2D echocardiography has become one of the most important investigations in the preoperative assessment of mitral stenosis. This study was undertaken to determine the reliability of the information so obtained, by comparison with the surgical appearances. The study population consisted of 104 patients (average age 45 years, 76% women) undergoing open heart surgery for pure mitral stenosis (72%) or mixed mitral valve disease (28%) between 1980 and 1981. All underwent 2D echo using a phased array Aloka SSD 800 80 degrees sector scanner. Cardiac catheterisation was performed in 102 cases and left ventricular angiography in 89 cases. The echocardiogramme was interpreted by an observer who had no knowledge of the surgical results. The mitral surface area, the condition of the valves and subvalvular apparatus and the predictive value of the possible surgical technique were analysed. The 2D echo mitral surface area was estimated by planimetry and quantitatively by using the Gorlin formula during catheterisation and by the surgical description preoperatively. 2D echo was more sensitive than M mode in the detection of severe mitral stenosis (90% vs 73%, p less than 0,01). The 2D echo-Gorlin correlation was quite good (R = 0,70, p less than 0,01) but was worse when the valves were very thickened. When compared with the surgical observations, 87% of the 2D echo data was correct. The thickness of the valves, their amplitude, the diastolic bowing of the anterior leaflet and the presence of calcification were assessed by 2D echo. The echo-surgical results matched perfectly in 76% of cases. The usual cause of error was underestimation of the degree of valvular damage. The valvular bowing and thickness were the most useful signs. Dense, brilliant echos of valvular calcification were found in only 58% of surgically proven cases of valvular calcification, but the error was often related to fine calcification, not visible on fluoroscopy, or to its localisation on the posterior leaflet. The subvalvular apparatus was evaluated in over 93% of patients, a complete study being possible in 73% of them. The 2D echo-surgical correlations were excellent in 90% of the cases in which it had been completely visualised. The chordal thickening was correctly predicted in 79% of cases. The surgical assessment was more pessimistic in 1/3 of cases in which the chordae appeared to be of normal thickness. The length of the chordae was correctly predicted in 68% of cases. The surgical assessment was more pessimistic in 1/2 of cases in which the chordae appeared to be of normal length.(ABSTRACT TRUNCATED AT 400 WORDS)