Ischemic mitral regurgitation (IMR) is a common complication after acute myocardial infarction due to annulus dilatation and papillary muscles displacement. In our opinion 3/4 and 4/4 IMR have always to be indicated for MV surgery. In presence of low EF and dilated LV, moderate (2/4) IMR has to be corrected. The end-systolic distance between the coaptation point of mitral leaflets and the plane of mitral valve annulus is the key point to decide repair (≦10 mm) or replacement (≫10 mm). MV annuloplasty has always been addressed to the posterior annulus, whose size can be easily reduced. A specially designed 40 mm long ring has been used to achieve a posterior overreductive annuloplasty. For MV repair thirty-day mortality was 2.4%. Five-year survival and the possibility of being alive and in NYHA class I-II were 75.6±4.7 and 59.8±5.4, respectively. After a mean of 38±35 months, the NYHA class decreases from 3.2±0.5 to 2.1±0.6 (P≪0.001). Most patients (77.4%) have an improvement of its own functional class. MR decreases from 3.2±0.8 to 1.2±1.1 (P≪0.001). 97.5% of the survivors have MR equal to or less than moderate.