWD / BNP
Surgery possible? — STS score / comorbidities
Heart team consensus — document the discussion

--- TABLE 70 (2 rows) ---
Draw your own decision tree / flowchart here.
COMPARE After completing your flowchart, compare it with the model decision tree in Chapter 11 of M-TEER Simplified. What did you miss? What did you add that wasn’t there?
--- END TABLE 70 ---

MODULE D3 — Challenging Anatomy Sketchbook
Eight dedicated pages for difficult cases. For each vignette: sketch what you expect on echo, sketch your clip strategy, and reflect on what Prof. Maisano would advise.
Vignette 1: Barlow's disease with bileaflet prolapse
Sketch what you expect to see on echo:
Sketch your clip strategy:

--- TABLE 72 (1 rows) ---
REFLECTION What would Prof. Maisano advise here?
--- END TABLE 72 ---

Vignette 2: Posterior leaflet length < 7 mm
Sketch what you expect to see on echo:
Sketch your clip strategy:

--- TABLE 74 (1 rows) ---
REFLECTION What would Prof. Maisano advise here?
--- END TABLE 74 ---

Vignette 3: Heavily calcified posterior annulus
Sketch what you expect to see on echo:
Sketch your clip strategy:

--- TABLE 76 (1 rows) ---
REFLECTION What would Prof. Maisano advise here?
--- END TABLE 76 ---

Vignette 4: Prior surgical annuloplasty ring
Sketch what you expect to see on echo:
Sketch your clip strategy:

--- TABLE 78 (1 rows) ---
REFLECTION What would Prof. Maisano advise here?
--- END TABLE 78 ---

Vignette 5: Coaptation gap > 10 mm
Sketch what you expect to see on echo:
Sketch your clip strategy:

--- TABLE 80 (1 rows) ---
REFLECTION What would Prof. Maisano advise here?
--- END TABLE 80 ---

Vignette 6: Rheumatic valve with restricted motion
Sketch what you expect to see on echo:
Sketch your clip strategy:

--- TABLE 82 (1 rows) ---
REFLECTION What would Prof. Maisano advise here?
--- END TABLE 82 ---

Vignette 7: Very small MVA (borderline 4 cm²)
Sketch what you expect to see on echo:
Sketch your clip strategy:

--- TABLE 84 (1 rows) ---
REFLECTION What would Prof. Maisano advise here?
--- END TABLE 84 ---

Vignette 8: Post-MI acute SMR
Sketch what you expect to see on echo:
Sketch your clip strategy:

--- TABLE 86 (1 rows) ---
REFLECTION What would Prof. Maisano advise here?
--- END TABLE 86 ---

SECTION E
DO IT
Procedural Step Visualisation
Rehearse the procedure with your pencil before you rehearse it with your hands.
MODULE E1 — The Transseptal Puncture Map
On the blank atrial septal diagram below, draw and label:
Ideal puncture site (posterior, superior — 3.5–4 cm above the MV plane)
Consequences of anterior puncture (too close to the aorta)
Consequences of inferior puncture (inadequate working height)
The “tenting” sign on the TEE bicaval view
Needle, dilator, and guide sheath trajectory
Reference Layout

--- TABLE 87 (7 rows) ---
Structure | Label It in Your Drawing
SVC | →
IVC | →
Fossa ovalis | →
Right atrium | →
Left atrium | →
Draw the atrial septum with right atrium and left atrium, and complete all labelling tasks.
--- END TABLE 87 ---

MODULE E2 — Clip Positioning: The Approach Vector
Step-by-step procedural storyboard — draw each of the six panels below.

