Mitral valve repair offers superior long-term survival, freedom from cardiac morbidity, and quality of life in patients with severe mitral regurgitation compared to medical management and mitral valve replacement; it is the treatment of choice in these patients. Mitral valve repair is the only treatment that restores normal life expectancy to otherwise healthy patients with advanced degenerative mitral valve disease. This review focuses on indications, timing and techniques for mitral valve repair in degenerative disease, emphasizing the importance of anatomy in surgical outcomes.