EVEREST II Pivotal Study High Risk Registry (HRR)

Inclusion Criteria: Candidates for the high risk arm of the study must meet all of the following inclusioncriteria:

• Predicted procedural mortality risk calculated using the STS surgical risk calculatorof ≥ 12% or in the judgment of the surgeon investigator the patient is considered ahigh 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 providesymptomatic relief for the patient. MR is determined as defined in Appendix A of theEVEREST II study protocol. American Society of Anesthesiologists (ASA) physical statusclassification of ASA IV or lower.

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

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

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

• The subject and the treating physician agree that the subject will return for allrequired 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 intendedtreatment (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 aCreatine Kinase MB Isoenzyme (CKMB) elevated above the institution's upper limit ofnormal).

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

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

• Mitral valve orifice area < 4.0 cm2 as defined in Appendix A of the EVEREST IIprotocol.

• If leaflet flail is present:

1. Flail Width: the width of the flail segment is greater than or equal to 15 mm, asdefined 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 inSection 4.3 and Appendix A.

• Leaflet anatomy which may preclude clip implantation, proper clip positioning on theleaflets 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 loadreduction or cardiogenic shock or the need for inotropic support or intra-aorticballoon pump.

• Need for emergent or urgent surgery for any reason.

• Prior mitral valve leaflet surgery or any currently implanted mechanical prostheticmitral valve.

• Echocardiographic evidence of intracardiac mass, thrombus or vegetation.

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

• History of bleeding diathesis or coagulopathy or subject will refuse bloodtransfusions.

• Active infections requiring current antibiotic therapy (if temporary illness, patientsmay enroll 2 weeks after discontinuation of antibiotics). Patients must be free frominfection prior to treatment. Any required dental work should be completed a minimumof 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 permanentpacemaker or pacing leads would interfere with placement of the test device or theplacement of the test device would disrupt the leads.

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