Given the complexity and the heterogeneity of mitral valve anatomy and pathology, different technologies and approaches (including repair and replacement methods) are potentially required to allow specific patient-tailored approaches, addressing each anatomy with the most appropriate device. Since we are still far from having an unbiased and evidence-supported process to select the best treatment for each patient, this review will provide an overview of the elements that should be taken into consideration when selecting the best procedure for each patient.