Surgical valve repair for mitral regurgitation (MR) has been used for decades. Percutaneous approaches to mitral valve repair have been undergoing evaluation in trials over the last few years, and could offer less-invasive alternatives to surgery for the treatment of MR. Patient selection for surgical repair has been defined not only by the pathophysiology of MR, but also by the likelihood of successful repair for degenerative compared with functional MR. Patients with degenerative MR have excellent acute and long-term results following surgical repair; the acute risks of surgery in patients with heart failure are high in comparison, and late recurrent MR has been problematic after surgical repair for ischemic MR. Patient selection for percutaneous approaches to MR will be influenced by both the underlying valve pathology and the expected outcomes in various patient subsets, and also by the characteristics of the various percutaneous devices. This Review examines the established selection criteria for surgical repair and discusses the potential impact of new percutaneous approaches.