Backgrounds: Revascularization is associated with an improved survival in patients with ischemic mitral regurgitation (IMR) compared with medical therapy, but the proper way of revascularization remains controversial. We tried to compare long-term outcomes of percutaneous coronary intervention (PCI) to surgical revascularization in IMR. Methods: From 1996 to 2008, a total of consecutive 185 patients with significant IMR, underwent PCI (PCI group, n = 66) or coronary artery bypass graft (CABG) operation (OP group, n = 119). In the OP group, 68 (57%) patients underwent CABG with concomitant mitral valve repair. The effective regurgitant orifice area (ERO) of MR was determined with the proximal isovelocity surface area method, and significant IMR was defined as functional MR occurring more than 1 week after myocardial infarction with ERO ��� 0.2 cm2. Cardiac event was defined as the composite of operative mortality, cardiac death, and hospitalization due to congestive heart failure (CHF) during follow-up. Improvement in MR was defined as decrease in ERO ��� 0.1 cm2 on 1-year follow-up echocardiography. Results: Baseline characteristics and clinical outcomes were compared between the two groups as shown in Table. During median follow-up of 54 months, there were 2 operative mortalities, 27 cardiac deaths and 11 CHF hospitalizations in the OP group, and 23 cardiac deaths and 9 CHF hospitalizations in the PCI group (P=0.047). The 7-yr survival rates were not significantly different, but improvement rate of MR and 7-yr event-free survival rates were significantly higher in the OP group. On Cox multivariate analysis, ejection fraction (HR=1.05, P<0.001), age (HR=0.96, P=0.002) and OP group (HR=1.81, P=0.014) were independent variables related with event-free survival. Conclusions: Compared with PCI, surgical revascularization is associated with an improved long-term event-free survival by improving MR and CHF hospitalization more effectively in patients with IMR.