--- TABLE 88 (1 rows) ---
Panel 1: Guiding catheter in LA — draw the curve | Panel 2: Clip delivery system deployed — draw orientation
--- END TABLE 88 ---


--- TABLE 89 (1 rows) ---
Panel 3: Clip opened, perpendicular to coaptation line — draw | Panel 4: Clip advanced to LV — draw depth
--- END TABLE 89 ---


--- TABLE 90 (1 rows) ---
Panel 5: Leaflets grasped — draw closed clip with tissue | Panel 6: Echo assessment — draw colour Doppler result
--- END TABLE 90 ---

MODULE E3 — The Double-Clip Strategy Map
For five different MR patterns, draw the position of clip 1, the residual jet after clip 1, the position of clip 2, and the final result with estimated gradient. Reflect on whether a second clip was the right call.
Double-Clip Map — Pattern 1

--- TABLE 91 (2 rows) ---
Draw clip 1 position, residual jet, clip 2 position, and final result.
Final residual MR grade | Estimated transmitral gradient | Was a second clip the right call? Why?
--- END TABLE 91 ---

Double-Clip Map — Pattern 2

--- TABLE 92 (2 rows) ---
Draw clip 1 position, residual jet, clip 2 position, and final result.
Final residual MR grade | Estimated transmitral gradient | Was a second clip the right call? Why?
--- END TABLE 92 ---

Double-Clip Map — Pattern 3

--- TABLE 93 (2 rows) ---
Draw clip 1 position, residual jet, clip 2 position, and final result.
Final residual MR grade | Estimated transmitral gradient | Was a second clip the right call? Why?
--- END TABLE 93 ---

Double-Clip Map — Pattern 4

--- TABLE 94 (2 rows) ---
Draw clip 1 position, residual jet, clip 2 position, and final result.
Final residual MR grade | Estimated transmitral gradient | Was a second clip the right call? Why?
--- END TABLE 94 ---

Double-Clip Map — Pattern 5

--- TABLE 95 (2 rows) ---
Draw clip 1 position, residual jet, clip 2 position, and final result.
Final residual MR grade | Estimated transmitral gradient | Was a second clip the right call? Why?
--- END TABLE 95 ---

MODULE E4 — The “Perfect Clip” vs. “Acceptable Clip” Illustration
Side-by-side drawing exercise.

--- TABLE 96 (2 rows) ---
Perfect Result | Acceptable Result
Draw: MR ≤ 1+, ΔP < 5 mmHg, both leaflets well grasped | Draw: MR 2+ but gradient safe, patient stable, anatomy limited
--- END TABLE 96 ---

Perfect Result — Drawing Canvas
Acceptable Result — Drawing Canvas

--- TABLE 98 (1 rows) ---
REFLECTION At what point do you stop? Write Prof. Maisano's teaching on this.
--- END TABLE 98 ---

SECTION F
FIX IT
Complication Scenario Mapping
The operator who has rehearsed the complication is the operator who survives it calmly.
MODULE F1 — Complication Recognition Cards
For each complication: draw what it looks like on echo, complete the decision flowchart for what to do next, and record the relevant Maisano teaching.
F1.1 — Single Leaflet Attachment (SLA)
What does it look like on echo?
What do you do next? (complete the flowchart)

--- TABLE 100 (1 rows) ---
MAISANO'S LESSON Record the principle or teaching that applies to this scenario.
--- END TABLE 100 ---

F1.2 — Significant residual MR post-clip
What does it look like on echo?
What do you do next? (complete the flowchart)

--- TABLE 102 (1 rows) ---
MAISANO'S LESSON Record the principle or teaching that applies to this scenario.
--- END TABLE 102 ---

F1.3 — Mitral stenosis (elevated gradient)
What does it look like on echo?
What do you do next? (complete the flowchart)

--- TABLE 104 (1 rows) ---
MAISANO'S LESSON Record the principle or teaching that applies to this scenario.
--- END TABLE 104 ---

F1.4 — Cardiac tamponade
What does it look like on echo?
What do you do next? (complete the flowchart)

--- TABLE 106 (1 rows) ---
MAISANO'S LESSON Record the principle or teaching that applies to this scenario.
--- END TABLE 106 ---

F1.5 — Clip embolisation
What does it look like on echo?
What do you do next? (complete the flowchart)

--- TABLE 108 (1 rows) ---
MAISANO'S LESSON Record the principle or teaching that applies to this scenario.
--- END TABLE 108 ---

F1.6 — Transseptal complications
What does it look like on echo?
What do you do next? (complete the flowchart)

