Functional mitral regurgitation is frequently observed in the setting of left ventricular dyfunction. This finding is a marker of poor outcome in patients with either ischemic or dilated cardiomyopathy. The mechanism accounting for this phenomenon is an altered balance of tethering versus coapting forces acting on the mitral valves in the failing heart. Tethering forces represent an anomalous tension on the mitral valves due to displacement of mitral valve attachments secondary to increased left ventricular chamber sphericity associated with systolic ventricular dysfunction. On the other hand, coapting forces are weak and unable to counteract the abnormal tension acting on the mitral valve, which restricts closure and leads to regurgitation. Vasodilators and inotropic drugs are effective in the management of functional mitral regurgitation. Although partial left ventriculectomy or Batista's procedure is still investigational, this new technique seems to provide an optimal control of functional mitral regurgitation and improve functional capacity and survival of some patients with heart failure.