Combined valvular and coronary surgery is more common every day. Coexistence of valvular and coronary disease makes a complex setting of physiopathological interactions, specially in the ischemic mitral regurgitation. So an ideal surgical strategy, including a thorough knowledge of valvular shape, ventricular function and myocardial reserve, as well as new mitral repair techniques and cardioplegic myocardial protection is essential. Despite these conditions, combined surgical mortality is higher than in isolated valve or coronary surgery. Severe complications in the early postoperative period and long term follow up are also more frequent. In any case, combined valvular and coronary surgery remains a challenge for surgical groups all over the world.