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We review our 10-year experience of mitral valve (MV) repair in comparison with MV replacement in the elderly for floppy mitral valves/mitral valve prolapse (FMV/MVP). The use of MV repair for this entity has not been fully utilized by surgeons. Two hundred ninety-two consecutive patients aged ≥70 years receiving mitral surgery for regurgitation due to FMV/MVP were reviewed from our prospective database between January 1, 1992, and December 31, 2002. Patients receiving concomitant coronary artery bypass grafting (CABG) were included. Two hundred eighteen patients underwent repairs and 74 replacements. Postoperative and long-term follow-up data were obtained. Mean follow-up time for survivors was 6.2 ± 2.5 years for MV repair and 6.8 ± 2.7 years for MV replacement. Patients with isolated MV repair showed lower inhospital mortality compared with MV replacement (0.7% vs 13.9%, P = .002) with reduced length of stay (8.7 ± 7.6 vs 9.6 ± 5.2 days, P = .049). There was improvement in 5-year mortality favoring repair versus replacement (81% ± 3% vs 63% ± 3%, P = .001). With concomitant CABG, there was minimal difference in survival up to 5 years. Freedom from valve replacement was 93.9% ± 1.3% for MV repair and 98.2% ± 0.4% for MV repair with CABG at 10 years. Mitral valve repair was an independent protector of long-term mortality within multivariate correlates (hazard ratio 0.43, 95% CI 0.19-0.97, P = .041). In elderly patients, MV repair reduced inhospital mortality and length of stay and increased long-term survival. With concomitant CABG, survival was similar to replacement. The preferred option for elderly patients with FMV/MVP is MV repair, especially in those without coronary artery disease.