In patients with severe mitral regurgitation who meet criteria for operative intervention, the preferred surgical approach is mitral valve repair, rather than replacement. Mitral valve repair avoids the disadvantages of a prosthetic valve, including suboptimal hemodynamics, long-term warfarin anticoagulation (with a mechanical valve), limited valve durability (with a bioprosthetic valve) and an increased risk of thromboembolic events, endocarditis, and paravalvular regurgitation with both types of prosthetic valve. In addition, patients undergoing mitral valve repair have a lower operative mortality (<1%), better post-operative left ventricular systolic function and improved long-term outcomes compared to patients undergoing mitral valve replacement. After successful mitral valve repair, over 80% of patients remain free of significant mitral regurgitation 15 to 20 years later.

However, the likelihood of a successful mitral valve repair varies widely between medical centers reflecting surgical team expertise and experience. Moreover, individual variation in mitral valve anatomy determines whether valve repair is possible and what specific surgical techniques are required in each patient. Echocardiographic evaluation both before and during operative repair is routine and three-dimensional (3D) imaging has greatly increased our appreciation of valve anatomy. In a milestone paper in this issue of Heart, Dr Mantovani and colleagues (see page 1111) convincingly demonstrate that 3D echocardiography also provides unique information that can help guide the surgical approach. In a series of 49 patients undergoing mitral valve repair, about 1/3 had a cleft-like indentation (CLI) in the posterior mitral leaflet, all of which required surgical closure to ensure …