As the US population ages, the burden of mitral valve disease has become an increasingly important and controversial issue. Traditionally, elderly patients have been denied surgical intervention due to poor preoperative functional status and higher risk for postoperative morbidity and mortality. Over the last decade, as the field has evolved, more elderly patients are being considered for surgical management. In this review, we examine the literature surrounding the safety of mitral valve surgery in the elderly, the type of procedure these patients should undergo, and the survival and quality of life associated with these interventions. Additionally, we examine some of the new technologies and advancements in the field that may allow for surgical intervention in patients who would otherwise be denied this treatment.