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Papers by Giovanni La Canna

Journal of Clinical Medicine

Infective endocarditis (IE) is still a life-threatening disease with frequent lethal outcomes des... more Infective endocarditis (IE) is still a life-threatening disease with frequent lethal outcomes despite the profound changes in its clinical, microbiological, imaging, and therapeutic profiles. Nowadays, the scenario for IE has changed since rheumatic fever has declined, but on the other hand, multiple aspects, such as elderly populations, cardiovascular device implantation procedures, and better use of multiple imaging modalities and multidisciplinary care, have increased, leading to escalations in diagnosis. Since the ESC and AHA Guidelines have been released, specific aspects of diagnostic and therapeutic management have been clarified to provide better and faster diagnosis and prognosis. Surgical treatment is required in approximately half of patients with IE in order to avoid progressive heart failure, irreversible structural damage in the case of uncontrolled infection, and the prevention of embolism. The timing of surgery has been one of the main aspects discussed, identifying ...

The Journal of Thoracic and Cardiovascular Surgery, 2016

Objective: The study objective was to assess the impact on follow-up outcomes of residual mitral ... more Objective: The study objective was to assess the impact on follow-up outcomes of residual mitral regurgitation 2þ in comparison with 1þ after MitraClip (Abbott Vascular Inc, Santa Clara, Calif) repair. Methods: We compared the outcomes of mitral regurgitation 2þ and mitral regurgitation 1þ groups among a population of 223 consecutive patients with acute residual mitral regurgitation 2þ who underwent MitraClip implantation at San Raffaele Scientific Institute (Milan, Italy) between October 2008 and December 2014. Results: Residual mitral regurgitation 2þ was found in 64 patients (28.7%). Overall actuarial survival was 63.1% AE 4.4% at 48 months. Cumulative incidence functions of cardiac death in patients with mitral regurgitation 2þ was significantly higher (Gray test P<.001) compared with the mitral regurgitation 1þ group. The adjusted hazard ratio was 5.28 (95% confidence interval, 2.41-11.56, P<.001). Cumulative incidence function of mitral regurgitation !3þ recurrence in patients with residual mitral regurgitation 1þ and mitral regurgitation 2þ at 48 months was 13.3% AE 3.8% and 45.2% AE 6.8%, respectively (Gray test P<.001). Multivariate model showed that mitral regurgitation 2þ was the only factor associated with the development of mitral regurgitation !3þ at follow-up (adjusted hazard ratio, 6.71; 95% confidence interval, 3.48-12.90; P<.001). Mitral regurgitation cause was not associated with cardiac death and recurrence of mitral regurgitation !3þ at follow-up. No relationship between New York Heart Association class and followup time after MitraClip implant was found (odds ratio, 1.07; 95% confidence interval, 0.98-1.15; P ¼ .11), and factors related to postoperative New York Heart Association also included residual mitral regurgitation 2þ (P ¼ .07). Conclusions: Residual 2þ mitral regurgitation after MitraClip implantation was associated with worse follow-up outcomes compared with 1þ mitral regurgitation, including survival, symptom relief, and mitral regurgitation recurrence. Better efficacy should be pursued by transcatheter mitral repair technologies.

Annals of cardiothoracic surgery, 2015

The Annals of Thoracic Surgery, 2015

Background. The objective of this study was to assess the fate at long term of mild-to-moderate f... more Background. The objective of this study was to assess the fate at long term of mild-to-moderate functional tricuspid regurgitation (TR) left untreated at the time of mitral valve repair in patients with dilated cardiomyopathy. Methods. We selected from our prospective hospital database 84 patients (age, 64 ± 9.6 years; ejection fraction, 0.31 ± 0.064) who underwent mitral repair for secondary mitral regurgitation in whom concomitant mild-tomoderate TR (nonlinear scale 1 to 4D) was left untreated. Tricuspid regurgitation was classified as mild in 61 patients (72.6%) and moderate in 23 patients (27.3%). Annular dilatation itself was not systematically measured and was not used as a trigger for tricuspid annuloplasty. Most of the patients were in New York Heart Association functional class III or IV (56 of 84; 66.7%). Results. At a median follow-up of 7.3 years (interquartile range, 4.5 to 9.3), 17 patients (20.2%) had moderate-to-severe TR and 21 patients (25%) showed a

