Inclusion criteria (all must be present)

·        Symptomatic SMR (≥3+) due to cardiomyopathy of either ischemic or non-ischemic etiology

·        Subject has been adequately treated per applicable standards, including for coronary artery disease, LV dysfunction, MR and HF

·        Subject has had at least one hospitalization for HF in the 12 months prior to subject registration and/or a corrected* BNP ≥300 pg/ml or a corrected NT-proBNP ≥1500 pg/ml

·        New York Heart Association (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

·        Left ventricular ejection fraction (LVEF) ≥20% and ≤50%.

·        Left ventricular end-systolic dimension (LVESD) ≤70 mm

•       The primary regurgitant jet is non-commissural, and in the opinion of the MitraClip implanting investigator can be successfully be treated by the MitraClip (if a secondary jet exists, it must be considered clinically insignificant)

·        CK-MB obtained within prior 14 days is < local laboratory ULN

·        Transseptal catheterization and femoral vein access is feasible per the MitraClip implanting investigator

·        Age 18 years or older

·        Subject or guardian agrees to all provisions of the protocol, including the possibility of randomization to the Control group and returning for all required post-procedure follow-up visits, and has provided written informed consent

Exclusion criteria (all must be absent)

·        Untreated clinically significant coronary artery disease requiring revascularization

·        CABG, PCI or TAVR within the prior 30 days

·        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 days

·        Severe symptomatic carotid stenosis (>70% by ultrasound)

·        Carotid surgery or stenting within prior 30 days

·        ACC/AHA stage D heart failure

·        Presence of any of the following:

–       Estimated PASP >70 mm Hg assessed by site based on echocardiography or right heart catheterization, unless active vasodilator therapy in the cath lab is able to reduce the PVR to <3 Wood Units or between 3 and 4.5 Wood Units with v wave less than twice the mean of the PCWP

–       Hypertrophic cardiomyopathy, restrictive cardiomyopathy, constrictive pericarditis, or any other structural heart disease causing heart failure other than dilated cardiomyopathy of either ischemic or non-ischemic etiology

–       Infiltrative cardiomyopathies (e.g., amyloidosis, hemochromatosis, sarcoidosis)

–       Hemodynamic instability requiring inotropic support or mechanical heart assistance

·        Physical evidence of right-sided congestive heart failure with echocardiographic evidence of moderate or severe right ventricular dysfunction

·        Implant of CRT or CRT-D within the last 30 days

·        Mitral valve orifice area <4.0 cm² by site-assessed TTE

·        Leaflet anatomy which may preclude MitraClip implantation, proper MitraClip positioning on the leaflets or sufficient reduction in MR by the MitraClip.

·        Hemodynamic instability defined as systolic pressure < 90 mmHg with or without afterload reduction, cardiogenic shock or the need for inotropic support or intra-aortic balloon pump or other hemodynamic support device.

·        Need for emergent or urgent surgery for any reason or any planned cardiac surgery within the next 12 months.

·        Life expectancy < 12 months due to non-cardiac conditions

·        Modified Rankin Scale ≥ 4 disability.

·        Status 1 heart transplant or prior orthotopic heart transplantation

·        Prior mitral valve leaflet surgery or any currently implanted prosthetic mitral valve, or any prior transcatheter mitral valve procedure.

·        Echocardiographic evidence of intracardiac mass, thrombus or vegetation

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

·        Active infections requiring current antibiotic therapy

·        Transesophageal echocardiography (TEE) is contraindicated or high risk

·        Known hypersensitivity or contraindication to procedural medications which cannot be adequately managed medically

·        Pregnant or planning pregnancy within next 12 months

·        Currently participating in an investigational drug or another device study that has not reached its primary endpoint.

·        Subject belongs to a vulnerable population or has any disorder that compromises his/her ability to give written informed consent and/or to comply with study procedures