Valve reconstruction, whenever technically feasible, is currently the treatment of choice for mitral valve regurgitation. Preoperative transesophageal echocardiography discloses the precise location and extent of these lesions, making it possible for the surgeon to determine the repairability of the valve and to devise a roadmap for the most appropriate surgical maneuvers. Today, the aim of surgery should not be limited to abolishing regurgitation, but should also comprise restoration of the normal valve geometry in order to ensure durability of the repair. This geometric redress involves a) leaflet enlargement or reduction, b) replacement of all ruptured, elongated or attenuated chords with Goretex sutures, and c) annuloplasty with a flexible, complete ring that prevents distension even in the intertrigonal area, maintains the saddle shape of the annulus and reduces the dilated anteroposterior diameter of the annulus. These techniques have made repair rates approaching 100% possible in patients with degenerative valve diseases. For functional ischemic regurgitation, treatment currently consists of reduction annuloplasty with a small complete ring performed at the time of revascularization. However, despite the improvements seen in these patients, late recurrence of insufficiency occurs in about 30% of them. Recent evidence that the mechanism of recurrence is the apical and lateral displacement of the papillary muscles suggests that in addition to annuloplasty, surgical approximation of the papillary muscles may be necessary.