**5. Indications for intervention**

Intervention is needed when the patient with PVL is symptomatic or has evolving subclinical consequences, such as left ventricular enlargement and function impairment, significant pulmonary pressure elevation at rest or with exercise, significant hemolysis, and infective endocarditis. In certain situations, the PVLsymptoms causality relationship has to be assessed in case of comorbidities. In other situations, symptoms have to be unmasked by effort tests. TPVL is currently considered in first-line when expertise is available. The first step is to eliminate contraindications to TPVL: evolutive sepsis, extensive disinsertion greater than the third of the circumference, and rocking valves. When these figures are present surgery is chosen. Otherwise, TPVL offers a less invasive solution in generally operated and frail patients.
