Organic mitral regurgitation (MR) is prevalent in the general population. Disease progression, involving potentially irreversible left ventricular dysfunction, implies a poor prognosis for patients who do not receive appropriate treatment. Immediate rescue surgery is indicated in those with severe MR in whom subclinical left ventricular dysfunction is suggested by echocardiographic measurements or the presence of symptoms, however minor. Patients whose symptomatology is unclear should be evaluated by exercise testing. Not all forms of severe organic MR are the same: the presence of risk factors in patients with severe asymptomatic MR and preserved ventricular function indicates a suboptimal prognosis over the medium-to-long term and should prompt early mitral repair if there is a low surgical risk and the probability of a successful repair is >90-95%. The patient should be referred to a specialized surgical center if necessary. Appropriate training of surgeons in mitral repair is essential. Ischemic MR carries a worse prognosis and the risk of surgery is higher. Consequently, treatment decisions must be patient-specific and take into account the possibility of repair, the risk of surgery, and the need for concomitant surgical revascularization. New percutaneous approaches to mitral repair are being developed for selected patient groups.