Using two-dimensional echocardiography, the complex anatomy of the mitral valve needs mental reconstruction into its three-dimensional shape. The power of both transthoracic and transesophageal three-dimensional echocardiography (3DE) lies in its possibility of showing the complex mitral valve anatomy in one single image, as opposed to the mental reconstruction based on multiple two-dimensional images and schematic assumptions. Several 3DE modalities are used in daily life, including real time (“live”) modes as wells as postprocessed images. 3DE is of special interest in the evaluation of mitral stenosis, complex mitral valve prolapse and mitral valve prostheses. It has an established role in the perioperative mitral valve assessment during mitral valve surgery as well as during percutaneous mitral valve procedures. Limitations of 3DE are relatively low frame rates, an important learning curve as well as timeconsuming processing.