Mitral valve repair is preferable to valve replacement because of a lower operative mortality rate and avoidance of the complications inherent to prosthetic valves. Although the final decision about repair versus replacement is made in the operating room, TEE can help predict surgical strategy beforehand. Thus, if repair is likely, it might be performed ear- lier in the course of the disease than if replace- ment is necessary. 3. In most cases, TTE provides the data needed for adequate cardiac evaluation of the patient with MR. However, in cases where TTE image quality is poor, CMR may be of value in MR evaluation. CMR produces highly accurate data on LV volumes, RV volumes, and LVEF, as well as an assessment of regurgitant fraction for estimating MR severity.6 9 However, outcome data on large numbers of patients have been derived from echocardiogra- phy, and it is uncertain whether CMR data can be used interchangeably with echocardiographic data in predicting outcomes. CMR is less helpful in establishing mitral pathoanatomy. CLINICAL STATEMENTS AND GUIDELINES 4. Intraoperative TEE is the standard for imaging dur- ing MR surgery. Before the operative incision, TEE may give the surgeon a better understanding of the valve anatomy and type of repair that will likely be performed, although this decision is ultimately made when the valve is inspected visually.10,11 Three-dimensional TEE ( surgical view ) may be helpful in further visualizing the abnormal mitral valve anatomy. Because anesthesia lessens after- load, preload, and mitral valve closing force, deci- sions about severity of MR should be evaluated at the same loading conditions as occurred during the awake state. 