Emerging evidence indicates that etiology plays an essential role in the results of mitral valve repair. In this study, we examined the long-term performance of this procedure in 61 consecutive patients with pure rheumatic mitral insufficiency.Patient ages ranged from 4 to 74 years (mean: 51.7 +/- 16). Preoperatively, 94% of the patients were in NYHA class II or III.There was no hospital mortality. According to actuarial methods 94.1% of the patients were alive 7 years postoperatively and 83.3% were reoperation free. Freedom from reoperation was significantly higher in patients who received a prosthetic ring than in those who had other types of annuloplasty (96.7% vs 59.3%; p = 0.001). As opposed to the literature, in our series there was no relationship between valve failure and age at the time of reoperation. There were only two cases of thromboembolism and one of infective endocarditis.This study confirms that mitral valve reconstruction in rheumatic valve insufficiency can yield satisfactory long-term clinical results, although they are less than optimum compared with those obtained in patients with degenerative disease. Favourable results depend on routine use of a prosthetic ring as well as adequate patient selection. Attention should be focused on improved detection and suppression of rheumatic activity at the time of operation.