BACKGROUND Symptomatic mitral restenosis develops in up to 21% of patients after percutaneous balloon mitral valvotomy (PBMV), and most of these patients undergo mitral valve replacement (MVR). OBJECTIVE Repeating PBMV (re-PBMV) might be an effective and less-invasive treatment for these patients. METHODS Forty-seven patients with post-PBMV mitral restenosis and unfavorable valve characteristics were assigned either to re-PBMV (25 cases; mean age 40.7 ± 11 y, 76% female) or MVR (22 cases; mean age 47 ± 10 y, 69% female) at 51 ± 33 months after the prior PBMV. The mean follow-up was 41 ± 32 months and 63 ± 30 months for the re-PBMV and MVR groups, respectively. RESULTS The 2 groups were homogenous in preoperative variables such as gender, echocardiographic findings, and valve characteristics. Patients in the MVR group were older, with a higher mean New York Heart Association functional class, mean mitral valve area, mitral regurgitation grade, and right ventricular systolic pressure (P = 0.03), and more commonly were in AF. There were 3 in-hospital deaths (all in the MVR group) and 4 during follow-up (3 in the MVR group and 1 in the re-PBMV group). Ten-year survival was significantly higher in re-PBMV vs MVR (96% vs. 72.7%, P<0.05), but event-free survival was similar (52% vs. 50%, P = 1.0) due to high reintervention in the re-PBMV group (48% vs. 18.1%, P = 0.02). CONCLUSIONS In a population with predominantly unfavorable characteristics for PBMV, short- and long-term outcomes are both reasonable after re-PBMV with less mortality but requiring more reinterventions compared with MVR.