EVEREST II Pivotal Study High Risk Registry (HRR)
EVEREST II Pivotal Study High Risk Registry (HRR)
Prospective, multi-center, single arm registry. Clinical follow-up at discharge, 30 days, 6,
 12, 18 and 24, months, and 3, 4 and 5 years.

 Concurrent Control (CC) group identified retrospectively from the patients screened for the
 HRR who did not enroll; patient survival determined at 12 months. NCT00209274 (EVEREST II
 RCT) Intended use Percutaneous reduction of clinically significant mitral regurgitation in
 symptomatic patients who are considered to be high risk for operative mortality (high
 surgical risk).
The EVEREST II HRR is a single-arm prospective, multicenter clinical trial enrolling high
 surgical risk patients of the EVEREST II study (NCT00209274).

 Patients were considered high surgical risk if either their Society of Thoracic Surgery (STS)
 predicted operative mortality risk was ≥ 12%, or the surgeon investigator determined the
 patient to be high risk (≥ 12% predicted operative mortality risk) due to the presence of, at
 a minimum, one of the following pre-specified risk factors:

 -  Porcelain aorta or mobile ascending aortic atheroma

 -  Post-radiation mediastinum

 -  Previous mediastinitis

 -  Functional MR with ejection fraction (EF) < 40%

 -  Over 75 years old with EF < 40%

 -  Prior re-operation with patent grafts

 -  Two or more prior chest surgeries

 -  Hepatic cirrhosis

 -  Three or more of the following STS high risk factors:

 i. Creatinine > 2.5 mg/dL ii. Prior chest surgery iii. Age over 75 iv. EF < 35%

 Upon completion of enrollment in the HRR, a process was initiated to ensure patient consent
 to participate in a Concurrent Control (CC) group was in place. Patients were identified to
 determine survival through 12 months with current standard of care treatment.CC patients were
 derived from a cohort of patients screened for enrollment in the HRR,yet did not enroll. All
 patients had moderate-to-severe (3+) or severe (4+) MR based on transthoracic
 echocardiography (TTE). To be considered eligible for inclusion in the CC group, the patient
 had to be classified as high surgical risk using the same criteria used for the HRR. Upon
 follow-up with the clinical sites, it was determined that some of the initially identified
 patients with moderate-to-severe (3+) or severe (4+) MR met the criteria for high surgical
 risk. Of these patients, some were not included due to; lack of Institutional Review Board
 (IRB) approval at the site, lack of informed consent and unable to be contacted. The
 remaining patients make up the CC group.
Inclusion Criteria:

 Candidates for the high risk arm of the study must meet all of the following inclusion
 criteria:

 -  Predicted procedural mortality risk calculated using the STS surgical risk calculator
 of ≥ 12% or in the judgment of the surgeon investigator the patient is considered a
 high risk surgical candidate due to the presence of one of the following indications:

 1. Porcelain aorta or mobile ascending aortic atheroma

 2. Post-radiation mediastinum

 3. Previous mediastinitis

 4. Functional MR with EF<40

 5. Over 75 years old with EF<40

 6. Re-operation with patent grafts

 7. Two or more prior chest surgeries

 8. Hepatic cirrhosis i Three or more of the following STS high risk factors: i)
 Creatinine > 2.5 mg/dL ii) Prior chest surgery iii) Age over 75 iv) EF<35

 -  Age 18 years or older.

 -  Symptomatic moderate to severe (3+) or severe (4+) chronic mitral regurgitation (MR)
 and in the judgment of the investigator intervention to reduce MR is likely to provide
 symptomatic relief for the patient. MR is determined as defined in Appendix A of the
 EVEREST II study protocol. American Society of Anesthesiologists (ASA) physical status
 classification of ASA IV or lower.

 -  The primary regurgitant jet originates from malcoaptation of the A2 and P2 scallops of
 the mitral valve.

 -  Male or Female. Female subjects of childbearing potential must have a negative
 pregnancy test within seven (7) days before the procedure.

 -  The subject or the subject's legal representative has been informed of the nature of
 the study and agrees to its provisions and has provided written informed consent as
 approved by the Institutional Review Board of the respective clinical site.

 -  The subject and the treating physician agree that the subject will return for all
 required post-procedure follow-up visits.

 -  Transseptal catheterization is determined to be feasible by the treating physician.

 Exclusion Criteria:

 Candidates will be excluded from the study if any of the following conditions are present:

 -  Evidence of an acute myocardial infarction in the prior 2 weeks of the intended
 treatment (defined as: Q wave or non-Q wave infarction having creatine kinase (CK)
 enzymes ≥ two times (2X) the upper laboratory normal limit with the presence of a
 Creatine Kinase MB Isoenzyme (CKMB) elevated above the institution's upper limit of
 normal).

 -  In the judgment of the Investigator, the femoral vein cannot accommodate a 24 F
 catheter or presence of ipsilateral deep vein thrombosis (DVT).

 -  Ejection fraction < 20%, and/or end-systolic dimension > 60 mm as defined in Appendix
 A of the EVEREST II protocol.

 -  Mitral valve orifice area < 4.0 cm2 as defined in Appendix A of the EVEREST II
 protocol.

 -  If leaflet flail is present:

 1. Flail Width: the width of the flail segment is greater than or equal to 15 mm, as
 defined in Section 4.3 and Appendix A, or

 2. Flail Gap: the flail gap is greater than or equal to 10 mm, as defined in Section
 4.3 and Appendix A.

 -  If leaflet tethering is present:

 a). Coaptation Length: the vertical coaptation length is less than 2 mm, as defined in
 Section 4.3 and Appendix A.

 -  Leaflet anatomy which may preclude clip implantation, proper clip positioning on the
 leaflets or sufficient reduction in MR. This may include:

 -  Evidence of calcification in the grasping area of the A2 and/or P2 scallops

 -  Presence of a significant cleft of A2 or P2 scallops

 -  More than one anatomic criteria dimensionally near the exclusion limits

 -  Bileaflet flail or severe bileaflet prolapse

 -  Lack of both primary and secondary chordal support

 -  Hemodynamic instability defined as systolic pressure < 90 mmHg without after load
 reduction or cardiogenic shock or the need for inotropic support or intra-aortic
 balloon pump.

 -  Need for emergent or urgent surgery for any reason.

 -  Prior mitral valve leaflet surgery or any currently implanted mechanical prosthetic
 mitral valve.

 -  Echocardiographic evidence of intracardiac mass, thrombus or vegetation.

 -  Active endocarditis or active rheumatic heart disease or leaflets degenerated from
 rheumatic diseased (i.e. noncompliant, perforated).

 -  History of bleeding diathesis or coagulopathy or subject will refuse blood
 transfusions.

 -  Active infections requiring current antibiotic therapy (if temporary illness, patients
 may enroll 2 weeks after discontinuation of antibiotics). Patients must be free from
 infection prior to treatment. Any required dental work should be completed a minimum
 of 3 weeks prior to treatment.

 -  Intravenous drug abuse or suspected inability to adhere to follow-up.

 -  Patients in whom transesophageal echocardiography (TEE) is contraindicated.

 -  A known hypersensitivity or contraindication to study or

 -  In the judgment of the Investigator, patients in whom the presence of a permanent
 pacemaker or pacing leads would interfere with placement of the test device or the
 placement of the test device would disrupt the leads.

 -  Currently participating in an investigational drug or another device study that has
 not completed the primary endpoint or that clinically interferes with the current
 study endpoints. [Note: Trials requiring extended follow-up for products that were
 investigational, but have since become commercially available, are not considered
 investigational trials].