The association of transcriptional coactivators with DNA-binding proteins provides an efficient mechanism to expand and modulate genetic information encoded within the genome. Myocardin-related transcription factors (MRTFs), including myocardin, MRTF-A/MKL1/MAL, and MRTF-B/MKL2, comprise a family of related transcriptional coactivators that physically associate with the MADS box transcription factor, serum response factor, and synergistically activate transcription. MRTFs transduce cytoskeletal signals to the nucleus, activating a subset of serum response factor-dependent genes promoting myogenic differentiation and cytoskeletal organization. MRTFs are multifunctional proteins that share evolutionarily conserved domains required for actin-binding, homo- and heterodimerization, high-order chromatin organization, and transcriptional activation. Mice harboring loss-of-function mutations in myocardin, MRTF-A, and MRTF-B, respectively, display distinct phenotypes, including cell autonomous defects in vascular smooth muscle cell and myoepithelial cell differentiation and function. This article reviews the molecular basis of MRTF function with particular focus on the role MRTFs play in regulating cardiovascular patterning, vascular smooth muscle cell and cardiomyocyte differentiation and in the pathogenesis of congenital heart disease and vascular proliferative syndromes.