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Purpose: Paravalvular leaks(PVLs) are potential complications of mitral valve replacement. Although most PVLs are asymptomatic and benign, some may cause severe regurgitation leading to reoperation. Evaluation of PVLs by two-dimensional echocardiography is limited. We performed real-time three-dimensional echocardiography (RT-3D TEE) to observe the en face view of mitral PVLs to localize the defect, and we compared the results to surgical findings.Methods: The study comprised of 137 patients with paravalvular regurgitation. RT-3D TEE was performed using 3D matrix-array TEE transducer immediately after detection of PVL on 2D TEE examination. The RT 3D TEE showed the the valvular anatomic appearance as seen from the atrial (surgeon's view) and we used the clock-wise format. Clinically ill patients with moderate to severe mitral paravalvular regurgitation underwent reoperation.Results: Mitral and aortic prosthesis included 107 and 30 patients, respectively. Mitral paravalvular leak was mild, moderate and severe in 18, 32, 57 patients, respectively. Twelve patients (%11) with moderate to severe mitral PVLs underwent reoperation. In preoperative evaluation with RT-3D TEE, 3 patients had PVLs localized anteriorly (11-01), 3 patients laterally (08-10), 3 patients posteriorly (05-07), and one patient medially (02-04). In 2 patients, 2 sites of PVLs (totally,12 patients with 14 PVLs) were noted. The site of PVLs were all (100%) confirmed at the time of surgery in each patient; 8 of them underwent surgical repair whereas the remaining 4 underwent replacement surgery with successful outcomes.Conclusion: RT-3D TEE has emerged recently as an essential guide for surgeons, especially in delineating localization and correcting paravalvular leaks.