The latest advances in mitral valve repair and replacement include a shift toward the transseptal platform. Gorav Ailawadi, Vinay Badhwar, Steven F. Bolling, and T. Sloan Guy discuss how catheter-based techniques will re-emulate the gold standard for mitral valve surgery, the important role of 3D Echo technology, the need for transseptal puncture skills, and navigating the local politics.