Chronic ischemic mitral regurgitation (IMR) is still a significant clinical problem. It is present in 10-20% of patients with coronary artery disease and is associated with a worse prognosis after myocardial infarction and subsequent revascularization. Currently, coronary artery bypass grafting combined with restrictive annuloplasty is the most commonly performed surgical procedure, although novel approaches have been used in limited numbers with varying degrees of success. The purpose of this review is to clarify the rationale for the surgical techniques applicable to IMR. In order to do so, the condition will be defined and the evolution of classic or traditional surgical approaches to repairing or replacing the mitral valve in the setting of IMR will be described. Finally, novel approaches to the repair of the ischemic mitral valve will be considered.