Ten patients requiring chronic dialysis who underwent mitral repair were identified and followed for clinical and echocardiographic outcome. Despite absence of significant valvular calcification at surgery and good immediate surgical results, reconstruction was associated with unusually accelerated valvular calcification, a rapid increase in postoperative mitral gradients, and a high incidence of failed repair requiring reoperation. In future, mitral valve repair and replacement should be compared prospectively in a population of patients requiring chronic dialysis.