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Purpose: It's well known that aortic and mitral (MV) valves are coupled by fibrous tissue and therefore have synchronous and reciprocal dynamics. The goal of this study was to characterize aortic-mitral coupling (AMC) before and after MV repair and annuloplasty to identify the effects on AMC induced by ring insertion, compared to normal valvular function, using custom software for annular tracking from transesophageal real-time 3D echocardiography (3DTOE).Methods: Twenty-eight consecutive patients (19 males, 59±11yrs) with degenerative MV disease and severe mitral regurgitation (MR) were studied by 3DTOE before (MR-PRE) and after (MR-POST) MV repair. In addition, an age-matched group of 25 patients (9 males, 55±19yrs) with normal valvular function was studied as control (CTLR). After manual initialization, mitral (MA) and aortic (AoA) annuli were tracked frame-by-frame and several parameters automatically computed: max surface area and percent area change (Area%, as pulsatility) with respect to end-diastole both for MA and AoA, MA height (H), MA anterior-posterior (Dap) and intercommissural (Dcc) diameters, distance between MA and AoA centers (dMA-AoA), angle between MA and AoA.Results: MR-PRE was associated with dilated MA (16±4cm2), increased H (13±3mm), DAP (43±5mm) and DCC (46±7mm), but MA pulsatility (23±8%), AoA (Area: 5±1cm2,Area%:30±14%) and AMC parameters (dMA-AoA:28±3mm,angle:126±16°) were unchanged compared to CTRL (MA Area:10±2 cm2,H:10±2 mm,DAP:30±11 mm,DAP:36±5mm, MA Area%:21±9, AoA area:5±1cm2, AoA area %:36±13, dMA-AoA:25±3, angle: 124±13°). Annuloplasty resulted in smaller MA area (5±1cm2), H (7±3mm), DAP (25±4mm) and DCC (28±5 mm), together with lower values for MA and AoA pulsatility (9±6%, 22±10%, respectively) compared both to MR-PRE and to CTRL. In addition, a global AMC constriction was noticed post-surgery, resulting in shorter distance between the MA and AoA centers (23±2mm) with a smaller angle between both valves (117°±11°).Conclusions: A constrictive effect due to the insertion of a MV ring was observed on the aortic annulus motion and function, despite unchanged morphology. Our dynamic analysis showed potential undesired alterations occurring in AMC mechanism in patients with severe MR treated with repair and annuloplasty, that could be involved in the development of secondary aortic regurgitation. Our results underline the importance of considering the aortic-mitral structure as a unique morphological and functional entity, whose evaluation is of fundamental importance in the diagnosis and needs to be taken into consideration in the treatment of mitral valvular disease.