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. Intraoperative TEE is especially help- ful in gauging the adequacy of repair.11 Because even mild residual MR after repair increases the likelihood of later repair failure that would necessi- surgeons strive for near-perfect operative repair. Adequacy of repair is judged by TEE after physiological filling pressure and blood pressure have been established. If more than trivial MR is detected in the operating room after repair, repair revision usually ensues. TEE also helps to diagnose underfilling of the LV, which can lead to systolic anterior leaflet motion with outflow obstruction and unneeded repair. In those patients with primary severe MR who are at high surgical risk, TEE is helpful in determining the feasibility of transcatheter edge-to-edge repair.22,23 7.2.2.2. Diagnostic Testing: Changing Signs or Symptoms Recommendation for Diagnostic Testing: Changing Signs or Symptoms in Patients With Primary MR Referenced studies that support the recommendation are summarized in Online Data Supplement 26. COR LOE Recommendation In patients with primary MR (Stages B to D) and new-onset or changing symptoms, TTE is indicated to evaluate the mitral valve apparatus and LV function.1,2 Synopsis A repeat TTE provides clinically relevant information about patients who are being followed for primary MR who develop new-onset symptoms. Table 17. 