Mitral valve reconstruction is now the procedure of choice for many mitral regurgitant lesions. Early enthusiasm and technical advances in plastic reconstruction of the mitral valve were overshadowed by the development of prosthetic and bioprosthetic valves. With long-term follow-up studies came the realization that the complication rates of prosthetic mitral valves and the durability of bioprostheses were less than ideal. The use of annuloplasty rings and standardization of mitral repair techniques have made these procedures more universally reliable and the excellent results reproducible. Due to the pathological diversity of mitral regurgitation, many different techniques are used to correct the various lesions. Many centers are reporting hospital mortality, survival, freedom from thromboembolism, freedom from reoperation, freedom from infective endocarditis, and freedom from valve-related complications results that compare favorably with those following mitral valve replacement. The preservation of the papillary muscles and chordae tendinea during mitral reconstruction, as well as a lack of foreign materials, contribute to the enhanced systolic function with improved survival and lower complication rates following mitral repair compared with replacement. With improved results and technical advances, the indications for mitral repair have expanded to encompass a broader diversity of lesions and earlier operative intervention.