**2.2 The first step of standardization: The prolapsing score**

During both transthoracic and intraoperative transesophageal examinations, each scallop must be analysed and a lesion code has to be ascribed: 0-normal, 1-elongated chordae, 2 prolapse, 3-flail and 4-marginal prolapse. The complexity of the valve disorders is expressed by the prolapsing score (PS), namely the ratio between the sick scallops and the total scallops (eg 1/8; 8/8) per patient (Cerin, 2006, 2010).

The echocardiographic message contained within the prolapsing score is fundamental for the surgeon to set the surgical approach. For example, when the echocardiographer states that the prolapsing score is 1/8 or 2/8, the surgical team expects a relatively 'simple' repair to be performed. Consequently, in such a patient the new surgical approaches such as minimally invasive surgery are more likely to be pursued. On the other hand, when the prolapsing score is as high as 8/8, the expected surgical approach will be different, more complex from the technical point of view, therefore more difficult and more likely to be done in classical sternotomy. In the operating theatre, the prolapsing score will be verified and confronted with the echo data Based on the experience of our center, around 75-80% of the echo information obtained from transthoracic exam fits the reality from the operating room.

The Degenerative Mitral Valve Regurgitation:

**2.4.1 The pattern of 'elongated chordae'** 

the classical prolapse.

left atrium; Ao – aorta.

**2.4.2 The pattern of 'prolapsing valve'** 

From Geometrical Echocardiographic Concepts to Successful Surgical Repair 7

In degenerative mitral insufficiency, many types of mitral valve lesions were classically described in the literature: from the classical mitral prolapse or mitral flail, to the billowing or floppy mitral valve. For a true dialogue between the echocardiographer, anaesthesiologist, and surgeon, all the team has to rigorously know the meaning of the most frequent lesions found in these patients. Alongside the well-known classically patterns of lesions, our group identifies some other particular patterns of mitral valve injuries*,* such as: elongated chordae, marginal prolapse, overturned mitral valve, undulating mitral valve or the mitral valve's pseudo-cleft. The main echocardiographic pattern used for the

This pattern defines the situation when the coaptation point is found to be into the left ventricular cavity, immediately below the level of the mitral annulus*.* It is a borderline situation between a normal aspect of the mitral valve and the mitral prolapse. Usually is not associated with mitral regurgitation. For the surgical planning, it is important to recognise it and indicate it to the surgeon. Sometimes it may interest one or both leaflets (Figure 3), involving one or more scallops. The relatives of patients with truly mitral valve prolapse may sometimes present 'elongated chordae' during the echocardiographic exam, without

Fig. 3. The pattern of 'elongated chordae'. In the presence of 'elongated chordae', the coaptation point (C) is found into the left ventricular cavity, immediately below or at the level of the mitral annulus. Note the shape of the triangle of coaptation which is flattened. The coaptation height of the triangle has practically disappeared. LV – left ventricle; LA –

The pattern of 'prolapsing valve' was classically defined as the presence of the coaptation point into the left atrium, above the level of the mitral annulus (Figure 4). By definition, the

**2.4 The third step of standardization: Check the pattern of mitral valve lesions** 

characterization of the degenerated mitral valve is presented further on.