European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery, Jan 10, 2015

To compare the surgical and percutaneous edge-to-edge (EE) repair in patients with severe left ve... more To compare the surgical and percutaneous edge-to-edge (EE) repair in patients with severe left ventricular (LV) dysfunction and secondary mitral regurgitation (MR). We reviewed the prospectively collected data of the first 120 consecutive patients (age: 65 ± 9.8 years, EF: 28 ± 8.2%) treated with surgical (65 patients) or percutaneous (55 patients) EE repair for severe secondary MR in our institution. Age (P = 0.005) and logistic European System for Cardiac Operative Risk Evaluation (P < 0.0001) were significantly higher in the MitraClip group. LVEF (P = 0.37), end-diastolic (P = 0.83) and end-systolic (P = 0.68) volumes and systolic pulmonary artery pressure (SPAP) (P = 0.58) were similar. The follow-up was 100% complete [median: 4 years; interquartile range (IQR): 2.2-7.2]. The length of hospital stay was 10 days (IQR: 8-13) for surgery and 5 days (IQR: 3.9-7.8) for MitraClip (P < 0.0001). Hospital mortality (3 vs 0%, P = 0.49) and freedom from cardiac death at 4 years (80.8...

European heart journal cardiovascular Imaging, 2014

Paravalvular leaks (PVL) occur in up to 17% of all surgically implanted prosthetic valves. Re-ope... more Paravalvular leaks (PVL) occur in up to 17% of all surgically implanted prosthetic valves. Re-operation is associated with high morbidity and mortality. Transcatheter closure via a surgical transapical approach (TAp) is an emerging alternative for selected high-risk patients with PVL. The aim of this study was to compare the in-hospital outcomes of patients who underwent surgery and TA-closure for PVL in our single-centre experience. From October 2000 to June 2013, 139 patients with PVL were treated in our Institution. All the TA procedures were performed under general anaesthesia in a hybrid operative room: in all but one case an Amplatzer Vascular Plug III device was utilized. Hundred and thirty-nine patients with PVL were treated: 122 patients (87.3%) underwent surgical treatment (68% mitral PVL; 32% aortic PVL) and 17 patients (12.2%) underwent a transcatheter closure via a surgical TAp approach (all the patients had mitral PVL; one case had combined mitral and aortic PVLs); in ...

JACC. Cardiovascular interventions, 2014

Undersized annuloplasty is an established first-line therapy option for functional mitral regurgi... more Undersized annuloplasty is an established first-line therapy option for functional mitral regurgitation (MR) (1). Percutaneous direct annuloplasty as a standalone therapy, as well as in combination with other transcatheter mitral interventions, aims to reproduce surgical annuloplasty (2). The "first-in-man" patient was a 69-year-old gentleman with ischemic cardiomyopathy and severe functional MR (effective regurgitant orifice area [EROA] 0.29 cm 2 ; regurgitant volume [RVol] 39 ml/beat) (Figure 1, Online Video 1

Nature Reviews Cardiology, 2011

| Mitral regurgitation (MR) is the most-common valvular heart disease in the western world. From ... more | Mitral regurgitation (MR) is the most-common valvular heart disease in the western world. From an etiologic point of view, MR can be either organic (mainly degenerative in western countries) or functional (secondary to left ventricular remodeling in the context of ischemic or idiopathic dilated cardiomyopathy). Degenerative and functional MR are completely different disease entities that pose specific decision-making problems and require different management. The natural history of severe degenerative MR is clearly unfavorable. However, the appropriate and timely correction of degenerative MR is associated with a life expectancy similar to that of the normal population. By contrast, the prognostic impact of the correction of functional MR is still a matter of debate. In this Review, we discuss the optimal treatment of both degenerative and functional MR, taking into account all presently available therapeutic options, including novel percutaneous methods. Since a clear understanding of the etiology and mechanisms of valvular dysfunction is important to guide the timing and choice of treatment, the role of echocardiography in the management of MR is also addressed.

Nature Reviews Cardiology, 2015

| Mitral regurgitation (MR) is a common, progressive, and difficult-to-manage disease. MR is dyna... more | Mitral regurgitation (MR) is a common, progressive, and difficult-to-manage disease. MR is dynamic in nature, with physiological fluctuations occurring in response to various stimuli such as exercise and ischaemia, which can precipitate the development of symptoms and subsequent cardiac events. In both chronic primary and secondary MR, the dynamic behaviour of MR can be reliably examined during stress echocardiography. Dynamic fluctuation of MR can also have prognostic value; patients with a marked increase in regurgitant volume or who exhibit increased systolic pulmonary artery pressure during exercise have lower symptom-free survival than those who do not experience significant changes in MR and systolic pulmonary artery pressure during exercise. Identifying patients who have dynamic MR, and understanding the mechanisms underlying the condition, can potentially influence revascularization strategies (such as the surgical restoration of coronary blood flow) and interventional treatment (including cardiac resynchronization therapy and new approaches targeted to the mitral valve).

