From Cutler's first attempt to treat the mitral valve by inserting a tenotomy knife through the left ventricle, to Carpentier's introduction of several repair techniques and a functional classification for assessing mitral valve lesions, the history of mitral valve treatment is exciting. Mitral diseases may be degenerative, ischaemic, infective or rheumatic, with or without superimposed impaired left ventricular function and calcification. Understanding the underlying pathological features is also important in determining whether mitral valve repair is feasible, how the valve should be repaired and the prospect for long-term durability of the repair. Recent advances in minimally invasive mitral valve surgery are promising but more effort is needed to ensure timely mitral valve repair.