Over-correction of mitral regurgitation is a well described issue complicating mitral valve repair. It occurs most often when the annuloplasty ring is undersized, which can be intentional in repairs performed for regurgitation secondary to cardiomyopathy or ischemic mitral regurgitation. Sometimes it can be the result of maneuvers used for more complex repairs, like an Alfieri stitch when used as a bailout. The key moment is immediately upon coming off bypass after a repair, when the trans esophageal echocardiographer (usually the anesthesiologist, sometimes a cardiologist invited to the OR) measures velocity through the repaired valve to determine the gradient across the valve. Anything above 5 mmHg makes me leery, and might prompt me to go back on pump and perform a chordal sparing valve replacement, if the extra time on pump doesn’t seem too dangerous. I perform mitral valve replacements and repairs fairly regularly, about 5 cases a month. I evaluate patients regularly for catheter based procedures for the mitral valve as a member of our Structural Heart Disease center.