Over a 5-year period, 1,292 patients had operation on their native mitral valves. Ischemia was the cause of mitral insufficiency in 84 patients (6.5%). Sixty-five patients (77.4%) had mitral valve repair. Mean age was 66 +/- 10 years; 35 patients (53.8%) were women. Mean degree of preoperative insufficiency was 3.2 +/- 0.7; mean preoperative New York Heart Association functional class was 3.3 +/- 0.7. Eleven patients (16.9%) had acute and 54 (83.1%) had chronic mitral insufficiency. Valve prolapse was present in 26 patients (40%). Restrictive leaflet motion secondary to regional or global left ventricular dilatation occurred in 39 patients (60%). All patients had associated myocardial revascularization followed by transatrial valvuloplasty. Multiple techniques were employed to achieve valve competence: leaflet resection (3), chordal shortening (15), papillary muscle reimplantation (10), papillary muscle shortening (3), and annuloplasty (63). There were six (9.2%) hospital deaths (acute, 9.1%; chronic, 9.3% [not significant]; prolapse, 11.5%; restrictive, 7.7% [not significant]). The mean degree of postoperative mitral insufficiency was 0.6 +/- 0.8 in 51 patients. At a mean follow-up of 3.1 +/- 1.6 years, patient survival was 96% for patients with valve prolapse and 48% for those with restrictive leaflet motion (p = 0.02). New York Heart Association functional class was improved in all groups. Ischemic mitral insufficiency is an uncommon cause of mitral valve disease that is amenable to repair in the majority of cases of both acute and chronic onset. The operative mortality is low, and operation is associated with superior survival in patients with valve prolapse.