--- TABLE 110 (1 rows) ---
MAISANO'S LESSON Record the principle or teaching that applies to this scenario.
--- END TABLE 110 ---

F1.7 — Acute haemodynamic deterioration
What does it look like on echo?
What do you do next? (complete the flowchart)

--- TABLE 112 (1 rows) ---
MAISANO'S LESSON Record the principle or teaching that applies to this scenario.
--- END TABLE 112 ---

MODULE F2 — My Toughest Cases Log
Reflective log — 10 illustrated pages. For each challenging case encountered, complete the entry below.
Toughest Case Log — Entry 1

--- TABLE 113 (7 rows) ---
Field | Detail
Date | 
Case summary | 
The complication or challenge | 
How it was managed | 
What I would do differently | 
Prof. Maisano's comment | 
--- END TABLE 113 ---

Sketch what happened:
Toughest Case Log — Entry 2

--- TABLE 115 (7 rows) ---
Field | Detail
Date | 
Case summary | 
The complication or challenge | 
How it was managed | 
What I would do differently | 
Prof. Maisano's comment | 
--- END TABLE 115 ---

Sketch what happened:
Toughest Case Log — Entry 3

--- TABLE 117 (7 rows) ---
Field | Detail
Date | 
Case summary | 
The complication or challenge | 
How it was managed | 
What I would do differently | 
Prof. Maisano's comment | 
--- END TABLE 117 ---

Sketch what happened:
Toughest Case Log — Entry 4

--- TABLE 119 (7 rows) ---
Field | Detail
Date | 
Case summary | 
The complication or challenge | 
How it was managed | 
What I would do differently | 
Prof. Maisano's comment | 
--- END TABLE 119 ---

Sketch what happened:
Toughest Case Log — Entry 5

--- TABLE 121 (7 rows) ---
Field | Detail
Date | 
Case summary | 
The complication or challenge | 
How it was managed | 
What I would do differently | 
Prof. Maisano's comment | 
--- END TABLE 121 ---

Sketch what happened:
Toughest Case Log — Entry 6

--- TABLE 123 (7 rows) ---
Field | Detail
Date | 
Case summary | 
The complication or challenge | 
How it was managed | 
What I would do differently | 
Prof. Maisano's comment | 
--- END TABLE 123 ---

Sketch what happened:
Toughest Case Log — Entry 7

--- TABLE 125 (7 rows) ---
Field | Detail
Date | 
Case summary | 
The complication or challenge | 
How it was managed | 
What I would do differently | 
Prof. Maisano's comment | 
--- END TABLE 125 ---

Sketch what happened:
Toughest Case Log — Entry 8

--- TABLE 127 (7 rows) ---
Field | Detail
Date | 
Case summary | 
The complication or challenge | 
How it was managed | 
What I would do differently | 
Prof. Maisano's comment | 
--- END TABLE 127 ---

Sketch what happened:
Toughest Case Log — Entry 9

--- TABLE 129 (7 rows) ---
Field | Detail
Date | 
Case summary | 
The complication or challenge | 
How it was managed | 
What I would do differently | 
Prof. Maisano's comment | 
--- END TABLE 129 ---

Sketch what happened:
Toughest Case Log — Entry 10

--- TABLE 131 (7 rows) ---
Field | Detail
Date | 
Case summary | 
The complication or challenge | 
How it was managed | 
What I would do differently | 
Prof. Maisano's comment | 
--- END TABLE 131 ---

Sketch what happened:
SECTION G
COLOUR IT
The M-TEER Creative Studio
This section is explicitly artistic. The science is embedded in the beauty.
MODULE G1 — “The Living Valve” — Full Anatomical Colouring Plates
Eight full-page colouring plates. A suggested colour palette is provided for each, but free expression is also invited. Use the notes space beside each plate for clinical observations.
Plate 1: The mitral apparatus en face (from the atrium)
Suggested palette: red (anterior leaflet), blue (posterior leaflet), gold (annulus), green (chordae)

