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Purpose: To evaluate mitral valve morphology in patients with mitral valve prolapse using quantitative analysis of real-time 3D echocardiographic (RT3DE) images.Methods: Thirty-eight MVP patients with severe MR [defined as effective regurgitant orifice area (EROA)≥0.4cm2], 34 MVP with mild or moderate MR (EROA<0.4cm2), and 28 normal adults underwent transesophageal RT3DE. Offline 3D measurements of mitral annular and leaflet dimensions and geometry were performed using a commercially available software.Results: Compared to both MVP patients with non-severe MR and normal subjects, MVP patients with severe MR had larger annular area (p<.0001), reduced annular non-planarity (p<.05), and larger anterior (p<.0001) and posterior (p<.0001) leaflet surface area, prolapsing volume (0<.0001) and prolapsing height (p<.0001). A strong correlation existed between EROA and leaflet prolapsing volume (r=0.87, p<.0001). Multivariate analysis identified leaflet prolapsing volume (odds ratio=6.3, p=.0025) and annular non-planar angle (odds ratio=1.1, p=.044) (Figure) as the independent predictors of severe MR. Leaflet prolapsing volume ≥1.1ml best identified MVP patient with severe MR (sensitivity 79%, specificity 88%). Quantitative analysis of mitral valve by RT3DE was feasible in all patients with reasonable inter- (<8%) and intra-observer variability (<5%) for all parameters.Conclusions: Mitral valve pathology in MVP can be quantified in a 3D perspective using RT3DE. Large leaflet prolapsing volume and loss of annular non-planarity may be important 3D echocardiographic determinants for severe MR in patients with MVP.