Echocardiography is an essential tool in managing patients with mitral regurgitation. It allows identification and precise summation of anatomic lesions that lead to valve dysfunction. In this article, we highlight important aspects of mitral valve anatomy and pathophysiology as they pertain to surgical repair and discuss the critical role of echocardiography in surgical planning and assessment. Better understanding of surgical anatomy of the mitral valve and systematic segmental valve analysis by echocardiographers will allow easy identification of complex valve lesions or dysfunctions that require advanced surgical skill, techniques, or expertise to affect a repair. By triggering referral of such patients to "reference" mitral valve surgeons and by providing information that enables the surgeons to adequately plan a repair preoperatively, echocardiographers will help eliminate the scenario in which mitral valve replacements are performed because the surgeons discover intraoperatively that it is beyond their skill to repair a valve.