In general, in patients with LV systolic dysfunction and symptoms of HF, the presence of chronic secondary MR of any sever- ity is associated with a worse prognosis than that seen in the absence of MR. Most patients with secondary MR have global LV dysfunction, but in some patients, a limited but strategically placed wall motion abnormality may also cause chronic secondary MR. An initial TTE helps establish the cause of chronic secondary MR and also serves as a baseline for future comparisons. In patients with secondary MR, severe MR is defined as an , but outcome studies have shown poor prognosis in those with moderate MR (ERO 2. Prognosis is poor for both ischemic and non- ischemic MR, but ischemic MR lends itself to the possibility of revascularization and potential improvement in LV function if CAD has led to large areas of hibernating viable myocardium. Long-term results of the STICH (Surgical Treatment for Ischemic Heart Failure) trial demonstrated an improved 10-year survival rate in patients with ischemic cardiomyopathy and LVEF <35% who underwent CABG plus GDMT as compared with those randomized to GDMT alone. CT angiog- raphy is usually adequate to rule out significant CAD and thus rule out ischemic MR. If CAD is detected and noninvasive testing demonstrates areas of viability, coronary arteriography is pur- sued to better define the anatomy for potential Although the presence of myocardial viability did not determine the effect of revascularization on survival in the STICH trial, there is a subset of patients with viable myocar- dium in whom the ischemic MR will respond to 3. Clinical trials have identified anatomic consid- erations, detectable by TEE, that can identify patients with secondary MR who have a valve morphology amenable to TEER. 