Circulation, Jan 9, 2014

To assess the long-term results of the edge-to-edge mitral repair performed without annuloplasty ... more To assess the long-term results of the edge-to-edge mitral repair performed without annuloplasty in degenerative mitral regurgitation (MR). From 1993 to 2002, 61 patients with degenerative MR were treated with an isolated edge-to-edge suture without any annuloplasty. Annuloplasty was omitted in 36 patients because of heavy annular calcification and in 25 for limited annular dilatation. A double-orifice repair was performed in 53 patients and a commissural edge-to-edge in 8. Hospital mortality was 1.6%. Follow-up was 100% complete (mean length, 9.2±4.21 years; median, 9.7; longest, 18.1). Survival at 12 years was 51.3±7.75%. At the last echocardiographic examination, MR ≥3+ was demonstrated in 33 patients (55%). At 12 years, freedom from reoperation was 57.8±7.21% and freedom from recurrence of MR ≥3+ was 43±7.6%. Residual MR >1+ at hospital discharge was identified as a risk factor for recurrence of MR ≥3+ (hazard ratio, 3.8; 95% confidence interval, 1.7-8.2; P=0.001). In patient...

European Heart Journal - Cardiovascular Imaging, 2013

Valvular regurgitation represents an important cause of cardiovascular morbidity and mortality. E... more Valvular regurgitation represents an important cause of cardiovascular morbidity and mortality. Echocardiography has become the primary noninvasive imaging method for the evaluation of valvular regurgitation. The echocardiographic assessment of valvular regurgitation should integrate the quantification of the regurgitation, assessment of the valve anatomy and function, as well as the consequences of valvular disease on cardiac chambers. In clinical practice, the management of patients with valvular regurgitation thus largely integrates the results of echocardiography. It is crucial to provide standards that aim at establishing a baseline list of measurements to be performed when assessing regurgitation.

The Journal of Thoracic and Cardiovascular Surgery, 2003

Edge-to-edge mitral valve repair is usually performed in association with annuloplasty, with rare... more Edge-to-edge mitral valve repair is usually performed in association with annuloplasty, with rare exceptions. We retrospectively analyzed the results of ringless edge-to-edge repair, particularly in view of minimally invasive and percutaneous approaches. Methods: From November 1993 to December 2001, 81 patients underwent edgeto-edge mitral repair without associated annuloplasty. The cause was degenerative in most patients. In 32 patients the annulus was severely calcified. Type I lesions were present in 6 patients, type II lesions in 60 patients, and type III lesions in 15 patients. A double-orifice repair was done in 69 patients, and paracommissural repair was done in 12 patients. In 5 patients edge-to-edge repair was used as a rescue procedure. Results: There were 3 hospital and 4 late deaths, for a 4-year survival of 85% Ϯ 6.7%. At latest follow-up, 63 patients were in New York Heart Association classes I or II, and 9 patients were in classes III or IV. Nine patients required reoperation (89% Ϯ 3.9% overall freedom from reoperation at 4 years). Annular calcification was associated with a greater reoperation rate (77% Ϯ 22% vs 95% Ϯ 4.6% freedom from reoperation, P ϭ .03). Intraoperative water testing and postrepair transesophageal echocardiography predicted late failure. Only 1 of 42 patients required reoperation in the follow-up period when annular calcification, rheumatic disease, or rescue procedure were not present as risk factors. Conclusions: Our data confirm overall suboptimal results of the edge-to-edge technique when annuloplasty is not added to the repair. Annular calcification, rheumatic cause, and edge-to-edge repair done as a rescue procedure were associated with the worst outcome. Midterm results in selected patients encourage future developments in catheter-based edge-to-edge procedures. A nnuloplasty is commonly recommended to complete mitral valve repair operations because its use has been associated with improved long-term durability. 1,2 However, some groups have debated the need for annuloplasty on a routine basis for every valve repair procedure. There are recent reports of comparable durability without annuloplasty in selected groups of patients. In these series, however, some sort of annular support was obtained by using either continuous 3 or interrupted 4 annular sutures. Annuloplasty is not considered mandatory in cases involving a small preoperative mitral annulus (eg, acute mitral regurgitation [MR]). Redefining the exact role for annuloplasty in mitral valve repair procedures is urged by recent developments of minimally invasive approaches and beating-heart

