Background We aimed to clarify the pathological characteristics of rheumatic mitral valve disease in Chinese individuals, as well as to determine the appropriate rheumatic mitral valve repair strategy according to such characteristics. Methods We obtained detailed statistics regarding the pathological characteristics of patients who underwent mitral valve repair or replacement for rheumatic disease during the past year at our centre. The outcomes of different repair techniques were compared. Multivariate logistic regression analyses were used to identify predictive factors for successful rheumatic mitral valve repair. Results Between August 2015 and August 2016, 163 patients underwent rheumatic mitral valve repair (77 cases) or replacement (61 cases) at our centre. Although the prevalence of pathological lesions was typically high, the prevalence of severe lesions was low in the leaflets and high in the commissure and subvalvular apparatus (more than one-third of all lesions in these areas). Commissurotomy (97.40%) and leaflet thinning (84.42%) were performed most frequently. On multivariate logistic regression analysis, pathological score > 17.5 (odds ratio [OR] for success, 0.049; p < 0.0001) and mixed lesion preoperatively (OR for success, 0.186; p = 0.011) predicted repair failure, whereas severe regurgitation preoperatively (OR = 4.897; p = 0.026) predicted successful rheumatic mitral valve repair. Conclusions Lesions of the commissure and subvalvular apparatus are the main pathological features in Chinese patients with rheumatic mitral valve disease. The commissure processing technique is beneficial in most such patients.