Objective: Long-term outcomes of mitral valve (MV) repair versus MV replacement for ischemic mitral regurgitation (IMR) in patients undergoing either prior (PCR) or concomitant coronary revascularization (CCR) by surgery (CABG) or intervention (PCI) are uncertain. Methods and Results: Of 446 patients receiving MV surgery for IMR between July 2006 and December 2010, 125 patients—87 CCR (69.1%) and 38 PCR (30.9%)—were eligible for inclusion in the study. Survival was higher in CCR versus PCR at long-term follow-up (78.83% vs. 57.9%,p= 0.016). The incidence of MACCE was lower in the CCR compared to PCR at both hospital discharge (34.11% vs. 63.57%,p= 0.003) and at follow-up (34.11% vs. 65.79%,p= 0.0008). Patients receiving CABG or CABG with PCI in PCR had higher mortality risks after MV surgery than CCR patients (X2= 6.029,p= 0.014 and X2= 6.466,p= 0.011, respectively). Whereas in the PCR group, MV repair and MV replacement achieved similar survival probability (X2= 1.551,p= 0.213), MV repair in the CCR group led to improved survival compared to MV replacement (X2= 3.921,p= 0.048). In MV replacement, LAD-CABG improved survival compared to LAD-PCI (U = 15,000.00, Z = −2.373p= 0.018), and a substantial impact of arterial IMA-LAD grafting was revealed in the Cox-regression analysis (HR 0.334, CI: 0.113–0.989,p= 0.048) as opposed to venous-LAD grafting (HR 0.588, CI: 0.166–2.078,p= 0.410). Conclusion: Early treatment of IMR concomitant to coronary revascularization enhances long-term survival compared to delayed MV surgery after PCR. MV repair is not superior to MV replacement when performed late after coronary revascularization; however, MV repair leads to better survival than MV replacement when performed concomitantly with CABG with arterial LAD revascularization.