**1. Introduction**

Echocardiography has become within the last years the main tool in the evaluation of the valvulopathies. Surgery plays a key role in the management of the valvular disorders, but it must be underlined that the surgical timing, planning and indication are all widely based on echocardiography. All the guidelines use the echocardiographic criteria to manage the valvular patients. Echocardiography became the main tool for the selection of the patient candidate to valve repair or replacement. The echocardiographic assessment is important in all the valvulopathies, but becomes crucial in the management of patients with mitral insufficiency, candidate to mitral valve repair.

Still, it should be noted, that there is no randomized study comparing the mitral valve repair and mitral valve replacement, and comparisons between the two, using propensity matching or other statistical methods are very difficult. On the other hand there are numerous studies which suggest that the short and long term outcomes of patients undergoing successful mitral valve repair are superior to those undergoing replacement.

Mitral valve repair has been proved to increase additional operative and long-term survival advantages over mitral valve replacement in case of chronic mitral regurgitation. The reduction in the left ventricular pump performance that has been observed after conventional mitral valve replacement, has not been obvious with mitral valve repair, provided that the postoperative contractile state remains pretty similar to the preoperative hemodynamic status. Compared to mitral replacement, mitral valve repair has lower mortality rates and higher long-term survival.. In addition, the thromboembolic and haemorrhagic complications associated with mitral valve reconstruction are also significantly decreased compared to mitral valve replacement. Several studies have reported that approximately 95% of patients are free from thromboembolic complications at 5 to 10 years after surgery. In contrast, 10% to 35% of patients with mechanical prostheses have thromboembolic events within 5 to 10 years after surgery (Bonow, 2011). Thus, the number of mitral valve repairs is expected to increase because the advantages over replacement were also clearly demonstrated by daily practice.

Nowadays, the number of patients undergoing mitral repair surgery is growing worldwide. The STS database proves that in the US, the percentage of patients undergoing mitral valve

The Degenerative Mitral Valve Regurgitation:

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

obtained from transthoracic exam fits the reality from the operating room.

scallops (eg 1/8; 8/8) per patient (Cerin, 2006, 2010).

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

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

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

mitral valve lesion for each one, focusing the attention on the leaflet coaptation.

From Geometrical Echocardiographic Concepts to Successful Surgical Repair 5

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