The Journal of Thoracic and Cardiovascular Surgery, 2001

The aim of this study is to report our results with the central doubleorifice technique used for ... more The aim of this study is to report our results with the central doubleorifice technique used for the treatment of complex mitral valve lesions. Methods: The central double-orifice repair has been used in 260 patients (mean age, 56 ± 14.3 years) over a period of 7 years. The mechanism responsible for mitral regurgitation was prolapse of both leaflets in 148 patients, prolapse of the anterior leaflet in 68, prolapse of the posterior leaflet with annular calcification or other unfavorable features in 31, and lack of leaflet coaptation for restricted motion or erosion of the free edge in 13. Degenerative disease was the cause of mitral regurgitation in 80.8% of the patients, rheumatic disease was the cause in 9.6%, endocarditis was the cause in 6.1%, and ischemic disease was the cause in 2.3%. Results: Hospital mortality was 0.7%, and the overall survival at 5 years was 94.4% ± 2.59%. Thirteen patients required a reoperation (2 early postoperatively and 11 late during the follow-up), for an overall freedom from reoperation of 90.0% ± 3.37% at 5 years. Freedom from reoperation was lower in patients with rheumatic valve disease and in patients who did not undergo an annuloplasty procedure. Conclusions: The effectiveness and durability of the central double-orifice technique were assessed in this study. This type of repair can be a useful addition to the surgical armamentarium in mitral valve reconstruction. R epair of a regurgitant mitral valve is superior to mitral valve replacement, with lower hospital mortality, longer survival, better preservation of ventricular function, fewer thromboembolic complications, and reduced risk of endocarditis. 1 Therefore, it is desirable to extend the population of patients who can benefit from mitral valve reconstruction. The most common cause of degenerative mitral regurgitation (MR) is a floppy (myxomatous) valve with segmental prolapse of the posterior leaflet. 2 This lesion can be corrected by means of quadrangular resection of the prolapsing portion of the posterior leaflet, with highly reproducible and durable results. 3 Other lesions, however, are associated with less-gratifying results, require more complex and surgically demanding techniques, or both, and many surgeons are hesitant to perform a reconstructive operation under these circumstances. For instance, correction of MR caused by anterior leaflet prolapse is less predictable than posterior leaflet repair, and the poor results obtained with anterior leaflet resection have led to other more complex and less reproducible techniques, such as chordal shortening, chordal transposition, and chordal replacement. 4-8 Similarly, prolapse of both leaflets in severe myxomatous degeneration

The Journal of Thoracic and Cardiovascular Surgery, 2014

The study objective was to report the midterm outcomes of MitraClip implantation in inoperable or... more The study objective was to report the midterm outcomes of MitraClip implantation in inoperable or high-risk surgical candidates with degenerative mitral regurgitation. Methods: From October 2008, data of all high-risk or elderly patients with severe degenerative mitral regurgitation who underwent MitraClip implantation were prospectively collected. Results: Forty-eight high-risk consecutive patients with severe degenerative mitral regurgitation underwent MitraClip implantation (mean age, 78.5 AE 10.8 years; 56.6% of the patients were aged !80 years). Mean Society of Thoracic Surgeons score was 12% AE 10%, and 71% were in New York Heart Association class III or IV. Mean left ventricular ejection fraction was 57% AE 11%. The device was successfully implanted in 47 of 48 patients (98%). In-hospital mortality was 2%. The median intensive care unit stay was 22 hours; patients were discharged from the hospital in an average of 4.5 AE 2.4 days. Predischarge echocardiography showed a mitral regurgitation reduction to grade 2þ or less in 43 of 47 patients (91.5%). Actuarial survival was 89% AE 5.2% and 70.2% AE 9% at 1 and 2 years, respectively (82% AE 9% in patients aged <80 years and 95% AE 4.4% in patients aged !80 years at 1 year; P ¼ .9). Freedom from mitral regurgitation 3þ or greater was 80% AE 7% at 1 year and 76.6% AE 7% at 2 years. At 1 year, 93% of survivors were in New York Heart Association class I or II (100% of patients aged <80 years and 88% of patients aged !80 years; P ¼ .4). Significant quality of life improvements were documented. A significant improvement in 6-minute walk test performance was observed. Conclusions: MitraClip therapy is a valuable alternative to surgery in high-risk and elderly patients with degenerative mitral regurgitation. Clinical benefits also are obtained in octogenarians. (

