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Background: Only half of the symptomatic pts with severe mitral regurgitation (MR) undergo surgery regardless of the clear message from the guidelines; among these only about 50% of pts undergo Mitral Valve repair (MVr). MVr through small incisions (MIS) emerges as the gold standard in the degenerative MR. The role of 2D-echo in the MIS needs clarification.Purpose: To analyze the impact of 2D-echo standardization of mitral valve assessment, using specific geometric concepts on the surgical planning and results in MIS.Method: From Jan ′09 to Dec ′10, 82 pts (mean age 55.3 ± 12.6y, 72% male) with MR of degenerative (82%) or other (18%) etiology underwent MIS. Accurate and standardized TT and TE 2D and 3D echoes were done preoperatively (PreOP) and postoperatively (PostOP) to identify the mechanism of MR. The normal MV geometry was defined by the triangle of coaptation (ToC): defined by the coaptation point, sited within the LV cavity and by two other points placed on the septal and lateral MV annulus. The coaptation length (CL) and height (CH) were assessed PreOP and PostOP. Each pair of scallops and commissure were classified as follows: normal, long chordae, prolapse and flail. The complexity of the lesions was PreOP defined by the prolapsed score (PS) - the ratio between the number of sick scallops and the total number (e.g. 1/8 till 8/8 scallop/pt).Results: No deaths were recorded. MR was severe in all pts and was resolved (MR PISA PreOP 87,7 vs 3,2 ml/sec PostOP). There was one conversion to sternotomy due to RV perforation. PreOP the ToC was absent in 93% of pts due to distortion of MV geometry as verified by the PS. PostOP the ToC was rebuilt in 98% of pts. The mean PostOP CH was 6,9mm and the mean CL was 6.9mm. Initially only pts with ‘simple’ lesions (eg. isolated P2 prolapse) were operated by MIS, as shown by the low PS of 1.9/8. Subsequently MIS was extended to more complex lesions involving the anterior or even both leaflets with a mean PS in the last 7 months of 4.5/8. Within the late months there were 6 pts with PS of 5/8, one with 6/8 and 5 with 8/8 scallop/pt.Conclusions: Based on the standardization of mitral valve assessment by geometrical tools as triangle of coaptation the feasibility of MVr by MIS was 98,8%. The geometrical algorithm showed a very good correlation with the surgical findings. This scheme allows a reliable surgical planning with a progressive extension of MIS from simple cases to more complex pts involving both leaflets. 2D Echo is commonly used in MVr, but in MIS echo appears to be a decisive tool to diagnose, plan and control the surgery.