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Secondary mitral regurgitation (MR), also known as functional MR, arises from changes in left ventricular geometry and function resulting in abnormal leaflet coaptation due to tethering of the mitral valve in patients with left ventricular dysfunction. Secondary MR is an independent risk factor for patients with heart failure (1,2). The 2017 AHA/ACC guidelines give a class IIb recommendation (level of evidence B) to isolated surgical mitral valve repair or replacement for patients with severe secondary MR who remain symptomatic (NYHA class III or IV) despite maximum tolerated guideline-directed medical therapy for heart failure (3). Meanwhile, the 2017 ESC/EACTS guidelines offer percutaneous repair as an alternative for these patients (class IIb recommendation; level of evidence C) (4). Percutaneous mitral valve repair with the use of MitraClip (Abbott Vascular, Santa Clara, CA, USA) has proven feasible, safe, and effective as an alternative for patients with severe symptomatic secondary MR and a high surgical risk in non-randomized studies (5). However, randomized data on hard clinical outcomes is lacking.

Mitral regurgitation (MR) is the most common valvular disorder and its prevalence is increasing in the aging population. MR is classically managed surgically or conservatively depending on its etiology and patient characteristics, however severe comorbidities preclude surgery in up to 50% of patients with severe MR (1). The development and widespread acceptance of transcatheter aortic valve replacement for patients with severe aortic stenosis over the past two decades has created a paradigm shift in the management of valvular heart disease.