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Background: Prominent clefts or slits have been noted as a cause of early failure of mitral valve repair, but there has been no attempt to systematically document their occurrence in mitral valve disease (MVD). Using 3D trans-oesophageal echo (TOE) and surgical corroboration we describe the frequency, distribution and clinical impact of slits in MVD and control patients.Methods: 161 patients were studied. 77 patients with MVD, 27 patients with alternative causes of mitral regurgitation, and 56 normal controls. All patients underwent TOE studies using an X72t transducer and an iE33 imaging platform (Philips). 3D zoom images were acquired of the mitral valve and analysed offline (MVQ, Philips). Echo images were corroborated with findings made at surgery for those patients who underwent mitral repair. The proportion of the valve that was prolapsing was recorded, and correlated to the number, distribution and depth of slits.Results: 3D TOE was 94% sensitive and 88% specific for detecting prominent slits. Slits were documented in 86% of patients with degenerative MVD, but significantly less frequently in patients with alternative MR (11%; p<0.01) and controls (11%, p<0.01). Slits always occurred in abnormal regions of the valve, and there was a strong correlation between the number of slits and the proportion of the valve that was prolapsing (r=0.71).Conclusions: Slits are a frequent finding in degenerative mitral valves but are uncommon in control patients. They only occur in abnormal regions of the valve,and are more frequent as a larger proportion of the valve prolapses. As such, they may play an important role in the aetiology of degenerative mitral valve disease.