**2.7.3 Tailored surgical strategy**

Based on the Prolapsed Score and on the structured echocardiographic analyses of the mitral valve, the surgical strategy has to be personalised. In order to choose the right surgical approach and to be able to interact with the surgeon, the echocardiographer needs to know the surgical techniques suitable for the given case. Building a trust-based relationship between the surgeon and the echocardiographer is crucial for the surgical result. Each case has to be discussed by the surgical team prior to the operation.

This approach allows the surgeon to make two types of surgical planning, both necessary: one is the planning with 'the closed atrium', meaning the mental planning based on the echocardiographic findings. The other one is performed after the left atrium was opened and the valve is directly inspected. In our experience the two coincide in most of the cases, due to standardization of the echo exam, to the presence of the echocardiographer in the operating room and due to the dialogue with the surgical team.

Recently, the importance of performing the mitral valve repair using the most 'physiological' approach has become crucial. Single valve orifice but also posterior mitral

The Degenerative Mitral Valve Regurgitation:

intraoperative photo (middle). LA = left atrium.

length of coaptation and valve geometry.

From Geometrical Echocardiographic Concepts to Successful Surgical Repair 21

After surgical repair, the essential issue is that the coaptation point must be dragged within the left ventricle, underneath the mitral annular plane (Figure 15). In the normal mitral valve, this type of coaptation expresses the physiological equilibrium between the collagen and elastic fibres, which confers the right balance between the elasticity and resistance of the valve. Same should be true about the repaired mitral valves, which will most probably

Fig. 16. TEE postoperative aspect of complex mitral valve repair. Notice the rebuilding of the triangle of coaptation (arrows) and the classical 'smile' aspect of the mitral valve on the

Even if already stated, it should be underlined that the triangle of coaptation and the coaptation length need to be carefully assessed in all the regions of the mitral valve before expressing the final judgement on the real immediate outcome of the repair. Keep in mind possible traps. The surgeon's "hurry" to know the results of repair; do not express any conclusions before appropriate ventricular loading conditions are achieved. Do not start the post-operative assessment by Colour Doppler. The most important thing is to assess the

In order to correctly assess the valve geometry, the loading conditions should be optimal: hypovolemia should be avoided as it may underestimate a potential residual mitral regurgitation or label as 'prolapsing' an otherwise normal valve leaflet. We have stated about the prepump exam that the importance of the Doppler techniques for the evaluation of the severity of the mitral regurgitation was lower than the importance of the geometrical analysis. This does not mean that Color Doppler mapping shouldn't be performed but it should integrate the geometrical analysis and not replace it. These details are essential to the surgeon. The outcome depends on that. This statement is also true about the post-pump examination. Geometry is more important than colour (meaning Colour Doppler mapping). Whenever the result of the repair is suboptimal and there is residual mitral regurgitation, the echocardiographer must be able to rapidly identify the true mechanism of mitral regurgitation. The problem may vary from residual prolapse or restriction of one or more valve sectors - presumably due to incorrect neo-cordal length, residual marginal prolapse if left untreated, oversized annuloplasty ring, persistence of pseudo-commissures, etc. In these cases further surgery with a second run pump might be needed. Rarely, the mitral valve problem may be a consequence of a ventricular dysfunction when a post-pump contractility

remain elastic and long-lasting when their geometry satisfies the mentioned criteria.

leaflet mobility became cornerstone principles that guide the mitral repair in our centre. The classical techniques of repair included the quadrangular resection of the posterior mitral leaflet and ring annuloplasty, which inevitably led to a rigid posterior leaflet (Verma, NYJM 2009). Lately, many surgeons have chosen to perform the triangular resection (instead of quadrangular) in order to guarantee a higher mobility of the posterior leaflet and thus an increased anatomical and functional leaflet reserve, convinced that this will subsequently achieve a better and longer lasting coaptation.

In conclusion, we may assume that the importance of the preoperative transesophageal examination is given by the accuracy in identifying the mechanism of mitral regurgitation and valve anatomy (flail, prolapse, loss of coaptation, perforation and so on), and by describing the geometry of the mitral apparatus. There is a close correlation between valve geometry and function. The Colour Doppler mapping might underestimate the entity of the regurgitant flow; thus, the prepump echocardiographic evaluation needs to rely more on valve geometry and regurgitant mechanism, and less on the Colour flow Doppler.
