Introduction: There is a significant percentage of Bulgarians suffering from ischemic heart disease (IHD) and its complications, such as ischemic mitral regurgitation (IMR). It plays an important role in Bulgarian society. Surgical treatment of this pathological conditions could have positive impact on life expectancy and the medical quality of life of patients.

Aim: The purpose of the study is to establish a reproducible algorithm to advise the appropriate surgical treatment of patients with IHD and significant, but not severe IMR based on their condition.

Materials and Methods: The study is based on the data collected prospectively at the Department of Cardiac Surgery, St. Marina University Hospital in Varna, Bulgaria. IHD and significant IMR (i.e. more than mild 1+, but less than severe 4+ degree) were diagnosed in 186 patients. Applying inclusion and exclusion criteria, 140 patients with pure secondary IMR remained in the study group. The data was analyzed in a retrospective fashion. We discussed two possible treatment strategies: coronary artery bypass grafting + mitral valve repair (CABG+MVRep) and isolated revascularization (CABG only). To obtain comparable data for those treatment strategies, we needed a formal stratification of the patients, allowing comparison between the groups.

Results: Creating formal algorithms we are able to divide the patients into comparable Group A (CABG+MVRep) and Group B (CABG only), and surgical strategy is based on characteristics of the individual pathology of every patient.

Discussion: Despite data from small randomized and non-randomized trials, to date there is no clear agreement and strategy regarding concomitant mitral valve repair with CABG during the first-time operation

Conclusion: Formal stratification with the algorithms created and applied gave us the opportunity for reliable comparison of relatively different patients, and to draw conclusion for the practice. This approach should be applied in such small non-randomized trials to achieve better understanding of the problem of secondary IMR.