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The experience of surgical treatment of high risk group patients with ischemic mitral regurgitation of different degree of manifestations was analyzed. The basic approaches to the management and the choice of treatment strategy are reported in this article. The authors suggested the priority strategy on the background of completed investigation: 1) the performance of the annuloplasty on pressure ring in combination with coronary bypass surgery in surgical treatment of ischemic mitral regurgitation of III degree, as most effective kind of intervention; 2) the performance of operation of isolated coronary bypass surgery on working heart for high risk patients with the presence of moderate ischemic mitral regurgitation, that allows the significant improvement of indices of postoperative period and the decrease of evidence of mitral regurgitation at the expense of a salvage of myocardial contractility.