OBJECTIVE: Preoperative cardiac risk assessment scoring systems traditionally do not include valvular regurgitation as a criterion for adverse outcome prediction. We sought to determine the impact of significant mitral regurgitation on postoperative outcomes after planned noncardiac surgeries. METHODS: Patients with significant mitral regurgitation (moderate-severe or severe) undergoing noncardiac surgery were identified using surgical and echocardiographic databases at the Cleveland Clinic. The mechanism of mitral regurgitation was identified and classified as ischemic or nonischemic. By using propensity score analysis, we obtained 4 matched controls (patients undergoing noncardiac surgery without mitral regurgitation) for each case. The primary outcome was defined as a composite of 30-day mortality, myocardial infarction, heart failure, and stroke. Secondary outcomes included 30-day mortality, myocardial infarction, heart failure, stroke, and atrial fibrillation. RESULTS: A total of 298 cases and 1172 controls were included in the study. The incidence of primary outcome was significantly higher among patients with mitral regurgitation (22.2%) compared with controls (16.4%, P=.02). Analysis of the secondary outcomes revealed significant differences in perioperative heart failure (odds ratio, 1.4; 95% confidence interval, 1.02-2.0) and perioperative myocardial infarction (odds ratio, 2.9; 95% confidence interval, 1.2-7.3). Of patients with mitral regurgitation, those with ischemic mitral regurgitation had significantly more events than those with nonischemic mitral regurgitation (39.2% vs 13.3%, P<.001). CONCLUSIONS: Patients undergoing noncardiac surgery with significant ischemic mitral regurgitation are at higher risk of a composite adverse postoperative outcome, including short-term mortality, heart failure, myocardial infarction, and stroke.