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The aim of this study was to determine whether assessment of left atrial (LA) function helps identify patients at risk for early deterioration during follow-up with mitral valve prolapse and mitral regurgitation.Patients with moderate to severe mitral regurgitation but no guideline-based indications for surgery were retrospectively identified from a dedicated clinical database. Maximal and minimal LA volumes were used to derive total LA emptying fraction ([maximal LA volume − minimal LA volume]/maximal L volume × 100%). Average values of peak contractile, conduit, and reservoir strain were obtained using two-dimensional speckle-tracking imaging. The study outcome was time to mitral surgery.One hundred seventeen patients were included; median follow-up was 18 months. Sixty-eight patients underwent surgery. Receiver operating characteristic curves were used to derive optimal cutoffs for TLAEF (>50.7%) and strain (reservoir, >28.5%; contractile, >12.5%). Using Cox analysis, TLAEF and contractile, reservoir, and conduit strain were univariate predictors of time to event. After multivariate analysis, TLAEF (hazard ratio, 2.59; P = .001), reservoir strain (hazard ratio, 3.06; P < .001), and contractile strain (hazard ratio, 2.01; P = .022) remained independently associated with events, but conduit strain did not. Using Kaplan-Meier curves, event-free survival was considerably improved in patients with values above the derived thresholds (TLAEF: 1-year survival, 78 ± 5% vs 28 ± 8%; 3-year survival, 68 ± 6% vs 13 ± 5%; P < .001 for both; reservoir strain: 1-year survival, 79 ± 5% vs 29 ± 7%; 3-year survival, 67 ± 6% vs 15 ± 6%; P < .001 for both; contractile strain: 1-year survival, 80 ± 5% vs 41 ± 7%; 3-year survival, 69 ± 6% vs 24 ± 6%; P < .001 for both).LA function is independently associated with surgery-free survival in patients with mitral valve prolapse and moderate to severe mitral regurgitation. Quantitative assessment of LA function may have clinical utility in guiding early surgical intervention in these patients.The left atrium is central to the heart's adaptive mechanism to chronic MR.We studied patients with moderate to severe MR and no indications for surgery.LA function identified patients who were more likely to require mitral valve surgery.Assessment of LA function may have use in guiding early surgery in patients with MR.