In Search of Best Practices for Patients With Heart Failure and Secondary Mitral Regurgitation: An Evaluation of the Inova Heart Failure Treatment Algorithm

Inclusion Criteria: * Symptomatic MR (≥2+) due to cardiomyopathy of either ischemic or nonischemic etiology * Subject has been adequately treated per applicable standards, including for coronary artery disease, LV dysfunction, MR, and HF. * NYHA functional class II, III, or ambulatory IV * Local heart team has determined that MV surgery will not be offered as a treatment option even if the subject is randomized to the Control group. * LVEF ≤50%. * LVESD ≤70 mm * The primary regurgitant jet , in the opinion of the MitraClip implanting investigator, can be successfully treated by the MitraClip (if a secondary jet exists, it must be considered clinically insignificant). * Transseptal catheterization and femoral vein access is feasible per the MitraClip implanting investigator. * Age 18 y or older * Subject or guardian agrees to all provisions of the protocol * NT-proBNP≥ 1500ng/ml or BNP≥ 300ng/ml Exclusion Criteria: * Untreated clinically significant coronary artery disease requiring revascularization * CABG, PCI, or TAVR within the prior 30 d * Aortic or tricuspid valve disease requiring surgery or transcatheter intervention * COPD requiring continuous home oxygen therapy or chronic outpatient oral steroid use * Cerebrovascular accident within prior 30 d * Severe symptomatic carotid stenosis (N70% by ultrasound) * Carotid surgery or stenting within prior 30 d * ACC/AHA stage D HF * Presence of any of the following: * Estimated PASP N70 mm Hg assessed by site based on echoca…