Emergency mitral valve surgery is a critical, high-stakes procedure performed to manage acute mitral valve dysfunction threatening patient survival. This chapter explores the surgical challenges and decision-making strategies unique to urgent interventions, encompassing conditions such as infective endocarditis, acute mitral regurgitation, and critical mitral stenosis. Rapid diagnosis, advanced imaging, and timely haemodynamic stabilisation are crucial for preoperative planning. Surgical techniques should be tailored to the specific pathology and patient condition, prioritising repair over replacement when feasible. Postoperative care focuses on managing complications and optimising recovery, underscoring the role of a multidisciplinary approach in improving outcomes in these complex cases.