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Because of the complex anatomy of the mitral valve, detailed imaging is a challenge. Transesophageal echocardiography (TEE) using two-dimensional echocardiography provides the backbone for the structural evaluation of the mitral valve. Interventional and surgical procedures on the mitral valve demand precise and sophisticated imaging for guidance and support. Three-dimensional (3D) transthoracic echocardiography and 3D transesophageal echocardiography (TEE) are now being used with increasing frequency to provide more comprehensive evaluations of the structure and function of the mitral valve complex. In this review, the authors present a framework for the application of 3D TEE in the evaluation of patients with structural or functional mitral valve disease, outline an examination protocol, and address the advantages and limitations of the current platform for 3D TEE. Real-time 3D TEE has the real potential to become the main imaging tool for the guidance of surgical and interventional procedures on the mitral valve. Although 3D TEE provides impressive images of the mitral valve, it now must be demonstrated, through scientific studies, that these beautiful images add clinical value to the management of patients with mitral valve disease.