Abstract OBJECTIVES Mitral regurgitation (MR) is frequently observed in patients undergoing left ventricular assist device implantation. We investigated the impact of preoperative MR on left ventricular assist device patients. METHODS A retrospective propensity score-matched analysis of adult patients enrolled in the EUROMACS registry between 1 January 2011 and 30 November 2021 was performed. Patients were divided into 2 groups according to the grade of preoperative MR: none-to-mild (MR 0–II) or moderate-to-severe (MR III–IV). RESULTS Following 1:1 propensity score matching, each group consisted of 914 patients. Incidence of postoperative temporary right ventricular support, reoperation for bleeding and dialysis was similar. MR III–IV demonstrated shorter median intensive care unit stay [14 days (6; 27.8) vs 10 days (5; 22), P = 0.004] and ventilation time [72 h (22, 320) vs 31 h (18, 150), P < 0.001]. Mortality was lower for MR III–IV patients [subdistribution hazard ratio: 0.66, 95% confidence interval (CI): 0.59–0.73, P < 0.001]. The 1-year survival was 68.1% (95% CI: 65.1–71.3%) in MR 0–II and 75% (95% CI: 72.1–78%) in MR III–IV. A lower incidence of total complications [odds ratio (OR): 0.93 (0.89–0.98), P = 0.003] and trend towards a lower risk of neurological dysfunction (subdistribution hazard ratio: 0.79; 95% CI: 0.61–1.01, P = 0.063) and sustained ventricular tachycardia [OR: 0.93 (0.54–1.03), P = 0.074] were demonstrated for MR III–IV. The risk of fatal stroke and pump thrombosis was similar. CONCLUSIONS Moderate-to-severe MR in patients undergoing left ventricular assist device implantation is associated with better mid-term survival and lower incidence of total major adverse events and complications. The incidence of severe postoperative complications including fatal stroke and device thrombosis was similar.