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Aim: To define feasibility, quality of imaging, accuracy, and practical usefulness of live Three-Dimensional Transoesophageal Echocardiography (live-3D TEE) in the preoperative definition of mitral valve (MV) anatomy in children affected by MV disease. To establish the superiority of live-3D TEE over 2D TEE in guiding the surgical approach.Methods: From April 2009 to April 2011 we enrolled for MV surgery 6 children (3 males) affected by severe MV insufficiency (4 post-rheumatic disease, 1 congenital mitral valve prolapse, 1 post-endocarditis). Mean age was 10 years (range 6-17yrs), mean weight was 30 kg (range 18-67 kg). We performed a complete pre- and post-operative 2D Trans-thoracic Echocardiographic (2D TTE) evaluation and both 2D TEE and live-3D TEE. We used a iE33 ultrasonograph unit (Philips, Andover, MA, USA) equipped with a S5-1 and a S8-3 2D probes, and a LIVE 3D X7-2t (2-7 MHz) matrix trans-aesophageal transducer. All data were digitally stored and reviewed together with surgeons; live-3D TEE images were discussed in real time with surgeons pre-operatively in order to plan the most fitting surgical repair for each specific MV anatomy.Results: Live-3D TEE feasibility was 100%. Its clear superiority compared to 2D TTE and 2D TEE was demonstrated since it allowed definition of the MV anatomy scallop by scallop in all cases, accurately showing to surgeons the site of prolapse/retraction as well as the coaptation gaps. No difference in feasibility was present in the various types of MV insufficiency. Live-3D information fitted with surgical findings in 100% of cases. Five patients underwent mitral valve repair (ring supported MV repair in 3 cases, MV replacement with bio prosthesis in 2, and isolated MV repair in 1). Live-3D TEE postoperative evaluation result showed optimal result in 5 cases, whereas mild to moderate persistent MV insufficiency was detected in 1. In this last case a MV re-repair was necessary 1 month later for recurrent severe mitral valve insufficiency.Conclusions: Live-3D TEE is an important tool for the decision-making on MV repair in children. It allows an online visualization of the anatomic structures clearly identifying the valvular apparatus and its defects, and mimicking actual anatomy as viewed in situ by the surgeons. Our data suggest a 100% feasibility in children, a 100% agreement with surgical findings, and a significantly higher segmental anatomic definition over 2D TEE. Its routine use might reduce the need for MV replacement leading to a more effective approach to MV surgery in paediatric patients.