--- TABLE 133 (1 rows) ---
Draw and colour this plate.
--- END TABLE 133 ---

Personal notes / clinical observations:
Plate 2: Cross-section of LV with valve and subvalvular apparatus
Suggested palette: pink (myocardium), orange (papillary muscles), green (chordae), red/blue (leaflets)

--- TABLE 134 (1 rows) ---
Draw and colour this plate.
--- END TABLE 134 ---

Personal notes / clinical observations:
Plate 3: The Carpentier scallop map — detailed
Suggested palette: six distinct shades, one per scallop (A1–A3, P1–P3)

--- TABLE 135 (1 rows) ---
Draw and colour this plate.
--- END TABLE 135 ---

Personal notes / clinical observations:
Plate 4: Normal coaptation in systole vs. diastole
Suggested palette: closed valve in deep red, open valve in light blue

--- TABLE 136 (1 rows) ---
Draw and colour this plate.
--- END TABLE 136 ---

Personal notes / clinical observations:
Plate 5: DMR — prolapsing P2 scallop
Suggested palette: highlight the flail segment in bright red against blue posterior leaflet

--- TABLE 137 (1 rows) ---
Draw and colour this plate.
--- END TABLE 137 ---

Personal notes / clinical observations:
Plate 6: SMR — tethered leaflets in dilated LV
Suggested palette: enlarged LV in pale pink, tethered leaflets in deep blue, displaced papillary muscles in orange

--- TABLE 138 (1 rows) ---
Draw and colour this plate.
--- END TABLE 138 ---

Personal notes / clinical observations:
Plate 7: MitraClip in situ (grasping A2–P2)
Suggested palette: metallic grey/silver clip, red and blue leaflets grasped together

--- TABLE 139 (1 rows) ---
Draw and colour this plate.
--- END TABLE 139 ---

Personal notes / clinical observations:
Plate 8: PASCAL device — illustrating paddle + spacer design
Suggested palette: differentiate paddles, spacer, and clasps with three distinct colours

--- TABLE 140 (1 rows) ---
Draw and colour this plate.
--- END TABLE 140 ---

Personal notes / clinical observations:
MODULE G2 — The Echo Art Studio
“Trace and Interpret” — beautified echo silhouettes. Trace, colour, and label each view.

--- TABLE 141 (1 rows) ---
PRINCIPLE “When you can draw what you see on echo, you understand it — not just recognise it.”
--- END TABLE 141 ---

The fish-mouth view (transgastric short-axis)

--- TABLE 142 (1 rows) ---
Trace, colour, and label this view.
--- END TABLE 142 ---

3D en-face view

--- TABLE 143 (1 rows) ---
Trace, colour, and label this view.
--- END TABLE 143 ---

Biplane A2–P2 view

--- TABLE 144 (1 rows) ---
Trace, colour, and label this view.
--- END TABLE 144 ---

MODULE G3 — Build Your Own MitraClip
Exploded engineering-style diagram for colouring and assembly understanding. Colour and label each component:
Clip arms (opened / closed)
Grippers
Delivery catheter tip
Lock mechanism
PASCAL: paddle, spacer, clasps

--- TABLE 145 (2 rows) ---
Draw the exploded MitraClip / PASCAL diagram and colour each component.
REFLECTION What does each component do mechanically? Write below.
--- END TABLE 145 ---

MODULE G4 — The Heart Team Ecosystem — Visual Map
On the blank canvas below, draw your own mind map of:
All the roles in the structural heart team
Decision flow between members
How imaging informs the operator
Post-procedure pathways

--- TABLE 146 (2 rows) ---
ARTISTIC FREEDOM ENCOURAGED Use diagrams, icons, colour coding, and arrows freely — this is your map, in your own visual language.
Draw your Heart Team Ecosystem mind map here.
--- END TABLE 146 ---

SECTION H
OWN IT
Personal Reflection & Fellowship Journal
The procedure is technical. The growth is personal. Capture both
MODULE H2 — “Maisano's Teachings” — My Personal Collection
50 entries for capturing teaching moments throughout your fellowship. Each entry includes the date, context, the teaching itself, what it means to you, and a small sketch space.
Teaching Entry 1

