The mitral valve apparatus is a complex structure that incorporates the leaflets, chordae tendinae, papillary muscles, annulus, and left ventricle (LV) in its function. As a result, diseases that affect any of these structures can result in severe mitral regurgitation (MR), which in turn, is associated with reduced survival.1–3 Classification of MR often differentiates between primary or degenerative cause attributable to diseases that affect the leaflets (eg, fibroelastic dysplasia, rheumatic disease, Barlow disease, endocarditis, prolapse) and secondary cause. In the latter category are diseases of the atrium or left ventricle, including ischemic dysfunction and functional disease (eg., dilated cardiomyopathy). Current guidelines recommend surgery in symptomatic patients with severe MR (recommendation class I), in asymptomatic patients with abnormal LV function (class I) as well as in asymptomatic patients with normal LV function when there is a high likelihood of successful repair (class IIa).4,5 Surgery may also be considered for secondary MR in symptomatic patients after optimal medical management (class IIb). It should be noted that the European and American College of Cardiology (ACC)/American Heart Association (AHA) guidelines differ slightly in the definitions of LV dysfunction and the level of evidence assigned to several of these recommendations.4,5 Although there are no randomized trials of surgery versus medical therapy for severe, symptomatic MR, observational studies have demonstrated improved survival with surgery, particularly with repair of primary mitral regurgitation.5,6 Nonetheless, surgery is associated with mortality rates of 1% to 5% and morbidity rates of 10% to 20%, including stroke, reoperation, renal failure, and prolonged ventilation.7 This is particularly true in elderly patients and those with left ventricular dysfunction; mortality in octogenarians may be as high as 17% with morbidity occurring in more than a third of patients.8 Furthermore, surgery in …