Percutaneous or Surgical Mitral Valve Repair

The patient population for this trial consists of adults with severe, primary degenerative
MR for whom the local heart team has verified that an indication for MV intervention is
present and for whom both transcatheter edge-to-edge and surgical repair strategies are
anatomically feasible. Specific inclusion and exclusion criteria are listed below. All
patients who meet eligibility criteria will be included in the study regardless of gender,
race, or ethnicity.

Inclusion Criteria:

   - Adult patients ≥65 yrs with moderately-severe or severe (3+ or 4+/4+) primary
   degenerative (Carpentier type II) MR defined by transthoracic echocardiography

   - Clinical indication for MV intervention and anatomic candidate for both MV
   transcatheter edge-to-edge and surgical repair per local heart team assessment

   - Patients across the surgical risk spectrum (low, intermediate, and high risk)
   depending on the local heart team assessment (see 2020 ACC/AHA guidelines for the
   management of patients with valvular heart disease)

   - Patients with AF who meet an indication for concomitant ablation may be included
   provided the local heart team verifies they are eligible for both catheter-based and
   surgical ablation.

   - Ability to perform 6-minute walk test (6MWT) and complete Kansas City Cardiomyopathy
   Questionnaire (KCCQ) instrument

Exclusion Criteria:

   - Non-degenerative types of primary MR (e.g., cleft leaflet)

   - Secondary or functional MR

   - Hypertrophic obstructive cardiomyopathy

   - Presence of an IVC filter or pacing/ICD leads that would interfere with TEER per local
   heart team assessment

   - Known allergic reactions to intravenous contrast

   - Febrile illness within 30-days prior to randomization

   - Any absolute contraindication to transesophageal echocardiography

   - Any contraindication to systemic heparinization including active bleeding diatheses,
   and heparin induced thrombocytopenia

   - Patients with CAD requiring revascularization

   - Any prior mitral valve intervention or any prior repair of atrial septal defect

   - Any prior MV intervention or any prior repair of atrial septal defect

   - Need for any of the following concomitant procedures: aortic valve or aortic surgery,
   tricuspid valve surgery

   - Need for any emergency intervention or surgery

   - Active endocarditis

   - Hemodynamic instability defined as cardiac index <2.0 l/min/m2 or systolic blood
   pressure <90mmHg or need for inotropic support or any mechanical circulatory support

   - Left ventricular ejection fraction <25%

   - Intracardiac mass or thrombus

   - Co-morbid medical or oncologic condition for which local heart team believes that
   meaningful survival beyond 2 years is unlikely

   - Active substance abuse

   - Suspected inability to adhere to follow-up

   - Treatment with another investigational drug or other intervention, assessment of which
   has not completed its primary endpoint or that clinically interferes with the present
   study endpoints.