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Background: Current surgical strategies for ischemic mitral regurgitation (iMR) include implantation of an undersized mitral annuloplasty ring with or without chordal cutting regardless of the underlying anatomy. We used three-dimensional echocardiography (3DE) to quantify the dynamic behavior of the mitral annulus and leaflets in patients with iMR compared to normal subjects.Methods: Full-volume 3D transesophageal images (Philips iE33, X7-2t probe) were obtained in 44 patients, including 27 patients with moderate to severe iMR (age 62±10 yrs) and 17 normal controls (NL; age 62±16 yrs). Prototype software (4D MVA, TomTec) was used to analyze mitral annular and leaflet dynamics throughout systole. The following mitral annular parameters were measured: non-planar angle, displacement, velocity, 3D area and area fraction. The following mitral leaflet parameters were measured: tenting volume, anterior leaflet area and posterior leaflet area.Results: Compared to normal patients, iMR patients had larger mitral annular areas with a flatter annulus (Figure). The annulus also had reduced displacement, velocity and area fraction. Mitral leaflet tenting volume and height were larger with iMR due to an increase in anterior leaflet area. Measured parameters correlated moderately with left ventricular ejection fraction (Table). In the iMR group, there was wider variability in measurements compared to normal controls.Conclusions: The great variability in mitral annular and leaflet parameters in iMR patients suggests that the standardized surgical approach may not be suitable for iMR treatment in all patients.