It has been long believed that ischemic mitral regurgitation is secondary to left ventricular remodelling and the mitral per se remains unaffected. This proviso has recently been challenged and the mitral valve has been described as a structure that responds and adapts to challenges and attempts to correct the mitral regurgitation. The response of mitral valves in this setting can be incomplete or can even be mal-adapted. The ability of the mitral valve to respond in this manner has been described as “mitral plasticity”. Endothelial to Mesenchymal transition and Valvular Interstitial Cells are key to this mitral plasticity and function through a complex array of signalling pathways. Identification and manipulation of these pathways may provide a possibility to correct the incomplete or mal-adapted mitral valve responses. Surgical treatment can also be tailored based on whether the valve has maladapted or has undergone incomplete adaptation.