Objectives. Valve repair is considered the treatment of choice for native mitral valve regurgitation, although the rate of feasibility when the defect is caused by acute infective endocarditis (IE) is debated. We report the experience of valve repair versus replacement following IE in a high-volume surgical center. Methods. We retrospectively analyzed 363 consecutive patients (123 women) admitted with a diagnosis of definite IE. We selected 108 patients with native mitral IE, potentially eligible for surgical repair. Of these 108, 90 (83%) underwent surgery and 18 were treated conservatively. The two primary endpoints were all-cause mortality and freedom from recurrent endocarditis. Results. Mean age at surgery was 63.6 years (SD 13.5). Mean vegetation length was 11.6 mm (SD 7.7). Among the 90 surgical patients, 57 (63%) underwent valve replacement and 33 valve repair (37%). Mean follow-up duration was three years. All-cause short-term (30 days: 3±3 vs 4±2% for repair and replacement respectively) and long-term (3 years: 26±9 vs. 36±11%) mortality was lower, although not-significantly, for valve repair (figure 1), as well as nonfatal adverse events (15±4 vs. 20±2%) and relapse rate (1±1% vs. 3±1%) at three years. At echocardiographic follow-up, no differences were reported between the two groups in terms of left ventricular systolic function and valvular continence. Conclusions. In our experience, over one-third of consecutive patients with native mitral are amenable to valve repair in expert hands. Mid-term outcome of repair in IE is comparable to valve replacement, and should be considered whenever possible, as in degenerative valve disease.