Journal of the American College of Cardiology, 2011

The edge-to-edge technique is a versatile procedure for mitral valve repair. Its technical simpli... more The edge-to-edge technique is a versatile procedure for mitral valve repair. Its technical simplicity has been the prerequisite for the development of a number of transcatheter technologies to perform percutaneous mitral valve repair. The evolution from a standard open heart surgical to percutaneous procedure involved the application of the technique in minimally invasive robotic surgery and direct access (transatrial) off-pump suture-based repair and finally in the fully percutaneous approach with either suture-based or device (clip)-based approach. The MitraClip (Abbott Vascular, Menlo Park, California) is currently available for clinical use in Europe, and it is mainly applied to treat high-risk patients with functional mitral regurgitation. A critical review of the surgical as well as the early percutaneous repair data is necessary to elucidate the clinical role and the potential for future developments of the edge-to-edge repair in the treatment of mitral regurgitation.

Journal of the American College of Cardiology, 2012

Functional or secondary tricuspid regurgitation (STR) is the most frequent etiology of tricuspid ... more Functional or secondary tricuspid regurgitation (STR) is the most frequent etiology of tricuspid valve pathology in Western countries. Surgical tricuspid repair has been avoided for years, because of the misconception that tricuspid regurgitation should disappear once the primary left-sided problem is treated; this results in a large number of untreated patients with STR. Over the past few years, many investigators have reported evidence in favor of a more aggressive surgical approach to STR. Consequently, interest has been growing in the physiopathology and treatment of STR. The purpose of this review is to explore the anatomical basis, pathophysiology, therapeutic approach, and future perspectives with regard to the management of STR.

European Journal of Cardio-Thoracic Surgery, 1998

Objective: Repair of mitral regurgitation (MR) is more demanding in case of prolapse of the anter... more Objective: Repair of mitral regurgitation (MR) is more demanding in case of prolapse of the anterior leaflet, posterior leaflet with calcified annulus, or prolapse of both leaflets. We evaluated a repair which consists of anchoring the free edge of the prolapsing leaflet to the corresponding free edge of the facing leaflet: the 'edge-to-edge' (E-toE) technique. The correction results in a double orifice valve when the prolapse is in the middle portion of the leaflet and in a smaller valve orifice when the prolapse is close to a commissure. Methods: Out of 432 patients with MR submitted to valve repair between January 1991 and September 1997, 121 (mean age 56 9 15.8 years) underwent E-toE correction. The most prevalent etiology was degenerative disease (82 patients, 68%). The mechanism of MR was anterior leaflet prolapse (61 patients), posterior leaflet prolapse (24 patients), prolapse of both leaflets (28 patients) and other complex mechanisms (8 patients). In 72 patients, a double orifice was created, the paracommissural repair was done in 49 patients. Results: Hospital mortality was 1.6%. Overall survival was 92 9 3.1% at 6 years with 95 9 4.8% freedom from reoperation. Mortality was unrelated to the type of repair. Mitral stenosis was never observed after the correction. At the follow-up (mean 2.2 91.5 years), all patients but 15 are class I or II. Symptoms at the follow-up are not related to residual MR. Conclusions: Midterm results of this alternative repair technique are promising, considering the high prevalence of complex anatomical lesions. The technique is simple, easily reproducible and rapidly feasible also when mitral exposure is suboptimal.

