**2. The role of echocardiography in the management of degenerative mitral regurgitation**

First of all, in patients with degenerative mitral regurgitation, Echo identifies the type of degeneration: Barlow disease, fibroelastic deficiency (FED), hyper-elastic deficiency in Marfan syndrome etc. It is important for the surgeon to know it is important to know the aetiology of mitral insufficiency because some types of degenerative mitral regurgitation, such as FED, are more difficult to repair. Moreover, echo allows the identification of the mechanisms of mitral regurgitation, the alteration of leaflet coaptation and the specific geometrical concepts, which will be addressed further on.

In fact, echocardiography stands out as the only evaluation tool used in mitral valve repair. In dedicated centers, the tight collaboration between the echocardiographer and the surgeon, transformed the mitral valve repair into the gold standard treatment of mitral regurgitation, with over 90-95% of feasibility.

### **2.1 Standardization of the echocardiographic evaluation**

The standardization of the perioperative echo exam is a key element; it allows the identification of specific patterns of lesions which consequently guide the surgical planning and determine the outcome. It may be considered that the standardisation of the echocardiographic lesions is, in fact, the first step to achieve a standardised surgical technique. At the very beginning, when the echocardiography was less powerful, the mitral repair and the surgical strategy were mainly done by direct anatomical assessment performed by the surgeon in the operating theatre, after opening of the left atrium*.* Over the last decade, due to to a better resolution of the echo machines and the experience of the echocardiographer, the method allowed a reliable assessment of mitral anatomy and lesions, and by doing so, permitted a reliable surgical planning before opening of the left atrium.

During the last decade, 'Cardioteam' has developed its own algorithm of mitral assessment, in order to standardize the lesions and the mechanisms of regurgitation. It uses some of the classically described patterns of lesions, such as mitral valve prolapse, flail, floppy or billowing mitral valve, but also new ones, such as 'undulating mitral valve', 'overturned' valve, 'marginal prolapse' of the anterior leaflet or 'pseudo-cleft' of the posterior leaflet. The application of this algorithm allowed a better understanding of the relationship between the mitral valve geometry and the valve function. This has significantly modified the surgical approach with subsequent improvement of the results.

Technically speaking, preoperative echocardiographic examination has to consider the mitral valve as an eight-component anatomical structure: three pairs of corresponding scallops (A1-P1, A2-P2, A3-P3) and the two commissures (Figure 1). This approach guarantees a better dialog with the surgical team, by mean of structured lesion localizations and standardization of the examination.

repair has increased from roughly 50% in 2000 to nearly 70% in 2007 (Bonow, 2011), for those patients with degenerative mitral regurgitation (excluding mitral stenosis, previous cardiac surgery and other types of surgery other than tricuspid valve procedures). The percentage of patients is expected to increase, considering that roughly 50% of the symptomatic patients

**2. The role of echocardiography in the management of degenerative mitral** 

First of all, in patients with degenerative mitral regurgitation, Echo identifies the type of degeneration: Barlow disease, fibroelastic deficiency (FED), hyper-elastic deficiency in Marfan syndrome etc. It is important for the surgeon to know it is important to know the aetiology of mitral insufficiency because some types of degenerative mitral regurgitation, such as FED, are more difficult to repair. Moreover, echo allows the identification of the mechanisms of mitral regurgitation, the alteration of leaflet coaptation and the specific

In fact, echocardiography stands out as the only evaluation tool used in mitral valve repair. In dedicated centers, the tight collaboration between the echocardiographer and the surgeon, transformed the mitral valve repair into the gold standard treatment of mitral

The standardization of the perioperative echo exam is a key element; it allows the identification of specific patterns of lesions which consequently guide the surgical planning and determine the outcome. It may be considered that the standardisation of the echocardiographic lesions is, in fact, the first step to achieve a standardised surgical technique. At the very beginning, when the echocardiography was less powerful, the mitral repair and the surgical strategy were mainly done by direct anatomical assessment performed by the surgeon in the operating theatre, after opening of the left atrium*.* Over the last decade, due to to a better resolution of the echo machines and the experience of the echocardiographer, the method allowed a reliable assessment of mitral anatomy and lesions, and by doing so, permitted a reliable surgical planning before opening of the left atrium.

During the last decade, 'Cardioteam' has developed its own algorithm of mitral assessment, in order to standardize the lesions and the mechanisms of regurgitation. It uses some of the classically described patterns of lesions, such as mitral valve prolapse, flail, floppy or billowing mitral valve, but also new ones, such as 'undulating mitral valve', 'overturned' valve, 'marginal prolapse' of the anterior leaflet or 'pseudo-cleft' of the posterior leaflet. The application of this algorithm allowed a better understanding of the relationship between the mitral valve geometry and the valve function. This has significantly modified the surgical

Technically speaking, preoperative echocardiographic examination has to consider the mitral valve as an eight-component anatomical structure: three pairs of corresponding scallops (A1-P1, A2-P2, A3-P3) and the two commissures (Figure 1). This approach guarantees a better dialog with the surgical team, by mean of structured lesion localizations and

with severe mitral regurgitation are still denied surgery. ( Mirabel & colab,)

geometrical concepts, which will be addressed further on.

**2.1 Standardization of the echocardiographic evaluation** 

approach with subsequent improvement of the results.

standardization of the examination.

regurgitation, with over 90-95% of feasibility.

**regurgitation** 

Fig. 1. The mitral valve scheme. The valve is divided into 8 components: three pairs of corresponding scallops (A1-P1, A2-P2, A3-P3) and two commissures. The Echo exam must describe the normality or the abnormalities of each component, assessing the pattern of mitral valve lesion for each one, focusing the attention on the leaflet coaptation.
