Ischaemic mitral regurgitation (MR) is associated with poor survival. The favoured surgical option remains debatable. Our aim was to perform a meta-analysis to compare the outcomes of mitral valve repair (MVRp) with replacement (MVR). A literature search was conducted in PubMed, Medline and Ovid using the terms ‘ischaemic mitral regurgitation’, ‘repair’ and ‘replacement’. The primary outcome measure was 30-day survival. The secondary outcome measures were MR recurrence and reoperation. Out of 310 articles, 18 fulfilled the inclusion criteria. A total of 3978 patients were included: 2563 (64%) MVRp cases and 1415 (36%) MVR cases. Operative techniques included annuloplasty for MVRp and subvalvular apparatus-sparing MVR techniques. Thirty-day mortality was lower after MVRp compared with MVR [OR 0.42; (95% CI 0.33–0.54; P = 0.0001)]. There was no difference in long-term survival ranging 1–5 years (HR 0.85, 95% CI 0.65–1.12). Recurrence of MR was significantly higher in the MVRp group (OR 4.26, 95% CI 2.52–7.22), as was the rate of reoperation (OR 2.03, 95% CI 1.49–2.77). Although MVR for ischaemic MR has a higher 30-day mortality rate compared with MVRp, MVRp is associated with the higher rate of MR recurrence and the need for reoperation. MVR remains an attractive option for ischaemic MR.