--- TABLE 147 (1 rows) ---
Date | Case / Context
--- END TABLE 147 ---

Prof. Maisano said:
What it means to me:
Sketch:
Teaching Entry 2

--- TABLE 149 (1 rows) ---
Date | Case / Context
--- END TABLE 149 ---

Prof. Maisano said:
What it means to me:
Sketch:
Teaching Entry 3

--- TABLE 151 (1 rows) ---
Date | Case / Context
--- END TABLE 151 ---

Prof. Maisano said:
What it means to me:
Sketch:
Teaching Entry 4

--- TABLE 153 (1 rows) ---
Date | Case / Context
--- END TABLE 153 ---

Prof. Maisano said:
What it means to me:
Sketch:
Teaching Entry 5

--- TABLE 155 (1 rows) ---
Date | Case / Context
--- END TABLE 155 ---

Prof. Maisano said:
What it means to me:
Sketch:
Quick Reference Tools
The M-TEER Workbook Pocket Reference Card (detachable / laminate)
SIDE A — Anatomy Quick Map
Scallop nomenclature grid
Carpentier classification summary
Normal valve measurements
SIDE B — Procedure Checklist
Pre-procedure echo checklist
Transseptal height target
Intraprocedural echo views
“Stop criteria” — when not to add a clip
Post-procedure assessment steps
Pocket Reference Card — Side A: Anatomy Quick Map

--- TABLE 157 (5 rows) ---
Scallop | Location | Notes
A1 / A2 / A3 | Anterior leaflet, lateral to medial | 
P1 / P2 / P3 | Posterior leaflet, lateral to medial | 
AC | Anterolateral commissure | 
PC | Posteromedial commissure | 
--- END TABLE 157 ---

Carpentier Classification Summary

--- TABLE 158 (5 rows) ---
Type | Leaflet Motion | Typical Cause
I | Normal | Annular dilation, perforation
II | Excessive | Prolapse, flail, chordal rupture
IIIa | Restricted (diastole + systole) | Rheumatic disease, calcification
IIIb | Restricted (systole only) | Tethering — SMR
--- END TABLE 158 ---

Normal Valve Measurements

--- TABLE 159 (5 rows) ---
Parameter | Normal Range
Mitral valve area | 4–6 cm²
Annular diameter (AP) | ~2.5–3.5 cm
Coaptation length | ≥7–8 mm
Transmitral mean gradient | < 5 mmHg
--- END TABLE 159 ---

Pocket Reference Card — Side B: Procedure Checklist
Pre-Procedure Echo Checklist
Confirm MR severity and mechanism (Carpentier type)
Measure coaptation gap, leaflet lengths, MVA, EROA, vena contracta
Assess annular dimensions (AP and IC)
Identify jet location and direction
Screen for anatomical exclusions (severe calcification, very small MVA)
Transseptal Height Target
Aim for puncture 3.5–4 cm above the mitral valve plane, posterior and superior on the fossa ovalis.
Intraprocedural Echo Views (in sequence)
Bicaval view — confirm transseptal puncture site
4-chamber and commissural views — guide catheter navigation
3D en-face view — clip orientation and alignment
Biplane A2–P2 — grasping confirmation
Colour Doppler — residual MR assessment
Spectral Doppler — transmitral gradient
“Stop Criteria” — When Not to Add a Clip
Residual MR is ≤1+ and gradient is acceptable
Transmitral mean gradient is approaching or exceeding 5 mmHg
Further grasping risks single leaflet attachment or leaflet injury
Patient is haemodynamically stable with an “acceptable” result per heart team discussion
Post-Procedure Assessment Steps
Final TEE assessment of MR grade and gradient
Confirm clip stability and leaflet attachment
Haemodynamic monitoring in recovery
Plan anticoagulation / antiplatelet strategy
Schedule echo follow-up (discharge, 30 days, 1 year)
THE COMPLETE BUNDLE
M-TEER Simplified (the textbook)
+
The M-TEER Workbook (this companion)
+
Quick Reference Card (detachable insert)
+
QR-Linked Echo Video Library
=
The Complete TEER Fellowship Learning System
with Prof. Francesco Maisano