The role of echocardiography in mitral valve repair

Mitral regurgitation is increasing in Europe despite the reduction in the incidence of rheumatic disease. The development of surgical mitral valve repair by Alain Carpentier has changed the management and prognosis of patients with severe mitral regurgitation. Imaging techniques provide precise information on the type and extent of anatomic lesions, mechanisms of regurgitation, etiology, amount of regurgitation, and reparability of the valve. Twodimensional transesophageal echocardiography is routinely used for planning mitral valve surgery. However, this technique has several potential pitfalls with regards to spatial relationships and valvular morphological abnormalities. Recently introduced, live, real-time three-dimensional transesophageal echocardiography has improved our understanding of the functional anatomy and pathophysiology of mitral valve disease, especially in functional mitral regurgitation. Nowadays, three-dimensional transesophageal echocardiography is a powerful tool, not only for the accurate diagnosis of mitral lesions, but also for the intraoperative monitoring and the guidance of invasive procedures in the catheterization laboratory. It allows evaluating online all cardiac structures and offers new views like the "surgeon view" of the mitral valve morphology with only one acquisition. The aims of this article are to review the contribution of two-dimensional and three-dimensional transesophageal echocardiography to the evaluation of the mitral valve functional anatomy and to summarize their clinical applications and therapeutic implications.