European Journal of Cardio-Thoracic Surgery, 2012

OBJECTIVES: Surgical mitral repair is the conventional treatment for severe symptomatic functiona... more OBJECTIVES: Surgical mitral repair is the conventional treatment for severe symptomatic functional mitral regurgitation (FMR). Mitraclip therapy is an emerging option for selected high-risk patients with FMR. The aim of this study was to report the outcomes of patients who underwent a surgical mitral repair and Mitraclip therapy for FMR in our experience. METHODS: From March 2000 and April 2011, 143 patients with FMR were treated in our institution: 91 patients (63.6%) underwent surgical mitral repair (49% ischaemic; 51% idiopathic) and 52 (36.4%) underwent Mitraclip implantation (71% ischaemic; 29% idiopathic). Associated procedures in the surgical group were myocardial revascularization in 35%, tricuspid repair in 25% and atrial fibrillation ablation in 26%. Follow-up was 100% complete (median 18; 6.4-45 months for surgery and 8.5; 4-12 months for Mitraclip). RESULTS: Mitraclip patients were older (P = 0.04), had higher log EuroSCORE (P < 0.0001), lower LVEF (P = 0.006) and higher left ventricular diameter (P = 0.01 for left ventricular end-diastolic diameter and P = 0.05 for left ventricular end-systolic diameter). Major postoperative infection or sepsis occurrence was higher in the surgical group (16.3 vs. 3.8%; P = 0.01), while no differences were observed in terms of acute renal failure, cardiogenic shock, cerebrovascular accident and acute myocardial infarction. Length-of-stay was 11 days (IQR: 7-19 days) for surgery and 5 days (IQR: 4-9 days) for MitraClip (P < 0.0001). In-hospital mortality was 6.6% for surgery (6/91) and 0% for Mitraclip (P = 0.01). Surgery was identified as a predictor of in-hospital death (OR: 2.61; P = 0.01). Residual MR ≥ 3+ at discharge was 0% for surgery and 9.6% for Mitraclip (P = 0.002). At follow-up, actuarial survival at 1 year was 88.9 ± 3.5% for surgery and 87.5 ± 7% for Mitraclip (P = 0.6). Actuarial freedom from MR ≥ 3+ at 1 year was 79.1 ± 8% for MitraClip and 94 ± 2% for surgery (P = 0.01). At last follow-up, most of the survivors were in NYHA class I-II. CONCLUSIONS: Mitraclip therapy is a safe therapeutic option in selected high-risk patients with FMR, and it is associated with a lower hospital mortality and shorter length-of-stay compared with surgery, in spite of worse preoperative conditions. Early and 1-year rates of recurrent MR are higher with Mitraclip. Further studies are needed to determine the long-term clinical impact.

Clinical Cardiology, 2013

Increasing age and new trends of mixed populations have newly aroused interest in valvular heart ... more Increasing age and new trends of mixed populations have newly aroused interest in valvular heart disease in the developed countries still in need of new clinical insights. In the clinical setting of systemic diseases, the proper assessment of cardiovascular abnormalities may be challenging, and the characterization of valvular involvement might help to recognize the underlying disease and cardiac sequelae. Prompt identification of valvular lesions may, therefore, also be useful for differential diagnosis. This article reviews the cardiac involvement in systemic diseases from etiology and background definition to echocardiographic assessment and clinical interpretation.

The American Journal of Cardiology, 2011

The aim of the study was to evaluate the additional diagnostic value of real-time 3-dimensional t... more The aim of the study was to evaluate the additional diagnostic value of real-time 3-dimensional transesophageal echocardiography (RT3D-TEE) for surgically recognized mitral valve (MV) prolapse anatomy compared to 2-dimensional transthoracic echocardiography (2D-TTE), 2D-transesophageal echocardiography (2D-TEE), and real-time 3D-transthoracic echocardiography (RT3D-TTE). We preoperatively analyzed 222 consecutive patients undergoing repair for prolapse-related mitral regurgitation using RT3D-TEE, 2D-TEE, RT3D-TTE, and 2D-TTE. Multiplanar reconstruction was added to volumerendered RT3D-TEE for quantitative prolapse recognition. The echocardiographic data were compared to the surgical findings. Per-patient analysis of RT3D-TEE identified prolapse in 204 patients more accurately (92%) than 2D-TEE (78%), RT3D-TTE (80%), and 2D-TTE (54%). Even among those 60 patients with complex prolapse (>1 segment localization or commissural lesions), RT3D-TEE correctly identified 58 (96.5%) compared to 42 (70%), 31 (52%), and 21 (35%) detected by 2D-TEE, RT3D-TTE, and 2D-TTE (p < 0.0001). Multiplanar reconstruction enabled RT3D-TEE to differentiate dominant (>5-mm displacement) and secondary (2 to <5-mm displacement) prolapsed segments in agreement with surgically recognized dominant lesions (100%), but with a low predictive value (34%) for secondary lesions. In addition, owing to the identification of clefts and subclefts (indentations of MV tissue that extended >50% or <50% of the total leaflet height, respectively), RT3D-TEE accurately characterized the MV anatomy, including that which deviated from the standard nomenclature. In conclusion, RT3D-TEE provided more accurate mapping of MV prolapse than 2D imaging and RT3D-TTE, adding quantitative recognition of dominant and secondary lesions and MV anatomy details.