Over the last decade, there has been rapid innovation in transcatheter mitral valve (MV) therapies, which continues to evolve. While percutaneous MV repair with MitraClip is beneficial in high-risk surgical patients with severe mitral regurgitation due to degenerative MV disease, there remain many situations where transcatheter mitral valve replacement (TMVR) would be a preferred treatment strategy. Before proceeding with TMVR, the importance of proper baseline assessment of etiology, degree of pathology, and evaluation of anatomy cannot be understated. After the decision has been made to proceed with TMVR based on transthoracic echocardiogram, transesophageal echocardiogram and multi-detector computed tomography, the actual procedure will be guided by TEE. After the proper access is gained via a transseptal puncture or transapical puncture, the next step is echo-guided positioning of the prosthesis for proper deployment.