Ischemic mitral regurgitation (IMR) is one of the common complications of coronary heart disease. The primary underlying mechanism is ventricular myopathy rather than disease of the valve itself. The decrease of myocardial blood supply will lead to myocardial damage, which will lead to the left ventricular remodeling, left ventricular enlargement, annular dilation, papillary muscle displacement and limited leaflet activity, resulting in mitral regurgitation. IMR has a certain effect on the prognosis of coronary heart disease, and the incidence rate of IMR has been increasing in recent years. IMR is a complex dynamic process, and it is a great challenge to deal with IMR. For patients with moderate or severe IMR, there are still many challenges and controversies in the choice of surgical methods. This article reviews the pathological process of left ventricular remodeling, the evaluation of IMR, the choice of mitral valve (MV) repair or replacement, and the reserve of MV function. Our review suggests that assessment of MV reserve function may be a predictor of IMR. In the future, assessment of MV reserve function may provide further useful information for evaluating MV function and determining MV repair or replacement in patients with IMR.